Final SSO Audit Report (PDF)
March 4, 2010
Senator Mikulski and other members of the National Capital Region Delegation, thank you for the opportunity to appear before you today to discuss the Federal Transit Administration’s recent audit of WMATA and the Tri-State Oversight Committee or TOC.
At the outset, I want to point out that this audit was very different from past audits conducted by the FTA. Because FTA is currently prohibited by law from having direct safety oversight of Washington Metro and similar agencies across America, FTA typically limits the focus of our audits to the State Safety Oversight agency or TOC, in this case. However, at the direct of request of Senator Mikulski and Secretary Ray LaHood, and with the encouragement of WMATA’s interim Chief Safety Officer, this audit, for the first time, took a hard look at WMATA’s own safety program.
FTA’s audit revealed a number of troubling findings both at Washington Metro and the TOC. Our audit makes clear that these two agencies are not doing enough to guarantee the safety of Metro passengers or Metro workers. While we have observed some improvements in recent months, a great deal more needs to be done to ensure that Metro passengers are receiving the safest possible service. A great deal more needs to be done to ensure that the lives of Metro workers are protected as they do their jobs maintaining and operating the system.
Our audit resulted in 21 findings and recommendations: 11 findings and recommendations for TOC and 10 findings and recommendations to WMATA.
Before I highlight the findings and recommendations made by FTA, I want to convey to you three important messages.
First, the findings in our audit are merely symptoms of a larger problem. Each finding and recommendation in our report reveals a hole or vulnerability in the very systems that have been implemented to ensure the safety of Metro passengers and employees. However, without a strong and daily commitment to safety from everyone at Washington Metro, from executive leadership down to the most junior employee, these systems cannot succeed. Addressing each of our recommendations, one by one, will not solve the whole safety problem. The overarching safety problem will only be solved through a top-to-bottom change in the safety culture and focus at Washington Metro.
Second, I want to emphasize that, under current law, the FTA, like the TOC, has no legal authority to compel Washington Metro to respond to any of our findings. As I have testified before, the FTA is actually prohibited by law from issuing safety regulations of any kind. And the State Safety Organizations like the TOC similarly have no legal authority to compel transit agencies like Washington Metro to respond to their safety findings. They don’t have to respond to them in a timely way. In fact, they don’t have to respond to them at all.
These are precisely the reasons why Secretary LaHood, on behalf of President Obama, formally transmitted a transit safety reform bill to the Congress back in December. I want to thank Senator Mikulski for her leadership in getting this bill introduced along with Chairman Dodd, Subcommittee Chairman Menendez and Senator Cardin. I also want to thank Representative Edwards for serving as an original cosponsor of the House bill along with Chairman Oberstar and Subcommittee Chairman DeFazio.
The Metrorail crash last summer certainly accelerated our efforts within the Obama Administration to develop and transmit our transit safety reform bill. However, we have also been focused on accidents and safety lapses at the Chicago Transit Authority, the MUNI system in San Francisco, the “T” up in Boston and elsewhere. While we believe the situation at Washington Metro is particularly troubling, some of the deficiencies and vulnerabilities that we identified in our audit of Metro and the TOC are similar to problems that exist at transit agencies and State Safety Organizations across America. That is precisely why we need Congress to move forward with our transit safety reform bill now. The U.S. Department of Transportation cannot move forward to address these problems in any meaningful way while we are still prohibited in law from issuing safety regulations or conducting direct safety oversight. Just a few weeks ago, Secretary LaHood used his authority to prohibit texting while driving nationwide for truck drivers, bus drivers and train operators. But even a simple common-sense safety measure like that cannot and will not apply to train operators at our nation’s transit systems like Metro until Congress changes the law. So, on behalf of the President and Secretary LaHood, I must ask you collectively to do all you can to rapidly move this legislation to the President’s desk.
Third, we must remember that, despite Metro’s safety challenges, every Washington area commuter is far safer traveling on Metro than they are traveling on our highways. Anyone who decides to drive to work instead of taking Metro is immediately putting themself at much greater risk of accident or injury. The Metro rail system has experienced 13 on-board crash-related fatalities during its 33-year history. While every one of the fatalities has been a tragedy, the fact is that automobile accidents on the roads of the Washington area claim the same number of fatalities every two weeks. Nationwide, a person is 107 times more likely to die and 57 times more likely to be injured as a motor vehicle passenger than as a rail transit passenger. So, does Washington Metro and the TOC need to make changes to improve safety? Absolutely! Should Metro’s safety challenges prompt riders to drive their cars instead? Absolutely not!
