Following a four-month investigation into safety practices at the MBTA, the Federal Transit Administration issued a final report Wednesday with a sweeping set of criticisms and directives, mostly based in a conclusion that the T for years has prioritized new construction over maintaining the safety and reliability of existing rail service.

The report details 20 findings across four main categories that the T needs to focus on — plus a fifth category of concern aimed at oversight of the MBTA by the state’s Department of Public Utilities — to resolve issues ranging from widespread staffing shortages to a lack of procedures for staff to report and track safety hazards. The findings come on top of the directives issued in June aimed at major safety concerns that federal regulators said could not wait for the full report.

Here are some of the federal investigators' key findings:

  1. The MBTA's organizational focus on capital projects has diverted management attention and resources from operations and maintenance, allowing the agency to operate a level of service that is not adequately staffed, trained, supervised or maintained.
  2. There is limited evidence that the MBTA adopted safety management practices in the field to support the identification, analysis and prioritization of safety information.
  3. There is a lack of routine, consistent and meaningful communication regarding safety issues across departments and with frontline workers.
  4. There are several areas where MBTA is not meeting its own written requirements; does not have adequate procedures, processes or requirements; does not have adequate training, coordination and supervision; and does not have independent quality assurance and quality control.

The FTA noted T’s budget for capital expansion projects has grown four-fold in the past four years, reaching $2 billion in 2022, including what investigators called an "unprecedented" transfer of $500 million from the MBTA’s operating budget to its capital budget in January.

And as the T has focused on capital projects, the report points out, its rail system has continue to deteriorate, leading to high-profile and sometimes deadly accidents. The death of a man on the Red Line this spring was caused by the malfunctioning of an “aging door assembly,” which allowed a train to start up again while the victim was trapped in the door. Similarly, the July fire on the Orange Line over the Mystic River was caused when a rusty panel fell off the train and onto the third rail.

Meanwhile, the report says, the MBTA is also greatly miscalculating labor costs. The positions written into its budget don’t reflect the real expense, with the agency often relying on overtime to cover staff vacations and training.

It all seems to amount to a huge problem with staff morale, mismanagement and misbudgeting of labor, and poor goal prioritization at the T.

“The combination of overworked staff and aging assets has resulted in the organization being overwhelmed, chronic fatigue for key positions in the agency, lack of resources for training and supervision, and leadership priorities that emphasize meeting capital project demands above passenger operations, preventive maintenance, and even safety," the report warned.

In addition, the T is still trying to recover from hundreds of millions of dollars getting cut from its maintenance and operations budget from 2015 to 2019, which prompted a reduction of hundreds of positions.

Federal regulators said the system is 1,500 to 2,000 positions short of where it needs to be.

The report does note that the T has a plan to hire more than 2,000 workers in fiscal year 2023, but it also points out that there will be more than 700 expected retirements in that same year. And, federal regulators write, the hiring plan will only help address the underlying problems at the MBTA to the extent that the agency focuses on filling key safety positions.

Regulators laid out more than 50 required steps for the MBTA, the agency's board of directors and the state Department of Public Utilities to collaboratively execute to prioritize safety for riders and transit workers on the T. Federal regulators are requiring the MBTA to deliver corrective action plans over the next four to six weeks describing how each of those steps will be implemented.

Some of those action items are essentially duplicates, directing MBTA to first study the shortcomings in a particular area and then, as a second requirement, implement the fixes indicated by the study.

Also on Wednesday, the MBTA announced the creation of a Quality, Compliance and Oversight Office. The agency said this office will implement actions identified in the FTA's report and share monthly updates on the T’s progress.

MBTA General Manager Steve Poftak said the agency has already taken steps to address some action items, including work on radio dead spots and changes to Safety Department meetings.

“The MBTA’s number one priority remains safety for both our riders and our employees,” Poftak said in a press release. “We are grateful to the FTA for their recommendations as we build on numerous actions and initiatives already in place across the organization to strengthen our safety management”

The FTA says that it will continue to monitor MBTA’s progress, and that it may penalize any failures to meet the requirements laid out in its orders. Punishments could include withholding up to 25% of the federal assistance MBTA receives or ordering a slowdown or cancellation of some or all rail services.