INITIAL ASSESSMENT OF THE 

CENTRAL ARTERY/TUNNEL PROJECT 

STEM TO STERN SAFETY REVIEW 

Federal Highway Administration 

Report Number: MH-2007-063 

Date Issued: August 16, 2007 
U.S. Department of 

Memorandum

Transportation 

Office of the Secretary 

of Transportation 

Office of Inspector General 

Subject: ACTION: Initial Assessment of 

the Central Artery/Tunnel Project 

Stem to Stern Safety Review 

Report Number: MH-2007-063 

Date: August 16, 2007 

From: Rebecca Anne Batts 

Acting Assistant Inspector General 

 for Surface and Maritime Programs 

Reply to 

Attn. of: JA-40 

To: James Ray 

Acting Deputy Administrator 

 and Chief Counsel 

This report presents the results of our initial assessment of the Commonwealth of 

Massachusetts’s ongoing Stem to Stern Safety Review. The Commonwealth 

initiated the safety review last year as an independent and comprehensive look at 

the overall soundness of the Boston Metropolitan Highway System, including the 

Central Artery/Tunnel Project. This project-wide review was prompted by the 

July 10, 2006, collapse of ceiling panels in a Central Artery Project tunnel, which 

killed a motorist. The safety review is divided into several phases, with Phase I 

being a purposely limited and expeditious review to identify immediate risks to 

public safety. In November 2006, the Commonwealth published the findings of 

Phase I in a report released to the public and made recommendations for further 

analysis and remediation.1

 

The Office of Inspector General (OIG) is overseeing the Stem to Stern Safety 

Review—and other Central Artery Project safety reviews and remediation work—

as directed by the National Transportation Safety Board Reauthorization Act of 

2006.2

 In addition to the Stem to Stern Safety Review, we provided independent 

oversight to the reopenings of sections of the Central Artery Project that were 

closed to traffic following the July 2006 collapse. This involved overseeing an 

8-stage series of safety reviews and remediation work to correct deficiencies. All 

sections of the Central Artery Project have since been reopened. Our broad 

 

1

 Issued November 15, 2006, http://www.eot.state.ma.us/stemtostern/. 2

 Public Law No. 109-443, § 11 (2006). 
2

objective is to provide assurance to the Congress, the Secretary of Transportation, 

and the traveling public that Central Artery Project safety reviews and remediation 

work are comprehensive and being performed in a rigorous and complete manner. 

For this report, we evaluated whether the findings and recommendations in the 

Stem to Stern Safety Review’s Phase I report adequately analyzed immediate risks 

and whether necessary remedial measures were identified. We monitored the 

Commonwealth’s activities after issuing the Phase I report, including activities 

initiated to address our observations on the classification of certain safety risks and 

on the Commonwealth’s follow-up activities (referred to as Phase IA). Further, 

we also assessed the methodology and work plans for the remaining phases of the 

safety review to determine whether they are clear and comprehensive. 

We contracted with the U.S. Army Corps of Engineers (Corps) in August 2006 to 

obtain its assistance and expertise in large infrastructure projects. Corps engineers 

worked directly with the Commonwealth’s engineers performing the safety 

review, monitored safety review activities, and provided updated information to 

our engineers on a regular basis. We conducted this performance audit in 

accordance with Generally Accepted Government Auditing Standards as 

prescribed by the Comptroller General of the United States. Exhibit A presents 

our scope and methodology. 

BACKGROUND 

Construction of the Central Artery Project began in late 1991 and was originally 

scheduled to be substantially completed by December 1998. Work on the project 

continues to this day. In response to rising project costs, which had increased to 

$14.625 billion by 2006, Congress in October 2000 limited Federal contributions 

to $8.549 billion.3

 Congress also directed the Secretary of Transportation to 

withhold obligations of Federal funds and all project approvals until OIG 

determines that the annual finance plan update is consistent with Federal Highway 

Administration (FHWA) guidance.4

 Exhibit B is a map of the Central Artery 

Project. 

Following the collapse of tunnel ceiling panels in July 2006, the overall safety of 

the entire Central Artery Project was called into question. In response, the Stem to 

Stern Safety Review was initiated by the former Governor of Massachusetts to 

provide an independent assessment of both near- and long-term safety. The 

review was authorized by the Massachusetts legislature, which appropriated 

$20 million specifically for a comprehensive audit of the safety of the 

 

3

 Department of Transportation Appropriations Act of 2001, Public Law No. 106–346, § 340(b) (2000). 4

 On June 27, 2007, we initiated an audit of the Massachusetts Turnpike Authority’s 2007 Finance Plan Update for the 

Central Artery/Tunnel Project. 
3

Metropolitan Highway System. The Governor issued an executive order to initiate 

the safety review in the summer of 2006. The previous Governor's term ended in 

January 2007 and a transition to a new administration ensued. The current 

Governor decided to continue the safety review.

In August 2006, the then-Governor of Massachusetts appointed his Secretary of 

Environmental Affairs as safety review director to provide overall leadership to 

the Stem to Stern Safety Review. Wiss, Janney, Elstner Associates, Inc. (WJE), a 

forensic engineering firm with significant experience in high-profile accident 

investigations, was retained to actually conduct the review. The scope of the 

review was divided into 10 separate areas, 9 of which covered major components 

of the Central Artery Project. The tenth area covered the ceiling systems of the 

Central Artery North Area (CANA) Tunnel, the Sumner Tunnel, and the Callahan 

Tunnel, which are distinct from the Central Artery Project. During Phase I, the 

Commonwealth evaluated all major components of the Central Artery Project and 

other components of the Metropolitan Highway System to identify immediate 

risks to public safety. A more comprehensive review of all safety risks is expected 

to be completed in Phase II. Of the $20 million appropriated by the Massachusetts 

legislature to conduct the safety review, $5.7 million has been budgeted for safety 

review activities leading up to Phase II. 

In addition to the Commonwealth’s safety review team, a five-member 

independent Advisory Panel was created by the then-Governor to help ensure the 

comprehensiveness, objectivity, and effectiveness of the review. The panel 

includes the chief engineer of the Port Authority of New York and New Jersey and 

the executive director of the Transportation Research Board of the National 

Academies of Sciences and Engineering. The chair formerly served in the 

U.S. Department of Transportation as an Assistant Secretary. 

