2023 Triennial Audit - Grouping 6. Safety Assurance – Compliance with Rules/Procedures

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

• Rail Operating Rule Book and required training
• Command and Control/Train Control SOPs and required training
• Field Supervision SOPs and required training
• Inclement Weather Procedures and refresher training
• Operator Certification/refresher training and record-keeping
• Inspection and Maintenance Manuals, SOPs, and standards, supervision, training, and competency

Positive Observations

• The MBTA has begun to evaluate the data collected during audits (largely SRCP audits), in addition to data collected from actual safety events, to help determine the accuracy of their data. The results of this should regularly be shared within MBTA and formally submitted to DPU.

Opportunities for Continual Improvement

• MBTA should do more to promote throughout the entire organization the importance of compliance in a rules-based operating environment.
• The Rail Operating Rulebook has too many pages for an operator to carry while operating a train, making it increasingly more difficult for the operator to consult the rulebook in making the correct decisions. MBTA should evaluate other RTA processes for ensuring accessible rules documentation.

Recommendations

• The MBTA should evaluate headways to ensure sufficient rest times for motorpersons consistent with infrastructure restrictions and fatigue management policies.
• The MBTA should retrain all frontline and management level staff on the importance of rule adherence and efficiency testing (SRCP).
• The MBTA should consider if the method of accounting for SRCP activities is diluting their overall compliance rates.
• The MBTA should continue its process of identifying and creating JHAs.
• The MBTA should assess rules violations based upon years of service. If there is a correlation that employees with shorter durations of years of service have a higher violation rate, a training gap analysis should be conducted.

Findings

• There have been several issues with the results of the SRCP process and DPU requires advance warning for field work related to the SRCP activities so that DPU staff can attend.
  • The MBTA must develop a new scheduling process for SRCP programs, and this process must include DPU notification when scheduling SRCP audits. This process should ensure that there is a risk-based approach to audits based on KPI’s and violation data.
• During this Triennial Audit and previous observations (in-person and through safety performance monitoring), DPU observed that the Green Line operations allow moving trains to operate too close together.
  • The MBTA must ensure train separation compliance throughout the system, including in station locations. A process for train separation must address NTSB recommendations.
• In December of 2022, the DPU ordered the MBTA to assess speeding on the Green Line system. During early 2023, of the 79 audits conducted by DPU from January through March, 53 speed violations were recorded. A follow up of 64 audits in May through June 2023 recorded 55 speed violations. The results of the 2023 targeted audits found that speeding on the Green Line increased from 67% to 86% over the posted speed limit. Much of this was outside of compliance with the enforcement guidelines for acceptable buffer speed.
  • The MBTA must consider whether its Green Line speeding oversight is sufficient (until the GLTPS system or alternative system is active) or if it needs to conduct more enforcement.
  • The MBTA must re-evaluate the posted/scheduled trips to determine if they are achievable under the current speed restrictions and speed limits in place and how to best manage the speed restrictions and speed limits going forward.
• On several occasions, MBTA has updated documents designated as MSS without notifying DPU and providing opportunity to review these changed/updated documents.
  • MBTA shall develop a process for all rulebook revisions to be presented to DPU for comment before finalizing it as a MSS.
• On several occasions, the DPU has expressed significant concerns with MBTA’s Rules Compliance program.
  • The MBTA must evaluate the Rules Compliance program and determine if it both meets the expectations of its executive management for rules compliance and is consistent with successful peer organizations.