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United States Government Accountability Office: 
GAO: 

Report to the Committee on Banking, Housing, and Urban Affairs, U.S. 
Senate: 

January 2011: 

Rail Transit: 

FTA Programs Are Helping Address Transit Agencies' Safety Challenges, 
but Improved Performance Goals and Measures Could Better Focus Efforts: 

GAO-11-199: 

GAO Highlights: 

Highlights of GAO-11-199, a report to Committee on Banking, Housing, 
and Urban Affairs, U.S. Senate. 

Why GAO Did This Study: 

Although transit service is generally safe, recent high-profile 
accidents on several large rail transit systems—notably the June 2009 
collision in Washington, D.C., that resulted in nine fatalities and 52 
injuries—have raised concerns. The Federal Transit Administration 
(FTA) oversees state agencies that directly oversee rail transit 
agencies’ safety practices. FTA also provides assistance to transit 
agencies, such as funding and training, to enhance safety. GAO was 
asked to determine (1) the challenges the largest rail transit systems 
face in ensuring safety and (2) the extent to which assistance 
provided by FTA addresses these challenges. GAO visited eight large 
rail transit systems and their respective state oversight agencies, 
reviewed pertinent documents, and interviewed rail transit safety 
experts and officials from FTA and the National Transportation Safety 
Board (NTSB). 

What GAO Found: 

The largest rail transit agencies face several challenges in trying to 
ensure safety on their systems. First, according to some experts we 
interviewed, the level of safety culture—awareness of and 
organizational commitment to the importance of safety—varies across 
the transit industry and is low in some agencies. NTSB found that the 
lack of a safety culture contributed to the June 2009 fatal transit 
accident in Washington, D.C. Second, with many employees nearing 
retirement age, large transit agencies have found it difficult to 
recruit and hire qualified staff. It is also challenging for them to 
ensure that employees receive needed safety training because of 
financial constraints and the limited availability of technical 
training. Training helps ensure safe operations; NTSB has identified 
employee errors, such as not following procedures, as a probable cause 
in some significant rail transit accidents. Third, more than a third 
of the largest agencies’ assets are in poor or marginal condition. 
While agencies have prioritized investments to ensure safety, delays 
in repairing some assets, such as signal systems, can pose safety 
risks. The transit industry has been slow to adopt asset management 
practices that can help agencies set investment priorities and better 
ensure safety. 

FTA has provided various types of assistance to transit agencies to 
help them address these challenges, including researching how to 
instill a strong safety culture at transit agencies, supporting a 
variety of safety-related training classes for transit agency staff, 
and providing funding to help agencies achieve a state of good repair. 
The Department of Transportation (DOT) has proposed legislation that 
would give FTA the authority to set and enforce rail transit safety 
standards, which could help improve safety culture in the industry. 
FTA is also planning improvements to its training program and the 
development of asset management guidance for transit agencies, among 
other things. Some legislative proposals, studies, experts, and agency 
officials have identified further steps that FTA could take to address 
transit agencies’ safety challenges, such as requiring transit 
agencies to implement asset management practices. Some of these 
suggested further steps may have the potential, if implemented, to 
enhance rail transit safety. DOT is currently developing a legislative 
proposal for reauthorizing surface transportation programs and may 
include new rail transit safety initiatives in this proposal. In 
addition, clear and specific performance goals and measures could help 
FTA target its efforts to improve transit safety and track results. 
GAO has identified leading practices to establish such performance 
goals and measures, but FTA has not fully adopted these practices. For 
example, FTA has not identified specific performance goals that make 
clear the direct results its safety activities are trying to achieve 
and related measures that would enable the agency to track and 
demonstrate its progress in achieving those results. Without such 
specific goals and measures, it is not clear how FTA’s safety 
activities contribute toward DOT’s strategic goal of reducing 
transportation-related injuries and fatalities, including rail transit 
injuries and fatalities. Furthermore, problems with FTA’s rail transit 
safety data could hamper the agency’s ability to track its 
performance. GAO is making recommendations for improving these data in 
a separate report (GAO-11-217R). 

What GAO Recommends: 

To guide and track the performance of FTA’s rail transit safety 
efforts, DOT should direct FTA to use leading practices to set clear 
and specific goals and measures for these efforts. DOT and NTSB 
reviewed a draft of this report and provided technical comments and 
clarifications, which we incorporated as appropriate. DOT agreed to 
consider the recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-11-199] or key 
components. For more information, contact David Wise, (202) 512-2834 
or wised@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Transit Agencies Face Challenges in Ensuring the Safety of Their Rail 
Systems: 

FTA Programs Have Assisted Transit Agencies in Addressing Safety 
Challenges, but Use of Leading Practices Could Help Target Efforts and 
Track Results: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Results of NTSB's Investigations of Rail Transit Accidents: 

Appendix II: Objectives, Scope, and Methodology: 

Appendix III: DOT Safety-Related Assistance Efforts That Address 
Transit Agencies' Safety Culture, Staffing, and Training Challenges: 

Appendix IV: GAO Contact and Staff Acknowledgment: 

Tables: 

Table 1: Causes of and Factors Contributing to Significant Rail 
Transit Accidents, 2004-2010, Based on Completed NTSB Investigations: 

Table 2: NTSB's Ongoing Investigations of Heavy and Light Rail Transit 
Accidents, as of November 2010: 

Table 3: Rail Transit Safety Experts Interviewed: 

Table 4: Efforts that Address Safety Culture, Staffing, and Training 
Challenges: 

Table 5: Efforts that Address State of Good Repair Challenges: 

Figures: 

Figure 1: Characteristics of Heavy and Light Rail Systems Nationwide, 
as of 2008: 

Figure 2: State of Good Repair Challenges at Transit Agencies We 
Visited: 

Figure 3: State of Good Repair Backlog and System Information for Six 
of the Seven Transit Agencies We Visited, 2009: 

Abbreviations: 

APTA: American Public Transportation Association: 

BART: Bay Area Rapid Transit: 

CTA: Chicago Transit Authority: 

DOT: Department of Transportation: 

FRA: Federal Railroad Administration: 

FTA: Federal Transit Administration: 

LA Metro: Los Angeles County Metropolitan Transportation Authority: 

MBTA: Massachusetts Bay Transportation Authority: 

NTSB: National Transportation Safety Board: 

NYCT: New York City Transit: 

Recovery Act: American Recovery and Reinvestment Act of 2009: 

SF Muni: San Francisco Municipal Transportation Agency: 

WMATA: Washington Metropolitan Area Transit Authority: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

January 31, 2011: 

The Honorable Tim Johnson:
Chairman:
The Honorable Richard C. Shelby:
Ranking Member:
Committee on Banking, Housing, and Urban Affairs:
United States Senate: 

Although rail transit is a relatively safe mode of transportation, 
recent high-profile accidents at several of the nation's largest rail 
transit systems have raised concerns. The most serious of these 
accidents was the collision of two metrorail trains in Washington, 
D.C., on June 22, 2009, resulting in nine fatalities and 52 injuries. 
Over the last several years, collisions and derailments resulting in 
injuries and, in some cases, fatalities, have occurred on other large 
transit systems, including those in Boston, Chicago, and San 
Francisco. Moreover, according to the Federal Transit Administration 
(FTA), from January 2004 through November 2010, 16 transit right-of-
way workers and inspectors were struck and killed by trains or other 
vehicles while working along tracks on five rail transit systems. 
[Footnote 1] 

FTA, an agency within the U.S. Department of Transportation (DOT), is 
responsible for monitoring and promoting safety on rail transit 
systems operated by 47 rail transit agencies that receive federal 
funding through FTA's State Safety Oversight Program and ongoing 
assistance programs.[Footnote 2] FTA requires states with one or more 
of these rail systems to designate a state safety oversight agency, 
which is responsible for establishing standards for rail safety 
practices and procedures to be used by rail transit agencies within 
its purview and for directly overseeing their compliance with these 
standards. While FTA does not directly oversee transit agencies, it 
does oversee these state safety oversight agencies. FTA also provides 
assistance to transit agencies to help them maintain and enhance 
safety, including funding for capital improvements, safety-related 
training, technical assistance, and guidance.[Footnote 3] FTA has less 
authority to oversee safety than some other DOT agencies, such as the 
Federal Railroad Administration (FRA) that oversees freight, intercity 
passenger, and commuter railroads by setting and enforcing safety 
regulations. DOT is seeking legislative authority to directly regulate 
and enforce rail transit safety. There were several legislative 
proposals introduced during the 111th Congress to give FTA authority 
to establish safety regulations for rail transit agencies and, in 
cooperation with the states, oversee and enforce compliance by these 
agencies with these regulations.[Footnote 4] 

Concerned about recent high-profile accidents, the former Chairman of 
the Committee and Senator Shelby asked us to identify and review the 
challenges associated with enhancing safety on major rail transit 
systems. In response, this report discusses (1) the challenges the 
largest rail transit systems face in ensuring safety and (2) the 
extent to which assistance provided by FTA addresses these 
challenges.[Footnote 5] Based on investigations completed by the 
National Transportation Safety Board (NTSB), we are also reporting on 
factors that have contributed to significant rail transit accidents. 
This topic is discussed in appendix I. We originally intended to also 
report on safety trends based on data collected by FTA, but we 
determined that these data were not sufficiently reliable for this 
purpose. We are reporting separately on the reliability of FTA's 
safety data.[Footnote 6] For the purpose of this study, we are 
focusing on heavy and light rail systems, as they represent more than 
90 percent of all rail fixed guideway systems.[Footnote 7] 

To determine the challenges that the largest rail transit systems face 
in ensuring safety, we selected and visited five large heavy rail 
transit systems and three large light rail transit systems operated by 
seven rail transit agencies, using criteria such as annual ridership 
(measured by unlinked passenger trips and passenger miles), the number 
of rail transit vehicles in revenue service operation, and total track 
mileage.[Footnote 8] The five heavy rail systems we selected were the 
Massachusetts Bay Transportation Authority (MBTA), the Metropolitan 
Transportation Authority New York City Transit (NYCT), the Washington 
Metropolitan Area Transit Authority (WMATA), the Chicago Transit 
Authority (CTA), and the Bay Area Rapid Transit (BART). The three 
light rail systems we selected were MBTA, the San Francisco Municipal 
Transportation Agency (SF Muni), and the Los Angeles County 
Metropolitan Transportation Authority (LA Metro). For each of these 
systems, we visited the transit agency, obtaining agency budget 
documents, accident and audit reports, corrective action plans, and 
staffing and training information, among other information and 
documentation. In addition, we interviewed representatives from these 
transit agencies and their respective state safety oversight agencies. 

To determine the extent to which FTA's assistance addresses the safety 
challenges faced by the largest transit agencies, we reviewed FTA 
documents on funding, state of good repair initiatives, technical 
assistance programs, transit safety training, and guidance and 
outreach related to rail transit safety. We also obtained information 
on transit safety training from the National Transit Institute and the 
Transportation Safety Institute. We interviewed officials from FTA and 
NTSB, representatives of the American Public Transportation 
Association (APTA), and 12 rail transit safety experts on the 
challenges that large rail transit agencies face in ensuring safety 
and the potential ways that FTA could improve its safety assistance 
efforts. The rail transit safety experts we interviewed were 
identified for us by the National Academies' Transportation Research 
Board and included representatives from the transit industry, 
academia, labor unions, and the rail consulting community. We also 
asked officials from the transit systems we visited and their 
respective state safety oversight agencies for their assessment of 
FTA's assistance efforts. We reviewed applicable federal regulations, 
laws, and legislative proposals. In addition, we consulted our prior 
work on performance management and rail transit issues. A more 
detailed description of our scope and methodology appears in appendix 
II, including a list of the rail transit safety experts we interviewed. 

We conducted this performance audit from November 2009 to January 2011 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

Rail transit is an important component of the nation's transportation 
network, particularly in large metropolitan areas. Rail transit 
systems provide around 4.3 billion passenger trips annually. The five 
largest heavy rail systems carried 3.2 billion passengers in 2008, 90 
percent of all heavy rail trips. The NYCT system surpassed all the 
other heavy rail systems by carrying almost 2.4 billion passengers--
2.1 billion more than the next largest heavy rail system. Conversely, 
the five largest light rail systems are much smaller, collectively 
carrying 244 million passengers in 2008. The largest light rail 
system, operated by MBTA, carried 74 million passengers. Public 
transit is seen as an affordable mode of transportation and a means to 
alleviate roadway congestion and emissions. Increases in gasoline 
prices over the past decade also have resulted in higher ridership, 
which peaked in fall 2008. Although ridership declined in 2009 by 
about 4 percent, following the 2008 economic recession and a decrease 
in gasoline prices, transit ridership is expected to grow in years to 
come.[Footnote 9] 

Heavy and light rail transit systems have developed throughout the 
nation over the past 100 years. The oldest systems in cities such as 
Boston, New York, and Chicago, among others, were generally built by 
private companies which eventually went out of business, requiring the 
systems' respective local governments to provide financial help to 
keep the systems operating. During the 1960s, Congress established a 
federal capital assistance program for mass transportation. With 
federal capital assistance, many other cities constructed rail transit 
systems, including heavy rail systems in Atlanta, San Francisco, and 
Washington, D.C. Heavy rail systems tend to be larger and carry many 
more passengers than light rail systems. While there are currently 
more than twice as many light rail systems as there are heavy rail 
systems, the heavy rail systems carry about seven times as many 
passengers and cover more than 50 percent more miles of track than 
light rail systems (see figure1). The types of safety risks associated 
with each rail mode differ somewhat. For example, the higher volume of 
passengers, the higher speed of the trains, and the third rail on the 
track pose safety risks for heavy rail systems; the numerous 
interfaces between rail cars and vehicular traffic and pedestrians 
pose safety risks for light rail systems. Since the 1980s, newly 
constructed systems have been predominantly light rail systems. 

Figure 1: Characteristics of Heavy and Light Rail Systems Nationwide, 
as of 2008: 

[Refer to PDF for image: 2 photographs and associated data] 

Heavy rail: A heavy rail train operated by CTA. [photograph] 

15 systems nationwide. 

A rail fixed guideway system that has high-speed and
rapid acceleration passenger rail cars operating singly or in
multicar trains that operate on exclusive tracks and are
powered by electricity (typically from a third rail).
There is usually a separate right-of-way from which all
other traffic is excluded. Heavy rail systems may also have
sophisticated signaling, high platform loading, and a heavy
passenger volume. Typically includes subways. 

Annual total passenger trips: 3.5 billion. 

Total track miles: 2,277. 

Light rail: A light rail train operated by SF Muni. [photograph] 

33 systems nationwide[A]. 

A rail fixed guideway system that operates on either exclusive
tracks or on tracks in the street on the same level with
pedestrians and vehicular traffic. Light rail typically draws
power from overhead wires and operates as single cars or
short trains. It has a lighter passenger volume compared to
heavy rail. Typically includes streetcars and trolley service. 

Annual total passenger trips: 454 million. 

Total track miles: 1,539. 

Sources: FTA and APTA 2008 data; GAO photos. 

[A] This does not include the Galveston Island Transit System, which 
is currently not in operation (but plans to resume in the future) and 
the Hampton Roads Transit System, which is projected to start 
operations in May 2011. 

[End of figure] 

Rail transit systems are managed by public transit agencies 
accountable to their local government. However, rail transit agencies 
rely on a combination of local, state, and federal funds, in addition 
to system-generated revenues such as fares, to operate and maintain 
their systems. Some states and local governments provide a dedicated 
revenue source for transit, such as a percentage of the state or local 
sales tax, or issue bonds for public transportation. In 2008, about 57 
percent of all funds for both operating expenses and capital 
investments were from local and state government. Other sources, such 
as farebox revenues, provided 26 percent. The federal government's 
share was about 17 percent. Even though federal funding has 
predominantly been for capital investments, by 2008 local government 
replaced the federal government as the largest source of capital 
investment funds.[Footnote 10] However, in the past few years there 
have been decreases in the amounts of state and local funding 
available to transit agencies, especially for those agencies that 
depend on tax revenues, which have experienced decreases as a result 
of the general economic slowdown faced by the nation. As a result, 
many transit agencies have faced budget cutbacks. 

