smtf final report

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Signal Maintenance

Task Force

Final Report


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TABLE OF CONTENTS

Executive Summary ...............................................................................................1

Final Report............................................................................................................3

I. Background ........................................................................................................3

II. Signal System Description ...............................................................................3 III.Areas of Concern .............................................................................................4 A. Verification of Safety Critical Signal functions.................................................4

B. Depth and Breadth of Falsification ....................................................................6C. Quality Control Processes..................................................................................7

D. Resource Allocation.........................................................................................10

E. The Culture within the Division of Signals......................................................16

F. The Signal Equipment Information System .....................................................21

G. Operations Training.........................................................................................25

IV.Key Findings...................................................................................................25V. Recommendations ..........................................................................................29

Appendix A: Categorization of Signal Testing

Appendix B: Record Keeping Standards Memorandum

Acknowledgements


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SIGNAL MAINTENANCE TASK FORCE

EXECUTIVE SUMMARY

In late July 2010, the Office of the Inspector General (OIG) notified executive level management at

the New York City Transit (NYCT) of reports that employees within the Division of Signals (DS)had been falsifying records of signal maintenance and testing. In response, the President conveneda Signal Maintenance Task Force (SMTF) in August 2010, which was chaired by the Office of

System Safety (OSS), to address concerns raised by this finding. The SMTF was comprised of

representatives from OSS, the Department of Subways (DOS), Capital Program Management

(CPM), Technology and Information Services (TIS) and the Metropolitan Transportation Authority,Audit Services (MTA AS). In addition, the SMTF was aided by the OIG and signal experts from

external agencies comprised of AMTRAK, Southeastern Pennsylvania Transportation Authority

(SEPTA) and Metro-North Railroad (MNR). The signal experts assisted the Task Force inidentifying the best practices pertaining to signal maintenance and testing that are used throughout

the industry and in developing the corrective action plan resulting from this initiative.

The SMTFs primary focus was to determine what deficiencies and omissions there are in NYCTs

inspection, testing and maintenance of the signal system, their underlying causes and contributing

factors, and what actions need to be taken to correct them in a permanent and effective manner. To

do this, the SMTF structured its activities to address the following areas:

Verification of Safety Critical Signal Functions Depth and Breadth of the Level of Falsification Quality Control Practices Resource Allocation The Culture within the DS The Signal Equipment Information System (SEIS) Operations Training

The first priority of the SMTF was to verify that the signal system was not compromised. TheSMTF requested that the DS immediately perform critical testing of the signal system. The results

of this activity did not reveal any deficiencies that would adversely affect safe train movement.

Additionally, the signal system is designed on a Fail Safe principle. This design characteristic ofthe signal system acts to ensure that a fault or malfunction of any element affecting safety will cause

the system to default to the safe state and not allow a permissive signal to be displayed.

The SMTF identified systemic problems within the DS that evolved over time. The primary

systemic problem that was identified was that the DS historically took an inflexible approach totesting, inspection and maintenance activities without performing a comprehensive evaluation of its

processes. Therefore, more efficient means and methods of performing work was not implementedand has left the department unable to meet its objectives with regard to successfully performing

signal maintenance and testing activities. The SMTF explored the depth and breadth of suspect

activities regarding maintenance records. The review identified that such activities appears to bewidespread. However, the specific individuals involved in the range of falsifications cannot be

determined with any degree of certainty without performing an in-depth case by case investigation.

This condition is primarily due to the lack of auditing capabilities in SEIS. In addition, there were


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variations in the level and magnitude of the types of falsification that had occurred, ranging from

individuals who may have taken procedural short cuts, to individuals who may have documentedmaintenance and testing activities that were not performed.

Based on internal interviews conducted, the SMTF determined that the most probable underlyingreason for falsifications was the perception held by supervisors and hourly employees thatmanagement was exerting undue pressure on them to increase productivity. It is further believed

that these individuals may have had a genuine, although incorrect, belief that they would face severe

repercussions should they be identified as performing below par. The investigation revealed thatDS management did exert pressure on subordinates to increase productivity to combat

nonproductive behaviors. However, there was no credible evidence uncovered by the SMTF to

confirm that management was aware of or had condoned the falsification that was occurring.Regardless of this finding, management is ultimately accountable for the performance of signal

maintenance, testing, and inspection activities. In addition, there have been previous OIG

investigations involving allegations that DS personnel had falsified signal records. Although

previous allegations had been made and there was evidence to support that falsification may havebeen occurring, DOS executive management and DS management did not take sufficient corrective

actions to prevent the likelihood of record falsification occurring in the future.

In April, 2010, the DOS initiated the restructuring of its organization due, in part, to concerns

regarding whether critical maintenance functions were receiving the proper degree of attention and

the level of competency in the ongoing day-to-day direction and management under the LineManagement organizational approach that began to be implemented 18 months prior. Consistent

with the decision to change the organizational structure, executive management within DOS hasbeen reviewing all of the maintenance functions to ensure that the proper direction and management

was being provided. With the exception of the signals area, to date those reviews have not revealed

any serious issues or lapses.

This report includes a series of findings. They include, among others, that despite the omissions

and deficiencies identified in DS, the signal system is safe. There has been widespread falsification

of testing, maintenance and inspection records and the quality controls employed by DS have beeninadequate. Attempts by DS to solve its chronic failure to meet performance goals focused almost

exclusively on resource allocation without considering other alternatives. In addition, the original

nature of the Line Managers Program had unintended negative consequences on testing,maintenance and inspection activities.

Finally, this report concludes with 22 recommendations, suggesting that DOS address six areas:

verification of safety critical signal functions; improvement of oversight and quality controlpractices; enhancement of staffing efficiencies; improvement of the culture within DS; development

and implementation of an effective asset management system; and enhancement of OperationsTraining. The SMTF has requested that DOS provide a response detailing the actions that will be

taken to implement each recommendation.


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FINAL REPORT

I. BACKGROUNDIn the course of its investigation, the OIG brought to the attention of the NYCT evidence offalsification of signal inspection and maintenance reports. In addition, the Inspector Generalconveyed his finding to date that this falsification appeared to be a systemic issue raising concerns

regarding the completion of inspections and scheduled maintenance, as well as supervisory and

management oversight.

The Inspector General stated that this information was being conveyed prior to the completion of

his investigation so that the NYCT could immediately begin to take the steps necessary to ensurethe safety of the system and its riders.

Due to time constraints, the availability of resources and the desire to minimize the occurrences of

repetitive tasks, the SMTF made the determination that the efforts to identify the specificindividuals engaged in falsifying records would be left to those parties with the greatest expertise in

this area. The activities of SMTF focused upon determining the underlying causes and contributing

factors as to why the signal issues came into being, why they still exist and what is needed toaddress them in a permanent and effective manner.

The following is a detailed summary of the SMTF activities:

II. SIGNAL SYSTEM DESCRIPTION:

The three primary functions of the signal system are: to maintain safe separation between trains; to

allow trains to cross between adjacent tracks; and ensure that once a train has been authorized toproceed on a route, no other opposing or conflicting route can be authorized. In addition, a signal

system provides for the efficient movement of trains by allowing trains to closely follow each other

(i.e. headway) to meet passenger carrying capacity demands.

The NYCT signal system is predominantly a fixed block system that is comprised of wayside

signals with automatic train protection (ATP) that enforces positive train separation by using a

mechanical stop arm associated with the signals.

