Introduction
The DPU is the Commonwealth’s designated Rail Transit SSO Agency (“SSOA”) which administers the SSO Program in the state. DPU provides safety oversight of the state’s only rail transit agency (“RTA”), the MBTA, including execution of a Triennial Safety Program Audit. The requirements of the Triennial Audit are defined in 49 C.F.R. Part 674.31.
“At least once every three years, an SSOA must conduct a complete audit of an RTA’s compliance with its Public Transportation Agency Safety Plan. Alternatively, an SSOA may conduct the audit on an on-going basis over the three-year timeframe. At the conclusion of the three-year audit cycle, the SSOA shall issue a report with findings and recommendations arising from the audit, which must include, at minimum, an analysis of the effectiveness of the Public Transportation Agency Safety Plan, recommendations for improvements, and a corrective action plan, if necessary or appropriate. The RTA must be given an opportunity to comment on the findings and recommendations.”
The DPU conducted this Triennial Audit of the MBTA in the third year since the prior audit, as allowed in the regulation.1
The DPU concluded the Triennial Audit and issues this report containing findings and recommendations resulting from the audit, including an analysis of the effectiveness of the ASP implementation. The findings and recommendations require the program documentation (ASP, minimum standards for safety, etc.) to be updated to reflect current activities, and also require activities to be changed or added so that the program documentation and activities are aligned. MBTA is required to develop CAPs or Corrective Actions, as needed, based on those findings and recommendations. The DPU provided the MBTA with two weeks to review and comment on the findings and recommendations.
Scope
The scope of the Triennial Audit is the ASP and its implementation, as required by the applicable federal regulations. The Triennial Audit includes a review of all aspects of the Safety Program at the MBTA. For the MBTA Rail System, the previous Triennial Audits completed by the DPU SSO Program were in 2017 and 2020.
The documents and records considered for this 2023 Triennial Audit are the following:
- FTA Audit of the DPU SSO Program – 2019
- Previous Triennial Audit of MBTA Rail Systems – 2020
- ASPs – 2020-2023, focused on the most recent ASP for 2023
- Minimum Standards for Safety documents referenced by the ASP or otherwise included in the Safety Program.
- Investigations – 2020-June 2023
- Internal Safety Reviews – 2020-2022
- CAPs opened or closed during the audit scope timeframe – 2020-June 2023
- Hazards and Hazard Management, Safety Risk Management – 2020-June 2023
- Responses for FTA Safety Advisories (“SA”), Safety Bulletins (“SB”), SD, or requests – 2020 through June 2023
- SA 20-1 Recommended Actions to Reduce the Risk of Coronavirus Disease 2019 (COVID-19) Among Transit Employees and Passengers
- SB 20-02 Inward and Outward Facing Image and Audio Recorders
- SA 21-1 Fleet-wide Inspection of Wheel Inspection of Wheel Gauging on Rolling Stock
- SA 22-1 Rail Car Passenger Door Inspection and Function Testing
- SA 22-2 Signal System Safety and Train Control
- SA 22-4 Suicide Prevention Signage on Public Transit
- SB 22-01 End of Railcar Door Signage and Messaging.
- DPU SSO Program Safety Data Analysis Report, March 2023 and August 2023.
- DPU Safety Risk Management (“SRM”) Monitoring activities completed through June 2023.
The DPU acknowledges the eight SDs issued by the FTA to the MBTA. As explained in the Executive Summary, while those SDs overlap with this Triennial Audit, the audit does not focus on the SDs (except where specifically noted) because DPU seeks to avoid creating potential ambiguity or interference with FTA’s comprehensive review process and communications on MBTA’s implementation of the SDs.
