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MBTA track department workers didn’t do their jobs and missed critical problems, new report says

With all the system's problems, twenty-six percent of the T’s subway tracks still required trains to slow down as of Thursday.Jonathan Wiggs/Globe Staff

MBTA workers responsible for checking subway infrastructure for defects either didn’t understand their responsibilities or didn’t fulfill them and, as a result, missed dangerous problems on vast swaths of the subway as recently as March, according to a new report.

The review, commissioned by the T after the agency implemented more than 100 new speed restrictions across the system earlier this year, also found that many workers in charge of inspecting the system’s tracks don’t have enough experience or training.

The new speed restrictions suddenly slowed down commutes for hundreds of thousands of people in the Boston region, deepening dissatisfaction with the state’s largest transit system. The report, together with an analysis from the T’s own safety department, offers riders a new view of the beleaguered agency’s dysfunction that has created such extra-painful commutes in recent months.


The 18-page report by Charles L. O’Reilly of Carlson Transport Consulting LLC, released by the T on Thursday, found the root causes of the failure were “a systemic lack of clarity” about the responsibilities of most positions in the Maintenance of Way department — responsible for track safety — and workers misunderstanding or failing to do their jobs. The 19-page MBTA safety department report found the root cause of the failure to be “employee error or organizational issue.”

Twenty-six percent of the T’s subway tracks still required trains to slow down as of Thursday, according to the agency’s dashboard, up from around 8 percent on March 8, before the added restrictions were imposed. Despite recent efforts to speed up track repairs, the T is having trouble eliminating slow zones more quickly than it is adding new ones. Travel times have increased significantly since Governor Maura Healey took office in January.

General manager Phillip Eng said he was not surprised by the evaluations, which began before he took over on April 10. But, in a decision a key advocacy group panned as a mistake, Eng said no one at the T will face discipline or termination for the failure.


“I think what was evident in this is that the way the organization was set up, it had too many blurred lines, and hence the roles and responsibilities went across multiple parties,” Eng said in an interview. “It wasn’t one person.”

O’Reilly recommended the T create “Standard Operating Procedures” for track inspections, increase qualification requirements, training, and staffing for track inspectors, change the criteria for track defect testing, and develop a long-term improvement plan. The findings, highlighting the T’s failure to properly maintain its system, are similar to those made by outside experts at least three times since 2009.

The reports do not name names.

As of Thursday, there were 227 speed restrictions in place across the MBTA subway system, up from 71 on March 8, before more trains were slowed.Pat Greenhouse/Globe Staff

The Maintenance of Way director job has been vacant for more than nine months, according to the T’s safety department report, dated Aug. 31. Joseph Cheever, chief of engineering and maintenance, who was managing the responsibilities of the director role in March, is ultimately responsible for the Maintenance of Way department. John Ray, assistant general manager for commuter rail operations, started in a new role as senior director of Maintenance of Way this week, Eng said.

Slow zones have plagued the subway system for years as the agency avoided making repairs to its tracks, opting to instead slow down trains over faulty areas. But the situation became considerably worse in March when the T’s state oversight agency, the Department of Public Utilities, found problems with tracks that the T didn’t appear to know about.


The T periodically uses “track geometry testing” in which a machine evaluates the subway tracks for defects that a human eye might miss during visual inspections. The defects found by those tests are supposed to be verified by the Maintenance of Way department to eliminate false positives — called “ghosts” — and then either repaired immediately or covered by a slow zone until the repair can be made.

O’Reilly found that the Maintenance of Way department did not verify or correctly respond to the results of geometry testing done in the third and fourth quarter of 2022 by the time the next round of testing was conducted in the first quarter of 2023, an extraordinary gap for such safety-related infrastructure. When the T discovered it hadn’t done that work, following a request for documentation from the DPU, the agency slowed trains across the entire system and then quickly hired several outside consulting firms to search all the tracks for defects.

The DPU and the T found “missed defects and prior defects that were not being reviewed and recorded in subsequent visual inspections, as well as missing documentation of verification of vendor testing including entry of verified defects into the MBTA asset management system,” O’Reilly’s report said.

As of Thursday, there were 227 restrictions in place, according to the MBTA’s dashboard, up from 71 on March 8, before more slow zones were added.


System repairperson positions are filled by Maintenance of Way laborers, according to the report, and require two years of experience in track maintenance. But sometimes that experience isn’t directly related to track repair, and instead in tasks like landscaping.

The T’s safety department report said the process for verifying defects on the subway system tracks “was not formalized and undocumented,” creating confusion about who was in charge of what, especially as senior roles in the Maintenance of Way department have been left vacant.

“We were stretched thin,” Eng said. “Certainly, the staff needs were not the top priority of the prior administrations.”

After the huge increase in speed restrictions earlier this year, the Healey administration vowed to quickly get to the bottom of the problem.

“The governor has directed the MBTA to conduct a thorough review of this situation and take immediate corrective actions to ensure accountability,” a Healey spokesperson, Karissa Hand, said in early April.

The T said it hired O’Reilly for 90 days to investigate what went wrong, agreeing to pay him $300 per hour and no more than $70,000 to figure out how the T was unable to account for so many track problems.

The MBTA will suspend service on the Red Line’s Ashmont Branch and Mattapan Line for more than two weeks in October.Erin Clark/Globe Staff

The T extended its contract with O’Reilly to complete a “final report” by Labor Day, T spokesperson Joe Pesaturo said in July.

The report said its scope was narrow, and only looked at the inspection and maintenance responsibilities of the Maintenance of Way department.


MBTA Advisory Board executive director Brian Kane said “austerity policies” that encourage T leadership to retire early and discourage lower managers from moving up because they’ll lose overtime pay haven’t helped the situation.

“We know they need more people to support a safe, effective, reliable system, but are we going to pay for it?” Kane said. “Over the last 30 years the answer to that question has been no. And we know what that result has been.”

TransitMatters executive director Jarred Johnson said he appreciates the T’s transparency about the failures, but wishes there were more repercussions.

“I would have liked to have seen some greater form of accountability for the folks whose failures led us to the slowdown and to have the system in such a poor state after riders have already endured this much,” he said.

Eng said he’s confident his new hires, including a chief of infrastructure and chief of stations, will help prevent those kinds of failures, along with better-defined roles and processes within the Maintenance of Way department.

A passenger waited for a Red Line train at Savin Hill.Erin Clark/Globe Staff

“There was never this oversight that was instilled in the organization,” he said. “What we’re doing now is we’re . . . clarifying those roles, and people are accountable going forward. The importance of this is that it’s rebuilding every level of our organization. And I think that’s sort of why it’s not an overnight fix. It is a cultural shift.”

As riders await that shift, the number of slow zones is not going down. Eng said that’s because the T is now doing a better job tracking the problems. He hopes the upcoming 16-day shutdown of part of the Red Line and Mattapan Line will turn the tide.

“We want them to realize that when they come out of it, and on that day we restore service, they will feel the improvements, they will see the improvements, and we will follow through on our commitments,” he said.

This is not the first time an outside expert has made similar recommendations to the MBTA.

O’Reilly noted that a December 2019 report by three top safety experts “touched on many of the items that continue to challenge the MBTA almost four years later.”

The inspection and maintenance of all infrastructure is fundamental to providing safe and reliable T service, O’Reilly’s report said. The pattern of serious safety incidents over the last few years, the report said, “provides evidence that both fundamental components are not being adequately managed.”

Taylor Dolven can be reached at taylor.dolven@globe.com. Follow her @taydolven.