There are three signal aspects that are predominantly used to convey information to the Train

Operator (T/O):

Aspect Indication

Green ProceedYellow Proceed with caution be prepared to stop at the next signal

Red Stop

ATP is accomplished by the interaction of the mechanical stop arm coming in contact with a carborne trip cock assembly mounted on the underside of a train, which will result in an emergency

brake application of the train should the T/O fail to comply with a red aspect on a signal. The


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signals are strategically spaced to ensure that if a T/O passes a signal displaying a red aspect,

sufficient distance is provided that the train with the emergency brakes applied will stop before itmakes contact with the leading train. Signal aspects change from red, to yellow, to green as the

distance between a following and a leading train increases.

The signal system is designed on a Fail Safe principle. This design characteristic of the signalsystem acts to ensure that a fault or malfunction of any element affecting safety will cause the

system to revert to a state that is known to be safe. Electrical circuits and electromechanical devices

called relays are interconnected to provide the logic of the system. This logic enforces safe trainseparation by controlling the signal aspects and the mechanical stop arms. These circuits are

designed on the closed circuit principle meaning that, if the energy source to the relay is lost, the

relay will de-energize and open the relay contacts causing the affected signals to default to the safestate (red aspect) with the associated mechanical stop arm positioned to engage the car-borne trip-

cock of any approaching train. Therefore, the most likely consequence of not performing

maintenance and testing activities will be an increase in fail safe failures that result in delays, e.g.

T/Os encountering red signals, Rapid Transit Operations (RTO) personnel being unable to establisha route at interlocking areas, etc.

The signal devices are maintained, tested and inspected at defined periodic intervals which differdepending upon the device in question. A brief description of each of these activities is as follows:

Preventive maintenance is conducted by S/Ms to ensure the operational reliability of the equipment.

The devices are cleaned, lubricated and checked to ensure that all components and hardware aremechanically secure; testing of the signal devices, which can be performed by either S/M or M/Ss,

ensures that the safety critical functions are operating as intended, e.g. a Track Circuit is tested toensure that the presence of a train occupying a segment of track will be detected; and inspections

are typically performed at the M/S level. This visual inspection of the signal devices is performed

to assess the overall condition of the equipment and any unusual conditions identified will bedocumented and scheduled for corrective action. All the foregoing maintenance, testing and

inspection activities are required to be recorded and tracked in the SEIS database, which is used to

forecast work. SEIS was originally deployed in 1984 and, by todays standards for an asset

management database, SEIS is antiquated. SEIS will be discussed in greater detail on page 21 ofthe report.

III. AREAS OF CONCERN:

A. Verification of Safety Critical Signal functions:

SMTF Corrective Actions:In response to the reports of falsification of maintenance and testing records occurring, the SMTF

set its first priority as verifying that the signal system is functioning as intended. As part of thisinitiative, Signals Operations Engineering (SOE) developed a matrix that categorizes testing

activities with the intent of identifying signal equipment that would be more susceptible to deviate

from the defined tolerances of the DS Standard Test Instructions. The categorization of the testing

does not suggest that it is more important to perform one test over the other, but rather the hierarchyof the matrix was developed based upon which equipment is believed to be more prone to come out

of proper adjustment due to a variety of factors. Based on this rationale, the tests associated with


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signal devices such as stop mechanisms, switch machines and track circuits that are exposed to train

movement and other adverse conditions like extreme variations in temperature were classified asCategory 1, while the tests associated with signal devices that are less likely to be influenced by

external factors, such as interlocking equipment that are housed off the right of way, were assigned

a lower Category. The standard tests were divided into four categories (see Attachment A).

The SMTF requested DS management immediately begin performing safety critical testing of signal

functions on all mainline tracks. The SMTF recommended that the Shunt Fouling Test (Test 3) and

Track Circuit Test (Test 7) be performed. These tests ensure that the presence of a train is detectedwhen it is occupying a segment of track. It should be noted that there are only two unique locations

in the system where Test 3 is required to be performed due to the wiring configuration (parallel) of

these specific Track Circuits differing from the wiring configuration (series) used on the rest of theTrack Circuits in the system. Test 3 was performed at the two locations and no anomalies were

found. The SMTF also recommended that the Roadway Element-Train Stop Test (Test 21), which

verifies that the mechanical stop arm is positioned at the correct location on the track, be performed

to validate the integrity of the signal system. In addition, the Switch Locking & Adjustment Test(Test 18), which ensures that an obstruction between a switch point and stock rail will be detected,

also fell into the same category. However, the falsification of Test 18 is considered to be less likely

to have occurred due to the requirement that DS personnel perform this activity with Division ofTrack (DT) personnel during the monthly Joint Switch Inspection. Therefore, the Switch Locking

& Adjustment Test was not included in the Special Signal Inspection that is taking place.

The current protocol being followed to conduct the Special Signal Inspection (Test 3, Test 7 and

Test 21) utilizes hourly personnel to provide flagging protection, while supervisors are performingthe operational tests and members of management are witnessing the testing. The methodology of

the Special Signal Inspection requires that a 20% inspection of each of the 105 signal sections (of

the total of 122 signal sections), that has this type of equipment on mainline tracks. Any sectionfound to have an anomaly rate greater then 5% of the inspected equipment will require all

applicable signal equipment on that section to be inspected. As of December 2, 2010, 37% of the

signal sections have an anomaly rate above 5%.

There are 9,535 signal devices throughout the system requiring testing. As of November 30, 2010,

77% of signals system wide were tested (Test 3, Test 7 and Test 21). The current total of signal

devices tested is 7,371 with 451 defects found. Although some deficiencies were present, none ofthem created imminent conditions that adversely affected the safety of train operation. There were

221 defects associated with the mechanical stop arms. These conditions were minor in nature and

would have typically been corrected during routine testing activities. The mechanical stop arms

identified with defects required minor adjustments in order to have the device aligned in the idealposition associated with the stop arm gauge. All of the mechanical stop arms inspected were found

to be in an acceptable range to engage a car-borne trip-cock on a train.

There were 230 anomalies associated with Test 7, which required minor adjustment to the track

circuits in question. Track circuits can be influenced by water intrusion as well as other external

factors that can affect their operation and the activities to correct these anomalies would also havebeen performed during routine testing activities. Here too no conditions were found that would

adversely affect safe train movement.


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Signal Experts Opinion:The experts agreed with the current protocol of performing Test 3, Test 7 and Test 21 as well as the

categorization of the signal tests used to verify that safety critical signal devices were functioning as

intended. However, the experts suggested that NYCT consider elevating Ground Testing fromCategory 2 to Category 1. SMTF personnel responded that part of the rationale for placing GroundTests in Category 2 is that in most areas automatic ground detection is present, which provides

continuous monitoring for grounds.

The DS senior management reported that they have compiled a database to track the status of the

grounds. In addition, DS General Superintendents are required to provide a weekly status report at

internal staff meetings and a ground trouble shooting gang will be created utilizing current staffwith a future request for additional personnel to support this effort.

The SMTF members and the signal experts also discussed Vital Relay Testing. The SMTF

personnel expressed that NYCT has been shop testing relays that are removed from service forother reasons. The shop test includes pick-up and drop-away values as required by FRA. The

SMTF believes that an audit test approach of a certain number of relays being shop tested and

evaluated for any sign of problems combined with continued visual inspection will be the bestapproach for a twenty-four hour-a-day, seven day-a-week operation. The signal expert from

SEPTA acknowledged that this approach may be correct for NYCT.

