2023 Triennial Audit - Grouping 5. Safety Assurance – Notifications and Investigations

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).

Scope

• RTA Investigation Procedure(s)
• SSO Program Standard Requirements/Procedures for Safety Event notifications and investigations
• Emergency Response/Operations Procedures
• Rail Operating Rulebook and Required Training
• RWP Plan and Required Training
• Command and Control/Train Control SOPs and Required Training
• Field Supervision SOPs and Required Training

Positive Observations

• The MBTA is generally successful at notifying the DPU when there is a reportable event via the Everbridge system.
• The revised Investigation Manual is thorough in its process for developing an accident investigation and report.
• The MBTA has identified Safety Sensitive employees and have them enrolled in the FTA’s required Public Transportation Safety Certification Training Program (“PTSCTP”) individual training plans with the Transportation Safety Institute.
• The MBTA has adopted an Hours-of-Service policy and has included it in the 2023 Rulebook.
• The MBTA has improved on the timeliness of responses to DPU’s Information Requests.

Opportunities for Continual Improvement

• The MBTA should continue to track investigation reports and investigational process through closure and subsequent mitigation.
• The MBTA should decrease the amount of time it takes to produce final reports.
• The MBTA should assure collaboration by all responsible MBTA departments with the results of the investigation reports and corrective actions.

Recommendations

• The MBTA should consider a uniform tracking mechanism for both safety rules violations and other key investigative milestones.
• The MBTA should develop improved training for MBTA departments on their investigation responsibilities and practices when responding to a safety event, to more effectively implement the Safety Event Investigation Manual.
• The MBTA should determine the appropriate staffing level required to ensure long-term compliance with regulatory investigation reporting requirements.
• The MBTA should consider training all OCC and Field Supervision on the Continuity of Operations (“COOP”) to ensure a smooth response should the need arise.
• The MBTA should train all employees on adverse weather operations and how that may impact safety.
• MBTA should determine which positions outside of Safety, including OCC controllers and supervisors, as well as Field Supervisors, should be designated as Safety Sensitive (designated personnel) for purposes of PTSCTP training.
• MBTA should develop a better process for implementing the SMS principle of the Organizational Accident in accident investigations. This should be used to better address response performance and capabilities, as well as keeping procedures updated.
• MBTA should develop a close call reporting system consistent with the FRA.
• The MBTA shall ensure the Accident Investigation report delivery to DPU is up to date and maintain on-time delivery. Written documentation should be provided in advance for reports that MBTA proposes to submit late.

Findings

• The MBTA has experienced several safety events that include smoke or noxious fumes and the evacuation of patron locations such as stations; however, MBTA decided that these safety events do not meet the required notification threshold for evacuations for life safety reasons.
• Evacuations for life safety reasons, including self-evacuations, or a situation such as a fire; the presence of smoke or noxious fumes; a fuel leak; a vehicle fuel leak; an electrical hazard; a bomb threat; a suspicious item or other hazard that constitutes a real or potential danger to any person, must be reported to the DPU as an FTA reportable event and otherwise investigated as an FTA reportable event.
• On multiple occasions for safety events that required notification, the MBTA did not provide timely two-hour notifications or determined that the safety events were not reportable (or notifiable) to the DPU or FTA. On several occasions, safety events were not notified in a timely manner but were later determined to have required notification to the FTA and DPU.
  • The MBTA must identify and retrain all Safety Event Response Team members and OCC controllers in-person on the requirements and thresholds for FTA, DPU, and NTSB safety events and how these events are reported to the FTA, DPU, and NTSB when applicable.
  • MBTA must record six months of on-time two-hour reporting of accident notifications to the DPU.
• On several occasions, MBTA operators have returned to operate revenue vehicles prior to both receipt of Post-Accident Drug Testing (“PADT”) results and the operator being cleared based on those results.
  • The MBTA must ensure that employees and contractors who are sent for PADT are not permitted to return to safety-related functions until cleared with results of the PADT by the MBTA Medical Clinic.
• MBTA Safety’s procedure for notifications and investigations includes a requirement that all departments responding to an accident (required safety event) use a checklist. These checklists are not always completed and available with the investigation documentation.
  • All departments that respond to a safety event must provide an on-scene investigation checklist in accordance with MBTA Safety Event Investigation Manual summarizing their investigative findings.
• MBTA reported that approximately 82% of the reported speeding notifications are false positives.
  • MBTA shall investigate how and why a high percentage of the reported speeding notifications are false positives and evaluate how best to control speeding and more accurately track speeds on the Green Line (until a capital project resolves speeding).
  • MBTA shall conduct an analysis of all employee safety rules violations (to include speeding) over the last 12 months. This analysis will provide a breakdown of the investigational findings into the following categories: ¹
    • Cleared
    • Sustained
    • Non-Sustained
    • Unfounded
    • Policy Review (to be combined with either Cleared or Sustained)
  • If revisions to policies are required, MBTA shall evaluate and develop revised policies associated with this analysis.

1. The categories have the following meanings:
   1. Cleared - The investigation of the incident disclosed that it did occur. However, the actions of the employee(s) were justified, lawful, and proper.
   2. Sustained - The investigation disclosed sufficient evidence to prove the allegation.
   3. Non-Sustained - The investigation failed to uncover sufficient evidence to clearly prove or disprove the allegation.
   4. Unfounded - The investigation indicated the alleged acts did not occur.
   5. Policy Review - The investigation indicated that the alleged acts did occur, but the action of the employee was consistent with policy, therefore the policy needs evaluation for potential change. When applicable, Policy Review will typically be combined with either Cleared or Sustained.