That said, I would like to present the results of our recent audit. I will not summarize all 21 findings and recommendations. Every Member should have a complete copy of the audit report. Rather, I will provide highlights of those that concern us most. But, as I summarize the audit findings and recommendations, you will see common challenges faced by both TOC and WMATA in the areas of:
Regarding WMATA, we believe there are serious organizational failures that must be addressed immediately. For example, our audit found that there is no internal process for communicating safety-related information across all WMATA departments. Worse still, there is no internal process for the Chief Safety Officer to communicate safety priorities to the General Manager. We are also deeply troubled by the fact that WMATA’s safety department does not routinely have access to operating and maintenance information so that it could analyze the information for safety implications. Put simply, Metro’s safety department has been isolated both from top management and from other Metro departments. In fact, the Safety Department has had their access and authority questioned by other operating departments. And this dynamic has seriously undermined the Safety Department’s ability to conduct its safety responsibilities.
For example, FTA found evidence that WMATA’s Safety Department is not “plugged-in” to critical conversations, decision-making meetings and reporting systems that provide information on hazards and potential safety concerns throughout the agency. Key documents, reports, and decisions are not consistently shared with the Safety Department. In addition, the Safety Department does not receive and review available monthly reports from the Rail Operation, Quality, or Maintenance departments. On numerous occasions during the audit interviews, Safety Department representatives indicated that they were learning for the first time that information of a safety nature was being documented by operating departments.
In addition to our concerns about WMATA’s silo approach to communication, we are also concerned about the resources dedicated for the Safety Department, the lack of stability within the Safety Department, and the scant attention it has gotten from senior management. Three illustrative observations are worth sharing with you:
Given this record, no one should be surprised that Metro’s Safety Department has been dysfunctional and ineffective.
Further, the lack of effective communication channels within WMATA also impacts the communication between WMATA and TOC wherein TOC members do not have access to top executives and decision-makers. Put simply, the multistate agency that is charged with overseeing safety at Metro hasn’t until recently, had a way to communicate with Metro’s senior management. Before October 2009, TOC members worked primarily with lower staff levels within WMATA and with WMATA’s Safety Department and its Chief Safety Officer to address safety issues, accident investigations, and open corrective action plans. Safety Department representatives were expected to advocate on behalf of TOC within WMATA. That means that the regulator had to depend on underpowered mid-level players within Metro to advance their safety concerns. Until recently, TOC members did not directly work with key personnel in WMATA’s rail operating and maintenance departments.
TOC representatives stated to us that when TOC members disagreed with the decision of the Chief Safety Officer, or did not believe that enough work had been done in a specific area, there were no processes in place to bring these concerns directly to the General Manager for action.
As a result, we recommend that WMATA develop internal processes for communicating safety-related information and procedures for elevating safety-related concerns.
Further, in 2005 and 2007, FTA determined that WMATA had not conducted internal safety audits according to approved schedules and requirements. Independent reviews conducted by TOC in 2004 and 2007 identified the same deficiency.
Over the last five years, TOC and FTA have made repeated findings regarding the inability of WMATA’s Safety Department to work with other WMATA departments to develop and manage an effective internal audit program. In interviews, WMATA personnel explained that they did not have the resources or training to conduct internal safety audits without the assistance of the American Public Transportation Association or other contracted support.
In addition, WMATA representatives revealed that there is general confusion regarding why the Safety Department would need to conduct or manage internal audits of other departments.
Given this, we are recommending that WMATA conduct a comprehensive review of its Safety Department to determine the level of resources and expertise needed to carry out its mission. The results of that assessment must be used to set adequate staffing levels and ensure that necessary expertise exist within the Safety Department.
Finally, , WMATA must finalize its right-of-way protection rules and develop consistent and comprehensive training as part of implementing the new rules and ensure that right-of-way employees and contractors receive the training before accessing the right-of-way.
During our audit, we found that WMATA’s procedural protections for right-of-workers, implemented after the 2006 Dupont Circle accident, were not developed in consultation with TOC or even evaluated for its impact on safety. In addition, while WMATA representatives stated that employees were provided training on this directive, during our interviews we found that employees were simply provided the directive and asked to sign a form stating that they understood the rule.
And, given the communication problems within Metro, it is troubling that while Metro intends to revise this rule, in light of the recent tracker worker deaths, the Safety Department has not been tasked to conduct an analysis of the revisions. Also, supervisors and operators told FTA that communications from right-of-way workers do not specify their exact location on the alignment. Specifically, operators stated that in some cases they do not know if workers are on the alignment until they have visual contact, and, when this occurs, especially in “blind spots”, operators have limited ability to slow the train.
WMATA must institute a better process for protecting track workers.
Regarding TOC, we found that the sponsoring jurisdictions for TOC do not devote enough resources to TOC for it to function efficiently and effectively.