B. Depth and Breadth of the Falsification:

As part of the SMTF investigation, discussions were held with signal personnel. The process for

performing test activities was explored in an attempt to determine the range of falsification

activities. One employee expressed the opinion that many of the tests were often difficult and timeconsuming to perform, e.g. the Track Circuit Test #7 requires that signal personnel place a shunt (a

15 foot long piece of #16 gauge wire connected to two metal files used to simulate the presence of a

train) at three different points on the rails of a track circuit when conducting the test. The employee

expressed the opinion that performing this test on exceptionally long Track Circuits, such as thosetypically found in an under river tube, could result in difficulties in communicating with the

employee designated to watch the operation of the track relay, as well as communicating with the

individual providing flagging protection to warn them of approaching train traffic. Therefore, dueto obstacles of this nature, it is the belief of the SMTF chairperson that some employees may be

short cutting testing activities. A different supervisor expressed the belief that on some occasions,

S/Ms had painted the mechanical stop arm yellow without actually gauging the stop arm as required

in Test 21. In addition, based upon the sheer volume of data entered into SEIS on some occasions,it is probable that there may be employees at the other end of the spectrum, who have entered false

records into the system without visiting the location where they were assigned to performmaintenance and/or testing activities.

MTA AS in conjunction with DS senior management attempted to determine the depth and breadth

of the occurrences of employees reporting more work than possible to be performed by a singleindividual in a single shift. These occurrences were given the term of outliers. MTA AS

reviewed data covering the time period from January, 2006 through June, 2010 and used the criteria


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established by the OIG as to what constitutes an outlier to evaluate the data. MTA AS found that

the majority of employees who worked on maintenance and testing tasks were identified as havingat least one day with outlier activity during the year. For example in calendar year 2006, 93% of the

employees had outlier activity on at least one day. Over time, there was a reduction in the number

of employees meeting the criteria for outlier activity and by 2010, 67% of the employees reflectedoutlier activity. In addition, the total number of outliers per year went down, going from a high of4,420 man days with outlier activity in 2006 to 1,180 in the first six months of 2010 (approximately

2,360 estimated for the year). The outlier activity was spread system-wide across the different M/S

zones and is not isolated to specific geographic areas. DOS executive management was providedwith detailed reports of these findings for review.

It should be emphasized that occurrences of unusually high maintenance and testing activityreflected in the SEIS system do not conclusively indicate that inappropriate reporting of such

activities were conducted by the individual credited with performing the work. The depth and

breadth of the suspect activity that constitutes an outlier is widespread; however, it cannot be

established with a great degree of certainty which specific individuals are involved withoutperforming an in-depth case by case investigation. The inability to identify the person inputting

data into SEIS is an obstacle that impacts investigators abilities to easily audit SEIS and identify

the specific individuals participating in committing record falsification. Employees, supervisorsand managers all have access to SEIS and the ability to input data. These factors may offer further

insight as to why these behaviors developed.

In some instances, outlier activities may be attributed to other factors. DS senior management was

of the opinion that some of the outlier activity reflected in SEIS can be the result of data inputerrors, i.e. an M/S performing manual data entry may have inadvertently entered multiple days of

work and credited it to a single individual on a single day. However, with the current deficiencies

in SEIS, the ability to audit the system is limited. Therefore, it is extremely difficult to identify theperson who entered the data and question them to distinguish between unintentional mistakes and

deliberate falsification. Additionally, overtime worked by the employees with the highest number

of outliers was reviewed and it was found that, while overtime was worked on some days, it was not

worked on the majority of the days that outlier information was entered into the database.

C. Quality Control Processes:

Signal Experts Quality Control Procedures:

During the discussions with the external signal experts, it was identified that they take a three-tiered

approach to quality control with regard to signal testing performed at their organizations. The first

two activities are performed internally. The signal expert from Metro-North stated that qualitycontrol inspections are performed by supervision and training personnel to assess the caliber of

signal personnels proficiency at performing testing. Their approach during this activity is intendedto be instructional, rather then punitive. In addition, they also require supervision to periodically

critique hourly employees performance. These critiques are documented and tracked. If the

critiques are not being performed, they have a system in place that will flag that the performance

checks are overdue, allowing management to easily monitor this program. It was suggested that itmay be possible to assess whether a maintainer is performing tests based upon the proficiency

exhibited by the individual when he/she is observed by supervision or others.


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With regard to external quality control inspections, all of the properties that the signal expertsworked at are required to follow Federal Railroad Administration (FRA) regulations and are

frequently visited by FRA personnel, who perform inspections. This quality control activity is

performed jointly with agency personnel and personnel from the FRA. The inspection typicallyconsists of the FRA inspectors witnessing both field testing of signal devices as well as reviewingtesting records and other related paperwork. At some properties, the FRA will inform the agency of

its intent to inspect. On other properties, the inspections are a combination of both announced and

surprise visits. Additionally, the FRA is empowered to fine the agency as well as an individual,such as a S/M, for a negative finding. Therefore, the consequences for falsification or improperly

performing testing can be immediate and severe, thereby discouraging this behavior from occurring.

Quality Control Process prior to the SMTF being convened:

The method of quality assurance utilized by the DS to gauge the proficiency of S/Ms performing

testing activities prior to the convening of the SMTF required the M/S to observe S/Ms perform

required testing at least once every 180 days. The goal of the observation was to assess theindividuals performance, identify deficiencies, and improve the quality of the test process. The

M/S captured this activity by entering a task code of 0235 into SEIS, which was intended to reflect

that the M/S observed a S/M perform the required testing at a specific location.

Proposed Quality Assurance Procedures for Immediate Implementation:

The SMTF reviewed the quality control methodology utilized by the DS mentioned above and wasnot satisfied that this approach provided any insight into the result of the inspection or the caliber of

the employees performance. Therefore, it is was agreed that, in addition to performing the testevery 180 days and entering the task code of 0235, the M/S will also be required to enter an action

code of 1, 2 or 3. An action code of 1 will signify that the employee was proficient at performing

the testing. An action code of 2 will signify that the employee was satisfactory; however, theemployee required minimal reinstruction on the performance of the tests, while an action code of 3

indicates that the employee was not proficient and further action, i.e. training is required. Any

instance resulting in an action code of 3 will require full documentation of the action taken to

improve the employees performance. DS management has also stated that it will be developingforms specific to each signal device, listing the tests required to be performed, which will be

distributed to the M/Ss to ensure consistency in the evaluation process. The M/S and the employee

evaluated will be required to sign the form regardless if a task code of 1, 2 or 3 was given to theemployee, which will provide hard copy documentation of the activity and improve accountability.

In addition, a Superintendent will be required to review the form prior to it being placed into the

employees file.

Presently there is no automated mechanism in place to flag noncompliance with this quality control

activity. Therefore, its performance is largely based upon the diligence of the M/S responsible toconduct the 180 day observation as well as DS managements commitment to monitor compliance

with this activity. This method of quality control could be further improved in the future with the

long-term goal being the implementation of a more user friendly format, similar to RTOs employee

evaluation program used by Train Service Supervisors (TSS) to evaluate T/Os. This aspect of thequality control inspections will be requested to be included in the future Enterprise Asset

Management (EAM) system.


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In addition to the routine observations performed by the M/Ss, DS senior management has alsocreated an internal quality control team consisting of a Maintenance Supervisor Level II (M/S II),

S/Ms and Signal Helpers to validate the quality of the maintenance and testing being performed by

signal personnel. These monthly inspections are unannounced and performed at random. The teamis not aware of the location to be inspected until the day of the activity. The supervisor in charge ofthe quality control team is provided with a checklist, requiring an examination of the condition of

the signal equipment assigned to that section, employees, compliance with both safety and use of

personnel protective equipment (PPE), a review of administrative duties, such as documentation ofsignal maintenance and testing activities, as well as general housekeeping of the facilities. The

results of the inspection are furnished to the responsible General Superintendent detailing any

deficiencies found and he/she is required to provide a written response within ten days to seniormanagement detailing corrective actions. This activity was implemented in May 2010 and to date

the DS has performed a total of five inspections of different areas and has identified a total of

thirteen conditions (Signal Maintenance-2, Safety-3, Administration-4 and Housekeeping-4) that

were reported to the responsible General Superintendent for corrective action.

