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The National Transportation Safety Board said Tuesday the failure of the automatic train-control system caused last year's Metro crash that killed nine and injured 70 near the Fort Totten Metro station, but systemic safety failures by Metro were among the contributing factors.

"The layers of safety deficiencies uncovered in this investigation are troubling and reveal systemic failures," said NTSB Chairwoman Deborah A.P. Hersman. "Metro was on a collision course long before this accident happened."

The safety board said blame extended from front-line workers to the top leadership of the Washington Metropolitan Area Transit Authority.

In the crash of June 22, 2009, the track signal circuits indicated that the track was clear when, in fact, train No. 214 was stopped at the station, said Jim Southworth, the NTSB's railroad division chief.

The signals sent an automatic command to train No. 112 to proceed at 55 mph toward the station. The operator of No. 112 had three seconds before she realized her train was not automatically slowing, and she pulled the emergency brake, Southworth said. But the train only slowed to 45 mph and collided with the stopped train, killing the operator and eight passengers in the lead car.

It was the deadliest crash in the system's history.

Metro carries more than 600,000 passengers daily and is generally safer than the highways, Hersman said. The 13 deaths in Metro's 30-year history are comparable to the tally every two weeks on the region's highways, she said.

But the board hammered Metro for failing to provide enough testing of track signals and for not replacing aging 1000 Series cars that did afford collision protection.

Hersman said recommendations by the NTSB set a high bar, but the public deserved to have safety put first.

Among the NTSB recommendations were: to replace the 1000 Series cars as soon as possible, the Metro board of directors must make safety a priority, an improved maintenance plan for track signals needs to be developed and employees must be able to report safety problems without fear of retribution.

Metro's board waited for safety reports to be issued rather than seeking out information on their own, NTSB board member Robert L. Sumwalt said.

"Clearly, the WMATA board of directors — not before this accident and even not immediately after — has not been keeping their eye on the safety ball," Sumwalt said.

"The culture of safety starts at the top," Sumwalt said.

Metro has overhauled its safety program and has taken dozens of actions to build a strong safety culture at the transit agency and improve safety, Metro officials said.

"Just as we have worked proactively and cooperatively with the NTSB to implement recommendations during the last year in advance of the NTSB's final findings, we stand ready to continue to work with them to build on our progress to date," said Metro interim general manager Richard Sarles in a statement.

Metro tests track signals twice a day and operates the trains on manual instead of automatic, he said. Also, the new cars are expected to replace the 1000 Series cars by 2013. The retirement of the 1000 Series cars is Metro's top safety priority.

Metro will purchase 428 new 7000 Series cars, 128 of them to expand Metro service and 300 to replace the 1000 Series cars that are being retired.

Metro recently pulled 100 cars to fix door motors as a precaution to a malfunction discovered in safety tests, Sarles said.

"We have begun to see the beginning of a safety culture shift from one that was reactive to one that is proactive in taking steps to solve and correct issues so that issues don't become problems," Sarles said.

Prior to Tuesday's NTSB meeting, Metro had dedicated more than $30 million in the capital budget to begin to address NTSB recommendations over the next three years.

But NTSB members were critical that after past events, Metro failed to follow through on recommendations.

"They're tone deaf, they're not hearing it or they're not getting it," Hersman said.

The safety department at Metro has been reorganized six times since 2007, Hersman said.

"This is just a manifestation of the sickness within the organization," she said. "They were never able to get control of what was going on within their safety system."

While the NTSB can make recommendations, it cannot order their enforcement, Hersman said.

However, the NTSB supports a bill in Congress to allow federal authorities to oversee public transit systems, she said.

"Nothing can replace the loss of a loved one or repair the trauma of a life-changing injury, but we can make sure the circumstances of this accident are never repeated," Hersman said.