The six TOC staff members combined devote between approximately one and one and half full-time equivalents or FTE to the program and TOC contractors also provide between approximately one and 1.8 FTEs to the program. In March of 2009, Virginia dedicated a full time staff person to TOC. During audit interviews, both Maryland and the District of Columbia representatives stated that there are initiatives underway in their jurisdictions to attempt to commit full-time members to TOC.
Even so, since its inception in 1997, TOC has experienced considerable turnover among its members. Only one TOC member has served on TOC for three years. In fact, only one current TOC member was serving on TOC when FTA conducted its 2007 audit, and no current member served on TOC when FTA conducted its 2005 audit.
In addition, until recently, assignment to TOC was a collateral duty for each jurisdiction, and TOC membership was not included in TOC member employee job descriptions with their home agencies.
Since there is a steep learning curve required to understand WMATA’s operations and safety issues, we believe committing the necessary resources will ensure continuity and consistency as well as the ability for TOC members to conduct the needed oversight activities.
Despite evidence of good intention, TOC staff also lacks the technical and professional skills to effectively carry out its oversight duties. There are some notable exceptions among the current membership, but that is a recent development and the jurisdictions neither provide training to TOC members nor, until recently, have actively recruited members with a background in rail transit safety.
With regard to authority, there are two areas of concern for us. First, the way in which TOC is organized has proven problematic when it comes to decision-making. It is nearly impossible for the members of TOC to act quickly and with one voice, when all decisions have to be elevated in each jurisdiction. In other words, when specific compliance issues emerge at WMATA, TOC members often must obtain the authority to act from higher level executives in three separate agencies.
In addition, since TOC is not a legal entity, there is no formal process to manage conflicts of law and policy that arise among the three jurisdictions. What we found is that the lowest common denominator often prevails because that is the only way for all three jurisdictions to agree.
TOC has not been empowered by the sponsoring jurisdictions to take decisive action when WMATA fails to implement corrective actions identified by TOC. This is particularly troubling when you consider that in 2007, TOC was tracking over 200 open corrective action plans designed to prevent the recurrence of accidents. Some of those corrective action plans date back to 2004.
For these reasons, we want TOC to consider whether full-time TOC positions can be vested with decision-making authority to act in specific safety situations with WMATA.
Overall, our audit concludes that TOC and WMATA still face serious challenges. Resources for both organizations must be identified and committed. Expertise, both for TOC members and WMATA’s Safety Department, must be addressed. TOC’s authority must be reconsidered both from an operational perspective as well as for enforcement purposes. WMATA must find a way to communicate and set safety priorities within its organization. Stove-piping within WMATA, especially regarding safety, will continue to hinder its ability to address corrective action plans and meet critical safety needs. WMATA must also communicate better with TOC and TOC members must have access to WMATA’s top executives, board members and other decision-makers.
In conclusion, I want to take a moment to explain how the Obama Administration’s transit safety reform bill would address many of the deficiencies that we found at WMATA and the TOC.
First, our legislative proposal would provide FTA direct oversight authority over individual transit systems. The bill would grant us the ability to issue regulations and enforce them. So our legislative proposal would allow FTA to set minimum, national standards regarding such issues as track worker protection, crashworthiness, on-board event recorders or the institution of safety management systems to ensure critical safety issues receive the attention they deserve.
Under our legislative proposal, the FTA would be empowered with the same tools that agencies like the FAA have to compel the compliance of regulated parties. While State Safety Oversight (SSO) agencies would have the opportunity to enforce Federal regulations on the FTA’s behalf, they would only be allowed to do so if they had the staff strength, expertise, and legislative authority to compel compliance by the transit providers.
Importantly, our legislative proposal would provide Federal funds to SSOs for hiring, training, inspections, and other safety-related activities. Rather than having SSO’s that are understaffed and undertrained, the FTA would provide resources to ensure that they are up to the task.
Most importantly, our legislative proposal is built around the goal of getting every rail transit provider, including Metro, to embrace state-of-the-art Safety Management Systems (SMS). An effective SMS is one where every employee, from the lowest to the highest rungs of the operation, are keeping their eyes and ears on safety concerns. Those employees are routinely reporting their observations and concerns in a non-threatening environment to agency experts who regularly analyze and address the most critical safety concerns first. It’s an environment where communication is constant and safety is paramount. That is our vision for safer rail transit systems across the nation, including Washington Metro. We ask for your help in getting us there by passing President Obama’s transit safety legislation promptly.
You have my commitment and Secretary LaHood’s commitment that we will continue to work with this regional delegation to advance the cause of safety on Washington Metro.
I thank you again for the opportunity to be here today to summarize our audit findings and I would be happy to answer any questions you may have.