Proposed Quality Control Procedure for Future Implementation:

In response to the SMTF request to consider a more independent means of performing qualitycontrol checks, SOE and CPM submitted a proposal that SOE personnel, with the support of DS

personnel, would perform a quality control check on each of the 105 DS signal maintenance

sections containing mainline signals and switches once per year. SOE would also be responsible forrecord keeping, periodic reporting, as well as written notification of discrepancies. This method of

inspecting would have an element of independent oversight as the SOE personnel responsible fordocumenting the activity do not report to DS management. The schedule would be randomized and

will not be published in advance. Additionally, the inspections would be scheduled with minimal

lead time to maintain an element of surprise.

The original proposal was that each time a quality control check of a section is conducted, the goal

would be to perform all of the Category I, Category II and Category III tests applicable to that one

piece of equipment. The only test in Category IV that would be performed during the inspection, ifapplicable, would be the Vital Relay Test (Test 4). Once the section to be inspected is selected, a

further selection of one signal location and one switch (if there is switch in the section) will be

made. Based upon the type of equipment, a test plan template identifying all the tests to beinspected will be completed, i.e. tests applicable to electro pneumatic (EP) switches can only be

performed if an EP switch is present, etc. Therefore, the number of tests that would be done during

each inspection would vary based on the equipment installed within each section. If the

recommendation to implement this layer of quality control is accepted, it may require SOE toreallocate existing positions or increase the number of positions available to establish this team.

The inspection team will be comprised of SOE personnel, a M/S II and two or more S/Msdepending on local conditions driving the flagging arrangement. The DS personnel on the

inspection team will fluctuate and be drawn from existing positions as needed.

In order to better evaluate the feasibility and value of such a program, SOE and DS beganconducting a few trial quality control checks drawing on existing positions within the organization.

As a result of this trial it has been found that it is very difficult to do all the tests associated with one


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trouble response, which are handled through a trouble desk, thus avoiding the need to divert signal

personnel away from maintenance activities during signal malfunctions.

The SEPTA representative estimated that 20% of their manpower is dedicated specifically to

performing testing. The other external signal experts expressed the sentiment that testing couldrequire greater than 20% of manpower when all activities necessary to perform the tests areconsidered. They emphasized that the actual performance of a single test may be brief. However,

preparing to perform the test can take much longer due to factors like travel time, prevailing service

conditions, equipment preparation, being granted permission to access the tracks, and determiningthat no trains will be affected prior to conducting the test. The example was given that it could

consume two hours total time to perform a ten minute test. In addition, non-productive time such as

standing by during the morning and evening rush hours to be available to respond to signalmalfunctions must be taken into account, as well as determining the amount of work that is not

being accomplished to attain goals should also be taken into consideration when calculating

manpower requirements. The signal experts determine manpower needs predominantly on historic

practices that have proven to be effective and will seek efficiencies by using new technology, suchas having signal modifications include vital processors to eliminate the necessity to perform labor

intensive tasks like vital relay testing.

History:

The past and present structure of the signal maintenance forces within the DS was reviewed. The

original structure within the DS to perform signal maintenance and testing activities was founded onthe basis of the two-person team. This approach was deemed to be inadequate and, over time,

created a culture where violations of safety rules occurred in order to perform testing activities, e.g.,a S/M is required to apply a shunt across the rails as his/her co-worker watches the track relay to

ensure that it assumes a de-energized state while performing the Track Circuit Test. In this

instance, there is no one available to watch for approaching trains as required by rule. In addition,signal modification projects have removed track relays from the field and relocated them to

enclosures off the tracks. Once this modification occurred, not only was short-cutting safety

required to perform the test, but the test itself may not occur in accordance with the policy

instruction due to lack of personnel. With no third person available to view the track relay operate,the two person team on the tracks performing the test are left to make assertions based upon the

consequences of their actions, e.g. I applied the shunt across the rails and the signal turned red,

therefore the track relay must have de-energized. In both situations, if done properly, instead, oneemployee should be applying the shunt across the rails, with a second employee positioned to watch

the track relay assume the full de-energized position, while a third employee is providing flagging

protection.

A Board of Inquiry (BOI) investigation into a Signal employee fatality that occurred on November

21, 2002 at 96th Street on the Seventh Avenue line resulted in heightened scrutiny of agency-wideflagging practices and the implementation of more restrictive flagging rules to protect employees

working on the tracks who are subjected to train traffic. In addition, in the aftermath of the

investigation, the DS revised the composition of the signal maintenance team to a minimum of three

people when working on the tracks. The DS reviewed maintenance and testing cycles performed atthe S/M level to determine if the cycles could be extended to achieve efficiencies. After


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In April 2010, DOS began the process of restructuring its organization to uncouple the track,

signal, power and communications functions from the Line Management structure that had beenimplemented some 18 months prior. Under the former structure, all critical maintenance functions

were grouped by Line (i.e. service route designation) along with the train service delivery and

station operations staff. The uncoupling was done in response to concerns that executivemanagement had as to whether, under the Line Management organizational approach, criticalmaintenance functions were receiving the proper degree of attention and level of competency in

their ongoing day-to-day direction and management. Consistent with that decision to change the

organizational structure, senior management within DOS has been reviewing all of the maintenancefunctions to ensure that the proper direction and management was being provided. With the

exception of the signals area, to date those reviews have not revealed any serious issues or lapses.

Signal Maintenance & Testing:

The DS has a self-imposed goal of 95% maintenance performed at the signal maintainer level. The

devices that were not maintained and tested during a particular maintenance cycle should have been

given priority in the next maintenance cycle. However, a review of recent maintenance recordsreveals that many devices were not maintained for prolonged periods of time. The SMTF

chairperson held discussions with mid-level signal management (Superintendents and General

Superintendents). The employees at this level indicated that there is no reasonable expectation thatthis goal is attainable with the existing structure, processes and available resources. The Zone

Summary Equipment Testing Report (MW-31) for the last nine years (2001 to 2009) reflects that

DS did not attain the 95% goal for maintaining all equipment that was due for maintenance within aspecific month at any time during the period reviewed. However, there were three occasions when

its overall percentage of total maintenance had reached 95% according to the MaintenancePerformance Summary Report (MW-2F). This discrepancy in the percentages is attributed to the

MW-31 Report tracking only the equipment that is due to be maintained during a specific period,

while all maintenance activities, e.g. maintenance of signal equipment that was due to bemaintained, as well as signal equipment that was maintained ahead of schedule, are included in the

percentage reflected in the MW 2F Report. The monthly averages reflected in the MW -31 Report

for each year were totaled to determine a yearly cumulative average for equipment maintained

within the prescribed time frame. The low point was calendar year 2003, when the DS averaged54.4% signal maintenance. The highest average of maintenance achieved for the same category

was 81.3% in calendar year 2007. In addition, it should be stated that the validity of the data used

to perform the analysis is questionable due to not having a complete picture of the extent andduration of the falsification of signal maintenance and testing activities. Therefore, these numbers

may be inflated. Based upon the MW 2F Report, the goal of 95% maintenance was only attained 3

times in the last nine years. However, DS senior management did not take effective corrective

action to address this issue.

The SMTF also did a concentrated analysis of the performance of the Track Circuit Test (Test 7)and the Roadway Element-Train Stop Test (Test 21) during the years 2001 through 2009. These are

two of the safety critical tests that the SMTF recommended that DS perform immediately to ensure

the safety of the system (see page 4 above). While rates of signal testing varied significantly for the

Track Circuit Test from a low of 59% in 2009 to a high of 82.9% in 2006, the Roadway Element-Train Stop Test has been performed at a rate of 98.6% or greater during eight of the nine years

reviewed. The single exception was in 2001, when the performance of the test averaged 89.9% for


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that year. The Roadway Element-Train Stop Test is required to be performed every thirty days,

which mirrors FRA standards. In some instances, it can take the entire month to perform thisactivity on heavily traveled corridors such as the Lexington Avenue Line. Once the task is finished,

signal personnel must almost immediately resume it again to meet the frequency requirement. The

impact of performing this single test means, on occasions there is little to no time available toperform other necessary maintenance and testing activities.