FTA uses many funding programs to support transit agencies. In 
particular, two FTA programs--the Urbanized Area Formula Program and 
the Fixed Guideway Modernization Program--provide funding that can be 
used by existing transit agencies in urbanized areas to modernize or 
improve their systems.[Footnote 11] Specifically, these funds can be 
used for purchasing and rehabilitating rail cars and preventive 
maintenance, among other things. In 2009, additional funds were made 
available through the American Recovery and Reinvestment Act (Recovery 
Act).[Footnote 12] Recovery Act funds are used primarily for capital 
projects, although some funds were made available for and have been 
used for operating expenses.[Footnote 13] 

In comparison with other modes of transportation, rail transit is 
relatively safe. For example, occupants of motor vehicles are more 
than 70 times more likely to die in accidents while traveling as are 
passengers of rail transit systems.[Footnote 14] However, several 
large rail transit agencies in recent years have had major accidents 
that resulted in fatalities, injuries, and significant property 
damage. NTSB has investigated a number of these accidents and has 
issued reports identifying the probable causes of and factors that 
contributed to them.[Footnote 15] Since 2004, NTSB has reported on 
eight rail transit accidents that, collectively, resulted in 13 
fatalities, 297 injuries, and about $29 million in property damages. 
In five of these accident investigations, NTSB found the probable 
cause to involve employee errors, such as the failure of the train 
operator to comply with operating rules and of track inspectors to 
maintain an effective lookout for oncoming trains while working on the 
tracks. Of the remaining three accidents, NTSB found that problems 
with equipment were a probable cause of two accidents and that 
weaknesses in management of safety by the transit agency were a 
probable cause in all three accidents. In six of these investigations, 
NTSB reported that contributing factors involved deficiencies in 
safety management or oversight, such as weaknesses in transit 
agencies' safety rules and procedures, lack of a safety culture within 
the transit agency, and lack of adequate oversight by the transit 
agency's state safety oversight agency and FTA.[Footnote 16] See 
appendix I for further information on these accident investigations. 

Transit agencies are responsible for the operation, maintenance, and 
safety and security of their rail systems but are subject to a tiered 
state and federal safety oversight program. The Intermodal Surface 
Transportation Efficiency Act of 1991 mandated FTA to establish a 
State Safety Oversight Program for rail fixed guideway public 
transportation systems that are not subject to FRA regulation. Through 
this program, FTA monitors 27 state safety oversight agencies that 
oversee the safety of rail transit operations in 25 states, the 
District of Columbia, and Puerto Rico.[Footnote 17] While FTA has 
discretionary authority to investigate safety hazards at transit 
systems it funds, it does not have authority to directly oversee 
safety programs of rail transit agencies. FTA, however, does have the 
authority and responsibility for overseeing transit agencies' 
workplace drug and alcohol testing programs.[Footnote 18] FTA also 
collects safety data, including data on types of accidents and causes, 
from the state safety oversight agencies and the transit agencies they 
oversee. Transit agencies provide safety data for FTA's National 
Transit Database while the state safety oversight agencies provide 
safety data through annual reports to FTA. 

Under FTA regulations, state safety oversight agencies must develop a 
program standard that outlines transit agencies' safety 
responsibilities. In particular, transit agencies are required to 
develop and implement safety programs that include, among other things, 

* standards and processes for identifying safety concerns and hazards, 
and ensuring that they are addressed; 

* a process to develop and ensure compliance with rules and procedures 
that have a safety impact; and: 

* a safety training and certification program for employees.[Footnote 
19] 

Moreover, FTA requires state safety oversight agencies to perform 
safety audits of their transit agencies at least once every 3 years, 
investigate transit accidents, and ensure that deficiencies are 
corrected. FTA, however, does not fund state safety oversight agencies 
to carry out this work. Our earlier work found that many state safety 
oversight agencies lacked adequate staffing, employed varying 
practices, and applied FTA's regulations differently.[Footnote 20] As 
noted earlier, FTA's role in overseeing safety on rail transit systems 
is relatively limited, which is reflected in the number of staff that 
it employs to fill that role. FTA's Office of Safety and Security has 
15 to 17 staff members managing safety, security, and emergency 
management programs. They are supported by contractor staff. 

In December 2009, DOT proposed to Congress major changes in FTA's role 
that would shift the balance of federal and state responsibilities for 
oversight of rail transit safety. DOT proposed the following: 

* FTA, through legislation, would receive authority to establish and 
enforce minimum safety standards for rail transit systems not already 
regulated by FRA. 

* A state may continue to have a state safety oversight program to 
oversee public transportation safety--by "opting in"--given that its 
program complies with the federal laws, regulations, and policies that 
FTA would implement if it receives expanded authority proposed in the 
legislation. DOT would provide federal assistance to states with FTA- 
approved state safety programs to enforce the federal minimum safety 
standards. Participating states could set more stringent safety 
standards if they chose to do so. 

* In states that decided to "opt out" of participation or where FTA 
has found the program proposals inadequate, FTA would oversee 
compliance with and enforce federal safety regulations. 

Subsequently, during the 111th Congress, several bills including these 
changes were proposed.[Footnote 21] 

Transit Agencies Face Challenges in Ensuring the Safety of Their Rail 
Systems: 

Instilling Safety Culture Is a Challenge for the Largest Transit 
Agencies: 

Instilling a safety culture agencywide is a challenge the largest 
transit agencies face that can impact their ability to ensure safe 
operations.[Footnote 22] The concept of safety culture can be defined 
in different ways and the level of safety culture in an organization 
can be difficult to measure. As we have previously reported, safety 
culture can include: 

* organizational awareness of and commitment to the importance of 
safety, 

* individual dedication and accountability for those engaged in any 
activity that has a bearing on safety in the workplace, and: 

* an environment in which employees can report safety events without 
fear of punishment.[Footnote 23] 

According to NTSB officials, in organizations with effective safety 
cultures, senior management demonstrates a commitment to safety and a 
concern for hazards that are shared by employees at all levels within 
the organization. Furthermore, such organizations have effective 
safety management systems that include appropriate safety rules and 
procedures, employee adherence to these rules and procedures, well- 
defined processes for identifying and addressing safety-related 
problems, and adequate safety training available for employees and 
management. 

FTA officials told us that it is difficult to define safety culture 
but noted that attributes of a strong safety culture include open 
communication about safety throughout the agency, nonpunitive safety 
reporting by employees, and the identification of safety trends based 
on agency-collected data. In addition, APTA officials told us that 
another attribute of safety culture is the accountability of 
individuals for how their actions and the actions of others affect 
safety. According to FTA, a strong safety culture can energize and 
motivate transit employees to improve safety performance. As we 
subsequently discuss, FTA currently has efforts underway that may more 
clearly communicate what a strong safety culture entails. All 12 of 
the rail transit experts we interviewed agreed that safety culture was 
important in helping transit agencies lower their accident rates. 

The experts we consulted offered several views about safety culture at 
large transit agencies. Seven experts noted that the extent of safety 
culture varies at large transit agencies across the country. Four 
experts stated that the extent of safety culture was generally low 
throughout the rail transit industry and needed to be improved. Some 
experts also noted that despite system differences, a major reason why 
certain systems have more or fewer incidents is the extent of safety 
culture present at the transit agency. One expert in particular said 
that all the other safety challenges transit agencies faced flow from 
safety culture issues. Some experts we interviewed identified the 
importance of training to help instill a safety culture at all levels 
of a transit agency. We have reported that training should support an 
agency's goal of changing workplace culture to increase staff 
awareness of, commitment to, and involvement in safety.[Footnote 24] 
Thus, the challenge faced by the largest transit agencies in providing 
sufficient training for staff--discussed below--can increase the 
challenge of instilling a safety culture at those same agencies. 

FTA officials have identified the need to improve safety culture as a 
continuing problem for the transit industry as a whole, which requires 
changing behaviors and processes that have become engrained over 
decades of service. FTA has reported that, to get to the root of 
safety culture, transit agency management and employees need to 
understand the current state of their safety programs, how employees 
perceive management's commitment to safety, how employees actively 
follow established safety rules and procedures and how they are held 
accountable for doing so, and how management monitors employees' 
safety performance.[Footnote 25] FTA officials noted that limitations 
in transit agencies' collection and analysis of safety data impede 
their ability to improve their safety culture, because these 
limitations affect their ability to identify and address safety 
hazards. 

Safety culture can have a significant impact on safety performance. In 
two of its reports on accidents since 2004, NTSB has noted that an 
inadequate safety culture contributed to the accidents.[Footnote 26] 
Probable causes in the accidents that the NTSB investigated included 
employee errors, such as failure to comply with operating rules, and 
inadequate safety management and oversight by transit agencies. 
Problems such as these may reflect a poor safety culture, as employees 
may not be motivated to follow operating rules and management may not 
be properly managing safety programs to ensure that hazards are 
identified and addressed. In its report on the 2008 accident on MBTA's 
system that resulted in one fatality and eight injuries, NTSB found 
that the probable cause was the failure of the train operator to 
comply with a controlling signal resulting from an episode of micro- 
sleep,[Footnote 27] and noted an MBTA report of an internal audit that 
stated the success of any new safety plan was largely dependent on the 
safety culture that MBTA fostered within each agency department and 
work group.[Footnote 28] Additionally, NTSB cited this report as 
stating that MBTA management needed to define, understand, and 
integrate effective practices into day-to-day work activities to 
ensure that the safety of employees and passengers remained a top 
priority. In its report on CTA's 2006 derailment that resulted in 152 
injuries, NTSB found that ineffective management and oversight of its 
track inspection and maintenance program was a probable cause. 
Specific problems included ineffective supervisory oversight of track 
inspections, lack of complete inspection records and follow-up to 
ensure defects were corrected, and insufficient training and 
qualification requirements for track inspectors.[Footnote 29] NTSB 
found that these identified problems were all part of a deficient 
safety culture that allowed the agency's track infrastructure to 
deteriorate to an unsafe condition. 

In its report on WMATA's June 2009 collision that resulted in nine 
fatalities and 52 injuries, NTSB identified the lack of an effective 
safety culture as a contributing factor to the accident.[Footnote 30] 
According to NTSB, shortcomings in WMATA's internal communications, 
recognition of hazards, assessment of risk from those hazards, and 
implementation of corrective actions were all evidence of an 
ineffective safety culture and were symptomatic of a general lack of 
importance assigned to safety management functions across the WMATA 
organization. NTSB made recommendations to WMATA to improve its safety 
culture. In response to NTSB's recommendations to improve its safety 
culture, WMATA is taking a number of actions, including: 

* the development of procedures to ensure clear communication and 
distribution of safety-related information and the monthly review of 
data and trend analyses, 

* the establishment of a safety hotline and email for employees to 
report safety concerns, 

* an updated whistleblower policy to encourage employee participation 
and upper management review of identified safety concerns, 

* an amended mission statement to reflect the agency's commitment to 
safety, and: 

* a newly formed committee of WMATA's Board of Directors to make 
recommendations monthly on assuring safety at WMATA. 

Some other transit agencies have also made efforts to increase the 
extent of safety culture present in their agencies. For example, 
officials from three transit agencies we spoke with stated that their 
transit agencies created and supported nonpunitive safety reporting 
programs such as whistleblower policies and anonymous tip hotlines to 
encourage employees to keep management aware of safety problems. One 
agency told us they have a close call reporting program. These 
programs can encourage employees to voluntarily and confidentially 
report close call incidents without fear of reprisal.[Footnote 31] We 
have previously reported that it is unlikely that employees would 
report safety events in organizations with punishment-oriented 
cultures in which employees are distrustful of management and each 
other. Blaming individuals for accidents not only fails to prevent 
accidents but also limits workers' willingness to provide information 
about systemic problems.[Footnote 32] To promote reporting in such 
environments, systems can be designed with nonpunitive features to 
help alleviate employee concerns and encourage participation. In 
addition, some transit agencies we visited are reaching outside of the 
organization for support to further instill safety culture at their 
agencies. For example, officials at three transit agencies told us 
they had hired or planned to hire consultants to audit the system and 
make recommendations for improvements to increase the safety culture 
at all levels of the organization. According to APTA officials, the 
transit industry recognizes that labor organizations must be engaged 
in a visible partnership at all stages of safety culture development. 

Multiple Factors Have Made Staffing and Training a Challenge for Large 
Transit Agencies: 

In addition to instilling safety culture at transit agencies, 
maintaining an adequate level of skilled staff and ensuring that they 
receive needed safety training are also challenges the largest transit 
agencies face in ensuring safety.[Footnote 33] Staffing challenges 
involve recruiting and hiring qualified employees to fill positions 
with safety responsibilities--such as safety department staff, 
maintenance staff, track workers, and operation managers--and 
adequately planning for the loss of such staff through vacancies and 
retirements. For example, several transit agencies told us it has been 
difficult to hire maintenance employees with the necessary expertise 
and knowledge of both aging and new technology systems. Officials from 
two transit agencies noted the difficulty in hiring maintenance 
employees who have experience working with older electronic technology-
-some of which dates from the 1960s--and who are also knowledgeable of 
current computer technology. In addition, many transit agencies face 
an aging workforce and the potential for large numbers of upcoming 
retirements. For example, one transit agency we visited identified 
more than 50 percent of its staff as eligible for retirement within 
the next 5 years. FTA officials told us that staffing is a challenge 
facing transit agencies nationwide due to the large number of 
employees nearing retirement eligibility and the difficulty in 
retaining and replacing qualified employees. In addition, a recent 
APTA report identified that the transit industry has an experienced 
but aging workforce, with a significant number of potential 
retirements expected in the next 10 years.[Footnote 34] 

The staffing challenge has been further exacerbated for transit 
agencies by recent budget cutbacks as a result of flat or decreased 
funding from state and local governments. Officials at six of the 
seven transit agencies we visited stated that their staffing levels 
have been or will be cut, including some safety staff at three of 
these agencies.[Footnote 35] For example, at one transit agency we 
visited officials stated that, due to their current budget shortfall, 
staffing levels would be reduced, including in the safety department 
where 3 positions from the overall 93 positions were cut. In addition, 
at another transit agency we visited, one official cited staffing 
levels being stretched to the point where it is difficult to conduct 
the necessary rail car maintenance to keep the system running. 

