The California Division of Occupational Safety and Health said a high-ranking manager who was supposed to be instructing the driver of the four-car Bay Area Rapid Transit train was not in the cab with the trainee when the incident occurred on Oct. 19.
Because the manager was sitting with other BART managers in a passenger area, he "was not located in a position to closely view the trainee's actions and observe the track" before the train hit Christopher Sheppard, 58, and Laurence Daniels, 66, Cal/OSHA said in citing the rail agency for "willful serious safety violations."
"Safety standards are designed to save lives and they were not followed," Acting Cal/OSHA Chief Juliann Sum said of the trainer's actions.
Sheppard, a BART engineer, and Daniels, a rail consultant, were killed while BART workers were on strike and regular passenger service halted. The train that hit them was on a maintenance and training run, BART has said.
The $210,000 fine — $70,000 for each of three violations — was the maximum allowed under state law, said Greg Siggins, a spokesman for the California Department of Industrial Relations.
Cal/OSHA also faulted BART for its since-discontinued practice of making track workers solely responsible for their own safety. Under the practice, the men received no prior warning that a train might be coming through the area.
In the October case, one worker was supposed to be acting as lookout, but neither did, state workplace safety inspectors found.
"The employees had no warning that a train moving at more than 65 mph was on the ... railway track approaching the location they were working," Cal/OSHA said in citing BART for failing to safeguard railway personnel.
BART has since changed its rules, requiring trains to slow down, stop or change course as they approach track workers and implementing new communication protocols.
BART said in a statement that it had corrected the safety concerns raised by the state.
"Cal/OSHA has informed BART these changes correct the concerns which are at the heart of their citations" BART General Manager Grace Crunican said in a statement.
"The BART family has spent the past six months mourning the loss of Christopher D. Sheppard and Laurence E. Daniels while making permanent changes to our safety procedures," she said.
Cal/OSHA also found that neither Daniels nor Lawrence was qualified to be performing the kind of work they were doing when they were killed because it involved exposure to electrified rails.
The deaths occurred during BART's bitter labor dispute with its two largest unions that led to two transit strikes within four months last year.
The strikes shut down service and snarled traffic for thousands of commuters in the region who turned to crowded buses, ferries and roadways as alternatives.
The tragedy prompted the unions and BART management to return to the bargaining table and quickly iron out a tentative deal two days later.