RESULTS IN BRIEF 

The Phase I report of the Stem to Stern Safety Review identified numerous high 

priority safety risks across the major components of the Central Artery Project. 

Overall, we found that the Phase I process was conducted in a professional manner 

and was generally comprehensive for the short time period in which it was 

conducted. However, due to the limited 90-day duration of Phase I, certain key 

safety studies were purposely deferred to the later Phase II, which is intended to be 

a longer-term effort. For example, we noted, as did the Commonwealth’s 

Advisory Panel, that the 90-day duration of Phase I limited the depth of the review 

of the Central Artery Project’s complex life-safety systems, such as fire detection, 

ventilation, communications, and traffic monitoring. The Phase I review did not 

include detailed field inspections on foundations and underwater structures, such 

as bridge piers. The work of the Stem to Stern Safety Review will not be 
4

complete until more thorough studies of these systems and structures are 

conducted during the safety review’s other phases. 

During the Phase I review, WJE identified and recorded safety risks as reportable 

conditions. According to the Phase I report, examples of reportable conditions 

include members exhibiting distress or deterioration, apparent safety-related 

construction deficiencies, and other safety-related conditions that required detailed 

investigation. Reportable conditions were included in the Phase I report and rated 

on a scale prioritizing when the Commonwealth should conduct follow-up 

activities. The most serious conditions were classified as “immediate or 

dangerous conditions” that warrant immediate follow-up activities to fully assess 

the safety risks and conduct remediation as necessary.5

 

Specifically, based on our assessment of the Phase I report and plans for future 

safety review activities, we concluded the following. 

• Phase I of the Stem to Stern Safety Review generally analyzed the correct 

project components, but certain items should have been classified as 

higher priority safety risks in the Phase I report, or necessary follow-up 

activities were not sufficiently clear. Thus, timely and thorough follow-up 

activities are necessary to complete the full assessment of immediate safety 

risks and conduct remedial work. For example, we noted that the risk 

assessment of warped anchor plates on the Central Artery Project’s Zakim 

Bridge, which connect the bridge’s cables to its steel girders, was incomplete 

in the Commonwealth’s Phase I report. The safety review team gave this 

reportable condition a priority rating that classified it as needing further 

analysis during Phase II. In contrast, based on the analysis conducted by the 

Corps, we concluded that the warped anchor plates posed a higher safety risk. 

The OIG recommended that the safety review team address this safety risk 

immediately without waiting for Phase II; this correlated to a rating of an 

“immediate or dangerous condition” using the Commonwealth’s scale. The 

Zakim Bridge’s most recent bridge inspection performed in 2005 did not report 

the warped anchor plates, which underscored the need to fully assess this 

safety risk in a timely manner. In addition to the Zakim Bridge deformations, 

we concluded that expeditious follow-up analysis is required in several other 

key areas, such as the possible effects of large fires in the tunnels. 

In response to our observations about some of the findings and 

recommendations in the Phase I report, the Commonwealth agreed in 

December 2006 to create “Phase IA”—a new short-term phase of the safety 

review to occur between Phases I and II. Phase IA is intended to expeditiously 

 

5

 See Exhibit C for an explanation of the system used by the safety review team to classify and prioritize safety risks. 
5

conduct follow-up work to fully assess the conditions that we highlighted in 

our review of the Commonwealth’s Phase I report. On August 14, 2007, the 

Commonwealth released reports addressing many of the issues included in 

Phase IA. We have initiated our review of these reports. Among the key areas 

that the Commonwealth agreed to expeditiously address in Phase IA are: 

o performing additional analysis on the adhesive anchors supporting the 

ceiling in the Ted Williams Tunnel. In the Phase I report, the safety review 

team expressed concern about the long-term reliability of the adhesive 

anchors used to secure the ceiling panels to the tunnel roof in the Ted 

Williams Tunnel. The July 2006 collapse of ceiling panels in the Central 

Artery Project is attributed to the failure of the adhesive anchors in a 

section of the Interstate 90 connector tunnels. The adhesive anchors in the 

Ted Williams Tunnel are distinct from the anchors that failed because they 

are produced by a different manufacturer, have different design 

specifications, were installed by a different contractor, and are supporting a 

ceiling system that is much lighter than the ceiling systems used in the 

other tunnels. Nevertheless, there have been occurrences in the Ted 

Williams Tunnel of adhesive anchor bolts being embedded into concrete at 

a less than optimal depth and of anchor bolts partially slipping out of the 

concrete. We concluded that additional analysis of the adhesive anchors in 

the Ted Williams Tunnel should not be put off to Phase II. The 

Commonwealth agreed to raise the priority of follow-up analysis and 

initiate efforts in Phase IA. 

o performing additional fire modeling in the tunnels. In Phase I, the safety 

review conducted fire modeling on the effects of a single bus or truck fire 

in the Central Artery Project’s tunnels, which meets the current design 

standard for tunnels established in 2004. However, our fire experts 

recommended modeling for a two-truck fire as an extra precaution, which 

could create as much as three times the amount of heat that a single bus or 

truck fire produces. Specifically, we expressed concern that a hightemperature fire could seriously damage adhesive anchors supporting 

ceiling panels in the Ted Williams Tunnel. The safety review team agreed 

to reevaluate its fire modeling and discuss modeling the effects of a more 

intense fire in Phase IA. 

• The leadership, scope, and methodology for Phase II of the Stem to Stern 

Safety Review need to be specified and aggressive action must be taken 

going forward. The Stem to Stern Safety Review is not complete and the 

Commonwealth must still produce a detailed scope and methodology for Phase 

II activities. On June 25, 2007, the Commonwealth’s Secretary of 

Transportation announced the appointment of a new Deputy Secretary for 

Public Works who would also fill the Stem to Stern director position, which 
6

had been vacant since January 2007. However, unlike the previous director, 

the new Deputy Secretary will not be exclusively dedicated to driving the Stem 

to Stern Safety Review’s completion, nor will he report directly to the 

Governor. The Commonwealth should reconsider where to place the 

leadership of the safety review. A dedicated director position will help ensure 

that attention and resources are not diverted from this critical safety review and 

the remediation of identified safety risks. Completion of the Stem to Stern 

Safety Review in a timely, thorough, and independent manner is necessary 

because many key safety-related analyses were deferred.

