Interviews with safety experts and former Metrolink officials and a review of thousands of pages of government documents show that the commuter line's founders made decisions two decades ago that -- knowingly or not -- gambled with passenger safety in the way they agreed to share tracks with two giant freight lines.
Their successors on the governing board extended the gamble, making no move to alter the basic operating arrangement, even as Metrolink became America's deadliest railroad in the decade.
The biggest gamble was to operate without a form of automatic braking that federal safety officials first recommended 70 years before Metrolink began. In 1922, the agency in charge of rail safety declared: "Disastrous collisions will continue to occur until automatic train-control devices are installed to protect against human failure."
This long-perfected technology would have prevented the Sept. 12 Chatsworth crash that killed 25 and injured 135, according to rail-safety experts, including Steven Ditmeyer, retired head of research and development for the Federal Railroad Administration, and George Elsmore, former railroad operations and safety program manager for the California Public Utilities Commission.
But when Metrolink was created in the early 1990s, it existed largely at the sufferance of the region's dominant freight rail companies. And the freight lines had long resisted automatic train controls as too expensive. Their contracts with Metrolink made it clear that if they were ever forced to install an automatic braking system, taxpayers and passengers would have to pay for it.
Metrolink founders spent $1.5 billion in public money to launch the railroad, buy or rent tracks from the freight lines, improve tracks and signal systems, and install a centralized traffic control system that allowed dispatchers to throw switches and set signals by remote control.
Metrolink could have sought to install the best available automatic braking system for its own trains for about $200 million, based on the experience of New Jersey Transit.
But despite the reality that their trains would have to share lines constantly with much larger, heavier freight trains, they never pressed for a train control system that would override an engineer's mistake and bring a train to a halt before a collision.
They were apparently anxious to avoid the additional expense and to keep good relations with the freight lines, which shared control of the rails.
In the way the freight lines dispatched their own trains, they could wreak havoc with the commuter line's most treasured objective: its ability to get passengers to and from work on time.
The result was "an unholy alliance" in which "there is no passenger advocacy point of view at all," said Denise Tyrrell, who was Metrolink's spokeswoman for more than three years. She resigned after being criticized by rail officials for acknowledging that the Metrolink engineer was probably at fault in the Chatsworth crash.
Some commuter rail advocates and operators argue that passengers today are safe enough. They note that the odds of dying in an American rail crash are about one-fifteenth those of a fatal automobile collision.
But it has become more difficult to make that argument about Metrolink, whose record of tragic accidents puts it in a hard-luck league of its own.
No other North American railroad has come close to its record of disasters since the start of this decade -- four crashes fatal to 38 passengers. Two of those crashes, accounting for 27 of the deaths, involved collisions with the region's growing number of freight trains.
Even before the latest crash, the Federal Railroad Administration cited Metrolink in a 2006 report to Congress as having had "an unusually adverse experience over the past several years."
Amtrak, the much larger rail system that offers intercity service across the United States to an average of 70,000 passengers a day, has recorded six passenger deaths from three collisions this decade. The only other such deaths reported to the railroad administration were on a commuter line in northern Indiana. It had two.
Longtime Metrolink Chief Executive David R. Solow declined to be interviewed, explaining through a spokesman that he did not want to discuss his agency's past because he is "not really interested in revisiting issues that have no relevance to recent events."
Two of Metrolink's founders, Neil Peterson, then director of the Los Angeles County Transportation Commission, and Richard Stanger, Metrolink's first chief executive, said they never considered an automatic braking system.
Metrolink spokesman Francisco Oaxaca, in a written response to questions, said the commuter system could not have installed one under its agreements with the freight lines.
"These agreements do not give Metrolink the power to obligate the freight railroads to install any type of train control system. They also call for Metrolink to pay for any installation that is requested of the freight railroads which would likely entail equipping hundreds if not thousands of freight-owned locomotives."
Metrolink, which transports about 48,000 passengers on weekdays, says that it meets or exceeds federal minimum safety standards.
Sen. Dianne Feinstein (D-Calif.) said Metrolink's contracts with freight lines are not good enough reasons to operate without a collision avoidance system.
After the Chatsworth crash, she got so angry on the Senate floor that she called the lack of such a system "criminal negligence."
She said of Metrolink in an interview: "They have to take very aggressive action. . . . If they have to renegotiate a contract, they should renegotiate a contract.
"Safety has to come first," Feinstein said. "I don't believe it has. I believe cost has."
After the Chatsworth crash, Feinstein and Sen. Barbara Boxer (D-Calif.) successfully pushed through Congress a rail safety bill requiring railroads to install a more advanced train control system by 2015.
Elsmore, the former rail safety chief of the state utilities commission, disputed Metrolink's contention that it was powerless to address the problem without cooperation from freight lines.
Metrolink could have asked federal regulators for permission to install a system on its own, he said. That would have been a departure from federal rules that normally require freights and passenger trains on a given rail system to use the same safety equipment.
In fact, since the Chatsworth crash it has asked for such a departure, but only to install a $1.5-million antiquated version that would not have avoided that collision.
The move seems emblematic of Metrolink management's reluctance to take bold steps.
Its leadership has been "driven solely by near-term, low-cost solutions as opposed to strategic or long-range solutions," said Mike McGinley, who retired as Metrolink's director of engineering and construction in 2006.
Metrolink operates as a "perpetual beggar," said Tyrrell, the agency's former spokeswoman.
From its start, Metrolink was an obscure agency controlled by the transportation commissions of Los Angeles, Orange, San Bernardino, Riverside and Ventura counties.
