WMATA’s Metrorail system has experienced a variety of serious safety incidents in recent years (see fig. 1 below). On June 22, 2009, one Metrorail train struck the rear of a second train stopped near the Fort Totten station on the Red Line, resulting in nine deaths and over 50 injuries. The NTSB report on the incident found that WMATA failed to institutionalize, and employ system-wide, an enhanced track-circuit verification test procedure that was developed following near-collisions in 2005. NTSB also found evidence of an ineffective safety culture within WMATA. More recently, WMATA has experienced smoke and fire incidents involving the electrical cables and other components supporting its third-rail system. On January 12, 2015, a Metrorail train stopped after encountering heavy smoke in the tunnel between the L’Enfant Plaza station and the Potomac River Bridge on the Yellow Line caused by electrical arcing resulting from a short circuit on the third rail power system, causing one passenger’s death and numerous injuries. In a report on this incident, the NTSB again found a lack of a safety culture within WMATA. NTSB specifically noted deficiencies in WMATA’s response to smoke reports, tunnel ventilation, railcar ventilation, emergency response, as well as the oversight and management of WMATA. In November 2015, WMATA’s new General Manager began his tenure and initiated a variety of efforts to address WMATA’s Metrorail safety issues. On March 14, 2016, an electrical fire occurred near the McPherson Square station involving the same kind of power cable that caused the L’Enfant Plaza smoke incident. Following this fire, WMATA closed the entire Metrorail system for a day for emergency inspections of the system’s third-rail power cables. On May 19, 2016, WMATA announced SafeTrack, “a massive, comprehensive, holistic effort to address safety recommendations and rehabilitate the Metrorail system on an accelerated basis by expanding all available maintenance windows.” The primary focus of SafeTrack is rehabilitating Metrorail’s track infrastructure by replacing over 45,000 crossties, which are the wooden beams that lay across the railroad bed on above ground sections of the track, and 35,000 fasteners, which secure rails directly to concrete on underground or aerial sections of the track where wooden crossties are not used. SafeTrack is being carried out through a series of “surges” that involve intensive work on specific areas of track that are either shut down to normal traffic or have only one of the two tracks open, a type of operation known as “single tracking” (see fig. 2 below). SafeTrack also involves the reduction of operating hours to allow additional work to be carried out overnight and on weekends in non- surge areas. Although the primary focus of SafeTrack is track assets, WMATA is also using the extended outages to address other safety concerns, such as concerns regarding power cables and other electrical components raised by NTSB and FTA. According to WMATA’s initial announcement, the project was designed to bring Metrorail’s track infrastructure to a “state of good repair,” which WMATA defines as the condition at which individual railroad assets can be sustained at ongoing, annual replacement rates under normal maintenance cycles. WMATA estimates that SafeTrack will cost approximately $120 million. According to WMATA and FTA officials, these costs will be covered by about $48 million in federal funding, which includes two FTA formula grants as well as funding authorized by the Passenger Rail Investment and Improvement Act of 2008 (PRIIA). The PRIIA funding is also matched by over $30 million in local funds from the three jurisdictions that help fund WMATA. Beyond the almost $80 million in federal and local matching funds, SafeTrack will require an additional $40 million in fiscal year 2017 funding; according to WMATA, the sources of this funding are yet to be finalized. Although SafeTrack was not specifically included in WMATA’s approved fiscal year 2016 or 2017 budgets, WMATA amended and its board approved its fiscal year 2017 budget, in November 2016, to include additional funding for the project. WMATA’s track rehabilitation projects and other capital investments are made through a 6-year Capital Improvement Program, with the current version covering fiscal years 2017 through 2022. Other transit agencies with aging infrastructure like WMATA have also undertaken, or plan to carry out, large-scale rehabilitation projects that involve extended disruptions to normal revenue service. For example, in 2013 CTA shut down the southern half of one of its lines for 5 months to completely rebuild the railroad and renovate rail stations on the branch. Additionally, NYCT is planning to shut down the Canarsie subway tunnel connecting Manhattan and