When the Stem to Stern Safety Review was initiated last year, officials of 

FHWA informed us that their role would be advisory during the initial phase 

because the Commonwealth initiated the effort with no Federal funding. At 

that time, they also informed us that they intended to exercise greater oversight 

over the remediation of identified safety risks. Now that safety risks have been 

identified and remediation has begun, FHWA will need to exercise greater 

oversight to ensure that the Commonwealth completes the remaining phases of 

the safety review and remedial work in a timely, thorough, and independent 

manner. 

FHWA has already recognized the need to provide more oversight. For 

example, in March 2007, FHWA formally issued a letter to the Commonwealth 

expressing concern about the lack of substantive progress on the Stem to Stern 

Safety Review since the former Governor’s term ended in January 2007. This 

was a positive first step from FHWA, although it needs to increase its oversight 

going forward because safety risks have been identified and considering the 

massive Federal investment in the project to date. Moreover, FHWA should 

ensure that the Commonwealth expeditiously determines the responsible 

parties and pursues cost recovery from consultants or contractors for those 

conditions identified during the safety review that appear to be caused by 

design errors or inadequate construction practices.6

 

Accordingly, we are recommending that FHWA (1) designate a lead official to 

monitor the Commonwealth’s progress on the Stem to Stern Safety Review 

and (2) report regularly to the Department of Transportation Oversight 

Committee on the Central Artery Project regarding progress being made by the 

Commonwealth to complete the safety review.7

 FHWA should provide a copy 

 

6

 The Massachusetts Attorney General’s office has the lead on pursuing cost recovery efforts for the Central Artery 

Project. 7

 Acting Secretary of Transportation Maria Cino established the Department of Transportation Oversight Committee 

on the Central Artery Project to provide independent assurance that FHWA’s response to the July 10, 2006, ceiling 

collapse is sufficiently robust and comprehensive in assessing the cause of the failure and in overseeing the remedial 

steps taken by the Commonwealth to address safety concerns, such as the Stem to Stern Safety Review. The 

Committee is comprised of high-level DOT officials from outside FHWA. 
7

of each report to OIG. A list of our complete recommendations is provided 

beginning on page 16. 

FINDINGS 

Timely and Thorough Follow-Up of Stem to Stern Phase I Activities Is 

Necessary To Complete the Full Assessment of Immediate Safety 

Risks and Conduct Remedial Work 

The Commonwealth’s Stem to Stern Safety Review Phase I report, issued in 

November 2006, generally analyzed the correct items across the major 

components of the Central Artery Project, such as the tunnels and the Zakim 

Bridge. Our oversight team examined the Phase I report and made 

recommendations in cases where items were not given high enough priority as 

safety risks, or in instances when follow-up activities were not sufficiently clear. 

In response to our observations, the Commonwealth agreed in December 2006 to 

create “Phase IA”—a new phase of the safety review to occur between Phases I 

and II—to expeditiously conduct rigorous follow-up analyses to fully assess the 

conditions that we highlighted in our review of the Phase I report. Progress on 

completing Phase IA’s assessment of immediate risks and remediating these 

problems has been slower than expected. On August 14, 2007, the 

Commonwealth released reports addressing many of the issues included in Phase 

IA. We have initiated our review of these reports. 

Certain Conditions Were Not Classified as High Enough Safety Risks in 

the Commonwealth’s Phase I Report, or Necessary Follow-Up Activities 

Were Not Sufficiently Clear 

The Commonwealth’s Phase I report identified 34 items in “immediate or 

dangerous condition” that require immediate assessment and remediation. 

Examples range from light pole and signage structures at risk of falling to water 

leaks in main electrical rooms. The report also designated numerous other safety 

risks that require further investigation during the Stem to Stern Safety Review’s 

future Phase II. Overall, we found that the Phase I process was conducted in a 

professional manner and was generally comprehensive for the short time period in 

which it was conducted. Based on our oversight of Phase I activities as they were 

occurring and review of the Phase I report, we recommended that the 

Commonwealth’s safety review team raise the priority of certain safety risks and 

quickly clarify follow-up activities in a number of key areas, including: (1) 

conducting a follow-up investigation of the Zakim Bridge’s warped steel anchor 

plates, (2) investigating missing records that document the strength and quality of 

the Zakim Bridge’s structural steel, (3) performing additional analysis of the 

adhesive anchors supporting ceiling panels in the Ted Williams Tunnel, 
8

(4) conducting a more rigorous analysis of the impact of potential earthquake 

conditions on the tunnels’ suspended ceiling systems, and (5) performing 

additional fire modeling to fully assess the effects of high-temperature fires in the 

tunnels. 

The Commonwealth agreed with our recommendations to expeditiously conduct 

additional analyses in these areas as part of a new short-term Phase IA, which was 

created in December 2006. The intention was to immediately begin Phase IA; 

however, progress was slower than expected between January and May 2007. In 

May 2007, the Commonwealth agreed to kick-start Phase IA activities and 

complete them as soon as possible. Timely and thorough completion of Phase IA 

is necessary to fully understand the extent of the general safety risks already 

identified in Phase I and set the stage for the longer-term Phase II. 

Conduct a follow-up investigation of the Zakim Bridge’s warped steel anchor 

plates. The safety review team found a total of six warped steel anchor plates on 

the Central Artery Project’s Zakim Bridge—a condition not disclosed during its 

most recent bridge inspection performed in 2005. Such warping should have been 

identified in the project’s quality assurance process if it had occurred during 

construction, but we found no evidence that it was identified. Anchor plates, 

which connect the bridge’s cables to its steel girders, should not exhibit visible 

warping under normal stress conditions.8

 Warping of this kind may suggest that 

the anchor plates are overstressed and warrant special attention to assess any 

possible safety risks they may present. According to the Corps, in a worse-case 

scenario, overstressed anchor plates could lead to progressive bridge failure.9

 

The safety review team gave this reportable condition a priority rating that 

classified it as needing further analysis during Phase II. In contrast, based on the 

analysis conducted by the Corps, we concluded that the warped anchor plates 

posed a higher safety risk that needed immediate follow-up. The OIG 

recommended that the safety review team address this safety risk immediately 

without waiting for Phase II; this correlates to a higher rating of an “immediate or 

dangerous condition” using the Commonwealth’s scale. The safety review team 

concurred with us and included an expeditious follow-up analysis in Phase IA 

instead of deferring it to a future Phase II. 

