By Lena H. Sun
Washington Post Staff Writer
Wednesday, October 17, 2007

Failure to keep up with basic maintenance and refusal to take safety steps recommended for years by internal and external reviews were the likely causes of a Metro derailment at the Mount Vernon Square station that injured 20 people in January, federal investigators said yesterday.

In a broad and severe critique of Metro practices, members of the National Transportation Safety Board also said that a $150,000 guardrail at the curved section of track where the accident occurred would have prevented the train's wheels from derailing and causing almost $4 million in damage.

After the hearing, Metro officials pledged to make installation of the guardrail a top priority. Officials said they had not done so earlier because similarly configured locations had equipment that was more worn-out than Mount Vernon Square's and needed to be replaced sooner. The transit agency has 100 other spots that still need safeguards because of curved track. Metro officials have installed guardrails at 83 trouble spots.

The specifics of the Mount Vernon Square accident were part of an in-depth criticism that focused on Metro's failure to heed warnings, coordinate between its departments and implement safety recommendations for the type of rail car involved in the Jan. 7 accident. The 5000-Series cars have been involved in 13 of 20 derailments since 2001, when they were introduced into Metro's fleet.

"These are safety issues," said NTSB board member Kitty Higgins. "There were internal warnings three years prior to this accident. I just want someone to be responsible for fixing it." Some board members noted similar safety and coordination issues that date back to a Metrorail accident at Shady Grove more than 10 years ago.

When NTSB board members were informed during testimony yesterday about Metro's management shake-up this year, board member Debbie Hersman responded: "I don't care how the boxes are organized or what they're called. At the end of the day, something needs to change on how they manage safety oversight."

NTSB Chairman Mark Rosenker said he has met with Metro General Manager John B. Catoe Jr. and other senior Metro managers and has been assured that Catoe's team "will take our recommendations seriously."

Catoe, who took over the agency three weeks after the accident, has pledged to make the system safe for riders. "I want to assure our customers that Metrorail is one of the safest rail systems in the country," he said in a statement. "But that's not good enough. We will become THE safest rail system in the country."

Shortly after starting, Catoe said, he put in place "an aggressive, five-year safety program," and Metro has been working with the NTSB to follow through on its recommendations.

In the Mount Vernon Square accident, a northbound Green Line train carrying about 120 passengers began to shake and bump as the wheels on its fifth car left the tracks. One car hit the wall of the tunnel. Shattered glass and other debris was scattered across the train's floor, and the lights went out as shouting passengers fled through the cars. Most injuries were minor. The station was closed for about eight hours.

Investigators found that the derailment was probably caused by shoddy maintenance that left rough surfaces on rail car wheels. The safety board recommended that Metro develop a standard for maintaining smooth wheels, which Metro officials said was done as soon as the issue was raised this year. Investigators had noted that mechanics used sloppy procedures on milling machines that "trued," or reshaped, wheels. New bits for the machine heads were intermingled haphazardly with used parts and scraps in three coffee cans, investigators found.

The type of rail car that jumped the tracks at Mount Vernon is manufactured by CAF, a Spanish company, and accounts for about 20 percent of Metro's 1,026-car fleet.

When Metro workers started noticing problems with the CAF cars, they asked three outside groups to look into the situation. All of the reviews, including one done as much as 15 months before the January accident, alerted the agency to the potential for derailments along that type of curved track and the need to add safeguards, investigators said.

Metro workers warned management about the same issues, but they, too, went unheeded, the NTSB noted.

Metro workers and outside experts also found problems with the rail cars' leveling valves, which keep the cars balanced on the tracks. One industry review panel found that 98 percent of the CAF cars failed a car-leveling check. As early as 2004, a Metro quality-assurance officer warned about the valves and noted that an internal derailment committee found that they contributed to a December 2003 derailment. He sent a memo to the Metro manager for the CAF cars, asking that engineers hold off ordering new rail cars with the same valves. But the Metro manager, who was subsequently promoted to oversee all rail car purchases, rejected that idea as premature, according to NTSB reports.

Metro's newest rail cars, the 6000-Series, have the same leveling valve as the CAF cars. The agency is also preparing design specifications for a series of cars with the valve issue unresolved, federal investigators said.

Metro said it is having CAF overhaul the valves on 5000-Series cars, a process that has been completed on 75 percent of them.

Investigators said they could not determine whether the leveling system was a factor in the Mount Vernon derailment because the valve was too damaged by the accident.

Metro officials said they have addressed the problem of poor internal coordination as part of a reorganization this year. Several departments -- including rail car maintenance, quality assurance and engineering -- that used to have turf battles have since been placed under a single person, the chief mechanical officer.