Training challenges for large transit agencies have included 
difficulties in ensuring that staff receive needed safety-related 
training--such as training in track safety, fire and evacuation, risk 
assessment, and the inspection and maintenance of track and equipment--
due to financial constraints as well as the limited availability of 
technical training. Some experts identified ensuring adequate levels 
and frequency of training as key challenges for large transit 
agencies. Some cited training cuts as being commonplace when budget 
cutbacks occur despite its importance and link to safety. All the 
transit agencies we visited identified a challenge in having employees 
participate in safety training either due to the inability of their 
agencies to pay for training or to cover employees' positions while 
they attend training, or a combination of both. For example, some 
officials explained that if a train operator attends safety training 
another train operator must work an extra shift to cover for the 
operator attending training. The transit agency pays for overtime 
hours for the extra shift worked by the train operator. Officials at 
some of the transit agencies we visited told us that these additional 
costs for training can be prohibitive. A recent APTA report identified 
safety training as well as supervisory and leadership training as top 
training needs for the industry.[Footnote 36] 

The large transit agencies we visited have different types of training 
programs available for their staff. For example, one transit agency 
has a large in-house training program that provides safety training 
and certification for their staff. Each department within the agency 
tracks employee training schedules, participation, and goals. At 
another transit agency, officials explained that, while they do some 
of their training in-house, they rely to a great extent on on-the-job 
training. Officials from three transit agencies noted that the 
availability of apprenticeship programs and external technical 
training, such as training in how to inspect rail and signals, is 
limited. One transit agency official and one state safety oversight 
agency official mentioned that the transit industry often relies on on-
the-job training. According to APTA officials, on-the-job training is 
a vital part of transit agencies' training programs and can mitigate 
institutional knowledge loss as attrition occurs. However, they also 
noted that transit agencies often have not formalized their on-the-job 
training by documenting key elements to be covered and that this type 
of training is not carried out consistently among transit agencies. 
The transit agencies we visited also sent staff to training courses 
offered by DOT's Transportation Safety Institute and FTA's National 
Transit Institute. However, due to the high costs of traveling for 
training--including lodging and transportation costs--most of the 
transit agencies we visited cited difficulty in participating in such 
training opportunities. Transit agencies have attempted to find more 
cost effective ways of addressing this problem. For example, officials 
from three transit agencies told us they have offered to host DOT and 
FTA training at their agencies to reduce the travel costs associated 
with staff attending safety training courses. 

Employees who have not had adequate safety-related training may be 
more likely to commit errors that can cause accidents. For example, in 
a 2009 investigation on how NYCT inspectors identified and reported 
defects in subway platform edges--which caused three transit riders 
within 3 years to fall onto the tracks after defective boards broke 
under their weight--the transit system's Office of the Inspector 
General identified the lack of training on accurately and consistently 
identifying safety hazards at platform edges as contributing to the 
accidents.[Footnote 37] The office recommended that NYCT provide 
intensive and continuing training for platform inspectors. In 
response, NYCT developed and implemented a training program in May 
2009 on identifying platform edge defects for all station managers and 
supervisors. In addition, in five of the eight rail transit accident 
investigations conducted by the NTSB since 2004, employee errors, such 
as not following procedures, were identified as a probable cause of 
the accidents. According to one expert we interviewed, training can 
help prevent accidents by preventing employee complacency and 
inattention in regards to safety rules and procedures. Some experts 
noted that attention to safety becomes more, not less, important as 
employees gain experience, as system familiarization leads some 
workers to drop their focus on safety. NTSB officials cited the 
importance of periodic refresher training for employees to ensure that 
staff maintain the skill set needed to identify and resolve safety 
issues. Another benefit of adequate training is helping to prepare the 
transit workforce to handle pending retirements. 

Currently, no industry standards exist for what an adequate level of 
safety-related training should be for transit agency staff. According 
to APTA, the transit industry lacks a standard training curriculum for 
transit employees and, as a result, transit safety-related training at 
transit agencies lacks consistency and is not always of high quality. 
FTA officials have also identified a lack of consistent training 
throughout the transit industry. According to one expert we 
interviewed, because of the lack of consistent training standards, the 
management of individual transit agencies has to determine on its own 
what safety training is needed for agency employees. According to NTSB 
officials, without minimum training requirements, the level of 
training available at each transit agency will vary, which can result 
in differing safety outcomes for each agency. 

Achieving a State of Good Repair Is a Challenge for the Largest 
Transit Agencies: 

Achieving a state of good repair is a challenge the largest transit 
agencies face that can impact their ability to ensure the safety of 
their heavy and light rail systems.[Footnote 38] In general, state of 
good repair is a term that transit officials use to refer to the 
condition of transit assets--for example, rail tracks, elevated and 
underground structures, rail cars, signals, ties, and cables (see 
figure 2). In a study of the seven largest rail transit systems 
completed in 2009, FTA determined that more than a third of these 
agencies' assets were in poor or marginal condition, indicating that 
they were near or had already surpassed their expected useful life. 
[Footnote 39] At six of the large transit agencies we visited, 
according to FTA estimates, the proportion of rail transit assets 
considered to be in poor or marginal condition ranged from zero 
percent, at LA Metro's relatively new system, to 41 percent, at the 
much older and larger NYCT system.[Footnote 40] 

Figure 2: State of Good Repair Challenges at Transit Agencies We 
Visited: 

[Refer to PDF for image: 3 photographs and accompanying data] 

SF Muni rail yard track that is stressed and worn. Track defects can 
increase the likelihood of derailments. 

CTA heavy rail elevated structure deterioration. The metal post was 
added to prevent instability in the structure. 

MBTA pump room before rehabilitation and replacement. Some transit 
agency electrical and pumping equipment is decades old, lowering the 
reliability of power and safe operations. 

Sources: GAO, CTA, and MBTA. 

[End of figure] 

Efforts to achieve a state of good repair include maintaining, 
improving, rehabilitating, and replacing assets. The delay of some of 
these efforts can affect safety. Officials at one transit agency 
identified potential safety risks that could arise from delayed 
repairs, including worn tracks that could contribute to derailments, 
failures with the signal system that could allow for collisions, and 
failures with the traction power cable that could cause fires in 
subway tunnels. However, according to FTA and transit agency 
officials, transit agencies prioritize funding for state of good 
repair efforts to ensure that repairs important for safety are not 
delayed. All the transit systems we visited reported taking measures 
to ensure that their systems are safe in planning their state of good 
repair efforts. For example, one transit agency has reduced cleaning 
and other maintenance not critical for system safety as it continues 
to fund safety improvements. According to officials from this transit 
agency, less critical system safety items, such as escalator and 
elevator maintenance, have been put on a prolonged maintenance 
schedule. However, officials at this transit agency also stated that 
the agency had reached a point where further budget cuts would cause 
deterioration in system safety. In another example, one transit agency 
we visited has delayed the approximately $500 million replacement of 
subway fans which would provide for better ventilation because the 
agency determined that this was not a high safety priority. Agencies 
have made efforts to maintain safe operation of their system despite 
delays in addressing identified state of good repair maintenance or 
replacement needs. For example, officials at one transit agency we 
visited told us that they have implemented "slow zones" where trains 
run at lower speeds to help ensure safe operating conditions on aging 
track. 

In some cases, unaddressed poor asset conditions have contributed to 
accidents. For example, in its investigation of a 2006 derailment on 
the CTA system that injured 152 people, NTSB found that rail track 
problems that should have placed the tracks out of service were not 
identified and repaired. NTSB found that the track problems were 
readily observable and should have been identified and corrected. 
[Footnote 41] 

According to FTA officials, the transit industry has been slow to 
adopt asset management practices that would allow transit agencies to 
efficiently manage state of good repair needs. Officials noted that 
reasons for this slowness include the cost of development and 
implementation of asset management practices as well as the diversity 
of assets across and within transit systems. Transit asset management 
is a strategic approach for transit agencies to manage their transit 
assets and plan appropriately for rehabilitation and replacement. 
Asset management practices can help agencies decide how best to 
prioritize their investments, which can help ensure that safety needs 
are addressed. Such practices include tracking assets and their 
conditions and using this information to conduct long-term capital 
planning. However, no common standards for asset management practices 
exist and transit agencies use varying methods for determining the 
condition of their assets. A recent FTA study found that the use of 
these asset management practices at large transit agencies varied 
widely. 

Another component of asset management is the compilation of asset 
inventories by transit agencies. FTA defines an asset inventory as a 
current and comprehensive listing of all major assets used in the 
delivery of transit services, compiling the attributes of asset type, 
location, condition, age, and history, among other things.[Footnote 
42] According to FTA, while some of the nation's larger transit 
systems, among others, have developed asset inventories specifically 
to assist with capital planning purposes, not all have done so and 
currently no industry standard or preferred method for retaining asset 
inventory data exists.[Footnote 43] Furthermore, not all large transit 
agencies conduct comprehensive assessments of their asset conditions 
on a regular basis. 

Investments that transit agencies have made in previous years on state 
of good repair efforts have not kept pace with asset deterioration. 
According to FTA's 2009 study, an estimated $50 billion is needed to 
bring the seven largest rail transit systems into a state of good 
repair.[Footnote 44] FTA found that these agencies were investing $500 
million less than the annual investment needed to prevent this state 
of good repair backlog from increasing.[Footnote 45] Based on FTA's 
estimates, the proportion of these agencies' assets exceeding their 
useful life would increase from 16 percent to more than 30 percent by 
2028 if funding levels remain unchanged. 

The state of good repair backlog for six of the seven transit agencies 
that we visited varies, in part due to system characteristics such as 
age, size, and use of the system (see figure 3). According to NTSB and 
FTA officials, having a large state of good repair backlog does not 
necessarily mean that a transit system is unsafe. NYCT has a 
considerably higher backlog in comparison with the other transit 
agencies we visited. For example, its backlog is more than five times 
that of CTA, the next largest backlog of the agencies we visited. The 
backlog for the five remaining transit agencies ranges from $5 million 
to about $5 billion. LA Metro's state of good repair backlog is much 
smaller in comparison to the other transit agencies we visited in part 
due to the young age of its heavy and light rail systems. These 
backlogs can be much larger than these agencies' capital budgets. For 
example, the state of good repair backlog for NYCT is $27.31 billion 
while its 5-year capital budget is $12.32 billion. According to a 2010 
FTA study of the transit industry as a whole, state of good repair 
investment backlogs are higher for heavy rail than light rail, 
reflecting the relatively young age of light rail assets in comparison 
to heavy rail assets.[Footnote 46] Recent budget cutbacks and 
budgetary shortfalls have negatively impacted transit agencies' 
ability to sufficiently invest to prevent the worsening of their state 
of good repair backlogs and asset conditions.[Footnote 47] All of the 
rail transit agencies we visited cited financial constraints as 
affecting their ability to achieve a state of good repair. 

Figure 3: State of Good Repair Backlog and System Information for Six 
of the Seven Transit Agencies We Visited, 2009: 

[Refer to PDF for image: vertical bar graph and associated table] 

Transit agency: BYCT; 
State of good repair backlog: $27.31 billion; 
Type of rail system: Heavy; 
Average age of fleet (in years): 20.4; 
Total track mileage: 835; 
Vehicles available for peak service: 5,288; 
Passenger miles traveled (in millions): 9,998; 
Percentage of assets in poor or marginal condition: 41%. 

Transit agency: CTA; 
State of good repair backlog: $5.06 billion; 
Type of rail system: Heavy; 
Average age of fleet (in years): 24.7; 
Total track mileage: 288; 
Vehicles available for peak service: 1,016; 
Passenger miles traveled (in millions): 1,184; 
Percentage of assets in poor or marginal condition: 27%. 

Transit agency: BART; 
State of good repair backlog: $1.91 billion; 
Type of rail system: Heavy; 
Average age of fleet (in years): 10.7; 
Total track mileage: 268; 
Vehicles available for peak service: 540; 
Passenger miles traveled (in millions): 1,449; 
Percentage of assets in poor or marginal condition: 22%. 

Transit agency: WMATA; 
State of good repair backlog: $1.01 billion; 
Type of rail system: Heavy; 
Average age of fleet (in years): 19.2; 
Total track mileage: 270; 
Vehicles available for peak service: 830; 
Passenger miles traveled (in millions): 1,640; 
Percentage of assets in poor or marginal condition: 12%. 

Transit agency: MBTA; 
State of good repair backlog: $1.00 billion; 
Type of rail system: Heavy/Light; 
Average age of fleet (in years): 24.5/15.8; 
Total track mileage: 186; 
Vehicles available for peak service: 472; 
Passenger miles traveled (in millions): 737; 
Percentage of assets in poor or marginal condition: 18%. 

Transit agency: LA Metro; 
State of good repair backlog: $0.05 billion; 
Type of rail system: Heavy/Light; 
Average age of fleet (in years): 12.0/14.7; 
Total track mileage: 150; 
Vehicles available for peak service: 172; 
Passenger miles traveled (in millions): 525; 
Percentage of assets in poor or marginal condition: 0%. 

Source: FTA. 

[A] We were not able to obtain comparable information for the other 
transit agency we visited, SF Muni, because it was not included in 
FTA's studies. All figures are for the year 2009 except for figures on 
the average age of fleet, which are for the year 2008, the most recent 
information available. 

[End of figure] 

FTA Programs Have Assisted Transit Agencies in Addressing Safety 
Challenges, but Use of Leading Practices Could Help Target Efforts and 
Track Results: 

FTA Programs Have Assisted Transit Agencies in Addressing Safety 
Challenges, Although Some Have Suggested Changes or Additional Efforts: 

Safety Culture: 

FTA has various efforts underway that may help instill a more robust 
safety culture at transit agencies. Through the Transit Cooperative 
Research Program, FTA has recently begun a study on safety culture at 
transit agencies.[Footnote 48] Given the difficulty of defining safety 
culture, this effort has the potential to more clearly communicate 
what a strong safety culture at transit agencies entails. The project 
will look at the culture of the working environment in which serious 
accidents occur, elements of an effective safety culture in a transit 
agency, and best practices for transit organizations to implement an 
effective safety culture. DOT's draft Strategic Plan also notes the 
importance of encouraging DOT, government partners, safety advocates, 
and industry leaders to adopt a strong and consistent safety culture 
that does not accept the inevitability of fatalities on the nation's 
transportation systems. 

According to FTA officials, their safety guidance, outreach, and 
training provided by the National Transit Institute and Transportation 
Safety Institute, have helped encourage transit agencies to discuss 
and examine institutional safety culture. An example of these efforts 
cited by FTA officials is a FTA-produced video, "A Knock at Your 
Door." The video re-enacts fatal rail transit accidents to underscore 
the importance of safety procedures. FTA officials also mentioned that 
they have encouraged discussions about the importance of safety 
culture at roundtable meetings with transit agency management and 
other officials, teleconferences, and training classes. In addition, 
FTA has also sent letters to transit agencies following incidents to, 
among other things, bring incidents and safety culture trends to the 
attention of transit agency management. FTA officials were uncertain 
how much transit agencies use such guidance and outreach, as well as 
what impact these efforts have on safety. FTA has distributed nearly 
500 copies of its safety video to rail transit agencies, state safety 
oversight agencies, and others. More information on current and 
planned efforts by FTA to address safety culture challenges at transit 
agencies is available in appendix III. 

Proposed legislation would give FTA the authority to set and enforce 
safety standards, which could also strengthen transit agencies' safety 
culture through increased oversight, in addition to assistance. 
[Footnote 49] If passed, this legislation would result in FTA 
receiving authority to directly regulate rail transit safety and, in 
cooperation with the states, to oversee and enforce rail transit 
systems' compliance with these regulations. We testified in December 
2009 that these changes in oversight would bring FTA's authority more 
in line with that of some other modal administrations within DOT, such 
as FRA.[Footnote 50] Additionally, the DOT Secretary has testified 
that with such authority, FTA would become more proactive in setting 
safety thresholds that would result in greater consistency and 
uniformity across transit systems in the United States. In our 
testimony, we noted that providing FTA and participating states with 
such authority could help ensure compliance with standards and 
improved safety practices, and might prevent some accidents as a 
result.[Footnote 51] However, we also noted that Congress may need to 
consider a number of issues in deciding whether and how to implement 
such legislation. These include how best to balance federal versus 
state responsibilities, how to ensure that FTA has adequate qualified 
staff to carry out such a program, and what level of resources to 
devote to the program. 

