A CULTURE OF SAFETY is lacking at the MBTA, according to a scathing report by three outside experts that blamed management turnover, misplaced priorities, and a workplace that inhibits frank communications and analysis about operational problems.
While Gov. Charlie Baker has focused on increasing capital spending at the transit authority and lawmakers and activists have called for more revenues, three high-powered safety experts hired by the MBTA’s Fiscal and Management Control Board reviewed the inner workings of the transit authority. What they found was a divided agency pulled in too many directions and failing to execute on one of its core missions – keeping riders and workers safe.
“In almost every area we examined, deficiencies in policies, application of safety standards or industry best practices, and accountability were apparent,” the experts concluded. “In essence, safety is not the priority at the T, but it must be.”
The 63-page report, written by former transportation secretary Ray LaHood, former Federal Transit Administration administrator Carolyn Flowers, and former New York Metropolitan Transit Authority administrator Carmen Bianco, focused almost entirely on subway operations, where the authors perceived the greatest risk. Commuter rail operations, overseen by the T and run by the private contractor Keolis Commuter Services, generally came in for praise for addressing safety issues, in part because of Federal Railroad Administration regulations that are clearly defined and have fiscal consequences for noncompliance. By contrast, MBTA transit operations are subject to oversight by the state Department of Public Utilities.
The report contains 34 recommendations and 61 individual corrective actions. The safety experts also hired an engineering and infrastructure firm to evaluate the MBTA’s track infrastructure. Between September 14 and October 31, the firm identified 1,121 “discrete items of concern,” of which 46 were immediate safety concerns.
The safety experts didn’t come out and say T subway riders are in danger – they describe the T as “relatively safe” – but their report suggests derailments and breakdowns are the outgrowth of a safety culture that is not functioning well. The report says a series of Red and Orange Line incidents over the past year can be traced to “systemic deficiencies” in preventive maintenance and inspections and a failure to investigate accidents properly and follow-up with corrective action plans.
MBTA officials and LaHood portrayed the passenger safety situation in a positive light. Both said the T is currently safe to ride, but it needs to be safer.
Fixing the problems identified in the report is likely to be costly, and the T plans to start budgeting for the safety makeover next week. No dollar figure was put on added staff and creation of new safety system, but the panel members said the cost of failing to address safety issues at the transit authority is already high. The safety panel reported that the T estimated its response to the Red Line derailment in June cost the agency $5 million, but the experts said they believe the actual cost was much higher.
Tim Lasker, president and business manager of OPEIU Local 453, said he wasn’t surprised at the report’s conclusions about the lack of communication between management and workers at the T. Over the last three years, he said, MBTA management has not listened to concerns raised by its workforce and often gotten rid of workers, only to discover their expertise was actually needed. “You can’t continuously overlook the experience that is in-house,” he said.
At a State House press conference, Baker seemed to embrace the recommendations in the report even though they highlighted major shortcomings in how his team has managed the T. He said he would be filing legislation next month to create a successor agency to the control board, and noted the bill will include two of the recommendations of the safety panel — reducing the number of meetings the control board is required to hold each month and requiring one member to have safety and operations experience. Baker also said the safety report underscored the need for the Legislature to release $50 million for a two-year program to hire workers at the T, although safety had not been mentioned previously as the need for the funding.
“Safety’s a common thread in every aspect of the MBTA,” said Baker. “It influences the way the organization’s built, the way the workforce functions, the way it keeps records, and the way the agency plans for repair work and new construction. It is the foundation for the entire operation.”
While the panel of experts focused on safety, many of the problems it identified are issues that could have an impact on all transit operations of the T. Here are some of the key conclusions in the safety report:
MANAGEMENT – One of the biggest problems at the T is a consistent approach at the top of the organization. “This may be the overarching reason that we see the level of safety deficiency at the agency,” the panel wrote in its report.