The DS and SOE concur that the priority should be given to performing safety critical testing, rather

than maintenance. Their rationale for this position is that the signal system is designed to fail safeand therefore should a condition exist that adversely affects the device it will assume a failure mode

that will not allow a permissive signal to be displayed. The importance of safety critical testing is

not being disputed. However, a review of the DSs Signal Equipment Testing Report (MW-30)indicates that there are numerous mainline switches and signals that far exceed their maintenance

and testing cycles. DS senior managements position is that they do not purposely defer

maintenance. However, regardless of DS managements policy, in practice such deferrals are

routinely occurring, in favor of performing testing. Deferring maintenance increases the probabilityof signal failures, which can result in S/Ms flagging trains past red signals without the benefit of

signal protection and increases the potential of a serious accident occurring due to human error.

DS Organizational Structure:

The present structure within the DS was reviewed. The most recent Signal Hourly Job Selection

(the Pick) that went into effect in September of 2010 revealed that most signal maintenancesections were comprised of teams of three individuals or larger. However, there are still 56 signal

maintenance sections where the teams are intentionally comprised of only two people at differentlocations through out the system, in spite of the fact that this arrangement is not sufficient to

perform work on the right of way. As a result, the employees assigned to the two person team must

be relocated and paired with additional personnel on a daily basis in order to perform routineactivities. The DS states that this structure is followed for a variety of reasons, such as not having

facilities on many lines that are capable of accommodating larger groupings of personnel and the

grouping of two people predominantly occurs on the 4-12 tour, where indoor equipment is serviced.

DS managements decision to utilize the two person team appears to be historically imbedded in theDS culture, although this arrangement offers little benefit to the organization.

Additional manpower constraints should be discussed to gain greater insight into the true level ofthe staffing problems within the DS affecting maintenance and testing activities. The DS manpower

strength report for September 2010 reflects that there are 1,278 heads allotted to the DS with 1,278

positions filled. Therefore, on paper, there are zero vacancies. This misrepresents the number of

persons available for productive work. The attendance sheets for the six signal maintenancedivisions (S1 through S6) that are responsible to perform signal maintenance reflect a total of 95

open jobs. The reason for the discrepancy in the manpower report and the number of unfilled jobson the attendance sheets is due to Signal Maintainer Trainees and Signal Apprentice titles being

included in the budgeted head count when, in actuality, they can be in training and not available for

productive use. It takes approximately 18 months for a Signal Maintainer Trainee to matriculate,

while a Signal Apprentice can take approximately 3 years, which prolongs and compounds staffingissues. The greatest number of open positions is on the 12-8 tour in mid-town Manhattan within the

heart of the Central Business District (CBD). The outer boroughs did not have the same rate of


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vacancies as Manhattan, which was attributed to signal personnel exercising their seniority rights

and selecting more desirable reporting locations. In past practice, a defined number of jobs wereheld back from the Pick, thereby limiting the number of jobs available to choose from and forcing

S/Ms to select essential signal sections. This practice does not appear to have occurred with any

great effectiveness in the most recent Signal Pick and speaks to a general lack of soundmanagement overseeing the daily operations of the department.

The effect of not having enough personnel to support maintenance and testing activities goes

beyond the obvious negative outcomes such as having a lower percentage of maintenance andtesting being performed. Trainee maintainers and apprentices are typically relegated to act as

flagman due to staffing shortages and are not being exposed to hands on work. Therefore, once

these employees matriculate and become full S/Ms, they may not retain the training they hadpreviously received due to not routinely performing the duties of a S/M, which can result in their

level of efficacy at performing the S/Ms duties being very low. Given the safety critical nature of

the S/Ms position, this deficiency needs to be addressed.

The DS staffing levels were reviewed from 2000 to present. The reports reflect that the DS has

received incremental increases in staffing from a low of 1,144 in 2000 to the current level of 1278,

which is an increase of 134 heads over that time period. However, as part of the SMTF activities,the present DS staffing levels were reviewed to determine if their headcount is sufficient to support

their current operations. The evaluation was performed by examining the personnel available and

the methods currently used by the DS to perform work. The review concluded that the current levelof staffing is not adequate to support these practices. Therefore, the work should be restructured to

improve efficiencies such that a high level of performance, measured as a percentage of scheduledmaintenance and testing, can be routinely achieved. This may also require a revision to the

frequency of some maintenance activities based on frequency of operation, level of train traffic,

equipment type and age, etc.

Corrective Actions:

The DS must thoroughly evaluate its current methods of performing maintenance, testing and

inspection activities and restructure its organization to meet its goals. There are approaches that canbe utilized to establish greater efficiencies. NYCT executive management can make a policy

decision to strategically shut down lines on a periodic basis to allow maintenance and testing

activities to occur during track outages. Another possible approach that can be taken by DSmanagement is to adopt a global gang maintenance structure, which in some instances is better

suited for our operating environment. Although it is not assumed that this is the best structure for

every place in the system, a gang format allows the numbers of flaggers to remain constant, while

the number of persons dedicated to performing work increases, resulting in greater productivity.This approach, if carried out under direct supervision, can also achieve a better quality of

maintenance, as well as improve validation that not only are the tests being performed, but they arebeing performed in accordance with the policy instruction. On September 14, 2010, the DS

implemented a pilot gang maintenance group on the 4th Avenue Line in Brooklyn and is awaiting

further data to make an assessment of this initiative.

Other methods utilized by the external signal experts also warrant evaluation, such as expanding the

use of trouble trucks to prevent personnel from being diverted away from maintenance and


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considering test squads for activities such as interlocking inspection and trouble-shooting grounds,

as well as adopting technologies, such as vital processors to reduce the amount of vital relay testingbeing performed. Additional approaches to creating efficiencies can include changing employees

Regular Days Off (RDOs) and tours of duty to increase opportunities for track access. In addition,

utilizing personnel with non-technical backgrounds to provide flagging protection is a moreeconomical approach to this activity.

E. The Culture within the Division of Signals

Signal Experts Culture:

The signal experts emphasized that it is clearly understood by all employees at their properties that

there is a zero tolerance policy regarding the falsification of an inspection record. This act will leadto immediate dismissal. However, it is also emphasized that there are no negative consequences for

not accomplishing maintenance and testing goals, assuming there are valid reasons for not

completing work.

DS Culture:

The SMTF chairperson interviewed DS personnel in an attempt to identify the root causes for the

falsification of maintenance and testing records occurring. A total of twenty four interviews wereconducted with the population of employees consisting of senior and mid-level signal management,

signal supervision and S/Ms. At the onset of the interviews, DS employees were informed that they

would not be offered amnesty for their testimony; however, they were also told that they would notbe asked directly if they committed falsification nor would they be asked to incriminate anyone

else. Instead, they were given the opportunity to describe their perception of what they believedcould have occurred and, therefore, they would not have to fear future punitive actions based upon

statements made during the interviews. In addition, although notes were taken during the interview

process, the names of the participants were intentionally not recorded to encourage the employees tospeak freely.

