Scope
The scope of the Triennial Audit is the ASP and MBTA’s implementation of it, as required by the applicable federal and state regulations, 49 C.F.R. Part 674.31 and 220 CMR 151.10(2). The scope of this Triennial Audit includes data and analyses from all audits, investigations, hazards, and corrective actions since the last Triennial Audit (2020) through June 2023. In addition, each version of the ASP and current minimum standards for safety are reviewed as part of this audit. All safety risk management monitoring (“SRMM”) activities and results during this period are also included, as well as Safety Advisories, Special Directives (in part; see below), and Safety Bulletins issued by the Federal Transit Administration (“FTA”) for the MBTA, DPU, or the transit industry.
FTA’s Safety Management Inspection and Special Directives
The DPU acknowledges the eight Special Directives (“SDs”) issued by the FTA to the MBTA in 2022. While those SDs overlap with this Triennial Audit, the MBTA’s compliance with the SDs are not the focus of the audit because they are being addressed by FTA. DPU seeks to avoid creating any potential ambiguity or interference in FTA’s comprehensive review and communications with MBTA on the matters addressed in the SDs. Yet, given the breadth of the SDs and MBTA’s extensive work to address them, it was not always possible to fully separate DPU’s audit from the issues the SDs address. As a result, many matters that DPU addresses in the Triennial Audit are intertwined with MBTA’s ongoing activities to address the SDs.
In August 2022, the FTA released the Safety Management Inspection (“SMI”) report for both the MBTA and the DPU. FTA’s report included eight SDs issued to the MBTA, which collectively have a total 631 corrective actions (“CAs”). The evolution of the SMI process required many corrective action plans (“CAPs”) to be revised, resubmitted, and superseded by new CAPs. The DPU staff has been involved in collaborative oversight of all CAPs approved by the FTA. This audit recognizes that the MBTA’s CAPs associated with FTA’s SMI target key areas for improved performance in developing a strong safety culture at the MBTA. Highlights of MBTA’s performance in responding to FTA’s Special Directives are summarized below. Future DPU triennial audits will review long-term compliance with the CAPs that lead to long-term safety improvement changes.
Audit Design
The design of this audit (along with internal safety reviews and audits), as well as MBTA’s ASP, focus on the FTA’s SMS. This Triennial Audit has been designed to include the four SMS components broken down into 12 groupings, including related minimum standards for safety.
- Grouping 1. ASP Updates and SMS Implementation
- Grouping 2. Safety Management Policy
- Grouping 3. Safety Risk Management
- Safety Assurance
- Grouping 4. Safety Performance Measures and Targets for Improvement
- Grouping 5. Notifications and Investigations of Safety Events
- Grouping 6. Compliance with Rules/Procedures
- Grouping 7. Compliance with Inspection and Maintenance (I&M) Requirements
- Grouping 8. Compliance with Federal, State, and Local Requirements
- Grouping 9. Management of Change
- Grouping 10. Continuous Improvement
- Safety Promotion
- Grouping 11. Competency and Training
- Grouping 12. Safety Communication
Audit Schedules and Activities
The audit team completed multiple required activities according to the Program Standard Operations Guide (“PSOG”) Section 5.3 for Triennial Audits:
- Rail Transit Safety Division (“RTSD”) began planning for the audit in early calendar year 2023;
- RTSD notified MBTA of the Triennial Audit and Documentation Request via letter on August 9, 2023;
- RTSD planned and completed interviews for the 12 audit groupings during the week of October 2-6, 2023. Contractor staff completed track safety training during this visit; RTSD completed field work in between the two formal onsite weeks for this audit; and
- RTSD planned and completed field work and follow-up interviews during the week of December 4-8, 2023.
Audit Results
The results from this Triennial Audit were analyzed according to the 12 groupings and are shown in this report. The analysis section provides a description of the grouping scope, positive observations, areas that need improvement, recommendations, and findings for each grouping.
