Feds find even more wrong with the T: Emphasis on new trains, rails means more day-to-day safety issues for seriously understaffed workforce

The Federal Transit Administration today released four new "directives" that find more fault with the MBTA and warned that something needs to be done before even more people are injured or killed.

The FTA said that the T has fallen far short of filling just its budgeted employee positions, never mind the staffing it really needs and that the Baker administration's emphasis on a large capital program has meant ignoring other, equally important daily maintenance tasks - and itself is not really working well:

FTA found that an organizational focus on capital projects has diverted management attention and resources away from the agency's operations and maintenance, allowing the agency to operate a level of service that is not adequately staffed, trained, supervised, or maintained. In addition, existing staffing levels and capabilities do not provide adequate safety oversight for the design, construction, and testing of new capital projects and do not support widespread safety certification of these projects, which is an industry standard practice. MBTA also has experienced a series of construction safety events due to the lack of oversight of worksites. ...

FTA also found that MBTA lacks resources to adequately manage its $2 billion capital program and complete capital projects on time and without need for retrofits and workarounds. This situation has resulted in deteriorated assets, whether rail transit vehicles, track, switches, stations, facilities, or other elements, remaining in service longer than intended with additional maintenance needs. These assets are vulnerable to failure in new and potentially unexpected ways, such as the September 28, 2021 safety event, when a piece of a restraining rail assembly came loose on the track outside of Broadway station and derailed a train; the April 22, 2022 event when an aging door assembly malfunctioned and a train took power with a passenger trapped between its door panels, resulting in a fatality; or the July 21, 2022 train fire on the transit bridge over the Mystic River, where a rusty sill panel fell off a rail transit train and contacted the third rail.

Emphasizing capital project demands above passenger operations and preventive maintenance can negatively impact the safety culture of the agency. FTA found that unwritten norms have emerged that emphasize a "get it done and go" mentality over following safety rules or ensuring compliance with minimum safety standards, particularly when staff are working 12 to 16-hour days, six days a week.

The FTA detailed the T's staffing issues:

So far in fiscal year 2023 (beginning July 1, 2022), there are 5,781 active employees for 6,679 budgeted positions, or a staffing gap of 898 positions or 13.4 percent. ...

In addition, specifically for MBTA's rail transit system, over the last two years, some key technical and supervisory positions have averaged 20 to 35 percent vacancy rates, including Operations Control Center dispatchers and supervisors, signal technicians, vehicles repairers, and traction power technicians. Interviews with MBTA personnel at all levels of the agency indicate that budgeted positions, which have increased under MBTA's current leadership team, do not reflect the true measure of required staff levels because they do not consider the additional responsibilities associated with capital project delivery. In some instances, required staff levels are calculated to rely on overtime to cover staff vacations and training. Interviews with a range of personnel throughout the MBTA's organization indicate that the overall MBTA transit system may be between 1,500 and 2,000 active positions short in managing its current level of activity.

All of these, plus apparent employee mistrust in management to fix things, coupled with a poor system for discovering and managing safety is just not good, the FTA says.

FTA observed instances where employees were not complying with required safety, operations, and maintenance rules and procedures. ... For example, FTA noted violations in right of way safety rules and vehicle operating rules, preventive maintenance inspections that were not completed as required, inappropriate storage of chemicals in rail yards, an unlocked signal on the right of way, incomplete repairs, and rule violations in readying trains for moves in the rail yard. FTA also observed a rail transit vehicle speeding through a work zone. ...

FTA reviewed over 100 final investigation reports completed for major safety events experienced at the MBTA between January 1, 2019, and April 29, 2022. In over 85 percent of these reports MBTA identified non-compliance with at least one safety, operating, or maintenance rule as a primary or contributing cause of the accident. Review of these reports also reveals the frequent use of unvetted and ad hoc shortcuts in work practices, outdated procedures that have not kept paces with changes in work environments, violations of safety rules to meet deadlines or vehicle counts, and lack of time and resources to review and update rules and procedures to align them with system changes. Finally, FTA found that MBTA does not use many tools, including checklists, to support implementation of key operating and maintenance procedures in the Operations Control Center (OCC) and rail yards. ...

In interviews, MBTA's rail transit leadership acknowledges that some new operators seem to be struggling in maintaining a balance between learning MBTA heavy rail operations and preserving a focus on safety. In addressing these challenges, numerous MBTA personnel at all levels of the agency noted that MBTA's bus operations has a mentorship program that many new bus operators find beneficial. ...

Finally, interviews with frontline operations, maintenance, and OCC personnel highlighted several key locations where radio quality does not consistently support effective radio communications. Radio communications are critical to the safety of the MBTA's rail transit service and FTA finds that more must be done to improve radio quality in these locations.

FTA found that MBTA's executive leadership has yet to provide explicit direction regarding the type of safety information it requires and has not established the necessary organizational structures to support the movement of safety data from the field to the Board room. FTA determined from interviews and document reviews that, in the absence of direction, MBTA leadership and managers receive raw, unanalyzed safety data as opposed to prioritized information to support strategic decisions related to safety resource allocation. FTA identified that MBTA primarily relies on corporate memory and management experience, rather than an analysis of safety information, as the means to support decision making related to safety concerns and safety risk. FTA appreciates the role that both corporate memory and experience play during safety risk management and safety assurance activities; however, MBTA was unable to provide evidence of safety analyses to support decisions made to assess and/or mitigate safety risk.

The feds did credit the T with paying somewhat more attention to safety of late, but said more needs to be done:

FTA reviewed over 100 safety event investigation reports completed by MBTA from 2019 through July 2022 and found that MBTA has greatly improved its investigation fact finding process. FTA observed improvement in the level of detail, analysis, and identification of probable cause and contributing factors included in the investigation reports. While there have been improvements, FTA observed gaps that remain in the safety event data collection process and opportunities for additional data and fact finding beyond information provided by MBTA's Safety Department during interviews and document submissions. ...

FTA also found that operating departments do not routinely collect data to monitor safety concerns. Based on interviews and records reviews, FTA found this to be primarily a symptom of a lack of sufficient resources for operations and maintenance needs and a lack of consistent processes for determining safety priorities. As a result, MBTA relies on information from safety accidents, incidents, and occurrences to identify weaknesses or shortcomings in safety risk mitigations instead of aligning its safety monitoring, auditing, and compliance activities with data-driven safety management priorities.