The National Transportation Safety Board released a scathing report Tuesday on the L'Enfant Plaza Metro station smoke incident last year which killed an Alexandria, Virginia woman. After more than a year, the NTSB has found the cause of the smoke was "a prolonged electrical short circuit" which resulted from Metro's "ineffective maintenance."
NTSB investigators said since Metro did not have enough smoke detectors in tunnels, it would send trains filled with passengers into tunnels to look for signs of smoke.
This report drew some sharp words such as "reprehensible" and "disturbing" from NTSB members discussing what they found on things like maintenance, safety, training and policies. For six hours on Tuesday, they detailed a long list of Metro's actions - and inaction - in the incident that happened on Jan. 12, 2015.
In addition to its probable cause, the NTSB issued 33 recommendations for Metro.
The smoke incident killed Carol Glover while she was onboard Train 302 that January day. Dr. Lillian Pitts, who was also on Glover's train that day, had to leave the hearing early on Tuesday because she became too emotional.
"So many people were affected," Pitts said. "I can recall it like yesterday. It's fresh in my mind. It's something that I would not want anyone to experience and I hope all the victims out of us can pull through this and continue on with our lives with our families."
The probable cause of the 2015 incident is one that by now is familiar to Metro passengers - an electrical connector became corroded from constant water leaks. The NTSB said that caused a prolonged electrical short circuit, filling the L'Enfant Plaza Metro station with smoke.
Also for the first time, NTSB released video from same type of the fire from last February at McPherson Square station. That incident led to a one-day safety shutdown of the rail system.
There was a long list of problems in the findings, including a malfunctioning smoke ventilation system and massive communication problems which prevented first responders from talking to each other. At one point, first responders were sent down into the wrong tunnel. It was also found that the D.C Fire Department incident commander was not properly trained in procedures to handle the L'Enfant Plaza incident.
Another eye-opening revelation in the NTSB report was that Metro allowed passenger trains to be used to spot and report smoke in tunnels to make up for its lack of smoke detectors in the system.
Following the hearing, NTSB chairman Christopher Hart and Metro general manager Paul Wiedefeld both spoke out, saying that they are taking safety seriously.
"WMATA's safety culture and safety oversight have not changed adequately," said Hart. "As a result, the specific hazards that we will consider today were allowed to develop and persist. WMATA did not adequately mitigate the presence of water in tunnels, despite the role that water can play in the type of accident that we will hear about today."
"It reinforces, obviously, what I have been trying to do since Day 1 here, which is begin changing the culture," said Wiedefeld. "We have to get the infrastructure correct, we have to get the policies right and we have to get the people right. And that is what I have been trying to do since Day 1 and I will continue to do it."
At the end of the hearing, Metro tweeted that it does not use passenger trains to spot smoke. We wanted to know if they were disputing the NTSB's finding and recommendation, and we were told by a Metro spokesperson that it is not in their policy to use trains to inspect for smoke.
U.S. Senators Mark Warner and Tim Kaine released the following statement on Tuesday:
"More than fifteen months after the smoke incident at L'Enfant Plaza, we are extremely disturbed that many of the safety hazards that allowed that deadly accident to occur have not yet been addressed. As the report states, responsibility for this incident, which resulted in the death of an Alexandria resident, is borne not just by Metro but other regional stakeholders. We urge Metro, the Federal Transit Administration, and regional authorities to move as urgently as possible to ensure that the problems identified in this report finally get fixed once and for all."