The National Transportation Safety Board (NTSB) today released the findings from its investigation of last summer’s MetroRail crash, giving the Washington Metropolitan Area Transit Authority (WMATA, ‘Metro’) a well-deserved slap in the face. According to the NTSB, Metro exhibited systemic problems well before the crash—both technological (a grossly insufficient automatic safety system) and cultural (a management failure to identify and fix safety problems).

There are few surprises, so far, in NTSB’s report. I covered many of these same points in my initial analysis of the June 2009 crash, and several more times in the months that followed. So far I’m only aware of one new piece of information that couldn’t be determined by attentive independent observers before: the report appears to exonerate the operator of the train. Less than three seconds after the stationary train became visible to Jeanice McMillan, she applied the emergency brake . . . but it was already too late. Even if she had somehow applied the break the very millisecond the train came into view, it would not have been enough to avoid the accident. She was a victim of a failed and un-safe transit system, as were the eight passengers who perished with her and the 80+ who suffered injuries in the crash.

So we arrive at the conclusion we expected: Metro’s failure to implement a fail-safe, redundant collision avoidance system, combined with Metro’s failure to follow previous NTSB recommendations and remove ‘1000 series’ trains from service, combined with Metro’s control system failing to detect that a train had disappeared from its grid, combined with probably another 100 or 1,000 irresponsible derelictions of duty are what caused this crash. The leaders of Metro, including former General Manager John Catoe and the entire Metro board, must be held accountable for their criminal negligence.

More importantly, Metro’s leadership—preferably a completely new, responsible leadership—absolutely must implement all past and present NTSB safety recommendations immediately. All ‘1000 series’ cars must be removed from service; a fail-safe, redundant train detection mechanism must be implemented; the tracking system in Metro’s control center must be upgraded to alert when trains ‘disappear’; malfunctioning track circuits must be repaired and all track circuits must be monitored for anomalies constantly. This is not rocket science; it’s Engineering 101. People’s lives are in your hands. No more excuses. No more blather about how expensive it will be (especially when MetroRail is the most expensive transit system to ride in the U.S.). No more pandering to the employee union. No more posturing. Fix the problems, and fix them now . . . before more people lose their lives.