The results of this audit include 43 Positive Observations, 22 Findings, and 62 Recommendations. Note that a few Findings and Recommendations are duplicative due to their relevance to more than one Grouping (* asterisk indicates a duplicate Finding was not added to count).
| Groupings | Findings | Recommendations | Positive Observations |
|---|---|---|---|
| 1. ASP Updates and SMS Implementation | 2 | 5 | 2 |
| 2. Safety Management Policy | 0 | 1 | 3 |
| 3. Safety Risk Management | 1 | 4 | 4 |
| 4. Safety Assurance (SA) – Performance Measures | 0 | 6 | 4 |
| 5. SA – Notifications and Investigations | 5 | 9 | 5 |
| 6. SA – Compliance with Rules/Procedures | 4* | 5 | 1 |
| 7. SA – Compliance with I&M Requirements | 3 | 6 | 4 |
| 8. SA – Compliance with Federal, State, and Local Requirements | 1 | 5 | 3 |
| 9. SA – Management of Change | 3* | 3 | 3 |
| 10. SA – Continuous Improvement | 0 | 4 | 5 |
| 11. Safety Promotion – Competency and Training | 3 | 8 | 4 |
| 12. Safety Promotion – Safety Communication | 0 | 6 | 5 |
| Totals | 22 | 62 | 43 |
Notable Areas of Improvement
In August 2022, FTA released the final Safety Management Report for the MBTA highlighting areas needing improvement within the MBTA transit system. MBTA’s response to FTA’s report led to key changes within the MBTA’s organizational and operational systems during the 2023 calendar year. During 2023, the MBTA demonstrated successes in defining and gaining FTA approval on CAPs for SDs 22-4, 22-5, 22-6, 22-7, 22-9, 22-10, 22-11 and 22-12. Examples of MBTA’s safety improvement include the following3:
Special Directive 22-4:
Within Special Directive 22-4, the MBTA established consistent Personal Protective Equipment (“PPE”) requirements for right-of-way (“ROW”) access. The MBTA actions that led to successful CAP closure, include:
- Analyzed existing MBTA PPE policies;
- Created and distributed an agency-wide, consistent PPE policy;
- Distributed PPE to employees;
- Developed training materials and trained all relevant personnel on new PPE policy; and
- Developed a PPE compliance verification process through the Safety Rules Compliance Program.
The DPU supported the FTA in completion of CAP verification and observed significant gains in both policy implementation and field compliance.
Additionally, the MBTA has closed the following SD 22-4 findings:
- Published updated Rulebook for Operations Employees incorporating PPE requirements
- The MBTA’s update addressed many important changes including limitations of hours of service to prevent fatigue.
- Raised Tufts Curve Speed Restriction after completing Cologne Egg replacement
- The MBTA replaced track and followed internal safety processes and procedures.
- Submitted budget requests for Maintenance of Way (“MOW”) equipment and resource needs
- The MBTA identified the projected needs and costs to ensure that the infrastructure can be brought into a state of good repair (“SGR”).
- Restored Green Line Work Train to Working Order
- Completed work orders for preventive and corrective maintenance for: Green Line Crane Car #4360, Green Line Generator-Pump-Lift (“GPL”) Car #4361, and Green Line Flat Car #4362, along with several other items of supporting documentation, and a successful test train.
Special Directive 22-6:
- Ensured that staff working in the Operations Control Center (“OCC”) are certified
- MBTA daily and monthly reports documented certification dates for OCC staff that worked during the time covered by the report.
- Established policies to ensure OCC staff have sufficient time off between shifts
- MBTA updated the hours-of-service requirements, and submitted daily status reports, to achieve minimum of ten hours off between each OCC staff’s shifts, and maximum shifts of 14 or 16 hours.
- Established Operating Procedures to Ensure No Staff Performing Dual Roles
- MBTA submitted daily reports documenting any instance where a supervisor was required to serve as a dispatcher, and submitted monthly reports that identified any violations of the hours-of-service requirements.
Organizational changes:
The DPU has observed a significant organizational change towards the end of the three years that this audit covers. The leadership has demonstrated increased commitment to ensuring all management and employees are individually accountable for the delivery of exceptional safety performance and implementation of SMS in accordance with the 2023 Agency Safety Plan.
Areas Needing Improvement
The audit identifies areas needing improvement which fall into many categories. A few general themes include Green Line operations regarding train car speed and separation, and Change Management implementation of the Safety Certification Program for new projects. The audit identified other areas where the MBTA has begun the implementation of new processes that require additional activities to further enhance the safety programs.
Next Steps
The Findings and Recommendations require the program documentation (ASP, minimum standards for safety, etc.) to be evaluated and, as appropriate, updated to reflect current activities, and require certain activities to be changed or added to ensure that the program documentation and activities align. The MBTA is required to develop a CAP for each Finding. For each Recommendation, the MBTA is required to provide the DPU with a response addressing it, or, at MBTA’s discretion, a CAP. If the DPU determines that the MBTA’s response is not sufficient, DPU may require a CAP.