It started with a miscommunication and led to a meltdown that created chaos on Metro's Green Line last month. The findings are part of an investigation by Metro into what went wrong during the January 30th incident.
Thousands of passengers were stranded on trains between Navy Yard and Anacostia. Metro says the miscommunication between transit officers in the control center and at the station resulted in the power being cut off.
The entire situation got worse when a passenger on one of the trains deep in the tunnel decided to lead people out against orders.
"Customers were alarmed. Some were frightened. All inconvenienced and very uncomfortable by the heat and crowding conditions on board those trains," said Metro Assistant General Manager Lynn Bowersox.
Metro says the miscommunication resulted from a failure to follow protocol. The situation was compounded by other problems, including a lack of information to passengers on one of the stranded trains.
Radio communication between the train operators and the control center were also problematic. The same channels are used for all train operations. So in addition to the emergency situation, the channels were being used for all other radio traffic, which made it more difficult to get through.
Metro General Manager Richard Sarles owned up to the problems.
"We would not have been there if the protocols had been followed," said Sarles.
The first train stopped short of the Anacostia station platform began evacuating people through the front car. With a thousand people on board, moving to the front cars, single file and out, the process took some time. The transit agency says the train operator who had just seven months experience failed to make adequate announcements and people in the back exited onto the tracks.
Some passengers on the second train, several thousand feet in the tunnel beneath the Anacostia River, began self-evacuating too. At the time, Nigel Charles told FOX 5 he opened the door and led riders into the tunnel and out.
"I wasn't thinking about danger," said Charles. "I was about getting in a better situation than we were in. My thing was how long are we going to be down here."
Metro says the train operator told the man to stay on the train, but he refused leading to a more dangerous and life-threatening situation. An off-duty Red Line operator followed to make sure they were safe, but some confused passengers thought they were being led by a Metro employee, not a passenger.
Board chairman Tom Downs said that it "made the hair stand up on the back of his neck," imploring the transit agency to do everything it can to make sure people realize the deadly consequences.
"They're risking their lives exiting a train without any direction or supervision or protection," Downs said during the safety and security committee meeting where the findings were presented.
The incident started with an arcing insulator on the tracks. Metro says it was ready to restore power after 16 minutes, but with people in the tunnel, the delay stretched to more than two hours. Emergency responders had to take every precaution to make sure everyone was cleared from the trackbed before power could be restored and for trains to start moving again.
"One of the few good things that came out of this is no one was injured and no one lost their life," Sarles said.
Metro says no one has been disciplined for the lapses and that it needs to improve training and drills for employees to better prepare for situations like this.
The fact passengers self-evacuated the train despite warnings and the possibility of electrocution troubled D.C. board member Muriel Bowser.
"Not only did they put their own life in danger, they prevent us from evacuating all the other passengers," she said.
She noted that "nobody gets off an airplane because they know what the consequences are."
In response to questions about whether passengers who refuse to obey orders and exit the train, Metro Transit Police Chief Michael Taborn said a person could be arrested for trespassing or unlawful entry onto the track bed. But he noted with only one train operator, those situations are hard to control.
"You're looking at a thousand [people] versus one," he said.