Safety Warnings Often Ignored at Metro

California, in contrast, allocates $2.3 million a year to oversee two subway systems and two commuter railroads. One of the few states with a muscular monitoring program, it has a team of expert inspectors, can fine transit systems that violate safety standards and can veto car or track designs.

"You can wait until an accident happens and try to fix problems, or you can be proactive and try to prevent accidents by having a highly skilled third party taking a look at issues from design through daily operations," said Richard Clark, who oversees rail safety for California.

Inside Metro, the safety department also wields little power. White brought Goodine to the agency in 1997 to set up an aggressive safety program. But Goodine said his biggest challenge has been persuading what he calls Metro's "frozen middle" to address issues that can endanger passengers.

"There needs to be more urgency and accountability," he said.

Goodine can warn the bus department, as he recently did, that its operators aren't consistently inspecting their vehicles before heading out for a shift, as required by law. But it's up to the bus department to force operators to do it. When the track department failed to lubricate tracks, Goodine had no authority to order workers to do so.

"What we lack," White acknowledged, "is a clear intervention process."

White said a recent agency-wide reorganization will help address that problem, but one of his changes is being met with mixed reviews. Some worry that the safety department's profile will drop further because Goodine no longer reports directly to White; he reports to Metro's auditor general, a move meant to consolidate the agency's investigative functions.

"We're concerned that critical safety matters may not be brought to the attention of the chief executive in a timely and unfettered way," said John Contestabile, a member of the Tri-State Oversight Committee.

Federal Warnings Ignored

After a 1996 crash in which a Metro train operator was killed at the Shady Grove Station, federal safety investigators delved into Metro's operations and found a troubling trend: Hundreds of trains a year were shooting past station platforms.

Although operators can manually brake a train, Metro mostly relies on an onboard computer system for routine stops. If the computer misses a signal from coil markers embedded along the track, the train enters the station too fast. It overruns the station and comes to rest with some cars inside the tunnel. Passengers often can't get off and must ride ahead to the next station and catch a train back.

Because Metro has a separate computer system that stops a train before it can crash into another, officials do not consider station overruns a safety concern. But both the National Transportation Safety Board and the Federal Transit Administration said in separate reports that Metro should pay more attention to overruns.

"All station overruns are serious and should be investigated" because operators rely so heavily on the automatic equipment, the FTA wrote in a 1997 report. Overruns could also signal a safety issue, such as a braking problem.

But unlike most rail agencies, the FTA said in the report, Metro had done little to get to the bottom of the problem. The agency failed to check whether the overruns were random or whether there was a pattern determined by weather, location or the type of rail cars, the report said.

Had Metro undertaken such an analysis, the FTA said, it would have seen that a significant number of overruns were occurring in wet and icy weather -- the type of conditions that the operator in the Shady Grove crash was facing as his train failed to brake in automatic mode. As it turned out, Metro was not properly setting its brake pressure to consistently stop computer-controlled trains on wet tracks. It also was ordering operators to use the automatic mode regardless of the weather.

In 2002, Metro officials assured NTSB investigators that they had purchased equipment that would fix the problem, records show. But it has worsened. In 1996, the year of the Shady Grove accident, Metro had 322 overruns, agency statistics show. Last year, trains missed their stations 583 times, records show. San Francisco's system, which Metro officials say has superior technology, had 37 overruns last year.

Metro's overrun problem is "something that needs to be looked at very, very carefully and quickly," said Brian Cudahy, a subway expert and former FTA official.

Metro officials stressed that the number of overruns is minuscule when compared with the 11 million station stops made last year. Nevertheless, in January, White told Assistant General Manager P. Takis Salpeas to get to the bottom of the problem quickly because the agency was under pressure from NTSB and other fronts. Salpeas said he hopes he has found the answer: installing an electronic backup system on the trains.

Metro must get the problem under control so it can go forward with plans to run eight-car trains to ease crowding, Salpeas said. Because eight-car trains are 600 feet long -- the same length as the platform -- there is no room for error.

