National Transportation and Safety Board investigators work in the tunnel near the site of a fatal incident near L'Enfant Plaza in Washington. (NTSB)

Metro’s subway ventilation processes are significantly flawed — as evidenced by a deadly Jan. 12 smoke incident on the Yellow Line — and the transit agency should take major steps to improve employee training, procedural manuals and the infrastructure for clearing noxious fumes from tunnels, according to a panel of outside experts.

In a “peer review” done for Metro and made available this week, a group of transit specialists from different parts of the country described an array of problems related to the agency’s Rail Operations Control Center, or ROCC, the Landover, Md., facility where train controllers monitor the subway in real time. The controllers had a big role in coordinating the response to the Jan. 12 crisis.

The seven-member panel did not specifically review the ROCC’s performance during the smoke incident. But the experts confirmed several shortcomings that were brought to light by the fatal incident — notably Metro’s inadequate tunnel ventilation processes, which were controlled Jan. 12 by ROCC employees who seemed ill-prepared for the task.

The peer review echoes the tone of reports since January, by accident investigators and the news media, indicating a need for better overall emergency readiness at Metro, particularly at the ROCC, the nerve center of the nation’s second-busiest subway.

Workers at the facility are not sufficiently trained in running the tunnel ventilation systems and lack clear written guidelines for doing so, according to the panel, which described confusing, even ad hoc emergency-response procedures at the control center.

“We take these issues very, very seriously,” Rob Troup, Metro’s deputy general manager, said Wednesday, referring to the panel’s many recommendations for improving control center operations. But he did not immediately embrace all of the report’s suggestions, which involved tunnel ventilation and other ROCC functions.

The 38-page report was finalized last week and delivered to Metro’s board of directors.

“Some of these are things that we recognized earlier and we’ve already been moving forward on,” Troup said. “With some of the stuff, the question is: Can we execute it and sustain it? In other words: Is it something that will work in our system?”

The National Transportation Safety Board, which is investigating the Jan. 12 incident, has said that Metro botched the operation of ventilation fans while a Yellow Line train loaded with passengers was stuck in a smoke-filled tunnel near the L’Enfant Plaza station. The noxious fumes sickened scores of riders, one of whom died.

The NTSB, which plans to issue a final report on the calamity early next year, has said that ROCC workers activated two sets of giant ventilation fans at cross-purposes, causing a mass of smoke in the tunnel to move toward the stopped train. If the six fans in the two groups had been properly coordinated, creating brisk air circulation, the smoke would have been expelled from the tunnel, the NTSB has said.

In addition, some of the six fans malfunctioned during the incident, which the safety board said was caused by an electrical problem on the tunnel tracks.

Another problem that hampered rescue efforts Jan. 12 was poor communications, not only among employees within the ROCC but also between the control center and first-responders at the scene, especially D.C. firefighters. “Lack of communication may have contributed significantly to delayed or improper responses,” the peer review found.

The ROCC also communicates poorly with passengers, the report said. That finding will come as no surprise to the commuters who were caught in the smoke incident. They received scant information as they sat choking for more than 30 minutes on the idled train, waiting for rescuers to arrive. Some riders evacuated from the train on their own.

Metro should adopt “a policy for providing information to patrons directly from the ROCC for delays caused by major incidents and emergencies,” the panel said. New York subway officials, for example, have “taken advantage of this option to help provide a calming authoritative reassurance that the situation is known, action is being taken, and that the public is guided on their actions, such as to stay in the vehicle, stay calm.”

But the report focused mainly on ventilation-related problems.

The panel’s seven public- and private-sector transit experts, from San Francisco, San Diego, Los Angeles, New York and elsewhere, put “particular emphasis on ROCC training, restructuring rule books to make reference easier and more direct, and developing pre-defined responses for ventilation operations so that better decisions can be made on the spot during the stress of emergency response.”

Peer reviews are a common practice in the transit industry. The group was assembled at Metro’s request by the American Public Transportation Association and spent several days at the ROCC this past spring before writing its report.

“Staff may need additional training to understand response in a fire emergency,” the panel said. “It may be beneficial to enhance the use of [Metro’s] tunnel mock-up facility for periodic and frequent training exercises, for both employees and first-responders.”

Troup said: “That’s something we’re already doing. . . . We need to do a better job with our ROCC staff from a ventilation training perspective.”

The report said that the transit agency should form a team of specialists at the ROCC to be in charge of tunnel ventilation systems. Members of the team “would be specifically trained in the complexities of properly setting fan operating mode,” the report said.

Also, Metro should take “a second look” at various manuals and documents that set out the processes for ROCC employees to follow when they activate tunnel ventilation systems during emergencies.

The current written materials offer “insufficient detail or guidance on fan operation, especially air flow direction,” the report said. “Within the ROCC Major Incident Plan Book, there are procedures for fire incidents and a note to initiate ventilation procedures, yet the panel was unable to identify such procedures in [other] manuals or documents.”

After reviewing that array of paperwork, “the panel could not confirm staff readiness to handle smoke/fire incidents from a tunnel ventilation perspective,” the report said. “Ventilation is manually commanded, not automated, which may make rapid and correct response more difficult.”

This is especially worrisome, the panel pointed out, because “it appears there are many fire and smoke incidents within the [Metro] rail system.” Records show that in 2014, “the number of fire incidents averaged 5.8 per month and 2.9 smoke incidents per month.”

In terms of air-moving capacity and operational sophistication, much of Metro’s tunnel ventilation infrastructure falls short of modern standards, having been built decades ago, the report said.

Although the ventilation systems along the year-old Silver Line are “compliant with current-day standards,” the systems in other parts of the subway, some dating to the 1970s, were “designed primarily for passenger comfort and not large fires,” meaning they were mainly intended to reduce subway temperatures in hot weather.

This is a reality for any “legacy” subway, the panel noted. However, Metro could improve its older tunnel ventilation systems by making mechanical adjustments.

For example, the report said, changing the angles of fan blades “results in higher air-volume flow rate, albeit slightly higher energy consumption. The idea is to make the best of what is already in place, optimized for a higher level of safety.”