In addition to these efforts, FTA has recently formed the Transit Rail 
Advisory Committee for Safety. The committee is expected to provide 
information, advice, and recommendations--including recommendations 
for instilling a safety culture at transit agencies--to the Secretary 
of Transportation and the FTA Administrator on all matters relating to 
the safety of U.S. public transportation systems and activities. 
Members of the committee include representatives with expertise in 
safety, transit operations, or maintenance; representatives of 
stakeholder interests that would be affected by transit safety 
requirements; persons with policy experience, leadership, or 
organizational skills; and regional representatives. The committee 
held its first meeting on September 9-10, 2010, and established two 
workgroups, one tasked with researching safety planning models for 
transit agencies and the other with identifying the best model for 
organizing a state safety oversight agency organization. Both of these 
workgroups were tasked to produce recommendations based on their work 
in May 2011. The safety planning model workgroup could help strengthen 
safety culture through its work to determine the best safety 
management system principles for transit agencies of any size to 
enhance rail transit safety, including policy practices, stakeholder 
relationships, and any desired changes to current law or regulations. 

NTSB officials, transit agency officials, experts we met with, and 
others have proposed that FTA take additional steps to help transit 
agencies address safety culture challenges. These have included: 

* Develop nonpunitive safety reporting programs. As previously 
discussed, nonpunitive systems can alleviate employee concerns and 
encourage participation in safety reporting. Nonpunitive systems can 
include voluntary, anonymous reports by employees that are reviewed by 
an independent, external entity.[Footnote 52] NTSB has recommended 
that FTA facilitate the development of nonpunitive safety reporting 
programs at all transit agencies that would collect safety reports and 
operations data from employees in all divisions. Safety department 
representatives from their operations, maintenance, and engineering 
departments and representatives from labor organizations would 
regularly review these reports and share the results of those reviews 
across all divisions of their agencies.[Footnote 53] FRA is piloting a 
voluntary confidential reporting program for workers in the railroad 
industry consistent with NTSB's recommendation and the Federal 
Aviation Administration has established such a program for air carrier 
employees, air traffic controllers, and others.[Footnote 54] FTA 
officials told us that identifying operating errors in a nonpunitive 
way is important and that they have begun research through the Transit 
Cooperative Research Program to examine ways to improve compliance 
with safety rules at transit agencies, including the use of 
nonpunitive reporting models. FTA plans to report on the results of 
this work by late 2011. 

* Increase efforts to encourage a strong safety culture. In addition, 
APTA and some transit agency officials have called on FTA to do more 
to develop and share information on establishing a strong safety 
culture at transit agencies. One expert we met with noted that 
establishing and enforcing regulations will not necessarily bring 
about an improvement in safety culture in the rail transit industry. 
APTA officials and officials at one large transit agency noted that 
FRA pilot projects aimed at addressing accidents caused by human error 
and identifying ways to better manage safety have helped encourage a 
strong safety culture in the freight railroad industry and that FTA 
could foster positive changes in safety culture in the rail transit 
industry through such methods.[Footnote 55] While FTA has various 
efforts underway to instill safety culture at transit agencies, these 
do not include pilot projects to evaluate or test safety culture 
concepts and ideas. 

Staffing and Training: 

FTA has provided some assistance to help transit agencies address 
staffing challenges, but its safety-related assistance has focused 
primarily on providing training. FTA has reported that it has a 
compelling interest in transit workforce development given its large 
investment in and oversight of transit. FTA has supported research on 
transit workforce challenges--including recruitment and retirement 
issues--through its Transit Cooperative Research Program. FTA's 
Southern California Regional Transit Training Consortium has worked to 
establish a model mentor/internship program that can be used by 
transit agencies of any size. These programs run in conjunction with 
local community colleges, where a primary objective is to introduce 
students to transit work, particularly maintenance and other support. 
Ultimately, this program allows transit agencies to hire from a 
greater pool of transit-trained interns. FTA's fiscal year 2011 budget 
request also described a proposed effort to design programs to help 
transit agencies build and develop a workforce with sufficient skills 
to fill transit jobs of the future. These efforts can help transit 
agencies recruit and hire qualified employees and address staffing 
challenges involving an aging workforce. 

To help address transit agency safety training challenges, FTA has 
provided funding to support a variety of training classes. Through 
programs managed by the National Transit Institute and the 
Transportation Safety Institute, FTA has supported training for 
transit agency employees.[Footnote 56] Both of these organizations 
offer safety classes attended by transit agency employees, as well as 
by state safety oversight agency staff.[Footnote 57] To avoid 
duplication, the National Transit Institute focuses on training for 
frontline employees, such as track workers and operators, while the 
Transportation Safety Institute provides classes for supervisory and 
management personnel. Classes have included current rail system safety 
principles and online fatigue awareness. In fiscal year 2010, the 
National Transit Institute and the Transportation Safety Institute 
held 220 training sessions related to safety and more than 6,700 
transit agency staff took part in this training.[Footnote 58] FTA has 
also provided specialized training aimed at transit agencies that have 
experienced recent safety incidents. For example, FTA recently 
concluded training on rail incident investigation and system safety 
for WMATA staff. In all, FTA has delivered seven courses to assist 
WMATA staff in receiving critical safety training.[Footnote 59] In 
another example, through the Transit Technology Career Ladder 
Partnership Program, FTA has funded partnerships in four states aimed 
at training transit employees to become proficient in safety practices 
and procedures. 

Currently, FTA is drafting a 5-year safety and security strategic plan 
for training. The plan will cover safety technical training for staff 
working at FTA, state safety oversight agencies, and transit agencies. 
While one aim of the plan will be to prepare FTA and state staff to 
handle new responsibilities should legislation be enacted that would 
change their oversight role for rail transit safety, FTA also intends 
to use the plan to identify improvements needed in the training it 
provides to transit agencies. Potential improvements include re- 
evaluating the levels and types of training that FTA supports. FTA 
officials estimated the training plan would be completed in May 2011. 
Officials also told us that they are collaborating with officials at 
APTA, state safety oversight agencies, and FRA to obtain their views 
on how to better provide training to transit agencies. In its fiscal 
year 2011 budget request, FTA has proposed additional resources to 
provide training for transit agencies, state safety oversight 
agencies, and FTA officials. More information on current and planned 
efforts by FTA to address staffing and training challenges at transit 
agencies is available in appendix III. 

A legislative proposal, as well as some APTA officials and others, 
identified additional efforts that, if adopted, might improve transit 
agencies' abilities to address their staffing and training challenges. 
These include: 

* Formulate a national approach to staffing and training. In 2009, the 
House of Representatives Committee on Transportation and 
Infrastructure issued draft legislation to reauthorize surface 
transportation programs that would require FTA to form a national 
council to identify skill gaps in transit agency maintenance 
departments, develop programs to address the recruitment and retention 
of transit employees, and make recommendations to FTA and transit 
agencies on how to increase apprenticeship programs, among other 
things.[Footnote 60] Furthermore, this proposed legislation as well as 
APTA and the Transportation Learning Center called for a national 
curriculum or certification program that would establish some level of 
training standardization for transit agency employees.[Footnote 61] 
APTA and transit agency officials have noted that potential benefits 
include achieving a level of consistency in safety training across the 
country as well as minimum thresholds for transit agency staff. FTA 
has created curriculum development guidelines to help transit agencies 
establish their own training curricula. Due in part to differences in 
transit agencies' operating environments and system technologies, FTA 
officials reported that in developing their upcoming safety and 
security strategic plan for training, they may examine whether setting 
standards for a national training curriculum would be appropriate. 

* Increase technical training. NTSB officials and some of the experts 
and transit agency officials we met with stated that FTA should 
increase the technical components of the training for transit agency 
employees that it supports. Transit agency officials reported that 
training provided by the National Transit Institute and Transportation 
Safety Institute includes valuable safety information, but overall the 
training provided is introductory and does not cover enough technical 
aspects of safety. According to NTSB officials, transit agency safety 
staff need periodic, refresher training to continue to learn and more 
technical training to adequately understand and perform their job. 
Technical aspects could include the overall mechanics and engineering 
involved in rail transit operations, as well as how problems with 
equipment can lead to unsafe conditions. Some state safety oversight 
and transit agency officials we met with said that available technical 
training is limited and that FTA could create a training curriculum 
that other organizations, such as local community colleges, could use 
to teach safety-related classes. Similarly, APTA has reported the need 
to develop core curricula to be used at universities and community 
colleges and to enhance partnerships between transit agencies and 
higher education in order to provide additional training and 
educational opportunities for current and future transit workers. 
[Footnote 62] 

* Increase federal support for training. In a past report, the 
Transportation Learning Center has noted that, of the billions of 
dollars the federal government provides to transit agencies annually, 
little is invested in human capital--that is, the people, knowledge, 
and skills necessary to provide reliable and safe service. In 
response, the center has recommended that federal funding provide 
support for transit agencies' workforce training.[Footnote 63] In 
addition, officials at APTA and transit agencies, as well as some 
experts we met with, favored increasing federal support to cover 
training and related travel costs for transit agency employees. FTA 
has provided funding to state safety oversight agency staff to cover 
such costs to attend training offered by the National Transit 
Institute and the Transportation Safety Institute, but this support 
generally has not been extended to transit agency staff. FTA officials 
reported that they support training offered around the country and 
that demand is high. Transit agencies also have the option of hosting 
training to reduce travel and other costs. 

State of Good Repair: 

FTA's assistance to transit agencies to help achieve a state of good 
repair--and therefore help ensure safe operations--has primarily 
consisted of providing grant funding, although FTA has also conducted 
studies and is taking steps to provide more guidance to agencies on 
asset management. The two major FTA grant programs transit agencies 
have used to help achieve a state of good repair are the Fixed 
Guideway Modernization Program and the Urbanized Area Formula Program. 
In fiscal year 2010, these FTA grants provided nearly $6 billion for 
transit agencies' capital projects and related planning activities. 
[Footnote 64] This support has helped transit agencies maintain system 
facilities such as stations and other equipment. Funding also has 
assisted transit agencies in rehabilitating or purchasing rail 
vehicles and modernizing track and other infrastructure to improve 
operations. Besides supporting achieving a state of good repair, FTA's 
grant funding programs can support other safety-related improvements, 
such as upgrading signal and communications systems. In its fiscal 
year 2011 budget request, FTA has proposed increasing assistance to 
transit agencies through a new $2.9 billion state of good repair 
program for bus and rail systems.[Footnote 65] This program would, for 
the first time, provide funding to transit agencies that exclusively 
focus on achieving a state of good repair. 

Besides providing funds, another activity FTA has recently engaged in 
involves helping transit agencies improve their asset management 
practices in order to enhance their ability to achieve a state of good 
repair and ensure safety. As previously discussed, FTA officials 
reported that the transit industry has been slow to adopt asset 
management practices that would allow efficient management of state of 
good repair and some related safety needs. As a result, transit 
agencies may have limited knowledge of asset conditions and how to 
best use scarce resources to ensure an efficient and safe operation. 
In DOT's fiscal year 2010 appropriation, $5 million was made available 
to FTA to develop standards for asset management plans, provide 
assistance to grant recipients engaged in the development or 
implementation of an asset management system, improve data collection, 
and conduct a pilot program designed to identify best practices for 
asset management.[Footnote 66] FTA has begun to undertake these 
efforts. It has reviewed national and international asset management 
practices and concluded that major opportunities for improvements 
exist in the United States.[Footnote 67] FTA is also currently 
soliciting for projects with transit agencies of various modes and 
sizes to demonstrate different aspects of good asset management 
practices. According to FTA officials, improved asset management by 
transit agencies will include better approaches for prioritizing 
rehabilitation and replacement projects and will therefore allow 
agencies to better ensure safety.[Footnote 68] Other FTA technical 
assistance in this area includes the development of capital planning 
tools and asset inventory guidelines, research on integrating 
maintenance management with capital planning, training and guidance to 
educate transit agency staff on asset management, and enhanced asset 
data collection. 

As previously discussed, while no common standards exist for asset 
management, it can include tracking asset condition and use, as well 
as planning appropriately for rehabilitation and replacement. The 
National Surface Transportation Policy and Revenue Study Commission 
has reported that, to achieve a state of good repair, local 
governments, states, and other entities must develop, fund, and 
implement an asset management system to ensure the maximum 
effectiveness of federal capital support.[Footnote 69] We have 
previously reported that in some surface transportation programs, 
including transit programs, agencies often do not employ the best 
tools and approaches to ensure effective investment decisions, an area 
where asset management can help.[Footnote 70] See appendix III for 
other current and planned efforts by FTA to help transit agencies 
address state of good repair challenges. 

Legislative proposals, one FTA study, and several organizations we met 
with have identified additional efforts that, if adopted, might hold 
transit agencies accountable for improving the management of their 
assets and therefore better ensure safety. These included: 

* Linking grant funding to the establishment of asset management 
systems. Congress has considered legislation that would direct DOT to 
establish and implement a national transit asset management system. 
[Footnote 71] This legislation would direct FTA to define a state of 
good repair and for the first time require transit agencies that 
receive federal funding to establish asset management systems. 
[Footnote 72] This would help transit agencies to prioritize which 
assets to maintain, rehabilitate, and replace to help ensure safe 
operating conditions. Separately, a report by the Senate Committee on 
Appropriations directs FTA to issue a notice of proposed rulemaking by 
September 30, 2011, to implement asset management standards requiring 
transit agencies that receive FTA funds to develop capital asset 
inventories and condition assessments.[Footnote 73] FTA officials told 
us that they have no plans to develop such a rulemaking at this time, 
but would do so if required by statute. FTA is to report to Congress 
in June 2011 on its investigations into asset management. We have 
previously identified principles that could help drive re-examination 
of federal surface transportation programs, including ensuring 
accountability for results by entities receiving federal funds and 
using the best tools and approaches, such as grant eligibility 
requirements, to emphasize return on targeted federal investment. 
[Footnote 74] 

* Increasing available transit agency asset data. Another option that 
FTA has reported on for it and Congress to consider involves 
establishing a system that ensures regular reporting of transit 
agencies' capital assets and a consistent structure and level for this 
reporting. FTA officials noted that they already collect transit 
vehicle data from agencies, but that they need more information to 
effectively report on transit agency assets. FTA is considering 
expanding transit agency reporting requirements to include data on 
local agency asset inventory, holdings, and conditions.[Footnote 75] 
FTA has reported that these data would support better national needs 
assessments and transit asset condition monitoring than is currently 
possible. Also, this would encourage transit agencies to develop and 
maintain their own asset inventory and condition monitoring systems. 

Besides the additional efforts outlined above, there are other 
proposals that would make more grant funding available to large 
transit agencies. FTA and transit agency officials reported that 
transit agencies maintaining older systems have received a smaller 
percentage of available federal funding as the number of transit 
systems competing for the same amount of funding has increased. For 
example, in its 2009 study on the state of good repair in the transit 
industry, FTA reported that the seven largest rail transit systems, 
which carry 80 percent of the nation's rail transit riders and 
maintain 50 to 75 percent of the nation's rail transit infrastructure, 
have received 23 percent of the total federal funding eligible for 
rail state of good repair investment.[Footnote 76] These agencies' 
percentage share of total federal funding for achieving a state of 
good repair has declined.[Footnote 77] In short, while total federal 
support for transit infrastructure has increased, the share allocated 
to the nation's oldest and largest systems has shrunk. To address 
this, FTA included an option in its 2009 study for it and Congress to 
consider modifying existing funding formulas to factor in system age, 
among other things. Congress is also considering new ways to 
potentially fund transit and other surface transportation projects, 
including the formation of a National Infrastructure Bank.[Footnote 78] 

The various proposals suggesting additional steps that FTA could take 
to provide safety-related assistance to transit agencies or strengthen 
their accountability for effectively managing their assets have the 
potential, if implemented, to enhance rail transit safety. Past 
reauthorizations of surface transportation programs have provided an 
avenue for Congress to identify programs to address problems, 
including those involving transportation safety. DOT is currently 
developing a surface transportation reauthorization proposal. As part 
of its effort to develop a surface transportation reauthorization 
proposal, DOT officials have conducted outreach events to collect 
input from experts on possible surface transportation initiatives to 
include in the proposal and have held internal discussions to develop 
the proposal. Additionally, DOT is considering options for improving 
transportation safety, including rail transit safety. Therefore, the 
proposal that DOT eventually puts forward may address some or all of 
the safety challenges that we cite. Furthermore, FTA's 5-year safety 
and security training plan, when it is completed, may include 
improvements that help address the training challenges that transit 
agencies face. 

