2023 Triennial Audit - Grouping 9. Safety Assurance – Management of Change

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

• Configuration Management Plan
• Safety and Security Certification Plan
• System Modifications
• Tracking of Significant Capital Projects
• Safety-Related Procurement Specifications/Requirements

Positive Observations

• The MBTA has Safety integrated directly into the Capital process.
• Vehicle Engineering is proactive in the Safety Certification process.
• The MBTA utilizes a Global Change Order system for department-wide changes to contract (procurement) language.

Opportunities for Continual Improvement

• The Internal Project Tracking spreadsheet should be formalized and locked by one owner to eliminate opportunity for errors.
• For large projects, a quarterly report may not be enough and more frequent administrative oversight may be needed.

Recommendations

• The MBTA should regularly account for the status of each new capital project in the system and determine if the Safety Certification Tier evaluation originally assigned is still appropriate.
• The GLTPS should be evaluated to determine if it is still a viable mitigation to the original issues presented during the accident investigations.
• As part of its implementation of FTA’s SD-9, the MBTA should evaluate whether Safety staff plus the current level of contractor support is a sufficient resource level to satisfactorily address Management of Change.

Findings

• The MBTA must reconsider the explanations (in the plans/programs referenced below) of Safety Certification Tiers and requirements for Risk Assessment and Hazard Analysis. ¹
  • MBTA must improve how Safety Certification Tier selection and appropriate communications of changes on capital projects are addressed in the Configuration Management Plan and Safety Certification Program, which MBTA is currently updating. These updated documents must be sent to DPU for comment and concurrence before finalizing. This Finding is intended to compliment, not alter, FTA’s SD 22-9.
• The GLX project prematurely commenced revenue service while several design specifications were not properly constructed (e.g., narrow gauge), which should have been revealed as part of the Safety Certification Program.
  • The MBTA must formalize and ensure transparency and effective communication of changes and safety hazards across its divisions/groups prior to introducing new capital projects into revenue service.
• The MBTA must formalize and consistently use the Change Management Committee structure in the MBTA’s Safety Certification Program (the Safety and Security Executive Review Committee, the Safety Certification Working Group, and the project-specific committees) for transparency and effective communication of changes across divisions/groups, including advance notification to DPU of the meeting schedules.
• The MBTA must submit a CAP that adequately describes short-term mitigation that addresses/assures required separation of Green Line trains while the GLTPS project (or an alternative) is being developed and implemented.

1. DPU is currently reviewing MBTA’s Safety Certification Plan that it revised in winter 2024. MBTA can postpone development of a CAP for this Finding until the DPU completes its review, provides comments, and identifies whether a CAP will be needed.