The report notes there have been nine general managers over the last 10 years, describing the turnover as disruptive. Six of the general managers, both interim and permanent, came on Baker’s watch. The current GM, Steve Poftak, took over in January (he earlier served as an interim GM) and is described as not possessing “in-depth transportation operations and safety knowledge, which are the core functions of the organization that he is tasked with managing.” Most members of the senior leadership team lack operations and safety backgrounds and many are new and unfamiliar with the agency’s mission and safety practices.
The Fiscal and Management Control Board recently began scaling back the number of meetings it holds each month, and it appears that shift was prompted by the safety panel. State law requires the control board to meet three times a month, a requirement the safety panel criticized. “The preparation, participation and demands placed on staff to support these frequent meetings takes an extraordinary toll on agency leadership,” the report said. “The Safety Review Panel cannot overstate how detrimental the frequency and demands placed on staff to prepare for these meetings are to the overall safety and operational performance of the organization.”
LaHood stressed the control board meetings are a real problem. “You all have too many meetings that take too much of their time,” he said, pointing to the general manager and the deputy general manager. “The less time they sit around here the more time they have to implement these recommendations.”
BUDGET PRACTICES – The report says T management has been fixated on controlling costs and stepping up capital spending, largely at the expense of operations and the operating budget. The report says “serious manpower shortages” have developed in departments supporting operations and service delivery and budgets have been cut for training, maintenance crews, emergency response teams, and safety personnel.
In fiscal 2017, the MBTA had 6,547 employees. A year later, the number was down to 5,643. “Recognizing that they cut too close to the bone, the T is slowly regaining the necessary staff needed to provide service and meet its business needs. As of June 30, 2019, the T has 6,198 employees,” the report said.
The report raised concerns that the agency’s focus on capital spending has hampered daily operations, by pulling maintenance and engineering personnel away from their day-to-day work. The report also noted that pressure to keep operating costs down has come at the expense of safety issues. A program to remove vegetation near tracks, for example, was curtailed because budgeted funding for the program ran out.
“It appears that on the transit side of the T operation, in many instances, financial considerations take precedence over operational performance and safety, even when it is extremely detrimental to the organization,” the report said. “This mindset demonstrates an ‘upside down’ set of priorities for running a transit agency. MBTA transit management has since reallocated funds to the vegetation control program and has resumed this activity.”
The T’s top-down budgeting approach, according to the safety panel, has also split the agency into two camps. “The top feels that the financial house needs to be in order and that the discipline must continue,” the report says. “The bottom of the organization feels that they are not being listened to and that the fiscal cuts have been too deep.”
CULTURE OF BLAME AND RETALIATION – The report says T employees lack trust in leadership or fear retribution, so they don’t report potential safety problems. The safety panel said this “culture of blame and retaliation” hinders safety efforts, putting the agency in the position of reacting to problems rather than preventing them in the first place.
“The workforce does not feel supported by management and are clearly frustrated with the management’s lack of responsiveness to their need,” the report said. “We heard countless situations where employees’ requests for needed safety equipment or support went unanswered. During this review, we also heard and gained first-hand knowledge of circumstances where employees, who reported safety issues on numerous occasions, eventually lost faith in management’s ability to care about getting anything done. As a result, it is likely that many safety issues today go unreported.”
The report also said communication within the agency is poor. “Employees at all levels told the panel that the T has many siloes and that communication is rarely, if ever, done across departments,” the report said.” Leadership has not identified or attempted to open channels of communication with the workforce. An overwhelming number of employees are not able to receive electronic communications and have minimal alternatives to communicate with agency leaders, nor do leaders have a way to communicate with the workforce. The only avenue for communication we identified during this review is a ‘safety hotline’ which does not appear to have received the confidence of the workforce in the field.”
