This is BAD
Category 1: Managing the impact of operations, maintenance, and capital project requirements on the existing workforce
1. “MBTA’s staffing levels are not commensurate with the demand for human resources required to carry out current rail transit operations and maintenance in addition to expanding capital program activities.”
2. “MBTA has not demonstrated the organizational capacity to recruit and hire personnel to meet authorized staffing levels.”
3. “Additional resources are needed to support MBTA’s safety engineering and safety certification process for capital projects.”
4. “MBTA requires additional oversight of contractor work sites.”
Category 2: Prioritization of safety management information
5. “MBTA has not ensured that the necessary structures are in place to support effective implementation and operation of its safety management systems.”
6. “MBTA executive leadership does not receive prioritized and actionable information related to safety risks or shortcomings in safety risk mitigations.”
7. “MBTA Executive Management does not consistently ensure its decisions related to safety risks are based on safety data analysis or documented facts.”
8. “MBTA’s safety investigations and safety assurance activities do not consistently collect and analyze information on precursor factors.”
9. “MBTA’s safety risk assessment guidance as part of its Safety Risk Management is ambiguous and has led to confusion among stakeholders regarding their responsibilities and authorities, which has created delays in carrying out safety risk assessments activities.”
10. “MBTA safety information management tools (hazard log, safety risk mitigation log, etc.) do not fully support prioritization of resources to address safety risk and safety performance monitoring.”
Category 3: Effectiveness of safety communication
11. “MBTA has not established explicit and formal provisions to ensure safety information from safety committee results in a consistent outcome of documented, prioritized, and actionable safety information.”
12. “MBTA has not documented explicit and formal provisions to ensure the participation of frontline employees in local safety committees as part of their job responsibilities in relation to the agency’s safety management systems.”
13. “MBTA management has not effectively communicated clear direction to frontline employees on what to report and what not to report through the Safety Hotline.”
Category 4: Operating conditions and policies, procedures, and training
14. “Documented operating and maintenance rules and procedures are not implemented as required.”
15. “MBTA does not monitor operations, including the conditions of the operating environment, to identify the reasons for deviations between formal, established standards, rules and procedures, and actual operations and maintenance practices.”
16. “MBTA’s QA/QC program is not sufficiently independent from the activities it oversees.”
17. “Technical training for operations and maintenance departments is under-resourced and decentralized, without sufficient resources and direction, and relies significantly on on-the-job training (OJT) which is informal and lacks oversight. Emergency response training is poorly integrated into overall training program.”
18. “MBTA lacks formal resource manuals in key maintenance areas and does not currently provide employees with checklists or other tools to support training and implementation of maintenance rules and procedures.”
19. “Due to workforce turnover, MBTA’s new motorpersons and officials no longer have access to mentoring from experienced motorpersons and officials (inspectors, chief inspectors, and supervisors).”
20. “Radio quality is deficient in several key locations and does not support adequate communications between OCC and field employees to ensure the safety of MBTA operations and maintenance.”
Category 5, findings for the Department of Public Utilities: Safety oversight for MBTA’s rail transit system
21. “The DPU does not use its available resources as effectively as it could to support field observations, audits, and inspections of MBTA’s rail transit system to identify safety deficiencies and require their immediate resolution.”
22. “DPU must examine and ensure its organizational and legal independence from the MBTA.”
23. “DPU has not validated MBTA’s fatigue management approach for rail transit officials and maintenance and engineering personnel.”
24. “DPU has not demonstrated an ability to address safety issues and concerns identified during FTA’s safety management inspection.”