Leading Practices Could Help FTA Target and Track the Results of Its 
Safety Efforts: 

As FTA undertakes efforts to help transit agencies address their 
safety culture, staffing and training, and state of good repair 
challenges, setting performance goals and measures can help it target 
these efforts and track results. Performance goals can help 
organizations clearly identify the results they expect to achieve, 
prioritize their efforts, and make the best use of available 
resources. Performance measures can help organizations track the 
extent to which they are achieving intended results. In the case of 
FTA, such prioritization is essential, given the relatively small 
number of staff it has devoted to safety and state of good repair 
efforts. For example, while FTA has requested 30 additional staff in 
fiscal year 2011 in anticipation of receiving authority to strengthen 
its safety oversight role, it currently has 15 to 17 full-time 
employees working in its Office of Safety and Security, as well as 
staff from other FTA offices working on state of good repair efforts. 
[Footnote 79] The ability to prioritize efforts and track progress 
will become even more important in the event that Congress enacts 
legislation that would give FTA greater oversight authority of transit 
agencies and expand its transit safety responsibilities. Furthermore, 
as FTA is faced with proposals to assume even more responsibility for 
transit safety in the future--through, for example, setting asset 
management or training curriculum standards for transit agencies--it 
is even more essential that it clearly identify the specific results 
it is trying to achieve, target its efforts, and track progress toward 
achieving those results. 

We have identified a number of leading practices agencies can 
implement to help set or enhance performance goals and measures. While 
FTA has created plans and other tools to help guide and manage its 
safety efforts, it has not fully adopted these practices. The next 
sections discuss these leading practices and the extent to which FTA 
has followed them.[Footnote 80] 

Focusing on Results: 

We have found that successful organizations try to link performance 
goals and measures to strategic goals and that, in developing these 
goals and measures, such organizations generally focus on the results 
that they expect their programs to achieve.[Footnote 81] DOT has 
identified an overall strategic safety goal of reducing transportation-
related injuries and fatalities, including rail transit injuries and 
fatalities, and FTA has identified measures in its fiscal year 2011 
budget request related to that goal.[Footnote 82] In its Annual 
Performance Plan for fiscal year 2011, FTA identified a general safety 
goal of further defining its leadership role in the area of surface 
transportation safety as well as some desired outcomes of its safety 
efforts, such as increased public confidence in the safety of public 
transportation and improved safety culture at transit agencies 
nationwide. It also identified some strategies for achieving this goal 
and these outcomes, such as establishing the Transit Rail Advisory 
Committee for Safety and assessing safety and security training. 
However, FTA has not identified specific performance goals that make 
clear the direct results its safety activities are trying to achieve 
and related measures that would enable the agency to track and 
demonstrate its progress in achieving those results. Without such 
specific goals and measures, it is not clear how FTA's safety 
activities contribute toward DOT's overall strategic goal of reducing 
transportation-related injuries and fatalities, including rail transit 
injuries and fatalities. 

In addition, in its fiscal year 2011 budget request FTA included the 
goal of improving the rail transit industry's focus on safety 
vulnerabilities. FTA also identified some activities associated with 
this safety goal, such as submitting legislation to Congress. However, 
FTA did not clearly articulate the expected results associated with 
this goal and activities. Nor did FTA explain how such results would 
be measured and how they relate to DOT's strategic goals. 

Linking FTA's performance goals to departmental goals can provide a 
clear, direct understanding of how the achievement of annual goals 
will lead to the achievement of the agency's strategic goals.[Footnote 
83] We have previously reported that a clear relationship should exist 
between an agency's annual performance goals and long-term strategic 
goals and mission. FTA officials told us that it can be difficult to 
set performance goals and measures for the agency's safety efforts due 
to its limited authority over safety in the transit industry. In past 
work, we have reported that developing goals and measures for outcomes 
that are the result of phenomena outside of federal government control 
is a common challenge faced by many federal agencies.[Footnote 84] 
However, despite this challenge, measuring program results and 
reinforcing their connection to achieving long-term strategic goals 
can create a greater focus on results, help hold agencies and their 
staff accountable for the performance of their programs, and assist 
Congress in its oversight of agencies and their budgets.[Footnote 85] 

Addressing Important Dimensions of Program Performance: 

Performance goals and measures that successfully address important and 
varied aspects of program performance are key aspects of a results 
orientation. While FTA has identified various activities aimed at 
improving rail transit safety, it has not established clear results- 
oriented goals and measures that address key dimensions of the 
performance of its various efforts related to safety, such as its 
training and state of good repair programs. FTA could address 
important dimensions of program performance in different ways. For 
example, the agency could set goals and measures to address identified 
safety challenges, such as those identified in this report, or to 
capture results of its various safety-related efforts, such as its 
training programs or asset management initiatives. Alternatively, 
performance goals and measures could relate to the causes behind 
certain types of transit accidents, such as setting a goal of reducing 
the number of accidents where human error is a probable cause in a 
given year. 

Without goals related to various dimensions of program performance, 
FTA has not identified the intended results of its various safety-
related efforts. Limited use of performance measures by FTA makes it 
difficult to determine the impact of these efforts on safety. While 
FTA has identified overall measures of transit safety--the number of 
transit injuries and fatalities per 100 million passenger-miles 
traveled--its annual performance plan lacks quantifiable, numerical 
targets related to specific goals, against which to measure the 
performance of its efforts.[Footnote 86] FTA's fiscal year 2011 budget 
request did include a performance measure to track the percentage of 
federal formula funding that transit agencies used for replacement 
versus new capital purchases by the end of fiscal year 2011 and 
related this measure to its goal of improving the rail industry's 
focus on safety vulnerabilities. However, this measure captures only 
one of the types of results FTA might expect to achieve from its 
various safety efforts.[Footnote 87] 

In the past, FTA safety planning documents have linked specific FTA 
performance goals and measures with DOT's overall strategic safety 
goals; however, FTA is no longer using these documents.[Footnote 88] 
For example, FTA's 2006 Rail Transit Safety Action Plan included 
safety goals and measures, such as reducing total derailments per 100 
million passenger miles, major collisions per 100 million passenger 
trips, and total safety incidents per 10 million passenger trips. 
These goals and measures are clearly linked to DOT's overall strategic 
goal of working toward the elimination of transportation-related 
injuries and fatalities, including rail transit injuries and 
fatalities. The plan also included a number of supporting priorities, 
such as reducing the impact of fatigue on transit workers, and how the 
agency planned to achieve them. The plan also included performance 
measures and target goals for FTA's state safety oversight program, 
such as the number of dedicated state personnel and necessary levels 
of training and certification.[Footnote 89] FTA officials reported 
that the goals and measures captured in this and other past planning 
documents were no longer in use because of changes in safety 
environments. At present, FTA has no active strategic plan, and FTA 
officials estimated the new strategic plan would be completed in late 
2011. 

Other agencies are presently making use of practices to enhance 
performance goals and measures for safety activities. For example, FRA 
has created a set of performance goals and measures that address 
important dimensions of program performance. In its proposed fiscal 
year 2011 budget, FRA included specific safety goals to reduce the 
rate of train accidents caused by various factors, including human 
errors and track defects. These goals are numeric, with a targeted 
accident rate per every million train miles. Collecting such accident 
data equips FRA with a clear way to measure whether or not those 
safety goals are met. FRA's budget request has also linked FRA's 
performance goals and measures with DOT's strategic goals. Another DOT 
agency, the Federal Motor Carrier Safety Administration, has a broad 
range of goals and related performance measures that it uses to 
provide direction to--and track the progress of--its enforcement 
programs, including measures of the impact of its enforcement programs 
on the level of compliance with safety regulations and on the 
frequency of crashes, injuries, and fatalities.[Footnote 90] The 
agency's end goal--to reduce crashes, injuries, and fatalities through 
its reviews--aligns with and contributes to DOT's overall strategic 
safety goals. 

While these leading practices are useful, problems with FTA's rail 
transit safety data could hamper the agency's ability to measure its 
safety performance.[Footnote 91] We have found that data contained in 
FTA's State Safety Oversight Rail Accident Database--which is compiled 
from data provided by state safety oversight agencies and transit 
agencies--are unreliable. Specifically, we found unverified entries, 
duplicative entries, data discrepancies, and insufficient internal 
controls.[Footnote 92] Without reliable data, it is difficult for FTA 
to measure performance based on goals to be captured in annual 
performance plans or agency strategic plans. Baseline and trend data 
also provide context for drawing conclusions about whether performance 
goals are reasonable and appropriate. Establishing procedures that 
ensure reliable data is an important internal control necessary to 
validly measure performance based on numerical targets.[Footnote 93] 
Additionally, decision makers can use such data to gauge how a 
program's anticipated performance level compares with past 
performance. FTA officials have acknowledged the important role that 
data play in making decisions regarding how to address challenges to 
rail transit safety. FTA has implemented changes to the data 
collection process to address some of the data problems we identified 
and plans to take additional actions to validate and correct 
discrepancies contained in its State Safety Oversight Rail Accident 
Database, but these plans do not identify specific efforts to 
establish procedures that would improve data reporting in the future. 
To ensure the accuracy and reliability of the State Safety Oversight 
Rail Accident Database, we have recommended that FTA develop and 
implement appropriate internal controls to ensure that data entered 
are accurate and incorporate an appropriate method for reviewing and 
reconciling data from state safety oversight agencies and other 
sources.[Footnote 94] 

Without clear, specific, and varied performance goals and related 
measures linked to DOT's strategic goal of reducing transportation- 
related injuries and fatalities, including rail transit injuries and 
fatalities, the intended results of FTA's safety efforts are unclear. 
Furthermore, the absence of clear goals and measures to guide and 
track progress limits FTA's ability to make informed decisions about 
its safety strategy and its accountability for its safety performance. 
Finally, without reliable data, FTA cannot establish useful 
performance measures, making it difficult to determine whether safety 
programs are accomplishing their intended purpose and whether the 
resources dedicated to program efforts should be increased, used in 
other ways, or applied elsewhere. 

Conclusions: 

Rail transit systems will remain vital components of the nation's 
transportation infrastructure and will need to continue to provide 
safe service for the millions of commuters that rely on them daily. 
Through its assistance efforts, FTA has worked with transit agencies 
to foster a safer operating environment for these passengers. Planned, 
new assistance efforts by FTA, as well as legislative proposals to 
enhance FTA's regulatory authority over transit safety, have the 
potential to further enhance safety on rail transit systems. Some 
additional proposals concerning new steps FTA could take to address 
safety challenges facing transit agencies also have the potential to 
improve rail transit safety. For example, while FTA is already working 
to instill safety culture at transit agencies, creating pilot projects 
to examine new approaches for instilling a strong safety culture at 
these transit agencies may have merit. Setting standards for a 
national training curriculum for transit employees may also ensure 
that a minimum threshold of training is achieved across the transit 
industry, if such standards could account for differences in transit 
agencies' environments and technologies. Asset management shows 
promise in both helping transit agencies and protecting federal 
investment. Similarly, holding agencies that receive federal funds 
accountable for using asset management practices could help ensure 
that federal funds aimed at addressing this problem are effectively 
used. DOT is uniquely positioned to examine various proposals to 
discern any worthwhile options for implementation going forward, given 
available resources and other competing priorities, and to propose in 
its draft surface transportation reauthorization legislation any 
options deemed worthwhile. We are not recommending at this time that 
DOT take actions on proposals for improving rail transit safety, as 
the department is considering various options for improving 
transportation safety, including rail transit safety, in developing 
its reauthorization proposal. 

As FTA helps transit agencies ensure safety, setting clear performance 
goals and related measures for its safety efforts, based on leading 
practices, will be vital to improve FTA's ability to set priorities 
and determine progress--both in overseeing transit agencies and in 
helping them maintain safety on their systems. Setting clear 
performance goals will help FTA to communicate a direction for its 
safety efforts and establish benchmarks for performance. Tracking 
progress through performance measures will help FTA in planning its 
future efforts and will help hold the agency accountable for achieving 
results. However, FTA must take further actions to improve the 
reliability of its safety data before it can track its safety 
performance based on new measures and goals. 

Recommendation for Executive Action: 

To ensure that FTA targets its resources effectively as it increases 
its safety efforts and is able to track the results of these efforts, 
we recommend that the Secretary of Transportation direct the FTA 
Administrator to use leading practices as FTA develops its plans for 
fiscal year 2011 and in the future. In particular, the Administrator 
should create a set of clear and specific performance goals and 
measures that (1) are aligned with the department's strategic safety 
goals and identify the intended results of FTA's various safety 
efforts and (2) address important dimensions of program performance. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to DOT and NTSB for their review 
and comment. Both provided technical comments and clarifications, 
which we incorporated into the report as appropriate. DOT agreed to 
consider our recommendation. 

We are sending copies of this report to interested congressional 
committees, the Secretary of Transportation, and the Chair of the 
National Transportation Safety Board. In addition, this report is 
available at no charge on GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-2834, or wised@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff who made major contributions 
to this report are listed in appendix IV. 

Signed by: 

David J. Wise: 
Director, Physical Infrastructure Issues: 

[End of section] 

Appendix I: Results of NTSB's Investigations of Rail Transit Accidents: 

Of the 48 rail accident investigations that the National 
Transportation Safety Board (NTSB) has reported on since 2004, 7 were 
on heavy rail transit systems operated by the Chicago Transit 
Authority (CTA) and the Washington Metropolitan Area Transit Authority 
(WMATA), and one was on the light rail transit system operated by the 
Massachusetts Bay Transportation Authority (MBTA).[Footnote 95] As 
shown in table 2, these accidents collectively resulted in 13 
fatalities, hundreds of injuries, and millions of dollars in property 
damage. 

In its reports, NTSB identified the probable causes of accidents as 
well as factors that contributed to these accidents.[Footnote 96] In 
five of these eight accident investigations, NTSB found the probable 
cause to involve employee errors, such as the failure of the train 
operator to comply with operating rules and of track inspectors to 
maintain an effective lookout for trains. Of the remaining three 
accidents, NTSB found that problems with equipment were a probable 
cause of two accidents and that weaknesses in management of safety by 
the transit agency, such as its management of maintenance and of 
equipment quality controls, were a probable cause of all three 
accidents. For six of these eight accidents, contributing factors 
identified involved deficiencies in safety management or oversight, 
including weaknesses in transit agencies' safety rules and procedures 
and in their processes for ensuring employees' adherence to these 
rules and procedures, lack of a safety culture within the transit 
agency, and lack of adequate oversight by the transit agency's state 
safety oversight agency and the Federal Transit Authority (FTA). In 
one accident report, NTSB found as a contributing factor the lack of 
safety equipment or technologies, such as a positive train control 
system that can prevent trains from colliding. 

Table 1: Causes of and Factors Contributing to Significant Rail 
Transit Accidents, 2004-2010, Based on Completed NTSB Investigations: 

Accident: Collision of 2 CTA trains; 
Date: 2/3/04; 
Impact: 42 minor injuries and $62,000 in property damage; 
Probable causes: Failure of the operator of the striking train to 
comply with operating rules; 
Contributing factors: Inadequate operational safety oversight by CTA. 

NTSB, Railroad Accident Brief: Collision of Two Chicago Transit 
Authority Trains, Chicago, Illinois, February 3, 2004 (Washington, 
D.C., July 7, 2004). 

