Metro riders swarm the platform at Farragut North after a Red Line train became stuck in a tunnel for nearly 45 minutes on Sept. 13. (Photo by Tom Lynch)

The nation’s second-busiest subway system is opting for a low-tech solution to tackle ongoing communications issues on trains: Metro will place handheld bullhorns in the cabs of all of its trains after a series of lapses that culminated in a dangerous self-evacuation on the Red Line last week.

Metro General Manager Paul J. Wiedefeld announced a series of changes Thursday aimed at preventing the gaps in communication that contributed to the Sept. 13 incident, which left hundreds of passengers stranded in a tunnel with no information about what was happening.

During the incident, a packed train was stalled near the Farragut North station for about 40 minutes with almost no announcements from the train’s operator and a broken radio that prevented the dispatcher from communicating with the operator. After a prolonged wait with no information, two frustrated passengers self-evacuated from the train.

A loose wire caused the car-mounted radio inside a new 7000-series train to stop working, Metro’s chief safety officer said at Thursday’s meeting of the agency’s board of directors. Paired with that problem, the operator’s handheld radio may have failed because of antenna issues in the pocket track where the train had stopped.

Metro has taken possession of the operator’s handheld radio to investigate why it was not used at the time.

“Clearly, there was a breakdown in communication,” Wiedefeld acknowledged.

Wiedefeld said his plan to install bullhorns in trains’ cabs will allow operators stuck in a tunnel to walk through crowded trains and make announcements to passengers if the public-announcement system is not working or if the speaker system causes messages to be garbled.

For some of the longer-serving members of the board, the incident was reminiscent of the circumstances that led to the January 2015 L’Enfant Plaza smoke incident, in which one woman died and scores of riders where sickened.

“This is an issue that comes up over and over again, and we don’t seem to know how to address it,” said board member Kathryn Porter, who represents Maryland. “We can’t just say, ‘Oops — somebody self-evacuated,’ when a whole train of people is sitting there for almost 20 minutes without being given sufficient information.”

The similarities were made more troubling by another presentation Thursday suggesting that Metro’s issues with smoke, fire and explosions were caused by the agency’s inability to keep tracks and tunnels clean and free of debris.

A peer review by the American Public Transportation Association said the agency is playing a constant game of “catch up” when it comes to the system that powers its trains.

The review, which was requested by Metro and conducted in July, found deep flaws in the agency’s management of its third-rail power infrastructure. Among its many findings was that traction power substations were the site of debris, a fire hazard.

“When we saw videos of the explosions and the testimony of glowing bolts, it was clear these things are caused by stray currents ... when you have dirty insulators ... when the rails themselves are in contact with ballast that’s not clean,” said Vernon G. Hartsock, chief engineer with the Maryland Transit Administration, who helped conduct the study.

“There’s nothing mysterious about them,” he added.

The original issue that caused last week’s Red Line incident was a blown fuse on a switch. Because of that, the signal in the tunnel remained red, and the train was not allowed to proceed. At the time, Metro’s Rail Operations Control Center (ROCC) attempted to redirect the train but could not reach its operator.

Wiedefeld said that the investigation into the incident continues and that officials are conducting a sweep of the system’s pocket tracks for signal problems. Pocket tracks are short segments of rail tucked between the two primary tracks and designed to help trains cross from one track to another.

Officials will determine whether there are communication dead zones in those pocket tracks and whether workers need to install additional antennas.

Wiedefeld also has directed staff to determine whether there is a technology solution that could allow dispatchers inside the ROCC to communicate directly with passengers over the speakers.

Metro board member Robert Lauby, chief safety officer with the Federal Railroad Administration, said he was worried by the fact that a train was sent out into the system with a nonworking radio.

“I’m concerned that the radio tests didn’t happen,” Lauby said.

Metro Chief Safety Officer Patrick Lavin said that officials are still investigating the incident to determine why the broken radio wasn’t caught before the train went into service. Lavin said he also has directed staff to alter the checks that must be performed before trains are put into service: In addition to double-checking that the car-mounted radio is operating, Metro will now start making sure that each operator’s handheld radio is working.

Lavin also confirmed that protocol was not followed after the two passengers were found walking inside the tunnel. According to rules, staff members are supposed to cut power to the electrified third rail.

Such a step would have prevented the train from moving as well as cut power to the air conditioning inside the packed train. Rather than cutting the power, the employee escorted the passengers to the station platform, walking on the catwalk along the tunnel wall.

Later, Wiedefeld said he did not believe that there was a significant safety risk in leaving the third rail electrified.

“I think, at the moment, what they did was safe — to get them off the tracks,” Wiedefeld said.

Board members also grilled the agency about its poor communication with riders — and board members regarding the incident.

“That’s one reason for the self-evacuation,” said Carol Carmody, head of the board’s safety committee. “Eighteen minutes with no information.”

Carmody said she was disappointed that Metro had not informed board members about the incident. Instead, she learned about it two days later — in the newspaper. She and other members urged Metro officials to consider similar incidents as more than just a protracted nuisance for passengers but as a serious safety issue.

“We put people in a situation where they feel they have no other options,” said Jack Evans, the Metro board’s chairman.

Evans said he did not blame the riders for trying to get themselves off the train by any means necessary; he imagined what he would have done in a similar situation.

“I understand why they do it. If I’m stuck on a train, and I’m not getting told anything, and 10, 15 minutes goes by ... in the back of my mind is, ‘Is this thing going to fill up with smoke?’ ” Evans said. “I’d kick the door open and get off, but I hope that other people don’t have that personality and they actually stay on the train.”

After the meeting, Porter said the failure to communicate during a crisis can have dangerous implications of its own.

“It has caused, at the least, frustration, on the part of people who are just sitting there not knowing what’s going on,” she said. “And at the most, it can cause things like people self-evacuating, which is an incredibly dangerous thing to do.”

She said she wants Metro to better communicate the risks of walking on live tracks, where passengers run the risk of contact with the 750-volt third rail.

Porter was also dismayed to learn that separate issues knocked out both the cabin radio on the new 7000-series train and the backup handheld device.

“That should be part of our checklist when a new train comes out of the yard. We should make sure that all the radio communication is working,” she said.