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2023 Triennial Audit - Grouping 3. Safety Risk Management

The Department of Public Utilities (“DPU”), as the State Safety Oversight Agency for rail transit (subway lines) in Massachusetts, has completed a Triennial Audit of the Massachusetts Bay Transportation Authority’s (“MBTA”) Public Transportation Agency Safety Plan and its implementation. The Triennial Audit is a requirement of 49 C.F.R. § 674.31 and 220 CMR 151.10(2).
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Scope

  • Hazard Identification
  • Risk Assessment
  • Selection and Implementation of Mitigations
  • Other sources of formal risk assessment, safety, and public safety related information.

Positive Observations

  • From the SMS implementation perspective, the SRM Process is starting to mature, although there is still room for growth.
  • The MBTA is using the Employee Safety Reporting System (“ESRS”). In 2022, MBTA fielded approximately 4,000 calls through the ESRS.
  • The MBTA has used consultant support for hazard analysis on capital projects, which has brought additional expertise to their hazard assessment process.
  • The organization has identified Origami as the new database to replace IndustrySafe.

Opportunities for Continual Improvement

  • To fully implement the SRM process with the staff (Safety Division staff at a minimum), more in-depth and in-person training (not just the LMS) should be considered.
  • While improving, the MBTA should continue to develop the tools and capabilities to fully implement SMS, in accordance with the FTA-approved CAP under 22-10.
  • Develop a policy for triage and assessment of hazards reported through the ESRS.

Recommendations

  • The MBTA should routinely evaluate the current risk level and ensure alignment with executive leadership on risk acceptance.
  • The MBTA should do an index of current job hazard analyses (“JHAs”) and determine if the current practice is sufficient or if it should develop updated or additional versions based on changes to the work environment that occurred after FTA’s SMI.
  • Develop guidance and employee outreach material for the MBTA staff and management on what is a critical reported hazard via ESRS and what is not.
  • The MBTA should ensure its use of the Origami database assists the DPU’s risk-based inspection program.

Findings

  • The MBTA has had multiple collisions, near-collisions, and signal violations on the Green Line.
    • For example, at Park Street a risk assessment and diagnostic evaluation shall be conducted at the double yellow light to determine mitigation required to prevent train bunching within the Park Street Station.
    • Additional assessments shall be conducted systemwide to determine additional locations where motorperson visibility to other rail equipment and signals increases the risk of train bunching.

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