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.

The NTSB report clears train operator Jeanice McMillan of any fault in the accident, but not Metro's managers, whose appalling lack of concern about public safety -- which should have been their highest priority -- is duly documented. Despite numerous prior warnings about the reliability of the automatic safety alert system, including a hair-raising near miss in the Rosslyn tunnel in 2005, Metro officials did not make sure the problems were corrected. As NTSB Chairwoman Deborah Hersman succinctly noted, "Metro was on a collision course long before the [Red Line] accident."

Even now, Metro interim General Manager Richard Sarles would only say he would "carefully consider" NTSB's recommendations to replace non-crashworthy rail cars and questionable track circuit modules that to this day continue to pose "an unacceptable risk to Metrorail users." Since NTSB has no power to force Metro to follow its latest safety recommendations, Sarles should be immediately replaced by a general manager who will.

But the buck ultimately stops at the Metro Board. Many of its members, such as former Chairman Jim Graham, are elected officials whose extreme negligence in the performance of their duties will remain a permanent blot on their records.