Investigate missing records that document whether the strength and quality of 

the Zakim Bridge’s structural steel meet project specifications. During Phase I, 

the safety review team was unable to locate records of mill certifications for the 

 

8

 See Exhibit D for pictures of the Zakim Bridge’s steel anchor plates. 

9

 According to the Corps, a progressive failure can occur when a critical tension member (like an anchor plate) fails 

and all of its tension is abruptly transferred to adjacent members causing their overstress and failure in a progressive 

“unzipping” mode. 
9

Zakim Bridge’s structural steel despite significant efforts to find them. Reviewing 

the certifications is necessary to document that the Zakim Bridge was not 

constructed using structural steel of lesser strength or quality than required by the 

original design plans, which in a worse-case scenario could ultimately lead to 

bridge collapse. The missing certifications will also assist with the analysis of the 

bridge’s previously mentioned six warped steel anchor plates, which could be 

deformed because they were made using lower quality steel. On July 13, 2007, 

the Commonwealth informed us that the mill certifications had been found, 

although at the time of this report we had not received them. 

The Phase I report recommended deferring the search for mill certifications to 

Phase II. However, considering past instances of poor quality construction, such 

as defects in concrete wall panels that led to water leaks and the use of inferior 

concrete mix found as part of on OIG investigation,10 we recommended that this 

activity receive higher priority. Leaks in the tunnel wall panels became a public 

concern in September 2004 when one panel was breached, spilling 300 gallons of 

water a minute onto the I-93 tunnel roadway. In this case, the examination of 

construction records was crucial to discovering numerous errors and irregularities 

in the oversight of the contractors that built the I-93 tunnel walls and in the walls’ 

construction. Separately, six current and former employees holding managerial 

positions in Aggregate Industries’ concrete division were charged in May 2006 

with highway project fraud and related offenses for their participation in a scheme 

to provide concrete to the Central Artery Project that did not meet contract 

specifications. 

The safety review team agreed with our recommendation and decided to further 

investigate the mill certifications in Phase IA. Thoroughly analyzing these mill 

certifications is critical to determining the structural integrity of the Zakim Bridge. 

Meanwhile, to fully address these concerns, the safety review team agreed to 

conduct tests of the bridge’s steel if the mill certifications are not found. 

Perform additional analysis of the safety of adhesive anchors supporting ceiling 

panels in the Ted Williams Tunnel. The July 2006 collapse of ceiling panels in 

the Central Artery Project tunnel was attributed to the failure of the adhesive 

anchors in a section of the Interstate 90 connector tunnels. Consequently, all 

adhesive anchors used to support ceiling panels in the I-90 tunnels have since been 

removed, excluding those in the Ted Williams Tunnel. The adhesive anchors in 

the Ted Williams Tunnel are distinct from the anchors that failed because they are 

 

10 On July 27, 2007, Aggregate Industries agreed to plead guilty and pay $50 million to resolve its criminal and civil 

liabilities in connection with a fraudulent scheme to deliver adulterated concrete to the Central Artery Project. The 

plea was a result of a multiparty investigation that included OIG, the Massachusetts Attorney General’s Office, the 

Federal Bureau of Investigation, the Massachusetts State Police, and the U.S. Attorney’s Office, District of 

Massachusetts. 
10

produced by a different manufacturer, have different design specifications, were 

installed by a different contractor, and are supporting a ceiling system that is much 

lighter than the ceiling systems used in the other tunnels. Nevertheless, the safety 

review team was still concerned about the long-term reliability of the adhesive 

anchors used in the Ted Williams Tunnel, which secure ceiling panels into the 

concrete of the tunnel roof. The safety review team came to this conclusion 

through its analysis of limited data on the long-term performance of adhesive 

anchors, which includes occurrences of adhesive anchor bolts being embedded 

into concrete at a less than optimal depth and of anchor bolts partially slipping out 

of the concrete. 

The Phase I report noted that more detailed analysis is needed in Phase II to 

evaluate possible long-term safety risks posed by these adhesive anchors. 

However, we concluded that these efforts should not be put off to the longer-term 

Phase II. The safety review team agreed with our recommendation to raise the 

priority of these activities and initiate them in Phase IA. These efforts will 

continue into Phase II when the safety review team will study the long-term safety 

of continuing to use adhesive anchors in the Ted Williams Tunnel, determine the 

probability of a ceiling failure, and identify appropriate design requirements for 

mitigating the likelihood of any ceiling failure. 

Conduct a more rigorous analysis of the impact of potential earthquake 

conditions on the tunnels’ ceiling systems. Design codes require that a seismic 

analysis be performed of structures like a highway tunnel. A seismic analysis 

involves evaluating the integrity of the structure under potential earthquake 

conditions. Considering the July 2006 collapse of ceiling panels in one of the 

Central Artery Project tunnels, we believe the safety review team should ensure 

the evaluation of the design is complete and includes the appropriate seismic 

analyses. Specifically, we recommended that the safety review team reexamine 

how it treated ceiling systems in its seismic analyses and consider using more 

stringent seismic design requirements for the ceiling systems. For example, the 

current formulation of the seismic analyses does not treat the tunnels’ ceiling 

systems as integrated components of the structure, as the roof, floor slabs, and 

walls are treated. Such components are subject to more stringent seismic design 

requirements. Since Boston is located in a designated earthquake zone, it is 

essential to provide clarification on the ability of the tunnels’ ceiling systems to 

withstand an earthquake. In response to our concerns, the Commonwealth’s safety 

review team agreed to reevaluate the current formulation of the seismic analyses. 

Perform additional fire modeling to fully assess the effects of high-temperature 

fires on the Central Artery Project’s tunnels. The safety review team conducted 

fire modeling on the effects of a single bus or truck fire in the Central Artery 

Project’s tunnels. This modeling meets the current design standard for tunnels 
11

established in 2004. In addition, according to the Commonwealth, the tunnels 

were built to design standards that were applicable at the time of construction. 