While station overruns and rail breaks draw little public attention, November's high-profile crash at the Woodley Park Station unnerved many daily riders. The crash occurred when an out-of-service train rolled backward and hit an idling, occupied train at about 30 miles an hour.

After the accident, the NTSB issued an unusual emergency directive to Metro that criticized the agency for not adequately training its operators.

Metro officials "did not anticipate a situation in which an uncontrolled rollback could occur," the NTSB wrote. Consequently, operators were never trained to manage "an event similar to the one that occurred."

After the 1996 Shady Grove accident, the NTSB warned Metro that its cars were susceptible to "telescoping" -- when a crash causes rail cars to fold like a collapsible telescope -- and urged Metro to strengthen the cars. Metro said it would buy stronger cars in the future but decided any benefit of retrofitting its fleet was outweighed by the huge cost.

At Woodley Park, some of the cars in the runaway train telescoped. Had the cars been full, experts said, passengers likely would have been killed.

Few Get Fired

After investigating the Woodley Park crash, Metro officials laid the blame on the novice train operator. The agency fired Lamont Lewis, accusing him of "gross violation of basic operations procedures."

It was a rare move at Metro, where employees seldom face stiff punishment, records show. This is true even for workers who put passengers in jeopardy.

Last year, Metro statistics show, bus and train operators committed 737 serious safety violations, such as a failure to pay attention to traffic control signals or opening the doors on the wrong side of the train. In more than half of the incidents, operators received a reprimand or lighter punishment. Fourteen, or less than 2 percent, were fired.

To some extent, Metro management is hamstrung by the protections afforded to unionized workers. In February 2004, for instance, a bus driver hit a pedestrian in the District. Metro recommended that the bus operator be fired. But the union appealed, and an arbitrator ruled that the operator could return to work.

Management also metes out discipline inconsistently, a review of accident records and personnel decisions show.

In 2001, Metro tried to fire a driver who lost control of his bus and hit two trees in a Pentagon parking lot. But two bus drivers who caused injuries to people that year were reassigned to desirable jobs after their accidents. One of those drivers fell asleep at the wheel and hit a pole, sending six passengers to the hospital. Metro switched that driver's job, making her a subway station manager.

The other driver hit pedestrian Patricia Ann Skinner, a 35-year-old editor at a newsletter publishing company. The driver had seen Skinner, honked the horn repeatedly and waved her arms -- but never applied the brakes, according to the accident investigation. Skinner's life changed forever that day; she lost a leg from the hip down. Metro paid her millions in an undisclosed settlement. The driver became a subway station manager.

Jack Requa, who heads Metro's bus department, called those decisions "mistakes."

"We don't do that anymore," he added.

White said one goal of his reorganization is to make personnel decisions more consistent by giving the human resources department the authority to review disciplinary actions.

"It's a new day around here," he said. "We slid into a comfortable period. Now we're going through the turbulence, and my job is to make sure that the rest of this organization is as shook up as I am."

But the agency continues to forge ahead with a pilot program, introduced last year, called "alternative discipline." Instead of suspending and docking the pay of unionized workers who violate safety rules, managers now routinely put a letter in their files and allow the workers to stay on the job.

The agency estimates that the new policy saved $700,000 last year by reducing the overtime costs of replacing suspended workers. The program also has improved labor relations, said R. Richard Froelke, Metro's chief labor negotiator. "Do you want to club employees over the head," he asked, or treat them "with dignity and respect?"

Jackie Rhodes Jeter, spokeswoman for Metro's largest union, said the program has done nothing to improve morale. Boston's Massachusetts Bay Transportation Authority, the only other transit agency in the country to try the program, dumped it after a year, concluding that it did nothing to correct unsafe behavior.

Goodine, Metro's safety chief, said he worries that lax penalties for serious safety violations lead to lax behavior.

"If you don't get a ticket for going through a stop sign, it probably won't change your driving behavior much," he said. "But if you get hit with a $200 fine, you'll think twice."

Database editor Derek Willis contributed to this report.