A judge has ruled that BART was guilty of "serious and egregious" safety lapses in the case of the deaths of two workers on the tracks who were struck by a train in 2013. Judge Kimberly Kim, an administrative law judge for the California Public Utilities Commission, issued her ruling Friday, as the Chronicle reports, saying, "The evidence in this case shows that there may be a serious safety culture problem at BART."

The tragic incident occurred on October 19, 2013, during a BART operator strike, when 58-year-old track engineer Christopher Sheppard and 66-year-old Lawrence Daniels, a contract employee, were investigating reports of a dip in the tracks between Walnut Creek and Pleasant Hill stations. A BART manager, Richard Burr, was being trained to operate the train in preparation for a possible extended strike, and a veteran manager, Paul Liston, was supposed to be observing him but was apparently sitting outside the operators cabin on his cellphone at the time of the incident — one of multiple safety violations cited by Judge Kim. Neither Burr nor Liston were aware that any workers might be on the track in this vicinity, and as the train rounded a long curve Burr was not able to stop the train in time or sound the horn when he spotted the men on the tracks. Leaked cab surveillance video that came out of this legal proceeding back in May suggested that Burr, who was not familiar enough with the control panel, hit the "door close" button multiple times when he probably meant to hit the horn button, which is right below it.

At the time of the incident, the workers were, under BART rules, supposed to be responsible for their own safety on the tracks, and one man was supposed to be acting as lookout, which he was not.

Judge Kim called it an "utter failure" on the part of BART that the trainee operating the train was not being properly supervised.

As NBC Bay Area reports, Sheppard's widow praised the decision as vindication after years in which BART tried to blame the two engineers for their own deaths.

The PUC is fining BART $659,000, as Bay City News reports, and staying two thirds of the fine, so BART will have 60 days to pay just under $220,000 to the state's general fund. BART was previously fined $210,000 by Cal/OSHA over this incident, and as the Chron notes, they settled a suit brought by the family of Daniels for $300,000.

Previously: BART Is Mad That In-Cab Video Of Fatal 2013 Accident Was Leaked, Takes PUC To Court