However, our fire experts, who include a prominent scientist from the National 

Institute of Standards and Technology, recommended, based on the current body 

of knowledge and the possibility of such an event, that the safety review team 

perform additional fire modeling for a two-truck accident. Such an event is 

plausible and could create as much as three times the amount of heat that a single 

bus or truck fire produces.11 

Additionally, our experts expressed concern over the impact of high temperatures 

in the plenum area. The plenum is the space between the roof of the tunnel and 

the suspended ceiling panels, which is used for ventilation purposes. We believe 

that high temperatures could have a serious impact on adhesive anchors, which 

secure ceiling panels to the tunnel roof in the plenum area of the Ted Williams 

Tunnel. A high-temperature fire could cause the anchors to fail. In the Phase I 

report, the safety review team recognized the need for further review by noting 

that “more detailed analysis and testing will be needed in Phase II to establish the 

performance of the ceiling system epoxy anchors during a large fire.” In response 

to our observations, the safety review team agreed to reevaluate its fire modeling 

and discuss modeling a more intense fire to examine the fire’s effects on the 

ceiling plenum and the adhesive anchors. 

The Leadership, Scope, and Methodology for Phase II of the Stem to 

Stern Safety Review Need to be Specified and Aggressive Action 

Must Be Taken Going Forward 

The leadership, scope, and methodology for Phase II of the Stem to Stern Safety 

Review need to be specified as soon as possible. The former safety review 

director resigned in January 2007 and the Commonwealth did not designate a 

replacement until June 2007. Additionally, the Commonwealth has yet to 

announce its specific plans for the direction of certain Phase II activities, including 

the role of the Advisory Panel, and what the detailed scope and methodology for 

Phase II will be. Phase I was purposely limited and intended to set the stage for a 

more rigorous and comprehensive Phase II. Sustained progress is necessary 

because many key safety-related analyses have not been completed. Completion 

of the entire safety review in a timely, thorough, and independent manner is 

critical to ensure that key safety-related analyses are accomplished. 

 

11 Tunnel fires with heat release rates higher than the rate of a single truck fire have occurred throughout the world. 

The results of the 2003 Runehamar fire tests published by the Fire Safety Journal in January 2006 indicate that the 

heat and temperature released in tunnel fires were considerably higher than the values reflected in the current 

design standard for truck fires used for the Central Artery Project. Further, a FHWA sponsored study issued in 

June 2006 on European underground transportation systems also highlights the occurrence of tunnel fires with heat 

release rates much higher than what is reflected in the current design standard. 
12

Going forward, FHWA will need to exercise greater oversight to ensure that the 

Commonwealth completes the safety review in this manner, considering the 

massive Federal investment in the project to date and the identified, significant 

risks. Moreover, the discovery of items in “immediate or dangerous condition,” as 

identified in the Phase I report, calls into question the quality of the Central Artery 

Project’s design and construction. FHWA should ensure that the Commonwealth 

expeditiously determines the responsible parties and pursues cost recovery from 

consultants or contractors for those conditions identified during the safety review 

that appear to be caused by design errors or inadequate construction practices. 

The Stem to Stern Safety Review Has Lacked a Designated Leader in 

Recent Months 

In a January 2007 transition report to the incoming Governor, the former safety 

review director identified the naming of a new director and the appointment of 

members to the Advisory Panel as immediate priorities, but these key decisions 

were not finalized for nearly 6 months. In announcing the newly appointed 

director on June 25, 2007, the Commonwealth’s Secretary of Transportation stated 

that the position would be organizationally located in the Executive Office of 

Transportation, hold the title of “Deputy Secretary of Public Works,” and have an 

array of other duties in addition to the Stem to Stern Safety Review, such as 

coordinating the inspection and construction of major highway and rail projects as 

well as pursuing cost saving opportunities at the Massachusetts Highway 

Department and the Massachusetts Turnpike Authority. 

The previous safety review director was exclusively dedicated to driving the safety 

review’s completion and reported directly to the Governor. Having the safety 

review director wear many hats creates the risk of diverting the director’s attention 

away from this critical safety review and possibly delays the review and the 

remediation of identified safety risks. The Commonwealth should reconsider 

where to place the leadership of the safety review. A dedicated director position 

will help ensure that attention and resources are not diverted from this critical 

safety review and the remediation of identified safety risks. Further, the role of 

the Advisory Panel, members of which serve at the pleasure of the Governor, 

remains unclear because the panel’s chair stepped down at the conclusion of Phase 

I. The Stem to Stern Advisory Panel can supply independent expertise and help 

provide assurance to the public that the review is being conducted in a rigorous 

manner. 

The Commonwealth Needs to Produce a Detailed Scope and Methodology 

for Phase II 

Phase II of the Stem to Stern Safety Review requires a clear and detailed scope 

and methodology to complete the full assessment of safety risks identified in 
13

Phase I. The safety review’s preliminary implementation plan for Phase II 

identifies and prioritizes follow-up activities to address Phase I recommendations, 

but lacks key components, including a realistic schedule with a critical path for 

sequencing activities, and reasonable cost estimates. On July 13, 2007, the 

Commonwealth informed us that it had finalized a scope of work with WJE for the 

Phase II work. Our review showed that the finalized scope of work does not 

include a detailed plan with specific activities that will be conducted during Phase 

II and time frames for their completion. This information will be needed. The 

methodology used in Phase II should also include activities to independently 

verify the remediation of safety risks. Additionally, the Phase II plan will need to 

be updated to reflect any new findings that are identified in the coming months 

during Phase IA. Finally, the Commonwealth’s safety review team should also 

continue to routinely communicate to FHWA and OIG the latest developments on 

Phase II planning and the status of Phase IA activities. 

In particular, we believe that our recommendations regarding fire protection and 

life safety should be carefully considered in designing a comprehensive scope for 

Phase II activities. These analyses were not conducted during Phase I of the safety 

review. Because detailed Phase II plans are not yet complete, it is unclear whether 

these recommendations will be included. Accordingly, we recommended that the 

safety review team conduct follow-up activities during Phase II to: 

• Perform an analysis of the ventilation system’s capability to maintain safe air 

quality in the tunnel during rush hour or traffic backups. The performance of 

the ventilation system during such non-fire situations, including its response to 

higher levels of carbon monoxide, was not evaluated. 

• Assess the fire resistance of various utility cables that run along the tunnel 

ceiling and evaluate the impact of cable failure. These cables need to perform 

during emergencies, such as fires, to allow centralized electronic systems to be 

fully operational and function as designed during fire emergencies. 