After concluding the interviews, it is the opinion of the SMTF chairperson that, although a

definitive conclusion has not been identified and there are multiple factors to consider that couldinfluence the situation, the most probable underlying reason for the falsification occurring is the

perception, held mostly by supervisors and hourly employees, that management was exerting undue

pressure on them to increase productivity. This factor, coupled with inadequate resources to attainthese objectives, most likely resulted in the personnel with low percentages of productivity in

maintenance and testing activities to falsify records in order to avoid managements scrutiny. It is

further believed that these individuals may have had a genuine, although incorrect, belief that they

would face severe repercussions should they be identified as performing below par when comparedto their more seasoned counterparts.

Upon the commencement of the interviews, all of the participants stated that they were not aware

that falsification was occurring. It is uncertain if the interviewees were genuinely unaware that

falsification was occurring or if they were answering questions in a guarded manner to ensure that

they would not be subjected to future discipline. When presented with the information regardingthe amount of signal devices that were either tested or maintained to qualify as an outlier, they all

expressed the opinion that the volume of work was impossible to complete by one S/M during a


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single tour of duty. However, some employees at the mid-level managerial and supervisory level

did state that management frequently instructed personnel at the supervisory level to assign S/Ms avolume of work that exceeded the range of what would reasonably be expected to be accomplished.

One interviewee at the supervisory level provided the most succinct explanation for the possibleroot causes of the falsification occurring. The individual providing this testimony is a self-described life-time civil servant with over twenty-five years of service at the NYCT who, from all

appearances, is extremely knowledgeable and proficient at his duties. This individual expressed the

perception that the onset of the falsification could stem from occasions when signal managementidentified S/Ms not engaged in productive work, e.g. sitting in the S/Ms quarters, rather then being

out on the tracks performing maintenance activities. When management would question these

employees as to why they were sitting around, the typical response received was that they hadcompleted the days assigned tasks and, therefore, there is no reason for them not to be in the S/Ms

quarters. In turn, DS management began instructing the M/Ss to assign hourly employees more

work than they can perform to remove the S/Ms excuses for not being engaged in productive

activities. The employee further stated that when he is given such an assignment, he freely acceptsit with the knowledge that he will never comply with it.

At this point in the conversation, the employee was specifically asked if he had personally beeninstructed by management to assign more work than was possible to complete; the employee

affirmed that he had been given that assignment. However, he added that he did not interpret this

action to mean that management was requesting or condoning falsification. This individual alsostated that he does not fear retaliation if he does not comply with the assignment because

management has no ability to take punitive action against him as long as he is able to provide areasonable explanation of why he is not able to complete the assignment and can account for his

time during the day, as well as the time of his subordinates. He cited that local management cannot

affect his raises, cannot affect his tour of duty and at best, the most it could do is change his weeklyRDOs on the next pick, making it less desirable for him to return to that section. However, if

management did try to affect his RDO, it would only be a minor inconvenience as he would exert

his seniority rights and bump another individual out of a job with the RDOs he wants. In addition,

he added that, should a S/M under his supervision actually tell him that he completed theunattainable volume of work in the assigned tasks, he would put the brakes on and explain to

them the seriousness of such actions, thus putting a stop to the behavior. The same individual also

expressed the opinion that some other supervisors, who may be new to civil service could be of thefalse perception that something significant would happen to them if they did not give management

what they asked for. It was his belief that these individuals could feel intimidated and would be

inclined to commit falsification to avoid managements scrutiny.

This opinion was reinforced during an interview with a different supervisor, who had been a

member of supervision for approximately ten years. When asked about his perception of whyfalsification was occurring, the employee also stated that he would only do what was reasonable and

would not give excessive productivity at the expense of quality. This employee became slightly

animated and went on to say, The superintendent can send me home. He can give me days in the

street (suspend him). I dont care. I wont do it. The employees demeanor suggested that hebelieved that this outcome was a real possibility. The employee was then asked if he could recall

anyone ever being sent home or if he had ever heard of someone being penalized for not meeting


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production demands. After a moment of reflection, the supervisor responded, I never heard of it

happening. Only moments earlier, the same employee appeared to express a very real belief thathe could be subjected to discipline for not meeting production demands.

The paradox in this situation was crystallized when interviews were conducted with DSmanagement, who expressed a contrary opinion regarding the amount of pressure exerted onsubordinates. The consensus of the interviewees at this level was that there is pressure associated

with any job and the amount of pressure they applied on subordinates to accomplish assignments

was normal. Based upon the supervisors statements regarding management instructing the M/Ssto assign more work than was possible for employees to accomplish, a small population of

management was interviewed a second time to either refute or affirm this allegation. The managers

interviewed stated that they did perform this act. They stated there were occasions when employeeswere found to be sitting in the S/M quarters not engaged in productive work and, to combat this

behavior; they instructed supervisors to assign the employees additional work. The assignments

were along the lines of telling the M/Ss to instruct the S/Ms that once they completed the typical

amount of work performed during one shift, which in practice was considered to be four signallocations or two switches, if time permitted the employees were to start maintenance and testing on

additional devices.

All of the mid-level managers freely expressed the sentiment that there was no expectation that they

could achieve the goals of the department and these individuals cited the fact that they routinely

supplied DS senior management with their maintenance and testing percentages, which wereconsistently well below the departments goal of 95%; however they were not subjected to any

negative consequences. Therefore, there was no compelling reason for them to exert such pressureon subordinates as might force them to falsify maintenance and testing records.

Disciplinary actions initiated by management toward DS supervisors were reviewed for a four-yearperiod (2006 through 2009.) The data reflects that DS management initiated only sixteen

performance-based disciplinary actions in this time frame. With a population of 129 supervisors,

this would indicate that less than 3% of the M/Ss per year had been written up for performance

based infractions. The percentage of individual supervisors experiencing discipline is even lower,when considering the fact that certain individuals had been written up for Improper Performance of

Duty more then once during the period reviewed, i.e. one individual is the subject of the discipline

in five of the sixteen occurrences. Therefore, it appears that the M/Ss belief that they would besubjected to discipline is more of a perception then a reality. In addition, the data indicates that, in

calendar years 2008 and 2009 when the greatest amount of supervisory performance based

discipline was being imposed (five cases in 2008 and six cases in 2009), the number of outliers was

steadily declining. Therefore, it can be argued that managements approach of holding thesupervisor directly accountable for non-productive behaviors of subordinates resulted in less

falsification occurring rather than more. This phenomenon may be attributed to the fact that theS/Ms had less incentive to falsify maintenance if they were not being permitted to engage in non-

productive behaviors and had to spend more time working on the tracks. Based on these

circumstances, the S/Ms would be less motivated to continue giving management excessive

numbers in regard to maintenance and testing activities.


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It should be noted that many of the managerial employees expressed the opinion that they were not

content with the daily situation in the DS. During their interviews, they expressed frustration thattheir requests for additional manpower directed to senior management went unanswered; ideas to

restructure the organization to perform maintenance and testing were ignored and have made them

demoralized. They also expressed the opinion that the approaches to accomplishing work presentedto them by DS senior management are often ineffective. One individual stated that he is routinelytold to piggyback on General Orders (GOs) to accomplish maintenance but, in his view, the

procedures for piggybacking make this solution unworkable. He cited the fact that the procedure as

written requires a face-to-face meeting with a project manager at the beginning and end of work.This specific DS manager felt that the project managers in charge of the General Orders were often

times difficult to track down and therefore performing this mandatory meeting cut deeply into the

time available to perform work. In his view, the work could just as easily be accomplished withpoint to point flagging if the rules were modified to better adapt to the working environment. Each

time he voices the opinion that piggybacking on GOs is not a workable solution, he is told to

forecast his work more efficiently. The SMTF endorses DOS executive managements review of

current work practices to determine if they are creating unnecessary obstacles to performing work.In the case of the piggybacking issue, perhaps routine maintenance activities that can be

performed under point to point flagging can be allowed without a face-to-face meeting with the

project manager taking place. The review may determine that notification to the RCC is sufficientand the face-to-face meeting may only be a requirement for work of a more invasive nature where a

full flagging arrangement is utilized.