Accident: Collision of 2 WMATA trains; 
Date: 11/3/04; 
Impact: About 20 injuries[A] and about $3.5 million in property damage; 
Probable causes: Failure of operator of the striking train to stop, 
due to reduced alertness; 
Contributing factors: Lack of rollback protection feature to stop the 
train while in manual operation mode. 

NTSB, Railroad Accident Report: Collision Between Two Washington 
Metropolitan Area Transit Authority Trains at the Woodley Park-
Zoo/Adams Morgan Station in Washington, D.C., November 3, 2004 
(Washington, D.C., Mar. 23, 2006). 

Accident: WMATA train struck and killed an employee working on a track; 
Date: 5/14/06; 
Impact: 1 fatality; 
Probable causes: Failure of train mechanic working on the track to 
stay clear of the approaching train either because he was not aware of 
it or because he lacked a physical reference by which to identify a 
safe area outside the train's dynamic envelope[C]; 
Contributing factors: WMATA's right of way rules and procedures did 
not (1) provide adequate safeguards to protect the wayside 
personnel[B] from approaching trains, (2) ensure that train operators 
were aware of wayside work being performed, and (3) adequately provide 
for reduced train speeds through work areas. Also, WMATA's lack of an 
aggressive program of rule compliance testing and enforcement on its 
rail system. 

NTSB, Railroad Accident Brief: Washington Metropolitan Area Transit 
Authority Train Strikes Wayside Worker Near Dupont Circle Station, 
Washington, D.C., May 14, 2006 (Washington, D.C., Jan. 23, 2008). 

Accident: Derailment of a CTA train; 
Date: 7/11/06; 
Impact: 152 injuries and more than $1 million in property damage; 
Probable causes: CTA's ineffective management and oversight of its 
track inspection, maintenance program, and system safety program; 
Contributing factors: CTA's state safety oversight agency's failure to 
require that action be taken by CTA to correct unsafe track 
conditions. Also, FTA's ineffective oversight of CTA's state safety 
oversight agency. 

NTSB, Railroad Accident Report: Derailment of Chicago Transit 
Authority Train Number 220 Between Clark/Lake and Grand/Milwaukee 
Stations, Chicago, Illinois, July 11, 2006 (Washington, D.C., Sept. 
11, 2007). 

Accident: WMATA train struck and killed 2 employees conducting a track 
inspection; 
Date: 11/30/06; 
Impact: 2 fatalities; 
Probable causes: Failure of track inspectors to maintain an effective 
lookout for trains and failure of the train operator to slow or stop 
the train to ensure that the workers ahead were aware of its approach 
and had moved to a safe area; 
Contributing factors: WMATA's right-of-way rules and procedures did 
not (1) provide adequate safeguards to protect personnel working along 
the tracks from approaching trains, (2) ensure that train operators 
were aware of wayside work being performed, and (3) adequately provide 
for reduced train speeds through work areas. Also, WMATA's lack of an 
aggressive program of rule compliance testing and enforcement on its 
rail system. 

NTSB, Railroad Accident Brief: Washington Metropolitan Area Transit 
Authority Train Strikes Wayside Workers Near Eisenhower Avenue 
Station, Alexandria, Virginia, November 30, 2006 (Washington, D.C., 
Jan. 23, 2008). 

Accident: Derailment of WMATA train; 
Date: 1/7/07; 
Impact: 23 injuries and $3.8 million in property damage; 
Probable causes: (1) Improper milling of a train wheel resulting in a 
rough wheel surface caused the wheel to climb on the train car and 
derail, (2) lack of quality control measures to ensure that wheel 
surfaces were smoothed after being milled, (3) lack of a guard rail at 
the location of the derailment, and (4) WMATA's failure to have an 
effective process to implement safety improvements identified 
following similar accidents and related research projects; 
Contributing factors: n/a. 

NTSB, Railroad Accident Report: Derailment of Washington Metropolitan 
Area Transit Authority Train Near the Mt. Vernon Station, Washington, 
D.C., January 7, 2007 (Washington, D.C., Oct. 16, 2007). 

Accident: Collision between 2 MBTA trains; 
Date: 5/28/08; 
Impact: 1 fatality, 8 injuries, and $8.6 million in property damage; 
Probable causes: Failure of train operator to comply with controlling 
signal indication, resulting from an episode of micro-sleep; 
Contributing factors: Lack of a positive control system that would 
have intervened to stop the train and prevent the accident. 

NTSB, Railroad Accident Report: Collision Between Two Massachusetts 
Bay Transportation Authority Green Line Trains, Newton, Massachusetts, 
May 28, 2008 (Washington, D.C., July 14, 2009). 

Accident: Collision between 2 WMATA trains; 
Date: 6/22/09; 
Impact: 9 fatalities, 52 injuries, $12 million in property damage; 
Probable causes: (1) Failure of the track circuit modules[D], built by 
GRS/Alstom Signaling Inc., causing the automatic train control system 
to (a) not detect and transmit speed information to the striking train 
of another train on the track and (b) transmit speed commands to the 
striking train up to the point of impact; (2) WMATA's failure to 
ensure that the enhanced track circuit verification test (developed 
after a near-collision in 2005) was institutionalized and used 
systemwide, which would have identified the faulty track circuit 
before the accident; 
Contributing factors: (1) WMATA's lack of a safety culture, (2) 
WMATA's failure to effectively maintain and monitor its automatic 
train control system, (3) GRS/Alstom Signaling Inc.'s failure to 
provide a maintenance plan to detect spurious signals that could cause 
track circuit modules to malfunction, (4) ineffective safety oversight 
by board of directors, (5) ineffective oversight and lack of safety 
oversight authority by WMATA's state safety oversight agency, and (6) 
FTA's lack of statutory authority to provide federal safety oversight. 

NTSB, Railroad Accident Report Collision of Two Washington 
Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten 
Station, Washington, D.C., June 22, 2009 (Washington, D.C., July 27, 
2010). 

Source: GAO analysis of NTSB accident reports and briefs. 

[A] These represent those who were taken to the hospitals for 
treatment of their injuries. 

[B] Wayside personnel work along the rail tracks. 

[C] A dynamic envelope refers to the total area occupied by a moving 
train. It not only incorporates the physical dimensions of the 
equipment but also accounts for suspension travel, overhang on curves, 
or lateral motion along the track. 

[D] Track circuit modules are electrical devices interconnected with 
tracks to help detect a train's location and communicate the location 
to other trains nearby. 

[End of table] 

In addition, as shown in table 2, NTSB has ongoing investigations on 
six accidents that occurred on heavy and light rail transit systems. 

Table 2: NTSB's Ongoing Investigations of Heavy and Light Rail Transit 
Accidents, as of November 2010: 

Accident: Derailment of CTA passenger cars on an elevated track; 
Date: 5/28/08; 
Impact: 14 injuries. 

Accident: Collision of two MBTA light rail passenger trains; 
Date: 5/8/09; 
Impact: About 46 injuries. 

Accident: Collision of two San Francisco Municipal Transportation 
Agency light rail vehicles; 
Date: 7/18/09; 
Impact: 48 injuries. 

Accident: Collision of two WMATA trains in Falls Church, VA; 
Date: 11/29/09; 
Impact: 3 injuries. 

Accident: The fatal striking of two wayside workers by a WMATA hi-rail 
vehicle; 
Date: 1/26/10; 
Impact: 2 fatalities. 

Accident: Derailment of a WMATA train; 
Date: 2/12/10; 
Impact: No injuries. 

Source: GAO presentation of NTSB information. 

[End of table] 

[End of section] 

Appendix II: Objectives, Scope, and Methodology: 

To determine the challenges that the largest rail transit systems face 
in ensuring safety, we conducted site visits, examined documents, 
conducted interviews, and consulted relevant literature. We obtained 
documents from and interviewed officials at five large heavy rail 
transit systems and three large light rail transit systems operated by 
seven transit agencies. The five heavy rail systems are those operated 
by the Metropolitan Transportation Authority New York City Transit 
(NYCT), WMATA, CTA, MBTA, and the Bay Area Rapid Transit (BART). The 
three light rail systems are operated by MBTA, the San Francisco 
Municipal Transportation Agency (SF Muni), and the Los Angeles County 
Metropolitan Transportation Authority (LA Metro). We obtained budget 
documents, accident and audit reports, corrective action plans, and 
staffing and training information, among other information and 
documentation, from each system. Also, we interviewed representatives 
from these transit agencies and their respective state safety 
oversight agencies about the transit agencies' challenges. We also 
analyzed published NTSB investigations of accidents on heavy and light 
rail transit systems since 2004 to help us determine the causes of and 
factors contributing to rail transit accidents in recent years. 

We used data from Federal Transit Administration's (FTA) National 
Transit Database (NTD) to select these eight transit systems.[Footnote 
97] The NTD data we used for our selection criteria were (1) annual 
ridership, as measured by unlinked passenger trips and passenger 
miles, (2) the number of rail transit vehicles in revenue service 
operations, and (3) total track mileage.[Footnote 98] To determine 
whether these NTD data were reliable for our purposes, we interviewed 
FTA officials who are knowledgeable about the database and assessed 
the accuracy of these data elements. We determined that these specific 
data elements were sufficiently reliable to be used as selection 
criteria. 

To determine the extent to which FTA's assistance addresses the safety 
challenges faced by the largest transit agencies, we reviewed FTA 
documents on funding, state of good repair initiatives, technical 
assistance programs, and guidance and outreach related to rail transit 
safety. We also obtained information on transit safety training from 
the National Transit Institute and the Transportation Safety 
Institute.[Footnote 99] We interviewed officials from FTA and NTSB and 
representatives of the American Public Transportation Association 
(APTA). We asked officials from the transit systems we visited and 
their respective state safety oversight agencies for their assessment 
of FTA's assistance efforts. We reviewed applicable federal 
regulations, laws, and legislative proposals. In addition, we 
consulted our prior work on performance management and rail transit 
issues. 

We further contracted with the National Academies' Transportation 
Research Board to identify rail transit safety experts from the 
transit industry, academia, labor unions, and the rail consulting 
community. We interviewed 12 experts on the challenges that large rail 
transit agencies face in ensuring safety, the factors that contribute 
to rail transit safety accidents, and potential ways that FTA could 
improve its safety assistance efforts (see table 3). We also 
interviewed officials from NTSB and representatives of the APTA on 
these topics. 

Table 3: Rail Transit Safety Experts Interviewed: 

Name of expert: Edward Beimborn, Ph.D.; 
Affiliation: University of Wisconsin-Milwaukee. 

Name of expert: Joe Calabrese; 
Affiliation: Greater Cleveland Regional Transit Authority. 

Name of expert: James Fox; 
Affiliation: Southeastern Pennsylvania Transportation Authority. 

Name of expert: Jackie Jeter; 
Affiliation: Amalgamated Transit Union. 

Name of expert: Karla Karash, retired; 
Affiliation: TranSystems, Inc. 

Name of expert: Richard Krisak; 
Affiliation: Metropolitan Atlanta Transportation Rapid Transit 
Authority. 

Name of expert: Clarence Marsella, retired; 
Affiliation: Denver Regional Transportation District. 

Name of expert: Robert Paaswell, Ph.D.; 
Affiliation: City College of New York. 

Name of expert: Robert Peskin; 
Affiliation: AECOM Transportation, Inc. 

Name of expert: Conrad Santana; 
Affiliation: Parsons Brinckerhoff. 

Name of expert: James Stem; 
Affiliation: United Transportation Union. 

Name of expert: Ed Watt; 
Affiliation: Transport Workers Union of America. 

Source: GAO. 

[End of table] 

In addition, as part of this review, we assessed FTA's safety data to 
determine whether they were sufficiently reliable for us to use to 
report on trends in rail transit accidents as well as causes of those 
accidents. During that assessment, we identified inaccuracies, 
discrepancies, and duplicative entries, and determined that these data 
were not sufficiently reliable for these purposes and decided to 
conduct a separate review of the data's reliability. We are issuing a 
report on our findings and recommendations based on this review. 
[Footnote 100] 

[End of section] 

Appendix III: DOT Safety-Related Assistance Efforts That Address 
Transit Agencies' Safety Culture, Staffing, and Training Challenges: 

Table 4: Efforts that Address Safety Culture, Staffing, and Training 
Challenges: 

Current efforts: 

Name: Training-National Transit Institute; 
Description: Program funded by FTA and managed through Rutgers 
University. Fiscal year 2011 proposed budget estimates that the 
National Transit Institute will deliver approximately 50 courses at 
locations through the country. Class topics include avoiding operator 
fatigue and asset management. The primary transit agency audience is 
frontline employees at transit agencies, such as mechanics and 
drivers. There are a few specialized classes for supervisors, and a 
course for midlevel managers on asset management is being piloted in 
2010 for a general offering in 2011; 
Time frame: Ongoing. 

Name: Training-Transportation Safety Institute; 
Description: Program funded through the Department of Transportation's 
Research and Innovation Technology Administration. Various training 
sessions are held each year, including classes on rail incident 
investigations and rail transit system safety. The primary transit 
agency audience is supervisory personnel. The state safety oversight 
community receives a three-tier training curriculum funded by FTA. The 
state safety oversight community also receives individual educational 
plans to guide members toward obtaining a transit safety and security 
certificate. Transit agencies can also help receive certification for 
their staff, but this requires a firm commitment from the transit 
agency, requesting to host classes and obtain a 3-5 year training plan 
to train its employees; 
Time frame: Ongoing. 

Name: Transit Technology Career Ladder Partnership Program; 
Description: Under this program, funded by FTA and managed by the 
Transportation Learning Center, the center develops and supports 
standards and models for training and career programs in public 
transit. Since 2002, this program has provided training for more than 
9,000 transit mechanics. Partnerships have been carried out in 
Pennsylvania, Utah, New York, and California; 
Time frame: Ongoing. 

Name: Southern California Regional Transit Training Consortium; 
Description: This program provides a training resource network 
comprising public and private organizations (community colleges and 
transit agencies in Southern California) focused on the development 
and employment of the transit industry's workforce. Training is 
provided largely for maintenance workers. Classes focus on upkeep and 
maintenance of mechanical and electrical systems on transit vehicles, 
as well as expanding into the arena of information and technology 
services; 
Time frame: Ongoing. 

Name: Guidance; 
Description: FTA provides various types of guidance to transit 
agencies on ensuring safety. Examples include a compilation of best 
practices on transit safety, hazard analysis guidelines, guidance on 
drug and alcohol testing, a video on protecting track workers, safety 
Webinars and teleconferences, curriculum development guidelines, and 
periodic letters to FTA grantees on safety issues in the industry and 
recommended practices to address them; 
Time frame: Ongoing. 

Name: Transit Cooperative Research Program; 
Description: Funded by FTA and administered by the Transportation 
Research Board, provides funds for national transit research and 
development projects, including projects related to safety. This 
results in products that are available to the transit industry. Recent 
reports have addressed safety in transportation tunnels and other 
operations. A 3-year study began earlier in 2010 that will report on 
best practices for maintaining safety culture at transit agencies; 
Time frame: Ongoing. 

Name: Annual transit agency executive officers safety summit and 
annual drug and alcohol conference; 
Description: In the past, the safety summit has included executive 
officers from 36 rail transit agencies and representatives from state 
safety oversight agencies and others. The summit has facilitated 
discussion of safety concerns. Next summit scheduled for late 2010 or 
early 2011. The drug and alcohol conference has included FTA and other 
expert speakers and information on running a successful drug and 
alcohol programs, solving common problems, and other topics; 
Time frame: Ongoing. 

Name: Support for industry safety standards; 
Description: FTA funds APTA's ongoing development of safety and other 
standards and recommended practices for the rail industry; 
Time frame: Ongoing. 