Triennial Audit Design
The design of this audit (along with internal safety reviews/audits), as well as MBTA’s ASP, focuses 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
- Review records and recordkeeping for the SMS and its implementation
- Annual ASP review and update
- Documentation and tracking of Minimum Standards for Safety
- Integration with Public Safety and Emergency Management/Response
- Integration of the Safety Department in policy and procedure development and changes
- Safety Performance criteria, thresholds, and targets for improvement are covered in Safety Assurance (Grouping 4)
Grouping 2. Safety Management Policy
- Safety Management Policy documentation, signed/endorsed by the Accountable Executive
- Agency’s safety objectives
- Organizational Accountabilities and Responsibilities, Safety-Related Committees
- Employee Safety Reporting System
- Policy Communication throughout the RTA
Grouping 3. Safety Risk Management
- Hazard Identification
- Risk Assessment and then Prioritization
- Selection and implementation of Mitigations
- Formal hazard analyses in other Safety Program Topics (see Grouping 9)
- Other sources of formal risk assessment, safety and public safety related (see Grouping 1)
Grouping 4. Safety Assurance – Safety Performance Measures and Targets for Improvement
- Safety Performance Criteria, Targets, and Measures
- National Safety Plan
- FTA Guidance on Safety Performance Measures and Targets
- Coordination with the State and MPO for Safety Performance Measures and Targets
- SSO Program Standard Requirements/Procedures for Hazard/Risk Identification, Data Collection, and Analyses/Assessments
- Hazard Log, Safety Risk Register, and Corrective Actions/Mitigations Tracking
- CAPs definition, tracking, closure process
Grouping 5. Safety Assurance – Notifications and Investigations of Safety Events
- RTA Investigation Procedure(s)
- SSO Program Standard Requirements for Safety Event notifications and investigations
- Emergency Response/Operations Procedures
- Rail Operating Rule Book(s) and Required Training
- Right-of-Way or Roadway Worker Protection (“RWP”) Plan and Required Training
- Command and Control/Train Control Standard Operating Procedures (“SOPs”) and Required Training
- Field Supervision SOPs and Required Training
Grouping 6. Safety Assurance – Compliance with Operations Rules/Procedures
- 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
Grouping 7. Safety Assurance – Compliance with Inspection and Maintenance (I&M) Requirements
- Transit Asset Management (“TAM”) Plan
- Inspection and Maintenance (“I&M”) Manuals, SOPs, Standards, Supervision, Training, and Competency
- RWP Plan and Required Training
- Maintenance (equipment and rail infrastructure/systems) Job-based Certification/Refresher Training
Grouping 8. Safety Assurance – Compliance with Local, State, and Federal Safety Requirements
- Fitness for Duty, Fatigue Management, and Hours of Service
- Drug and Alcohol Policy
- Adherence to Occupational Safety and Health Administration (“OSHA”) Standards
Grouping 9. Safety Assurance – Management of Change
- Configuration Management
- Safety and Security Certification
- System Modifications
- Tracking of Significant Capital Projects
- Safety-Related Procurement Specifications/Requirements
Grouping 10. Safety Assurance – Continuous Improvement
- Tracking the Three-Year Cycle of Internal Safety Reviews (“ISRs”)
- Process for completing ISRs and results, including CAPs
- Assessment of Safety Performance Measures compared to the targets for improvement
- Assuring integration of the Safety Department in policy and procedure development and changes
Grouping 11. Safety Promotion – Training and Competency
- 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
- Inclement Weather Procedures and refresher training
- Operator Certification/refresher training and Record-Keeping
- Maintenance (equipment and rail infrastructure/systems) Job-based Certification/refresher training
- Inspection and Maintenance Manuals, SOPs, and Standards, Supervision, Training, and Competency
Grouping 12. Safety Promotion – Safety Communication
- Policy Communication throughout Transit Agency
- Safety Performance Criteria, Targets, and Measures
- Employee Safety Reporting System
- Hazards Identification and Resolution
The Triennial Audit is not intended to be a comprehensive review in each of the Groupings; however, some aspects of each Grouping are reviewed to assure compliance with the Safety Program,2 ASP, and SMS implementation. In addition, the Triennial Audit follows verification methods provided by FTA in a recommended best practice document. 3
- Document Review: Sampling the RTA’s Safety Program Description and referenced and/or supporting procedures to ensure that each required element of the State’s Program Standard and 49 C.F.R. Part 674 is addressed.
- Rules Review: Sampling the RTA’s operating rules and bulletins and maintenance rules and procedures to determine if they have been reviewed and updated on a regular basis, if they have been distributed to appropriate RTA personnel as specified in the Safety Program Description, if training has been offered, and if this process has been tracked.
- Records Review: Sampling of the RTA’s records for evidence of implementation of the Safety Program Description and referenced or supporting procedures. Records reviewed and/or sampled may include, but are not limited to, training records, records of employee rules compliance checks, internal safety audit reports, maintenance inspection reports, minutes of safety committee meetings, etc.
- Interviews with RTA Senior Management: Discussions held with senior RTA management, including the RTA’s Chief Executive Officer, to assess their knowledge of the RTA’s safety program, as specified in the Safety Program Description and referenced or supporting procedures, and to gauge their commitment to the safety program.
- Interviews with RTA Safety Personnel: Discussions held with RTA safety personnel, including the Chief Safety Officer, to assess implementation of the RTA’s safety program, to identify issues in its implementation, and to highlight areas of compliance and non-compliance with Part 674 requirements.
- Interviews with Other RTA Personnel: Discussions held with other RTA personnel (including a representative sample of frontline operations and maintenance personnel) to verify their understanding of requirements specified in the Safety Program Description and referenced or supporting procedures.
- Field Observations: Observations and sampling conducted onsite at the RTA to observe implementation of the processes and procedures described in the Safety Program Description and supporting or referenced documents, procedures and materials related to the RTA’s safety program.
- Inspections: Inspections conducted onsite at the RTA to ensure that the RTA’s infrastructure and equipment is maintained to the specifications identified in the RTA’s standards, procedures, and manuals.
Each of these verification methods has specific strengths and limitations. To adequately assess implementation of each of the Safety Program Description topics, FTA states that more than one verification method should be used. The DPU SSO Program uses all these methods.
Triennial Audit Report
This report is presented with a summary of the Triennial Audit process that was followed. The next section provides a summary of the results of the Triennial Audit by Grouping. The following appendices are provided for transparency of the process.