• Initiate an investigation to determine an acceptable time period for the back-up 

Operational Control Center (OCC) to take over if the primary OCC were to fail 

and put plans into place to help ensure the preparedness of the back-up OCC. 

We believe an acceptable time period for the back-up OCC to take over should 

be established and that the back-up OCC should be tested periodically to make 

sure it is in working order. 

Furthermore, for the Stem to Stern Safety Review to be more comprehensive, it 

should take into consideration all previously identified problems and those that 

may be identified in other ongoing investigations. For example, the 

Commonwealth should incorporate the results of the National Transportation 

Safety Board’s (NTSB) forensic investigation into its comprehensive plan for 
14

Phase II.12 Further, the Commonwealth should take into account the results of 

FHWA’s independent review. The Commonwealth should not wait for the final 

NTSB report or the results of FHWA’s review, but update its Phase II plan as 

necessary. 

Enhanced FHWA Oversight Is Needed Going Forward 

When the safety review was initiated last year, FHWA officials informed us that 

their role would be advisory in nature because the Commonwealth initiated the 

effort with no Federal funding. They also stated that they intended to exercise 

greater oversight over the remediation of identified safety risks. Now that safety 

risks have been identified and remediation has begun, FHWA will need to exercise 

greater oversight to ensure that the Commonwealth completes the remaining 

phases of the safety review and remedial work in a timely, thorough, and 

independent manner. 

As the Operating Administration in charge of overseeing the Federal 

Government’s investment in the Central Artery Project, FHWA recently 

recognized the need to become more involved in the Stem to Stern Safety Review. 

For example, in March 2007, the Acting Deputy Federal Highway Administrator 

issued a letter to the Massachusetts Secretary of Transportation noting FHWA’s 

concern about the lack of substantive progress on the Stem to Stern Safety Review 

since the former Governor’s term ended in January 2007. This was a positive first 

step. Going forward, FHWA will need to increase its oversight considering the 

massive Federal investment in the project to date and the significant risks that 

have already been identified. 

Moreover, the discovery of 34 items in “immediate or dangerous condition,” as 

identified in the Phase I report, calls into question the quality of the Central Artery 

Project’s design and construction. Timely and thorough execution of the 

remaining phases of the Stem to Stern Safety Review will help determine whether 

these problems emerged from errors, omissions, or other deficient or 

unsatisfactory performance in designing or constructing the project and what 

remediation actions will be necessary. The Commonwealth should pursue cost 

recovery for conditions resulting from design or construction deficiencies. For 

example, we identified the following key areas that warrant investigation into 

whether problems resulted from design or construction deficiencies. 

• The Zakim Bridge, at a cost of over $110 million, is a “signature” structure that 

represents the state of the art in bridge design and construction. However, after 

only about 4 years in service, the safety review team found that there were 

 

12 NTSB investigated the circumstances of the July 2006 collapse of ceiling panels in the Central Artery Project. Its 

investigation has focused on those issues surrounding the failure of the adhesive anchors. On July 10, 2007, NTSB 

released an executive summary of the results of its investigation, with a final report expected in the coming weeks. 
15

deformations in the steel anchor plates for cables, discrepancies between 

as-built conditions and the designs, and the lack of material certifications for 

the bridge’s structural steel. These problems warrant immediate attention. 

Accordingly, the Stem to Stern Safety Review will address them in Phase IA, 

which will help determine the root causes of the problems and the extent to 

which cost recovery is possible. 

• The Central Artery Project OCC houses the centralized electronic systems that 

monitor traffic flow, tunnel ventilation, and fire detection and control 

communications. The Commonwealth has reported that the center contains 

“the most advanced electronic traffic monitoring and incident response system 

in the world.”13 However, all the systems were not delivered as originally 

planned upon substantial completion of the project, which was declared in 

January 2006. Rather, final activation and testing of the fully integrated 

systems has been delayed until 2008. 

The Phase I results revealed that the installed OCC and centralized systems’ 

noncompliance with design specifications is attributable to delays as well as to 

deficiencies. During Phase I, the safety review team found “the fire detection 

system is not in full compliance with the modified basis of design” and 

identified inconsistencies regarding the fire detection time. Separately, we 

found the systems related to traffic incident detection, highway advisory radio, 

and variable message signs to be incomplete or not in service. The safety 

review team made recommendations in its Phase I report, supplemented by 

recommendations from our review, to identify the causes of these deficiencies 

and restore full compliance with project design specifications. Because of the 

substantial Federal investment made in the OCC and centralized systems, we 

believe that the Phase I recommendations should be implemented immediately 

to identify the root causes for these deficiencies. 

Evidence of design or construction deficiencies identified in the course of the 

safety review could lay the foundation for cost recovery by the Commonwealth. 

FHWA should ensure that the Commonwealth pursues cost recovery expeditiously 

because determining who is responsible to pay for remedial work is complex and 

requires additional analysis. Problems could be caused by poor construction, 

design errors, poor oversight, or a combination of those factors. The resulting 

“finger-pointing” that usually follows such investigations increases the complexity 

of determining the responsible parties. 

FHWA’s efforts to ensure an expeditious cost recovery effort are necessary 

because, historically, the Commonwealth’s cost recovery efforts have been 

time-consuming. We have previously reported that as of March 2003, 8 years of 

 

13 “Cost/Schedule Status of the Central Artery/Tunnel Project,” Massachusetts Turnpike Authority, April 1, 2005. 
16

cost recovery efforts led to only $30,000 in recoveries from a single consultant, 

even though 76 cost recovery items, involving $53.7 million in change orders, had 

been resolved. Over the next 2 years, a new cost recovery team directed by a 

retired Probate Court judge was more successful, but recovered only $3.5 million. 

Since February 2005, when the Massachusetts Turnpike Authority transferred cost 

recovery efforts to the Massachusetts Attorney General’s Office, the 

Commonwealth has not reached any significant settlements. 

Accordingly, we are recommending that FHWA (1) designate a lead official to 

monitor the Commonwealth’s progress on the Stem to Stern Safety Review and 

(2) report regularly to the Department of Transportation Oversight Committee on 

the Central Artery Project regarding progress being made by the Commonwealth 

to complete the safety review. FHWA should provide a copy of each report to 

OIG. 

