TWO NEW REPORTS trace the eruption of slow zones on the MBTA to a systemwide breakdown in track repair efforts brought about by poor communication between engineers identifying rail defects and the employees assigned to fix them.

Phillip Eng, the T’s general manager, said policies and procedures have been put in place to address the problems since they first surfaced in March, but the percent of track with slow zone restrictions has not declined dramatically.

Part of the problem, according to the reports, is inadequate and poorly trained staff. One report highlighted the fact that the director’s position at the MBTA’s maintenance of way unit, which is charged with repairing track defects, has been vacant since late last year. Eng insisted a number of newly hired executives will lend a hand with the maintenance of way unit and  veteran T executive Jody Ray is coming over from the commuter rail system to serve as the senior director of maintenance of way.

Eng indicated no one will be disciplined or fired for what went wrong at the maintenance of way unit. He said his focus will be on changing the organization’s culture. “It wasn’t one person,” he said. “The way the organization was set up it had too many blurred lines.”

The slow zone problem surfaced in early March when the MBTA’s state safety oversight agency, the Department of Public Utilities, inspected the Red Line between Ashmont and Savin Hill stations. A DPU official asked the T to produce documentation that repairs of track defects uncovered during a previous rail scan had been completed. It turned out that none of the defects identified by scans during the second half of 2022 had been reviewed and addressed.

Jeffrey Gonneville, who was the acting general manager at the time, feared the entire subway system was vulnerable, so he slowed speeds to 10 to 25 miles per hour across the system to guard against a severe accident. Only after teams of engineers were dispatched to check the tracks was the universal speed restriction lifted, replaced by narrower speed restrictions that nevertheless slowed a large chunk of the subway system to a crawl.

The MBTA commissioned an internal safety review and also hired an outside consultant to find out what went wrong. The two reports were both completed August 29, but Eng did not release them until Thursday. “This news is difficult to hear and talk about,” he said.

The reports analyze the breakdown in rail inspections and repairs, but don’t explain why slow zones have remained stubbornly high. According to the MBTA website’s dashboard on slow zones, 28.2 percent of the subway system, or 38.5 miles of track, was operating under speed restrictions on March 21, the day after the last universal speed restriction was lifted. On Thursday, nearly six months later, the percentage of track under speed restrictions was down to 25.8 percent, or 35.2 miles.

“This wasn’t intended to solve the speed restrictions,” Eng said, referring to the studies. “This was intended to help us better address the needs of the organization and our procedures.”

The MBTA regularly inspects its rail system using its own employees and third-party vendors. Reports of rail defects are processed by a team of engineers who then pass on repair requests to the maintenance of way division, which makes the repairs.

“All stated that the process was not formalized and undocumented,” said the MBTA safety report. “It relies on knowledge being handed down from senior personnel to newer ones. This proposes an issue, as the number of senior personnel is decreasing through attrition (i.e., retirements, etc.). It was also shared that prior [maintenance of way] management did not share information when they retired, and a good deal of institutional knowledge left the MBTA with them.”

The MBTA report said rail defects, once detected, often fell through the cracks and went unrepaired. The report referred to the rail defects as “exceptions.”

“There isn’t always a clear follow through to ensure that exceptions are validated and addressed,” said the report. “Once the [maintenance of way] engineers hand off the data, the line personnel manage it. There are inconsistencies on how each individual processes the data, based on the on-the-job training received. There is no communication back to the MOW engineers or department leaders to know that exceptions have been addressed.”

The external report, conducted by Charles O’Reilly Jr. of Carlson Transport Consulting, reached similar conclusions. “The first and primary cause is systemic in the form of lack of complete clarity regarding the roles and responsibilities of positions within the MBTA’s Maintenance of Way organization,” the report said.  “Contributing to the situation is the limited track maintenance experience of individuals with track inspection responsibility, inadequate training for these individuals, the absence of a Standard Operating Procedure for the visual and vendor inspections, and a vendor inspection process that does not adequately engage the MBTA individuals with front line responsibility for timely verification and action associated with track defects.”

The Carlson report said maintenance of way employees also failed to do their jobs, primarily because there was no standard operating procedure for dealing with track defects. The report also said staffing was inadequate and many workers lacked proper experience. The MBTA also prioritized new capital construction over maintenance work, the report said.

Maintenance work was also handcuffed by defect detection systems not attuned to MBTA track configurations. Most third-party vendors, for example, rely on tests designed to detect defects on freight rail systems that typically have long radius curves. By contrast, the MBTA system, particularly the Green Line, is filled with short and tight radius curves, which means the third party vendors often reported rail defects that didn’t actually exist.

The report said MBTA maintenance of way workers often wasted a lot of time pursuing these “ghost” defects – time that could better be spent on defects that did exist. Over time, the Carlson report said, these ghost defects led many maintenance of way workers to dismiss the third party rail scans as unreliable and ignore them.

Eng said the T is addressing the ghost defect issue, but a top aide said work remains to be done.

Eng also said the T is making progress in dealing with track defects. “We are much better with our operating procedures. We are much better with the follow-up,” he said.

The big question is why the percent of subway track with speed restrictions, a reflection of track defects, remains stubbornly high. Eng blames the slow zones on decades of disinvestment, which he is trying to address through targeted investments to bring the rail system into a state of good repair. The T overhauled chunks of the Blue Line track structure prior to the shutdown of the Sumner Tunnel this summer and in October plans to spend 16 days replacing all of the track on the Red Line between the JFK/UMass Station and Ashmont and all of the track on the Mattapan trolley line.

Eng has no timetable for eradication of slow zones across the entire system, which appears to be a whack-a-mole type of situation, with new problems surfacing as old ones are addressed.

“Even if it ends up with more restrictions, the important thing is we’re keeping it safe,” he said.