A string of problems at the Maryland Transit Administration - from poor leadership to inadequate mechanic training to faulty parts - led to the rash of incidents in which wheels fell off buses and dozens of people were injured, state investigators have concluded.
In a highly critical 22-page report released yesterday, investigators said the problems began at the top of the MTA with a failure to emphasize safety or launch a formal investigation until wheels had fallen off 10 buses.
"Safety wasn't a front-burner issue," said Fred Goodine, a member of the investigation team. "Execution and implementation of a safety program was shoddy and inconsistent at best."
Wheels fell off MTA buses in 18 incidents from August 2001 through June of this year, rolling down city streets, striking cars, bouncing off curbs and, on one occasion, hitting a natural gas tank. The runaway wheels led to 54 injury claims from passengers and drivers and at least $5,000 damage.
The top MTA official during that period, acting administrator Virginia L. White, resigned in June. She declined to comment yesterday, saying she had not seen the report.
The investigators concluded that a failure of the studs that hold the wheels together was the immediate cause of the separations, but added that people also were to blame.
Training was haphazard, written guidelines were out of date and MTA leadership was slow in responding to the problems, the report said.
"It's clear this wasn't simply a mechanical issue," said state Transportation Secretary John D. Porcari. "It was a failure on a number of levels - management, quality control and inventory, just to name a few."
The report lists 17 specific recommendations for fixing the problems, and officials said many are under way. Bus drivers are receiving more training, parts have been standardized and a new MTA administrator with a zeal for safety has taken over, officials said.
MTA failures cited
The report focused on three areas of failure:
Leadership: The report condemns a "lack of decisive action" between January and April of this year as the incidents mounted. White was faulted for not taking action soon enough. The report says she "intervened in the investigation in a manner that did not support identifying the root cause of the problem."
The author of the report, MDOT chief engineer John M. Contestabile, was more critical still in an interview yesterday.
"There's ample evidence in the report to point to the former acting administrator's actions as not supporting the safety efforts and the prompt resolution of this," Contestabile said.
In February 2001, the MTA's safety division found nine areas of concern about buses, including maintenance training, and asked that a corrective action plan be developed by May 31, 2001. It was never delivered.
"It was unacceptable that those questions were not answered promptly," Porcari said yesterday, "and it's part of the reason for the management change."
Training: The MTA lacked a systemwide maintenance training policy, and training often varied from one bus garage to another, the report said.
The manuals followed by mechanics were sometimes long out of date. The report notes that written guidelines provided to mechanics and supervisors on wheel studs, nuts and torque had not been updated since 1991. The guidelines made reference to steel wheels, even though the entire MTA fleet now uses aluminum wheels.
"Standard operating procedures and ongoing training for mechanics and supervisors appears lacking," the report said.
There was no formal training on wheel installation until May of this year, providing "little assurance" that any mechanic was properly trained, the report said. And while the wheel lug and tire replacement program began May 9, the new training did not begin until May 15.
Investigators were surprised to learn that some mechanics and supervisors still had not been trained by summer in wheel lug and tire replacement, even though the MTA said everyone had received training.
MTA officials said yesterday that some mechanics missed training because they were sick or on vacation, but all have now been trained.
Parts: The report found that the MTA used a hodgepodge of parts that may not have been made to work together. The MTA used at least four kinds of hubs, two drums, two types of wheel separators and up to four brands of studs.
Now, officials said, the MTA uses just one kind of each.
Investigators tested the various studs used by the MTA and found failures across the board. Four of the 18 studs manufactured by BATCO failed the tests, as did three of six unmarked studs.
"Based on inquiries and laboratory tests," the report concluded, "some safety critical parts of questionable quality were delivered to some shops. Therefore, the current MTA quality control procedures are apparently insufficient to guarantee parts integrity."
Officials said quality control has been upgraded and pointed to the fact that no wheels have fallen off buses since June 12 as evidence of their success.
"We're not ready to say that we've absolutely repaired the problem," said the new MTA administrator, Robert L. Smith. "But with me, safety is the most critical thing we're doing here."
MTA workers pleased
Deoleous Bridges, head of the local drivers and mechanics union, said workers are pleased with the changes Smith has made - the increased training, the standardization of parts and the frequent testing of materials.
Workers are also pleased, he said, that the state report did not point the finger of blame at them.
"The public was really pointing to the mechanics, but they felt that they were doing a good job and that this wasn't their fault," Bridges said. "Morale was low during that time. They'll be very pleased with this."
State Del. Peter Franchot, a Montgomery County Democrat who chairs a transportation subcommittee in the House of Delegates, said he's eager to see the report and that his panel will make sure the technical recommendations are followed.
"It sounds like they've got their arms around the problem and they're taking steps to correct it," he said. "For the integrity of the mass transit system, we cannot afford to have any kind of repetition because it cripples the confidence of people in the system."
Porcari said people should have confidence in the bus system and in the new administrator.
"He's simply not going to permit things to slide and gradually decline as they have over a number of years," Porcari said.
"This did not happen overnight, and it's not going to be fixed overnight. But we are well on our way to correcting every issue that has been identified."
Excerpts from state report
The following is from the state report, "Investigation of Maryland Transit Administration Bus Wheels," released yesterday:
Stud failure
Rear wheels came off the buses due to stud failure. ... Human factors in the form of inadequate care in assembly, inadequate training on the proper procedure and inadequate written guidance may have all contributed.
Some of the studs showed signs of rust along the failure plane. This would indicate that the stud had previously sustained damage by the over-application of force. This would create cracks in the stud ...
A number of studs had been in service for some time. The MTA did not have a policy of replacing studs on any regular schedule nor tracking the number of uses. Therefore, the very age of the studs ... may also have contributed to this failure.
Training
Although we would agree that these [mechanics] apparently need additional training and supervision, the hypothesis that this problem is due to a propensity of new mechanics does not seem warranted.
Additionally, the team determined that formal training on proper wheel installation did not exist prior to May of this year; therefore, there is little assurance that any mechanic was properly trained in the correct methods. Training was initiated on May 15, 2002, therefore not all mechanics or supervisors were trained by the beginning of the re-studding campaign (which began in earnest on May 9, 2002). Also, the training materials were revised at least twice during the training period. Consequently, there is a lingering concern as to whether the mechanics and supervisors have received sufficient training.
Leadership
The MTA did not respond quickly enough as an agency to address these incidents. There was a lack of communication and leadership in mobilizing to respond and a lack of teamwork in utilizing the full resources of the agency (including consultant and contractor assistance) in addressing what has proven to be a complex issue.
There was little top management involvement and direction prior to April 20th despite the fact that several senior managers were carbon copied on e-mails on the subject.
[MTA administrators] determined a corrective action plan (i.e. replacing the studs) with little outside expert advisory assistance. Outside technical assistance was not called upon until May 3, after the corrective action plan had been devised.