The roots of the worst passenger rail disaster in modern California history go far deeper than whether a Metrolink engineer ran through a red stop light and into the path of a Union Pacific freight train.
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.