RECOMMENDATIONS 

To ensure prompt action on the Central Artery safety reviews and protect the large 

Federal investment in the project, we recommend that FHWA: 

1. Designate a lead official to ensure that the Commonwealth: 

a. Completes the analyses of all safety risks—especially those posing 

immediate safety risks—in a timely, independent, and thorough manner, 

since many key safety studies were limited or deferred, and carries out 

prompt remediation for any deficiencies identified. 

b. Produces a clear and comprehensive methodology for Phase II, including a 

realistic schedule with a critical path for sequencing activities and 

reasonable cost estimates. The methodology should reflect the analyses 

and remedial work to be performed on outstanding findings and 

recommendations of the Commonwealth’s Phase I report. The 

methodology should also include plans to independently verify that 

remedial work is completed. 

c. Expeditiously pursues cost recovery to the extent possible for those 

conditions that result from design errors or inadequate construction 

practices. 

d. Continues to routinely communicate latest developments to key 

stakeholders, including FHWA and OIG. 

2. Report regularly to the Department of Transportation Oversight Committee on 

the Central Artery Project regarding progress being made by the 
17

Commonwealth to complete the safety reviews and on any concerns the 

FHWA may have. FHWA should provide a copy of each report to OIG. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

We provided FHWA with a draft of this report on July 18, 2007. On August 3, 

2007, FHWA provided us with formal comments on our draft report (see 

Appendix). FHWA stated that on the whole “the findings in the report are valid.” 

Recommendation 1. FHWA concurred with the recommendation. FHWA 

designated the Acting Deputy Administrator and Chief Counsel as the lead official 

to ensure that the Commonwealth progresses in the noted areas. 

OIG Response. FHWA’s planned actions meet the intent of our recommendation. 

Recommendation 2. FHWA concurred with the recommendation to report to the 

Department of Transportation Oversight Committee on the Central Artery Project 

on progress being made by the Commonwealth to complete the safety reviews. 

FHWA agreed to provide a copy of each report to the OIG. 

OIG Response. FHWA’s planned actions meet the intent of our recommendation. 

Based on FHWA’s comments, we revised the second recommendation to clarify 

that FHWA will provide to OIG a copy of each report submitted to the Department 

of Transportation Oversight Committee on the Central Artery Project. 

ACTION REQUIRED 

FHWA’s actions taken and planned satisfy the intent of our recommendations, 

subject to follow-up provisions in DOT Order 8000.1C. We appreciate the 

cooperation and assistance provided by you and your staff during our review. If 

you have any questions concerning this report, please call me at (202) 366-5630. 

# 

cc: Secretary of Transportation 

 Deputy Secretary of Transportation 

Members of the Department of Transportation Oversight Committee on the 

 Central Artery Project 
18

Exhibit A. Scope and Methodology 

EXHIBIT A. SCOPE AND METHODOLOGY 

To accomplish our broad objective of ensuring that Phase I of the Central Artery 

Project’s Stem to Stern Safety Review was comprehensive and conducted in a 

complete and rigorous manner, we assessed whether the findings and 

recommendations of the Phase I report adequately identified and analyzed 

immediate risks and whether necessary remedial measures were identified. We 

monitored the Commonwealth’s activities after issuing the Phase I report, 

including activities initiated to address our observations on the classification of 

certain safety risks and on the Commonwealth’s follow-up activities (referred to as 

Phase IA). We also evaluated whether work plans for remaining phases of the 

safety review were clear and comprehensive. 

As a part of this audit, we reviewed the work plan for Phase I to determine 

whether it included a comprehensive review of safety priorities in the project’s 

physical infrastructure, mechanical and electrical systems, and integrated project 

control systems. We monitored the progress of Phase I to ensure that the activities 

adhered to the work plan and complied with established engineering standards and 

protocols, and to identify risk areas that were not addressed. We also evaluated 

the Commonwealth of Massachusetts’s November 2006 Phase I report to ensure 

that mitigation plans were developed to address identified risks, and reviewed the 

implementation plan for subsequent activities in Phase II. 

Due to the complexity of this audit and the limited time frame in which to 

complete it, we engaged the U.S. Army Corps of Engineers (Corps) to provide 

technical assistance to our engineers during Phase I of the review. The scope of 

work for our review of Phase I was developed by the Corps under the direction of 

our engineers. Using these guidelines, the Corps closely and independently 

monitored the safety review by: 

• assembling a technical team of experts and embedding this team with the 

consultant performing the safety review; 

• participating in initial Wiss, Janney, Elstner Associates, Inc. (WJE) field 

activities; 

• reviewing WJE work plans and providing comments; 

• reviewing WJE interim submissions and providing comments; 

• attending weekly meetings of the Governor’s Advisory Panel; 

• attending site visits (along with members of the audit team); and 

• regularly briefing OIG engineers on the status of Phase I. 
19

Exhibit A. Scope and Methodology 

The Corps performed its technical reviews using criteria from the American 

Association of State Highway and Transportation Officials, the FHWA, the 

National Fire Protection Association, and the American Concrete Institute. 

Additionally, the Corps used geologic conditions/seismic zoning criteria for the 

review of the seismic analysis. 

We closely monitored the progress of Phase I and will continue to monitor future 

phases. At the outset, we conducted planning sessions with senior Corps 

executives to discuss the scope of the work to be performed and established rules 

of engagement with WJE. The Corps provided updated information to our 

engineers on a regular basis. After reviewing information that the Corps provided, 

our engineers shared their concerns with the Commonwealth’s safety review team, 

as necessary, to affect the direction of the safety review. Our engineers also 

performed some site visits along with the Corps during Phase I. 

