Highlights of the NTSB report
Here are the key points in the National Transportation Safety Board's report. A summary will be available on the NTSB's Web site, , http:/
Probable causes of the crash
-- Failure of track circuit modules that were built by General Railway Signal/Alstom Signaling. The problem caused the automatic train-control system to fail to detect a train stopped near the Fort Totten Station.
-- Metro's failure to widely use a track circuit test instituted after a 2005 near-collision in a tunnel near Rosslyn Station.
Contributing factors to the crash
-- Metro's lack of a work culture devoted to safety.
-- Metro's failure to effectively maintain and monitor its automatic train-control system.
-- GRS/Alstom's failure to provide a maintenance plan for detecting false signals in the track circuit modules.
-- Ineffective safety oversight by Metro's board and the Tri-State Oversight Committee, the regional supervisory body.
-- Metro's failure to replace or retrofit its oldest rail cars contributed to the severity of injuries and the number of deaths.
Key recommendations of the NTSB
-- Metro should replace all 1000 series rail cars, the oldest in the fleet, with cars that are at least as crashworthy as the 6000 series, which is the newest model in use by the agency. (Metro placed an order Monday night with Kawasaki for new 7000 series rail cars.) The NTSB also found that placing the older cars in the middle of trains "is not an acceptable substitute for removing the cars from service."
-- Metro should replace all of the track circuit modules whose failure is a probable cause of the crash and regularly examine all modules to detect problems consistent with what happened in the Red Line crash.
-- Metro should implement a non-punitive safety reporting program for all employees.