A “systemic breakdown of safety management at all levels” — that’s what the National Transportation Safety Board has determined was the ultimate cause of the fatal accident on Metro’s Red Line last year that killed nine people and injured dozens more. The NTSB findings are a devastating indictment of a transit agency that has consistently ignored urgent safety warnings. As far back as 1988, Metro officials knew there were major flaws in their supposedly “fail safe” automatic track circuits, but failed to employ any of the methods at their disposal to find and fix the problems that directly led to the worst accident in Metro’s history.

Despite the transit agency’s previous promise that it would run a monthly test to search for bad circuits, NTSB investigators found no record that any such tests had ever been done. Instead, Metro’s operations control center routinely ignored thousands of safety alerts every week that should have triggered a major overhaul of the malfunctioning system. And in perhaps the most disturbing revelation from the final report, Metro ignored its own procedures by failing to run a three-point track circuit test that would have detected the faulty equipment at the Fort Totten station five days before the crash. That’s the very definition of criminal negligence.