This performance audit was performed from July 2006 through August 2007 in 

accordance with Generally Accepted Government Auditing Standards as 

prescribed by the Comptroller General of the United States. 
20

Exhibit B. Map of the Central Artery/Tunnel Project 

EXHIBIT B. MAP OF THE CENTRAL ARTERY/TUNNEL PROJECT 

Source: Massachusetts Turnpike Authority, http://www.masspike.com/ 
21

Exhibit C. The Commonwealth of Massachusetts’s Classification of 

Safety Concerns 

EXHIBIT C. THE COMMONWEALTH OF MASSACHUSETTS’S 

CLASSIFICATION OF SAFETY CONCERNS 

Safety risks identified by the Commonwealth’s Stem to Stern Safety Review 

during Phase I were classified using the following categories of risk: 

• IC: Immediate or dangerous conditions that pose the greatest safety risk—such 

conditions were immediately reported to the Massachusetts Turnpike Authority 

for remediation 

• R1: Conditions that require remediation as soon as possible 

• R2: Conditions requiring remediation that should be coordinated with nearterm maintenance and capital improvement programs 

• MR: Conditions that should be monitored and considered for remediation if the 

condition worsens 

• PII: Phase II follow-up work recommended to confirm or resolve identified 

concerns 

• NA: No follow-up necessary as part of the Stem to Stern Safety Review 
22

Exhibit D. Pictures of the Zakim Bridge and Its Anchor Plates 

EXHIBIT D. PICTURES OF THE ZAKIM BRIDGE AND ITS 

ANCHOR PLATES 

A. Zakim Bridge 

B. Close-up of cables C. Close-up of anchor plate securing cable to a steel 

girder. According to the Phase I report, six of the 

anchor plates are deformed. 

Source: U.S. Army Corps of Engineers 
23

Exhibit E. Major Contributors to This Report 

EXHIBIT E. MAJOR CONTRIBUTORS TO THIS REPORT 

THE FOLLOWING INDIVIDUALS CONTRIBUTED TO THIS REPORT.

Name Title 

Kurt Hyde Former Assistant Inspector 

General for Surface and Maritime 

Programs 

Tom Yatsco Program Director 

Eric Mader Project Manager 

Donald Lango Senior Auditor 

Charles Wilson Analyst 

Rodolfo Pérez Engineer Advisor 

Anne-Marie Joseph Engineer 

Aron Wedekind Engineer 

Harriet Lambert Writer-Editor 
Appendix. Management Comments 

24

APPENDIX. MANAGEMENT COMMENTS 

Memorandum

Subject: INFORMATION: Federal Highway Administration 

 Response to Office of Inspector General (OIG) Draft 

 Report, “Initial Assessment of the Central Artery/Tunnel 

 Project Stem to Stern Safety Review” 

From: James D. Ray 

 Acting Deputy Administrator and 

 Chief Counsel 

To: Calvin L. Scovel III 

 Inspector General (JA-40)

Thank you for the opportunity to review and comment on the OIG Draft 

Report, “Initial Assessment of the Central Artery/Tunnel Project Stem to Stern 

Safety Review.” As noted in the Report, the scope of the Stem to Stern Safety 

Review (STS) initiated by the Commonwealth is not limited to the Central 

Artery/Tunnel (CA/T) Project; it covers the entire Boston Metropolitan 

Highway System, which includes wholly State funded facilities. In light of the 

Federal investment in the CA/T Project and the need to restore public 

confidence in the safety of the entire system, FHWA, from the inception of the 

STS, has recognized its responsibility to ensure that the former and current 

Administration in the Commonwealth proceed with the appropriate dispatch to 

correct all safety concerns identified as part of the review. We will continue to 

provide diligent oversight of the progress made by the Commonwealth in 

completing the STS and implementing the recommendations. On the whole, 

we believe the findings in the report are valid. We also believe the 

Commonwealth has taken steps recently to steadily move the STS forward. 

Date: August 3, 2007 

 In Reply 

 Refer To: HCC-3 
Appendix. Management Comments 

25

Our comments and planned actions on the specific audit report 

recommendations follow. 

Recommendation 1: “To ensure prompt action on the Central Artery safety 

reviews and protect the massive Federal investment in the project, we 

recommend that FHWA: 

1. Designate a lead official to ensure that the Commonwealth: 

a. Completes the analyses of all safety risks—especially those posing 

immediate safety risks—in a timely, independent, and thorough manner, 

since many key safety studies were limited or deferred; and carries out 

prompt remediation for any deficiencies identified. 

b. Produces a clear and comprehensive methodology for Phase II, including a 

realistic schedule with a critical path for sequencing activities and 

reasonable cost estimates. The methodology should reflect the analyses 

and remedial work to be performed on outstanding findings and 

recommendations of the Commonwealth’s Phase I report. The methodology 

should also include plans to independently verify that remedial work is 

completed. 

c. Expeditiously pursues cost recovery to the extent possible for those 

conditions that result from design errors or inadequate construction 

practices. 

d. Continues to routinely communicate latest developments to key 

stakeholders, including FHWA and OIG.” 

Response: We concur in the recommendation to designate an official in 

FHWA to ensure the State progresses in the above noted areas. In carrying out 

our oversight responsibilities, we will utilize the tools available to us to spur 

appropriate action by the State, recognizing and respecting our differing roles. 

In keeping with our response to Recommendation 2 below, we will apprise the 

Department of Transportation Oversight Committee of any issues of major 

concern. As Acting Deputy Administrator, I will perform the functions of the 

designated lead official and serve as the point of contact to coordinate the 

efforts of relevant units in FHWA involved in overseeing action by the State. 

Recommendation 2: “Report monthly to the Department of Transportation 

Oversight Committee on the Central Artery Project and the OIG regarding 

progress being made by the Commonwealth to complete the safety reviews and 

on any concerns the FHWA may have.” 
Appendix. Management Comments 

26

Response: We concur in the intent of the recommendation to report 

periodically to the Oversight Committee on progress made by the State. We 

have in the past reported to the Committee as needed on all of the activities 

FHWA is involved in related to the CA/T Project, and we have provided copies 

of our reports to the OIG. We would continue to provide the OIG copies of 

our report to the Committee. However, we do not believe it appropriate to 

characterize our actions as “reporting” to the OIG. It appears to suggest that 

the OIG is part of the FHWA’s management chain of command. 

We would defer to the Oversight Committee on the frequency of our reports 

rather than requiring monthly reports regardless of activity levels with respect 

to the Stem to Stern Review. Moreover, because the makeup of the Committee 

may change over time, FHWA will continue to report to either the Committee 

or its functional equivalent until such time as it is determined by the 

Committee to be no longer necessary. 

In closing, we would like to emphasize that the FHWA is committed to being 

good stewards of the Federal investment in the CA/T and the Federal interest 

in public safety. 

The efforts of the OIG auditors are greatly appreciated. If you have any 

questions or comments regarding this response, please contact Jo Anne 

Robinson at (202) 366-0740.