Planned efforts: 

Name: Technical Assistance and Workforce Development Program; 
Description: Reformatting and restructuring technical assistance 
programs to emphasize transportation safety, among other things. FTA 
funding will include safety technical assistance, such as training and 
capacity building programs to develop a workforce with sufficient 
skills to fill transit jobs of the future; 
Time frame: Proposed fiscal year 2011. 

Source: GAO analysis of FTA information. 

[End of table] 

Table 5: Efforts that Address State of Good Repair Challenges: 

Current efforts: 

Name: Fixed Guideway Modernization Program (49 U.S.C. § 5309(b)(2)); 
Description: Capital assistance to modernize or improve existing fixed 
guideway systems. Eligible uses include the purchase and 
rehabilitation of rolling stock, maintenance facilities and equipment, 
and preventive maintenance. Funds are apportioned based on a 
multitiered formula. The program's fiscal year 2010 funding level was 
$1.6 billion[A]; 
Time frame: Ongoing, funds apportioned annually. 

Name: Urbanized Area Formula Program (49 U.S.C. § 5307); 
Description: Through this program, FTA provides assistance for capital 
and planning projects in urbanized areas (and operating assistance in 
areas with a population of less than 200,000).[B] Eligible uses 
include the purchase and rehabilitation of rolling stock, preventive 
maintenance, and the overhaul and rebuilding of vehicles, track, and 
signals. The program's fiscal year 2010 funding level was $4.1 billion; 
Time frame: Ongoing, funds apportioned annually. 

Name: Grants to WMATA; 
Description: Congress authorized $1.5 billion for WMATA over 10 years. 
These federal grants for capital and preventive maintenance projects 
leverage equal financial contributions from the District of Columbia, 
Maryland, and Virginia to the transit agency. Funds are intended for 
WMATA to use to address maintenance and upkeep. For fiscal year 2010, 
$150 million was appropriated; 
Time frame: Fiscal years 2010 to 2020. 

Name: Rail modernization studies; 
Description: FTA's original April 2009 study outlined the financial 
challenges facing transit systems in addressing state of good repair 
issues.[C] FTA released a new study in June 2010 that concluded that 
$78 billion is needed to address the backlog of capital investment 
faced by all transit agencies nationwide[D]; 
Time frame: April 2009 and June 2010. 

Name: State of good repair roundtables and advisory groups; 
Description: These meetings include industry, engineering, and capital 
planning experts who share approaches and solutions to common state of 
good repair problems, as well as help ensure that FTA state of good 
repair efforts reflect real word realities; 
Time frame: Fiscal years 2009 and 2010, with more planned. 

Name: Transit Asset Management Practices Scan; 
Description: The objective of this report is to build on efforts to 
date to create a resource of information about existing practices in 
Transit Asset Management. The report details the published literature 
in this area, and includes additional information on existing 
practices in 11 organizations prepared through a set of case studies; 
Time frame: June 2010. 

Planned efforts: 

Name: Bus and Rail State of Good Repair Program; 
Description: This new program would provide increased capital 
assistance for the modernization of fixed guideway systems, focusing 
on bus and rail transit assets that are in marginal or poor condition. 
FTA's fiscal year 2011 budget request proposed merging existing grant 
programs into this new $2.84 billion effort; 
Time frame: Proposed for fiscal year 2011. 

Name: Transit asset management; 
Description: In DOT's fiscal year 2010 appropriations, $5 million was 
made available to FTA to develop standards for asset management plans, 
provide assistance to grant recipients engaged in the development or 
implementation of asset management plans, improve data collection, and 
conduct a pilot program to identify best practices for asset 
management. FTA is to submit a report on its activities to Congress in 
June 2011; 
Time frame: June 2011. 

Name: Definition and measurement of state of good repair; 
Description: FTA aims to reach consensus with the industry on how to 
define and measure "state of good repair." The goal is to find a 
common language to facilitate discussion and an agreed upon method to 
measure various aspects of state of good repair; 
Time frame: End of fiscal year 2011. 

Name: Transit Economic Requirements Model (TERM) Lite; 
Description: TERM is a model that can be used to forecast long-term 
transit investment needs. TERM Lite will be a modification of this 
model to enable distribution to grantees for use as an asset 
management tool; 
Time frame: During fiscal year 2011. 

Source: GAO analysis of FTA information. 

[A] The American Recovery and Reinvestment Act of 2009 appropriated 
approximately $8.4 billion to fund public transportation throughout 
the country. Recovery Act funds have primarily supported grants in 
capital projects at transit agencies, although some funds have been 
used for operating expenses. As of August 25, 2010, approximately $190 
million had been obligated for use as operating expenses. 

[B] Urbanized areas are areas encompassing a population of not less 
than 50,000 that have been defined and designated in the most recent 
decennial census as an "urbanized area" by the Secretary of Commerce. 

[C] FTA, Rail Modernization Study (Washington, D.C., April 2009). 

[D] FTA, National State of Good Repair Assessment (Washington, D.C., 
June 2010). 

[End of table] 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgment: 

GAO Contact: 

David J. Wise, (202) 512-2834 or wised@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Judy Guilliams-Tapia, 
Assistant Director; Catherine Bombico; Matthew Cail; Martha Chow; 
Antoine Clark; Colin Fallon; Kathleen Gilhooly; Brandon Haller; Hannah 
Laufe; Grant Mallie; Anna Maria Ortiz; and Kelly Rubin made 
significant contributions to this report. 

[End of section] 

Footnotes: 

[1] A rail right-of-way is an area of land over which a train runs. 

[2] 49 C.F.R. Part 659. FTA also is responsible for monitoring and 
promoting security at rail transit agencies. This report focuses on 
safety only. We reported on FTA's State Safety Oversight Program in 
2006; see GAO, Rail Transit: Additional Federal Leadership Would 
Enhance FTA's State Safety Oversight Program, [hyperlink, 
http://www.gao.gov/products/GAO-06-821] (Washington, D.C.: July 26, 
2006). 

[3] FTA does have authority to investigate unsafe conditions in any 
operation it finances. FTA can withhold federal funds until a plan for 
correcting unsafe conditions has been approved, but it does not have 
authority to levy fines or take legal actions against transit agencies. 

[4] Public Transportation Safety Act of 2010, S. 3638, 111th Cong. 
(2010); Public Transportation Safety Program Act of 2010, S. 3015, and 
H.R. 4643, 111th Cong. (2010). 

[5] The DOT Office of Inspector General currently is reviewing the 
challenges and risks related to increasing federal oversight of 
transit safety, and expects to issue a report in March 2011. To avoid 
overlapping reviews, we focused on DOT's efforts to provide safety- 
related assistance to transit agencies. We testified on this proposed 
strengthening of federal oversight of rail transit safety in late 
2009; see GAO, Rail Transit: Observations on FTA's State Safety 
Oversight Program and Potential Change in Oversight Role, [hyperlink, 
http://www.gao.gov/products/GAO-10-293T] (Washington, D.C.: Dec. 8, 
2009). 

[6] See GAO, Rail Transit: Reliability of FTA's Rail Accident 
Database, [hyperlink, http://www.gao.gov/products/GAO-11-217R] 
(Washington, D.C.: Jan. 31, 2011). 

[7] FTA defines a rail fixed guideway system as any light, heavy, or 
rapid rail system, monorail, inclined plane, funicular, trolley, or 
automated guideway that: (1) is not regulated by FRA; and (2) is 
included in FTA's calculation of fixed guideway route miles, or 
receives funding under FTA's formula program for urbanized areas; or 
(3) has submitted documentation to FTA indicating its intent to be 
included in FTA's calculation of fixed guideway route miles to receive 
funding under FTA's formula program for urbanized areas. Heavy rail 
systems operate on exclusive tracks while light rail systems operate 
on either exclusive tracks or tracks in the street on the same level 
with pedestrians and vehicular traffic. 

[8] Unlinked passenger trips are the number of passengers boarding the 
public transportation vehicles; passenger miles are the cumulative sum 
of the distances ridden by each passenger. 

[9] GAO, Public Transportation: Transit Agencies' Actions to Address 
Increased Ridership Demand and Options to Help Meet Future Demand, 
[hyperlink, http://www.gao.gov/products/GAO-11-94] (Washington, D.C.: 
Nov. 30, 2010). 

[10] [hyperlink, http://www.gao.gov/products/GAO-11-94]. 

[11] Urbanized areas are areas encompassing a population of not less 
than 50,000 that have been defined and designated in the most recent 
decennial census as an "urbanized area" by the Secretary of Commerce. 
For fiscal year 2010, $4.1 billion was apportioned for the Urbanized 
Area Formula Program (49 U.S.C. § 5307) and $1.6 billion was 
apportioned for the Fixed Guideway Modernization Program (49 U.S.C. § 
5309(b)(2)). The New Starts and Small Starts programs provide funds 
for the design and construction of new fixed guideway projects, but 
not existing projects. 49 U.S.C. § 5309(d)(e). 

[12] Pub. L. No. 111-5, 123 Stat. 115 (Feb. 17, 2009). Approximately 
$8.4 billion in Recovery Act funds were awarded through fiscal year 
2010 orders from FTA's base transit formula programs, including the 
Urbanized Area Formula and the Fixed Guideway Modernization programs, 
to support transit projects that can contribute to creating jobs. 

[13] In June 2009, urbanized areas and states were given the authority 
to use up to 10 percent of certain Recovery Act transit funds for 
operating expenses. Supplemental Appropriations Act, 2009, Pub. L. No. 
111-32, §1202, 123 Stat. 1859, 1908 (June 24, 2009). 

[14] For information on fatality rates by type of mode, see DOT Bureau 
of Transportation Statistics' National Transportation Statistics 2010. 

[15] NTSB is an independent establishment of the U. S. government 
charged with investigating every civil aviation accident in the United 
States and significant accidents in other modes of transportation. 
NTSB may elect to investigate certain accidents related to the 
transportation of individuals that it decides are catastrophic, 
involve problems of a recurring nature, or whose investigation is 
expected to bring about safety improvements. 

[16] As we discuss later in this report, safety culture can be defined 
in different ways but is essentially an awareness of and 
organizational commitment to safety shared by all employees at all 
levels within the organization. 

[17] This program covers all states with rail fixed guideway systems 
operating in their jurisdictions that: (1) are not regulated by the 
FRA; and (2) are included in FTA's calculations of fixed guideway 
route miles or receive FTA formula program funding for urbanized 
areas; or (3) have submitted documentation to FTA to be included in 
FTA's calculation of fixed guideway route miles to receive FTA formula 
funding. 

[18] FTA's rule on drug and alcohol testing is found at 49 C.F.R. Part 
655. 

[19] See 49 C.F.R. Part 659, Rail Fixed Guideway Systems; State Safety 
Oversight. 

[20] [hyperlink, http://www.gao.gov/products/GAO-06-821]. 

[21] One bill, The Public Transportation Safety Act of 2010, S. 3638, 
111th Cong. (2010), proposed broadening DOT's proposed scope by 
requiring DOT to establish a public transportation safety 
certification training program for federal, state, and rail transit 
agency employees and others who are responsible for safety oversight 
and establish a national transit asset management system to measure 
and track the conditions of rail transit assets. 

[22] All 12 rail transit safety experts we interviewed identified 
safety culture as a challenge large transit agencies face in ensuring 
safety. In addition, four of the seven transit agencies we visited 
identified safety culture as a challenge for their transit agency. 

[23] GAO, Biological Laboratories: Design and Implementation 
Considerations for Safety Reporting Systems, [hyperlink, 
http://www.gao.gov/products/GAO-10-850] (Washington, D.C.: Sept. 10, 
2010). 

[24] GAO, Architect of the Capitol: Management and Accountability 
Framework Needed for Organizational Transformation, [hyperlink, 
http://www.gao.gov/products/GAO-03-231] (Washington, D.C.: Jan. 17, 
2003). 

[25] FTA, "Improving Safety Culture," Rail Transit Safety Quarterly 
Newsletter (Washington, D.C., 2009). 

[26] See NTSB, Derailment of Chicago Transportation Authority Train 
Number 220 Between Clark/Lake and Grand/Milwaukee Stations, Chicago, 
Illinois, July 11, 2006 (Washington, D.C., Sept. 11, 2007) and NTSB, 
Collision of Two Washington Metropolitan Area Transit Authority 
Metrorail Trains Near Fort Totten Station, Washington, D.C., June 22, 
2009 (Washington, D.C., July 27, 2010). 

[27] A micro-sleep is an episode of sleep that may last from a 
fraction of a second up to 30 seconds or more. Although often 
associated with sleep disorders such as sleep apnea, narcolepsy, or 
hypersomnia, episodes of micro-sleep can occur in any individual 
suffering from fatigue or inadequate sleep. 

[28] NTSB, Collision Between Two Massachusetts Bay Transportation 
Authority Green Line Trains, Newton, Massachusetts, May 28, 2008 
(Washington, D.C., July 14, 2009). 

[29] NTSB, Derailment of Chicago Transit Authority Train Number 220. 

[30] NTSB, Collision of Two Washington Metropolitan Area Transit 
Authority Metrorail Trains. 

[31] Close call incidents are defined as situations in which an 
ongoing sequence of events was stopped from developing further, 
preventing the occurrence of potentially serious safety-related 
consequences. 

[32] [hyperlink, http://www.gao.gov/products/GAO-10-850]. 

[33] All of the experts we interviewed identified staffing or training 
as a challenge facing large transit agencies in ensuring safety. 
Officials we interviewed at six of the seven transit agencies we 
visited identified staffing and training as a challenge. 

[34] APTA, APTA Preliminary Skill Development and Training Needs 
Report (Washington, D.C., July 2010). 

[35] A recent survey by APTA of transit agencies found that 53 percent 
of the 151 agencies that responded eliminated positions recently and 
32 percent laid off personnel. See APTA, Impacts of the Recession on 
Public Transportation Agencies, Survey Results (Washington, D.C., 
March 2010). 

[36] APTA, APTA Preliminary Skill Development and Training Needs. 

[37] Metropolitan Transportation Agency, Office of the Inspector 
General, An Inquiry Into Whether MTA New York City Transit 
Consistently and Correctly Identifies and Reports Subway Platform-Edge 
Safety Defects (New York City, N.Y., April 2009). 

[38] Eleven of the 12 rail transit safety experts we interviewed 
identified achieving a state of good repair as a challenge faced by 
the largest transit agencies in ensuring safety. In addition, all of 
the large transit agencies we visited cited this as a challenge facing 
their transit agencies. 

[39] FTA, Rail Modernization Study: Report to Congress (Washington, 
D.C., April 2009). This study covered the heavy, light, and commuter 
rail systems of the following agencies: CTA, MBTA, New York 
Metropolitan Transportation Authority (which includes NYCT), New 
Jersey Transit Corporation, BART, Southeastern Pennsylvania 
Transportation Authority, and WMATA. FTA determined the extent to 
which these assets were in a state of good repair by evaluating 
transit asset conditions based on the asset type, age, rehabilitation 
history, and other factors using its Transit Economic Requirements 
Model and asset inventories provided by the participating agencies. 

[40] These estimates are based on a broader follow-up study of transit 
agencies completed in 2010. See FTA, National State of Good Repair 
Assessment (Washington, D.C., June 2010). They do not include one 
transit agency we visited, SF Muni, which did not participate in FTA's 
studies. 

[41] NTSB, Derailment of Chicago Transit Authority Train Number 220. 

[42] FTA, Rail Modernization Study: Report to Congress. 

[43] In its most recent study on state of good repair, FTA found that 
seven large transit agencies had developed asset inventories, 
including CTA, MBTA, NYCT, BART, WMATA, New Jersey Transit 
Corporation, and Southeastern Pennsylvania Transportation Authority. 
FTA, National State of Good Repair Assessment. 

