Metro riders who heard Tuesday’s report by the National Transportation Safety Board into the cause of fatal Jan. 12, 2015 smoke incident near L’Enfant Plaza must have felt as if they were experiencing a sort of deja vu.

That’s because the most shocking and infuriating aspect about the NTSB’s report was the panel’s contention that warning after warning after warning from the NTSB has been ignored over the years. One board member said he thought the 2009 Red Line crash the killed 9 would have been a watershed moment for the agency. Still, not much has changed.

“Many of the same organizational and oversight shortcomings that we cited in 2009 continue to plague WMATA,” NTSB chairman Christopher A. Hart said.

On Tuesday, after 13 investigations over 33 years into incidents in which 18 people died, the NTSB was trying yet again: the panel criticized Metro’s poor safety culture, the failure of regional and federal officials to appoint a watchdog with real teeth to have oversight over the transit agency, and Metro’s failure to act on repeated warnings about the hazards of water accumulating in the tunnels, inadequate ventilation fans, and faulty high-voltage electrical connections. The NTSB was, in effect, once more warning that something terrible was going to happen again if nothing changes.

The NTSB also didn’t just fault Metro: in the calm, dispassionate language of engineers and accident investigators, the agency also ripped the system’s regional partners, the District’s Fire and EMS Department, and the Department of Transportation–and, arguably and by extension, Congress.

The safety board said the Tri-State Oversight Committee (TOC) was, as its acronym sounds, nothing but talk: it lacks enabling legislation, enforcement authority and the ability to conduct independent investigations. The NTSB suggested that the newly announced Metro Safety Commission — which is the creature of the District, Maryland, and Virginia and won’t get up to speed until 2019 — would likely be more of the same.

And once again, the NTSB called for the Federal Railroad Administration to take control of oversight of the commuter agency, instead of the Federal Transit Administration, arguing that the FRA is in the best position to apply its expertise and regulatory powers to whip Metro into shape.

What was perhaps hardest to believe in the post-Sept. 11 world — after all the money spent on emergency preparedness – was the finding that neither WMATA nor the District’s Fire and EMS Department had bothered to conduct drills for a mass-casualty event in a Metro tunnel in the five years leading up to the accident. The emergency radios didn’t work. The signage in the tunnels was of no use. The tunnels didn’t even have smoke detectors. Instead, Metro was effectively using train operators on trains with passengers like canaries in a coal mine to determine whether or not there was smoke up ahead.

Tuesday’s NTSB hearing reviewed in meticulous detail the cascading series of events that began about 3:15 p.m. on Jan. 12, 2015, when train No. 302 stopped after entering the smoke-filled tunnel between the L’Enfant Plaza Station and the Potomac River Bridge. The southbound train, which was carrying about 400 passengers, was unable to return to the platform before power to the electrified third rail was cut. Some passengers bailed on their own; others awaited rescue. One passenger died and 91 people were injured, 89 of whom suffered smoke inhalation.

Here are some of the lapses listed Tuesday by the NTSB that occurred before, during, and after the accident:

  • “Had the Washington Area Metropolitan Transit Authority followed its standard operating procedure and stopped all trains at the first report of smoke, train 302 would not have been trapped in the smoke-filled tunnel.”
  • Metro put operators and passengers at risk by routinely using trains carrying people to investigate reports of fire or smoke.
  • Metro has known for years that allowing water to accumulate in tunnels near the rail bed can cause small electrical short circuits that damage the insulation around the system’s power cables, setting them up for even bigger short circuits, or arcing. Yet Metro terminated its dedicated inspection program it designed to combat water intrusion in 2012; the current inspection program does not emphasize identifying water leaks.
  • Neither WMATA nor the District’s fire department conducted tunnel evacuation drills in the five years before the accident. The last one was conducted in March 2010. Federal Railroad Administration regulations that require annual drills; the NTSB noted that the FTA has no such regulation and urged Metro and the D.C. fire department to conduct them quarterly.
  • The safety walkway in the tunnel was poorly lit and wall-mounted obstacles posed a safety hazard that could have tripped up passengers or first responders.
  • Metro’s ventilation system in the tunnel was inadequate, in part because that part of the line was built before a 1983 safety standard went into effect that required installing sufficient fan capacity to clear the tunnel of smoke. Metro failed to increase the fan capacity, add jet fans to increase air flow, or use blocking devices to seal off part of the tunnel.
  • A work order about the potential for arcing at the site of the accident was flagged in October 2014 — yet nothing was done to ensure that the cables were properly fitted with insulated sleeves to protect them from water that could cause arcing.
  • Metro lacks sufficient smoke detectors to pinpoint the source of arcing, smoke or fire inside the tunnels.
  • Metro had no written procedure or effective training for operating ventilation fans in response to smoke or fire.
  • It took 4 minutes, 19 seconds for the District’s emergency dispatch center, known as the Office of Unified Communications, to handle and dispatch first responders to the incident. The national standard requires that the message be effectively communicated in 64 seconds to 106 seconds.
  • Metro lacked a procedure to shut down ventilation on all the cars in a train. Metro regulations at the time required train operators to obtain permission to shut down the ventilation system on the train, and when he did, the system shut off ventilation only in that car, not the rest of the train.
  • Radio communication broke down for District fire and EMS teams in the tunnel. They had to use runners. The Metro Transit Police chief was left out of the loop by the District’s fire department commanders managing the scene.

The NTSB noted that following the accident, it issued a fresh batch of urgent recommendations designed to protect the system’s riders. And yet, more than a year later, Metro has failed to follow through.

“Since that tragic accident, WMATA’s safety culture and safety oversight have not changed adequately,” Hart said. “As a result, the specific hazards that we will consider today were allowed to develop and persist.”

NTSB member Robert L. Sumwalt summed it up best when he said he found it “amazing” that so many safety hazards identified by the NTSB decades ago still exist. Several of them contributed to the January 2015 smoke incident.

“I was shocked — shocked — to learn that after the January 12th event of last year, WMATA did not have an after-action debrief to see what could be learned,” Sumwalt said at the meeting. “To me, this shows that WMATA, historically speaking, has had a severe learning disability. Quite simply, they have not been willing to learn from prior events. … Learning disabilities are tragic in children, but they are fatal in organizations. And literally that is true in this case.”