In addition, many of the managers complained that they had become super maintainers and were

overtaxed. Not only are they saddled with excessive amounts of paperwork and no administrativestaff to assist with these activities, they also routinely respond to common-place cases of signal

trouble due to M/Ss and S/Ms inexperience and ineffectiveness at correcting signal malfunctions.

This activity appears to be occurring as expected in the CBD, where the employees at the M/S andS/M level have the least seniority and the current vacancy rate is the highest. These underlying

conditions offer one explanation for why an environment was created where negative behaviors

were unintentionally rewarded and positive behaviors were penalized. Due to being overburdened,

management appeared to devote more time to closely scrutinizing maintenance records of non-performing M/Ss, while only giving a cursory glance at supervisors work, whose numbers were

average or greater. In addition, management primarily concentrated on work that was coming due

in the near future or overdue and rarely examined records of completed work, resulting in occasionswhen an unattainable amount of work was entered into the database and, due to the SEIS system

being antiquated, there is no automated mechanism in place that would alert management to these

instances. Therefore, DS management apparently did not detect that falsification was occurring.

Additionally, the SEIS system lacks the ability to identify the individual inputting data into thesystem, which creates obstacles in holding an individual accountable for falsification at a later date.

Therefore, due to these circumstances, it is plausible that a new supervisor could be presented with

determining which path he/she will follow with regard to record falsification. He/she can perform

the supervisors position correctly and, due to limited resources, produce low averages of

maintenance, thus drawing the attention and ire of management for being a low achiever. The sameemployee can avoid detection, along with the S/Ms they are supervising, by falsifying records. This

essentially allows them not to be identified as producing maintenance and testing averages that are


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still below the unattainable departmental goals; however, their numbers are on par with their more

seasoned counterparts. It is believed that the supervisors who committed record falsification mayhave performed these actions based upon a genuine, although incorrect, belief that there would be

serious ramifications for not achieving the norm. This discussion should not be misinterpreted to

suggest that management encouraged or condoned falsification, but rather it appears thatoverburdened DS midlevel management does not have the time and resources to sufficientlymonitor the actions of subordinates. The current organizational structure of the DS and the systems

in place are inadequate to successfully maintain, inspect and test the signal devices, primarily due to

manpower deficiencies and inefficient work practices preventing the DS from arranging personnelin an effective manner to carry out these activities. Correcting these obstacles needs to be

aggressively pursued by DOS executive management. In addition, it appears evident that the

existing DS culture makes it more tenable for a M/S to falsify records than to inform managementthat he or she is unable to complete assignments. This issue needs to be resolved.

The most disturbing and significant finding regarding the DS culture is the fact that DS senior

management historically did not perceive the low percentages of maintenance and testing that wereconsistently occurring as a major issue of concern in spite of the fact that it appears that

subordinates routinely reported this information at staff meetings and these numbers were far below

its internal goal of 95%. In addition, although DS senior management stated that they do notpurposely defer maintenance, the percentage of signal maintenance and testing being performed was

far behind the intended schedule and they did not appear to grasp the gravity of this fact. Therefore,

their habitual inability to achieve their goals was not addressed and the problem was never broughtto DOS executive managements attention for remediation.

In addition, although previous OIG reports, which will be discussed in greater detail in the SEIS

section of this report, had identified that signal records appeared to have been falsified, DS

management did not implement any significant corrective actions to reduce the likelihood of thisactivity occurring in the future, such as frequently performing effective logbook reviews to ensure

conformity with SEIS data, reviewing data entry in the SEIS reports for accuracy and establishing a

culture where falsification is not tolerated. Additionally, DOS executive management had also been

aware of the problematic SEIS database and did not take sufficient action to implement an effectiveComputerized Maintenance Management System (CMMS).

Corrective Actions:The signal experts suggested that Executive NYCT management communicate to all employees that

record falsification will not be condoned or tolerated at the NYCT. This message should be

tempered by expressing to employees that we have an obligation to the public to provide safe

service and that these acts give the appearance of compromising safety. In response to thissuggestion, on October 21, 2010, DOS executive management issued a memorandum (see

Attachment B) entitled, Recording Keeping, which echoed the sentiments expressed by the signalexperts.

DOS executive management has been made aware that the DS has been routinely deferring

maintenance and testing activities so that actions can be taken to remediate this issue.


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TIS is currently working on methods to enable the identification of the individuals who input data

into SEIS to improve auditing capabilities and to provide accountability to discourage recordfalsification.

F. The Signal Equipment Information System:

Signal Expert Practices for Tracking Maintenance & Testing:

The signal experts stated that, at their properties, signal testing activities are recorded by having

signal personnel fill out and sign hard copy documentation indicating the testing activities that wereperformed; the forms used provide the ability to add additional comments to denote unusual

conditions. Supervision is required to review and sign the paperwork submitted by the maintainers.

Additionally, these records are retained and available for inspection. The signal expert fromAMTRAK stated that his agency currently captures information in the same fashion; however they

intend to eliminate paper and are transitioning to an electronic record system which the FRA will

accept as valid documentation of testing activities.

SEIS Description:

Signal maintenance, testing and inspection activities are recorded in the SEIS database, which was

first deployed in 1984. At the time, data was manually entered into the system at a mainframeterminal. In 2000, the system was enhanced with the implementation of barcode reader technology.

Presently, data can be entered into the SEIS system via either method. M/Ss and S/Ms are provided

with barcode readers to capture data. When conducting maintenance, testing and inspectionactivities, they are required to first scan an identification card that identifies the specific individual

performing the work. Next, they scan a barcode that is strategically mounted on the associatedsignal equipment to identify the device. Signal personnel will then navigate the barcode reader

program selecting and entering information on the screen at each prompt to record their work and

will repeat this process (with the exception of scanning the identity card) for each activityconducted and at each location where work is performed. After returning from the field, the

barcode reader is placed inside its cradle and the data is transmitted to a server assigned to Signal

Operations. This information is subsequently uploaded to a mainframe computer, where the SEIS

database resides. A problem arises due to the fact that the data regarding the number on theemployee identification card that was scanned at the beginning of work activities and the barcode

reader that was utilized to capture the information is only available in SEIS for five days. Although

this information is temporarily available, the employees identification card number and the serialnumber of the barcode reader does not appear in any of the reports generated by SEIS and this vital

information is not being archived. The data is removed from SEIS after the five days have elapsed.

The final SEIS maintenance and/or test record will only reflect the name of the person who is

credited with performing the work, but not the method in which the data arrived in the system, e.g.by a barcode reader with the unique employee identification card number used to identify the

specific individual who transmitted the data.

The second method of entering data into SEIS occurs at a mainframe terminal normally located in

the Signal Maintenance field offices. Typically, only M/Ss and DS managers are granted access

rights to SEIS to conduct manual data entry. Presently, the individual entering data at a mainframeterminal is not able to be identified in SEIS. However, TIS has developed a solution to the issue of


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identifying the individuals entering data into SEIS by either method (barcode reader or data entry at

the mainframe terminal), which is currently in the test stage and is being evaluated.

Previous Investigations/Audits Related to SEIS:

The SMTF chairperson performed a review of previous OIG investigations, MTA AS audits andOSS audits pertaining to the DS. A recurrent theme in many of the reports is the need for a CMMSwith the ability to identify the individual inputting data into the system.