POOR USE OF DATA – The safety panel criticized the T’s transit operation for failing to establish safety objectives, targets, or performance indicators. The panel’s report said monthly safety reports have only one metric, derailments. “There are no targets or key performance indicators for other operational incidents such as collisions, fires, employee lost time injury rates, and preventative maintenance, as some examples. The agency does not use performance monitoring tools such as dashboards, balanced scorecard, strategy maps, or industry benchmarking to set targets or track performance. Most of the reports can be characterized as record keeping, providing month to month trends with no analysis and causes for variance in the data reported.”
The report said many preventive maintenance initiatives were not being performed in the T’s transit operations, primarily because of a shortage of manpower and/or lack of access to track infrastructure. “Essentially, deferred maintenance has been institutionalized in some areas of the organization. Without established safety performance targets and indicators in place, there is no mechanism to alert executive leadership of this shortcoming,” the report said. “As a result of these constraints, managers at the departmental level are placed in the untenable position of self-selecting what critical aspects of their [preventive maintenance] regimes will be performed and what [preventive maintenance] will be deferred. This circumstance was elevated to senior managers; however, it was not sufficiently acted upon. The general manager and Fiscal and Management Control Board appeared to be blind to this organizational risk until they were alerted to it by the Safety Review Panel.”
ACCIDENT INVESTIGATIONS – The report was critical of how the T investigates accidents and often fails to follow up on corrective actions to make sure problems are resolved. The safety panel said this problem was evident in the wake of the Red Line derailment in June and on a visit to a rail maintenance facility by members of the safety panel team. During the visit to the maintenance facility, a number of obvious safety issues were documented first-hand: “No post inspection hands-on maintenance audits, improper tagging of defective parts, and storing defective and good parts together instead of isolating them.”
The report said there is also a rush to address a problem and then move on. “Following an incident, there is a feverish response to a very specific problem without developing and implementing a global strategy to address the hazard,” the report said. “The corrective action is tracked for a brief duration and then closed. The corrective action plans are not being effectively audited to evaluate whether the required actions are continuing to take place or if the corrective action is effective. As a result, no substantial corrective actions are institutionalized, which if nourished, could create permanent change. Hence, the safety concerns and operational incidents persist.”
Part of the problem, according to the safety panel, is the inadequacy of the T’s safety department, which has only one person who could be identified as a subject matter expert. The safety panel said a derailment on the Green Line between Beaconsfield and Brookline Hill stations uncovered a host of safety issues, including “multiple track defects simultaneously co-existing at the point of derailment.”
According to the safety report, “The safety department cannot lead an independent, comprehensive accident investigation, and this inadequacy is even more pronounced for events centered around mechanical and engineering issues.”
RECOMMENDATIONS — Many of the findings in the narrative of the report were incorporated into the 34 recommendations. For example, the finding that senior leaders at the MBTA and members of the control board lack “hands-on” transit operations and safety experience became three recommendations — provide direct mentoring and coaching to executives, expand the leadership team to include more seasoned transit professionals, and consider adding people with operations and safety skillsets to the control board.
A finding that bus safety training instructors covered too much material too quickly and even wrote answers to exam questions on the board became a recommendation that training sessions should be routinely audited to ferret out “deviations in training protocols.”
A finding that deep budget reductions have cut resources in critical areas and been implemented as part of a top-down management approach became two recommendations — to perform a zero-based budget analysis of each department and “have an inclusive dialogue” with those impacted by budget decisions.
A finding that the control board is overly fixated on expanding capital spending translated into a recommendation to begin requiring T management to regularly report on safety key performance indicators.
The safety panel found that “the absence of trust and respect, insufficient communications, an increased silo mentality resulting in poor teamwork, coupled with inadequately trained leaders are at the core of the T’s poor safety performance and low morale.”
The panel also found that “there is no incentive to become a manager since an employee can earn substantially more than his/her supervisor by working overtime.” The panel recommended an “equity analysis” to attract and retain managers.
LaHood gave no timetable for adoption of the panel’s recommendations, but he indicated the T should tackle the suggestions with a sense of urgency. “A year from now, if you get all of these done, boom, you’re in the catbird seat,” he said.