[44] We found, in analyzing FTA data, that NYCT's backlog makes up 
more than half of this estimated state of good repair backlog for 
these seven transit agencies. See FTA, Rail Modernization Study: 
Report to Congress. 

[45] According to FTA, the state of good repair backlog is an estimate 
of the costs needed to maintain, rehabilitate, and replace system 
assets to attain a systemwide state of good repair for the seven 
largest rail transit systems, including heavy, light, and commuter 
rail. See FTA, Rail Modernization Study: Report to Congress. This 
estimate was produced primarily by using FTA's Transit Economic 
Requirements Model. In addition, FTA obtained data on fixed capital 
assets from selected transit agencies and adjusted its estimates as 
appropriate to better reflect costs and asset life expectancies. The 
Transit Economic Requirements Model is also used to estimate transit 
capital investment needs for DOT's biennial Report to Congress on the 
Condition and Performance of the Nation's Highways, Bridges, and 
Transit. 

[46] FTA, National State of Good Repair Assessment. 

[47] A March 2010 survey by APTA of transit agencies found that, of 
the 151 agencies that responded, 69 percent projected budget 
shortfalls and 49 percent have transferred funds from capital to 
operations uses, which has aggravated efforts to keep systems in a 
state of good repair. The impacts were most severe among the larger 
transit agencies. See APTA, Impacts of the Recession on Public 
Transportation Agencies. 

[48] FTA funds the Transit Cooperative Research Program of the 
Transportation Research Board at the National Academy of Sciences, 
which conducts research to help transit agencies solve operational 
problems, adopt useful technologies from related industries, and 
encourage innovation. 

[49] Public Transportation Safety Act of 2010, S. 3638, 111th Cong. 
(2010). 

[50] GAO, Rail Transit: Observations on FTA's State Safety Oversight 
Program and Potential Change in Its Oversight Role, [hyperlink, 
http://www.gao.gov/products/GAO-10-314T] (Washington, D.C.: Dec. 10, 
2009). 

[51] [hyperlink, http://www.gao.gov/products/GAO-10-314T]. 

[52] [hyperlink, http://www.gao.gov/products/GAO-10-850]. 

[53] NTSB, Collision of Two Washington Metropolitan Area Transit 
Authority Metrorail Trains near Fort Totten Station. 

[54] The FRA pilot program, called the Confidential Close Call 
Reporting System, is designed to reduce accidents in the railroad 
industry and strengthen safety cultures. Employees are encouraged to 
voluntarily and confidentially report close call incidents without 
fear of discipline or punishment, and data are stored and analyzed to 
identify trends, new sources of risk, and corrective actions. The goal 
is to avoid more serious incidents. We have reported that such efforts 
hold promise and have contributed to reductions in accidents in other 
transportation industries. See GAO, Rail Safety: The Federal Railroad 
Administration Is Taking Steps to Better Target Its Oversight, but 
Assessment of Results Is Needed to Determine Impact, [hyperlink, 
http://www.gao.gov/products/GAO-07-149] (Washington, D.C.: Jan. 26, 
2007). The Federal Aviation Administration's program has established 
confidential, voluntary reporting systems to identify and report 
safety and operational concerns. We have reported that aviation 
industry personnel have some incentives to participate in voluntary 
programs, such as promised immunity from disciplinary action. In 
addition, these programs generate safety data that are not available 
from other sources. See GAO, Aviation Safety: Better Management 
Controls are Needed to Improve FAA's Safety Enforcement and Compliance 
Efforts, [hyperlink, http://www.gao.gov/products/GAO-04-646] 
(Washington, D.C.: July 6, 2004) and Aviation Safety: Improved Data 
Quality and Analysis Capabilities Are Needed as FAA Plans a Risk-Based 
Approach to Safety Oversight, [hyperlink, 
http://www.gao.gov/products/GAO-10-414] (Washington, D.C.: May 6, 
2010). 

[55] In addition to sponsoring the Confidential Close Call Reporting 
System, FRA has managed the Human Factors Research and Development 
Program, which has included pilot projects at freight railroad 
properties and other studies. The pilot projects used safety processes 
to change at-risk worker behavior at freight railroads by using peers 
to observe each other and provide safety-related, confidential 
feedback; compiling worker data to identify and implement corrective 
actions to improve safety; and training managers to effectively 
support the process. 

[56] The National Transit Institute is funded by FTA and managed by 
Rutgers University. The Transportation Safety Institute is managed by 
DOT's Research and Innovative Technology Administration. The 
Institute's Transit Safety and Security Division is funded by FTA to 
develop and deliver a variety of safety and security training and 
education to the transit industry. 

[57] We have previously recommended that FTA develop and encourage 
completion of a recommended training curriculum for state safety 
oversight staff. In response, FTA has created a recommended training 
curriculum and is encouraging oversight agency staff to successfully 
complete the curriculum and receive certification for having done so. 
See [hyperlink, http://www.gao.gov/products/GAO-06-821]. 

[58] In fiscal year 2010, the Transit Safety Institute trained 4,998 
transit agency staff in safety-related courses compared with 36 staff 
from state safety oversight agencies. The National Transit Institute 
did not have exact numbers, but estimated that more than 95 percent of 
the 1,926 participants it trained in fiscal year 2010 were from 
transit agencies. 

[59] FTA has planned three additional safety training classes for 
WMATA staff, tentatively scheduled in 2011. 

[60] U.S. House of Representatives, Committee on Transportation and 
Infrastructure, The Surface Transportation Authorization Act of 2009: 
A Blueprint for Investment and Reform (Washington, D.C., June 18, 
2009). 

[61] Additionally, APTA officials reported that they are partnering 
with FTA and the Transportation Learning Center to develop guidelines 
for rail vehicle, rail signal, and other training. This effort is in 
the beginning stages, but could serve as a starting point in 
developing a national curriculum. 

[62] APTA, Final Recommendations of APTA's Blue Ribbon Panel on 
Workforce Development (Washington, D.C., 2010). 

[63] Transportation Learning Center, International and Domestic 
Comparisons: Building Capacity for Transit Training (Silver Spring, 
M.D., 2010). The Transportation Learning Center is a nonprofit 
organization whose mission is to improve public transportation through 
labor and management training partnerships focused on workforce and 
organizational performance issues. FTA provides funding and technical 
assistance to the center for certain transit-related projects. 

[64] This amount does not include additional funding the Recovery Act 
provided for public transportation. The Recovery Act appropriated 
approximately $8.4 billion to fund public transportation throughout 
the country. Besides capital projects, the Urbanized Area Formula 
Program can help transit agencies fund related planning activities. 

[65] As requested in FTA's fiscal year 2011 budget request, the new 
formula for the state of good repair initiative would combine the 
existing Fixed Guideway Modernization Program (49 U.S.C § 5309) and 
the Bus and Bus Facility Grant Program (49 U.S.C. §§ 5309, 5318) and 
would provide $2.9 billion, an 8 percent increase over the combined 
programs' fiscal year 2010 level of funding. 

[66] Consolidated Appropriations Act, 2010, Pub. L. No. 111-117, div. 
A, title I, 123 Stat. 3034, 3062 (Dec. 16, 2009). FTA is to report its 
findings from the pilot program to the House and Senate Appropriations 
Committees by June 16, 2011. S. Rep. No. 111-69, at 88 (2009). 

[67] FTA, Transit Asset Management Practices: A National and 
International Review (Washington, D.C., June 2010). 

[68] In addition to these efforts, FTA conducted the two previously 
discussed studies to determine the extent to which transit agencies' 
assets were in a state of good repair. FTA also is working with 
transit industry stakeholders to better define what a state of good 
repair entails and how to measure and track it. 

[69] National Surface Transportation Policy and Revenue Commission, 
Transportation for Tomorrow (Washington, D.C., December 2007). The 
commission was established by the Safe, Accountable, Flexible, 
Efficient Transportation Equity Act: A Legacy for Users in 2005. Among 
other things, it was required to conduct a comprehensive study of the 
current condition and future needs of the surface transportation 
system, evaluate possible funding alternatives, and develop a 
conceptual plan with alternative approaches, to ensure that the 
surface transportation system will continue to serve the needs of the 
United States. The commission listed its highest priority as bringing 
the nation's infrastructure, including transit assets, to a state of 
good repair. Pub. L. 109-59, § 1909(b), 119 Stat. 1144, 1471-1477 
(2005). 

[70] GAO, Surface Transportation: Restructured Federal Approach Needed 
for More Focused, Performance-Based, and Sustainable Programs, 
[hyperlink, http://www.gao.gov/products/GAO-08-400] (Washington, D.C.: 
Mar. 6, 2008). 

[71] Public Transportation Safety Act of 2010, S. 3638, 111th Cong. 
(2010). The proposed legislation described a transit asset management 
system as a strategic and systematic process of operating, 
maintaining, and improving public transportation capital assets 
(track, railcars, and other system elements) effectively throughout 
the life cycle of those assets. 

[72] According to FTA officials, the agency does not currently have 
the authority to require transit agencies to establish asset 
management systems as a condition of receiving FTA funds. 

[73] This report accompanies the Senate fiscal year 2011 
appropriations bill for the Departments of Transportation and Housing 
and Urban Development. See S. Rep. No. 111-230, at 99 (2010). 

[74] [hyperlink, http://www.gao.gov/products/GAO-08-400]. 

[75] FTA, National State of Good Repair Assessment. 

[76] FTA, Rail Modernization Study. 

[77] FTA calculated 23 percent from the amount of federal funding 
available through the Fixed Guideway Modernization, Urbanized Area 
Formula, and bus capital programs and how much the seven largest 
transit agencies received from these sources. 

[78] The House of Representatives Committee on Transportation and 
Infrastructure has proposed that legislation to reauthorize surface 
transportation programs include the creation of a National 
Infrastructure Bank. The bank would be a government corporation that 
would sell bonds and provide direct subsidies to infrastructure 
projects. The bank's board of directors would be responsible for 
monitoring and overseeing energy, environmental, telecommunications, 
and transportation infrastructure projects. 

[79] These numbers do not include contractor staff. 

[80] For additional information on developing performance goals and 
measures through certain practices, see GAO, Agency Performance Plans: 
Examples of Practices That Can Improve Usefulness to Decisionmakers, 
[hyperlink, http://www.gao.gov/products/GAO/GGD/AIMD-99-69] 
(Washington, D.C.: February 1999); GAO, Executive Guide: Effectively 
Implementing the Government Performance and Results Act, [hyperlink, 
http://www.gao.gov/products/GAO/GGD-96-118] (Washington, D.C.: June 
1996); and GAO, Tax Administration: IRS Needs to Further Refine Its 
Tax Filing Season Performance Measures, [hyperlink, 
http://www.gao.gov/products/GAO-03-143] (Washington, D.C.: Nov. 22 
2002). 

[81] [hyperlink, http://www.gao.gov/products/GAO/GGD/AIMD-99-69]. 

[82] These measures are transit injuries and fatalities per 100 
million passenger miles traveled. 

[83] In past work, we have identified ways to make federal transit 
grant programs more performance based, such as the use of data to 
measure performance. For example, we have reported that FTA has set 
targets for some broad goals and has some initiatives aimed at 
increasing performance. However, FTA does not, in general, use the 
performance data it collects to evaluate the effectiveness of its 
grant programs. GAO, Federal Transit Programs: Federal Transit 
Administration Has Opportunities to Improve Performance 
Accountability, [hyperlink, http://www.gao.gov/products/GAO-11-54] 
(Washington, D.C.: Nov. 17, 2010). 

[84] We have reported on ways that agencies have overcome challenges 
in developing measures of program results. See GAO, Managing for 
Results: Measuring Program Results That Are Under Limited Federal 
Control, [hyperlink, http://www.gao.gov/products/GAO/GGD-99-16] 
(Washington, D.C.: Dec. 11, 1998) and GAO, Pipeline Safety: Management 
of the Office of Pipeline Safety's Enforcement Program Needs Further 
Strengthening, GAO-04-801 (Washington, D.C.: July 23, 2004). 

[85] GAO, Managing for Results: Enhancing Agency Use of Performance 
Information for Management Decision Making, [hyperlink, 
http://www.gao.gov/products/GAO-05-927] (Washington. D.C.: Sept. 9, 
2005). 

[86] We have reported that FTA has set targets for some broad goals 
and has some initiatives aimed at increasing grantee performance, but 
does not, in general, use the performance data it collects to evaluate 
the effectiveness of its grant programs. We also identified ways to 
make federal transit programs more performance based. See [hyperlink, 
http://www.gao.gov/products/GAO-11-54]. 

[87] In regards to public transit workforce development, APTA has 
recommended developing, implementing, and maintaining an ongoing 
tracking and monitoring system to measure performance and continuous 
improvement. 

[88] To improve FTA's management of its oversight of state safety 
oversight agencies, we previously recommended that FTA set performance 
goals, along with measures to make sure the program is making progress 
toward meeting those goals and to evaluate the impact of its 
management on safety and security. FTA later met this recommendation; 
however, as described above, FTA later discontinued using these set 
goals and measures. See [hyperlink, 
http://www.gao.gov/products/GAO-06-821]. 

[89] FTA, Rail Transit Safety Action Plan (Washington, D.C., September 
2006). 

[90] The Federal Motor Carrier Safety Administration's primary mission 
is to reduce crashes, injuries, and fatalities involving large trucks 
and buses by issuing, administering, and enforcing federal motor 
carrier safety regulations and hazardous materials regulations, among 
other things. 

[91] FTA may also need to collect additional data elements in support 
of new performance measures. FTA collects data from state safety 
oversight agencies and transit agencies. State safety oversight 
agencies report transit agency data to FTA as part of FTA's oversight 
program. Recipients or beneficiaries of grants from FTA under the 
Urbanized Area Formula Program (49 U.S.C. § 5307) or Other than 
Urbanized Area (Rural) Formula Program (49 U.S.C. § 5311) are required 
to submit data to the National Transit Database in order to be 
eligible for a grant award. 49 U.S.C. § 5335 (b). 

[92] These data were used by FTA to prepare its 2009 Rail Safety 
Statistics Report. See [hyperlink, 
http://www.gao.gov/products/GAO-11-217R]. 

[93] We have reported on various internal control standards to help 
agencies better achieve missions and program results. See GAO, 
Standards for Internal Control in the Federal Government, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: 
November 1999). 

[94] [hyperlink, http://www.gao.gov/products/GAO-11-217R]. 

[95] NTSB may elect to investigate certain accidents related to the 
transportation of individuals that it decides are catastrophic, 
involve problems of a recurring nature, or whose investigation is 
expected to bring about safety improvements. 

[96] NTSB issues reports and recommendations pursuant to its duties to 
determine the probable cause or causes of transportation accidents and 
to report the facts, conditions and circumstances relating to such 
accidents. See 49 C.F.R. § 800.3(c). In addition to reporting on 
probable causes, NTSB often reports on factors that it found to have 
contributed to the accidents. 

[97] Established by Congress, the NTD is the primary source for 
information and statistics on the nation's transit systems. Recipients 
or beneficiaries of grants from the FTA under the Urbanized Area 
Formula Program (§5307) or Other Than Urbanized Area (Rural) Formula 
Program (§5311) are required by statute to submit data to the NTD in 
order to be eligible for a grant award. 

[98] Unlinked passenger trips are the number of passengers boarding 
the public transportation vehicles, and passenger miles are the 
cumulative sum of the distances ridden by each passenger. 

[99] The National Transit Institute is part of Rutgers University 
Transportation Center, but is funded by FTA. The Transportation Safety 
Institute is part of DOT's Research and Innovative Technology 
Administration, but its transit safety training is funded by FTA. 

[100] [hyperlink, http://www.gao.gov/products/GAO-11-217R]. 

[End of section] 

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