In 1999, the OIG conducted an investigation into anonymous allegations that DS Superintendentswere instructing Signal M/Ss to enter false testing and inspection data in the SEIS system. The OIG

report (MTA/IG 2000-18), issued in October, 2000 indicates that records maintained relative to the

performance of required visual inspections and tests appeared falsified. The OIG recommended,

The current signal inspection and testing computer system or any other future system implemented

should be strengthened to ensure accountability, including validating data input. In 2000, when

this report was issued, the DS was in the process of implementing the barcode reader technology.

In regard to this aspect of the investigation, the OIG report stated, While the barcode reader willallow NYC Transit to determine where the MS, maintainer and helper were physically during a

particular day, it will not provide assurance that particular visual inspections or tests were actually

conducted on the equipment.

In 1999, the MTA AS conducted an audit (Report Number NY2-99027) of signal maintenance,

which was issued on August 31, 2000. The objectives of the audit were to determine theeffectiveness of the process by which signal devices are maintained and repaired and to identify

opportunities for improved performance. The audit identified the need for a CMMS in order toimprove the DSs ability to record and report repair times for all maintenance activities including

trouble calls.

In February of 2002, MTA AS issued Report Number NYT-01-76 to determine the implementation

status of recommendations made in their aforementioned audit. The report indicates that the

CMMS was scheduled to be implemented by the fourth quarter of 2002. On June 29, 2004, MTA

AS once again followed up on its previously issued recommendations made to the DS and issuedReport Number NYT-04-013; the report reflects that the implementation of the new CMMS was

now scheduled for the fourth quarter of 2004.

In 2005, the OIG conducted an investigation into anonymous allegations that signal personnel had

falsified documents indicating that inspections had been conducted when the inspections had not

been performed. OIG report (MTA/OIG #2005-62L) states, Maintenance Supervisors can

manually enter information into the SEIS, to indicate that inspections were performed by themaintainer. SEIS does not differentiate between manually entered information and information

scanned while in the field by maintainers. In light of this finding, the OIG recommended thatSEIS should be adapted to differentiate between entries scanned in versus manually entered andalso be able to record the identity of the maker of any entry. In addition, Signal maintenance

personnel routinely had unauthorized photo copies of barcodes in the S/Ms quarters that were used

to record maintenance activities without needing to go to the field. The NYCT response to thesefindings stated, These issues have been previously identified and are being addressed with the new

Spear CMMS database, which is currently scheduled for implementation in 2006.


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Barcode Reader Technology:

SMTF chairperson and the SMTF DS representative had differing opinions on the current use of thebarcode reader technology. The DS position is it will continue to have barcodes installed at

individual signal locations and require personnel to scan the barcodes at the location. In addition,

DS management has an ongoing campaign to ensure that unauthorized barcodes are not present atother locations on NYCT property that would provide someone with the ability to falsify data entryof maintenance or testing activities.

The SMTF chairperson has a differing view and believes that using the barcode system as a quasi-performance monitoring tool is not the best application for this technology. As previously

identified by the OIG, a S/M scanning a barcode is not a guarantee that the signal maintenance or

testing was performed. In addition, previous OIG reports have also identified that DS personnelroutinely develop unauthorized methods of defeating the barcodes, which is most probably driven

by the obstacles created by using this technology in a manner for which it is not well adapted.

Therefore, until existing advancements in the technology are implemented such as time-stamping

when the S/M scanned a barcode, there does not appear to be great value in using this methodologyas a means of verifying that maintenance was performed. However, in the near term, use of the

barcode readers as an input device will be part of the means by which accountability for data entry

is tracked.

Both the barcodes and the barcode readers are exposed to harsh environmental conditions such as

cold weather which, on many occasions, has caused the readers to malfunction. The barcodes arealso subjected to adverse conditions typically associated with a transit environment such as steel

dust, moisture, heat, etc. On occasions where either the barcode or the barcode reader ismalfunctioning, manual data entry at a mainframe terminal will be required, thus creating the

necessity to perform behaviors that the DS is trying to eliminate. In addition, the actual process of

scanning the barcodes in the field can create impediments to productivity, e.g. a S/M arrives at asignal location to perform the Roadway Element-Train Stop Test (Test 21) during the First of

Month. Based upon local conditions, the S/M may be capable of performing this task by

establishing flagging on only one track. However, while preparing to perform the test, the S/M

identifies that the stop mechanism, where the barcode resides to protect it from the elements, isbench mounted between two tracks. Therefore, by rule, he/she must establish flagging on the

adjacent track in order to work between the tracks to unlock the stop case to gain access to the

barcode. The S/M performing preventive maintenance and the suite of tests associated with a signallocation may have to scan a barcode four times to capture the maintenance and tests associated with

the device. This scanning action is occurring on live tracks and can be an unnecessary distraction.

Providing DS personnel with the ability to capture data in a clean, well-lighted, climate-controlledenvironment such as the S/Ms quarters offers a safer and more logical application of the barcode

technology. The focus of capturing data should be on having the entry correctly reflect the workthat the employees are performing and having the ability to authenticate the information and hold

them accountable for falsified records, if the need arises. Verifying that maintenance and testing is

actually being conducted is a function of supervision.


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G. OPERATIONS TRAINING:

SMTF members and Operations Training personnel held discussions to determine if the current

training provided to signal personnel was adequate. The SMTF determined that the classroom

portion of the training provided to S/Ms was sufficient. However, during the field portion of thetraining, Signal Maintainer Trainees may not be receiving sufficient exposure to the duties of a S/M.The SMTF also identified that there is no formal training curriculum available specific to

performing interlocking inspection. Therefore, depending on the level of competency of the

individual supervisor, the method of performing the inspection can have a large degree of variation.In past practice, this activity was the responsibility of the signal superintendent, who also never

received formal training but was believed to have had sufficient signal knowledge and experience to

effectively carry out a comprehensive inspection. In early 2009, this responsibility was shifted tothe M/Ss with the Superintendent monitoring the performance of a portion of each individual test to

ensure the proficiency of the supervisors performing it. The consensus of the SMTF is that it would

be beneficial to establish a formal training curriculum that defined the methodology and the process

for performing the multiple interlocking tests. Operations Training has agreed to develop acurriculum to address this concern. The target audience for this training will be M/Ss and DS

management at the Superintendent level. The training is anticipated to be rolled out in 2011. In

addition, consideration is being given to incorporating this training into the induction training fornew DS M/Ss.

The DS 2011 refresher training developed by Operations Training personnel will focus onperforming the standard signal tests (with the exception of interlocking testing). The belief is that

some employees who do not routinely perform these activities, such as employees working a 4-12tour who predominantly maintain indoor equipment or employees who have returned to signal

maintenance from other areas, such as Capital Construction, would benefit from the refresher.

Additionally, S/Ms who routinely perform testing will have their existing knowledge basereinforced. The target audience for this training will be S/Ms and M/Ss.

IV. KEY FINDINGS

Verification of Safety Critical Signal Functions:

The signal system is designed on the Fail Safe principle. Therefore, should a condition existthat adversely affects signal equipment, the most likely consequence will be that the signal

device will assume a failure mode that will not allow a permissive signal to be displayed.

The Signal Special Inspection that is underway has not revealed any deficiencies that wouldadversely affect safe train movement.

Depth and Breadth of Falsification:

It is believed that there were wide variations in the level and magnitude of the types offalsification that had occurred, ranging from individuals who performed assigned tasks but took

procedural short-cuts, to individuals who documented maintenance and testing activities that

were not performed.


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The depth and breadth of the number of outliers is widespread across different M/S zones and isnot isolated to specific geographic areas.

The occurrences of outliers and the number of individuals attributed with outliers have beensteadily declined from 2006 through 2010.

The specific individuals involved in the range of falsifications cannot be determined with a greatdegree of certainty without performing an in-depth case by case investigation. This condition is

primarily due to the lack of

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