Its mission was to operate as inexpensively as possible. The system gets about half its revenue in passenger fares and the other half from the governments of the five counties it serves. Its overall budget this year is $159 million.
The freight railroads it shares tracks with -- Union Pacific and Burlington Northern -- are, by contrast, multibillion-dollar operations that dominate railroading in the West.
Charles V. Smith, a former Orange County supervisor who was a Metrolink board member from 1993 to 2004, said the disparity became a problem when freight dispatchers repeatedly delayed Metrolink's trains. Metrolink was considered such a pipsqueak by one freight rail that its senior executives would not even return telephone calls from the transit line's leaders, Smith recalled.
Smith said he had to travel to Washington to enlist the help of an Orange County businessman he knew, Gus Owen, who was then a federal rail regulator.
Owen got through to a senior freight executive by telephone and bellowed, "Talk to them," Smith recalled.
Owen confirmed Smith's account and said he set up a meeting at which senior executives of Metrolink met for the first time since operations began with senior officials of Union Pacific and Burlington Northern. Metrolink had by then been operating for three or four years, Owen said.
The regulatory will of federal officials -- the Interstate Commerce Commission and its successor, the Federal Railroad Administration -- seems to have ebbed and flowed in relation to the frequency of deadly accidents.
In the early 20th century, regulators grew alarmed at the number of passenger deaths in collisions.
The Interstate Commerce Commission ordered many railroads to install either an automatic train control system that would stop a locomotive before it ran a signal, or a less sophisticated "automatic train stop" that would sound a warning that an engineer could override.
Rail lines that put in those devices saw collisions decline.
But the rail industry as a whole resisted, arguing that its money could be better spent, and the commission ultimately backed off.
Two decades later, when a high-speed crash near Chicago killed 45 people, commissioners ordered that railroads wanting to operate at more than 79 mph would have to install automatic braking systems.
Restrictions were eased again in the late 1950s and 1960s, as passenger rail travel waned. Some railroads won permission to remove automatic braking systems, saying that they were too expensive to maintain. A recent resurgence of passenger travel on commuter lines such as Metrolink has not brought them back.
In recent years, only a few commuter rail lines have installed them. And despite repeated urgings by the National Transportation Safety Board, which investigates accidents and recommends ways to prevent them, regulators have not required automatic train controls to be reinstated.
"What we ended up with was the status quo," said James Hall, who chaired the safety board from 1994 to 2001. "No expense for safety and continuing to gamble with the lives of their passengers."
Rather than install existing safety systems, most railroads, like Metrolink, want to wait for what has become the Holy Grail of the industry -- a more advanced and less expensive collision avoidance system that has been under development by freight railroads for 20 years.
The system uses a global positioning satellite to pinpoint trains with enough accuracy to allow them to be run closer together -- a potentially huge economic benefit for freight lines. It goes by the name "positive train control."
At a Senate hearing shortly after the Chatsworth crash, freight officials contended to Feinstein that such a system is still being developed.
But around 1992, Gerald Grinstein, then chairman and chief executive of Burlington Northern, announced that his railroad had successfully tested positive train control and "the system is now ready for implementation."
Shortly afterward, Burlington Northern abandoned the project, which "greatly disappointed" national safety board officials. They said the railroad had a "field tested and demonstrated" technology.
Ditmeyer, then Burlington Northern's chief communications engineer, wrote in an academic journal in 2006 that executives at Burlington Northern and other freight lines decided "to use available capital for mergers and acquisitions, believing they 'would yield a higher rate of return' " than positive train control.
In an interview this week, Grinstein disputed that, saying "We weren't even thinking about mergers at that point." To take full advantage of positive train control, he said, the railroad needed to centralize dispatching. By the time that was done, he had left the firm.
But federal safety regulators who backed freight railroads' decisions to proceed slowly, explicitly cited cost reasons. Officials with the Federal Railroad Administration told Congress in 1994 that ordering freight carriers to install the advanced braking system "could not be currently justified based upon normal cost/benefit principles . . . ."
An industry group reported to the rail administration in 1999 that positive train control still was not worth installing. The cost of deploying a nationwide system -- estimated to be from $1.2 billion to $7.8 billion, depending on its sophistication -- would result only in "benefits from avoided accidents [that] ranged from about $500 million . . . to about $850 million."
In the aftermath of the Chatsworth crash, Metrolink is taking what safety experts characterize as a half measure: Its leaders have asked regulators for permission to waive the requirement that all railroads sharing tracks be similarly equipped, so that it can install the least sophisticated and cheapest automatic braking system available.
The system, now in place on a small portion of track from Santa Ana to northern San Diego County, functions like a snooze alarm when a signal is about to be missed.
If the engineer acknowledges the alarm within eight seconds, he retains control of the train. Otherwise, it slows to a stop.
That system would not be as effective as automatic train control and would not have stopped the Chatsworth crash, said Elsmore, the former PUC rail safety chief. "They might have collided at a slightly lower speed," he said.
The PUC has begun to investigate whether it should order Metrolink and other in-state railroads to install the more sophisticated automatic train control system until advanced positive train control becomes a reality.
"I personally have investigated half a dozen major train accidents in California involving collisions between trains," Elsmore said. "I think people look at this as a one-in-a-million event. But there's lots of them."
Rohrlich is a Times staff writer.
More on MetrolinkA photo gallery of past crashes involving the commuter line and an interactive graphic on safety options can be found on the Web.