Brooklyn to facilitate extensive repairs from damage caused by Hurricane Sandy in 2012. Similarly, the Port Authority of New York and New Jersey is rehabilitating tunnels used by its PATH service between New Jersey and Manhattan and installing positive train control technology, which can reduce the risk of accidental collision between trains on the same track. In recent years, FTA has been provided with an expanded role in overseeing public transportation safety within WMATA and in other transit agencies. The Moving Ahead for Progress in the 21st Century Act (MAP- 21) expanded FTA’s safety oversight role over public transportation systems and established the public transportation safety program, providing FTA with new authority to inspect and audit a public transportation system. This new authority also required FTA to promulgate regulations requiring states to establish state safety oversight programs and agencies for states’ public transportation systems. Additionally, MAP-21 provided FTA with more safety oversight authority and more options for enforcement when transit agencies were found to be out of compliance with federal safety laws. For example, in response to concerns regarding WMATA’s safety performance over the last decade, FTA conducted a Safety Management Inspection of the WMATA rail and bus systems. The Safety Management Inspection evaluated WMATA’s operations and maintenance programs, safety management capabilities, and organizational structures. FTA found that, in recent years, WMATA has implemented new management initiatives and programs to address safety concerns, but organizational deficiencies and operational concerns continue to limit WMATA’s effectiveness in recognizing and resolving safety issues. For example, FTA found that WMATA work crews do not have sufficient access to the rail right-of-way to perform critical inspection, testing, and maintenance activities. FTA also found serious safety lapses in the rail operations control center. More broadly, FTA also reported that in key areas, WMATA’s organization is not effectively balancing safety- critical operations and maintenance activities with the demand for passenger service. In response to WMATA safety incidents, FTA assumed temporary and direct safety oversight of WMATA in October 2015. Specifically, as part of its investigation of the January 2015 smoke and fire incident near the L’Enfant station, NTSB found that the Tri-State Oversight Committee’s safety oversight of WMATA was deficient and recommended that DOT seek an amendment to federal law so that the Federal Railroad Administration within DOT could exercise regulatory oversight over the WMATA rail system. DOT agreed that the Tri-State Oversight Committee was deficient and ineffective, but disagreed with NTSB that the most urgent and effective solution was to transfer safety oversight of WMATA’s rail transit system to the Federal Railroad Administration. Instead, in October 2015, DOT directed FTA to take direct and temporary control of safety oversight at WMATA from the Tri-State Oversight Committee. To perform direct safety oversight of WMATA, FTA established the FTA WMATA Safety Oversight (FWSO) office, which is currently comprised of FTA personnel, inspectors on detail from FRA, and contractor support staff, according to FTA officials. In February 2016, FTA found the Tri-State Oversight Committee was incapable of enforcing its safety findings and thus, using new authority provided by the Fixing Americas Surface Transportation (FAST) Act, FTA determined that it would continue with its direct safety oversight of WMATA. FTA’s FWSO and region three office, which includes the Washington metropolitan area, have jointly managed oversight of SafeTrack. When WMATA announced SafeTrack in May 2016, the FWSO was in place and performed initial safety oversight of the project. However, FTA’s various regional offices exercise project management oversight over “major capital projects,” which include, among other things, projects that involve the rehabilitation or modernization of an existing fixed guideway with a total project cost in excess of $100 million. Using this project management oversight authority for major capital projects, FTA can monitor the project’s progress to determine whether a project is on time, within budget, in conformance with design criteria, constructed to approved plans and specifications, and is efficiently and effectively implemented. According to FTA officials, FTA designated SafeTrack as a major capital project based upon WMATA’s decision to group together funding from multiple FTA formula grants, as well as funding authorized by PRIIA, and to manage those activities as a discrete project estimated to cost more than $100 million. FTA’s region three office provides project management oversight of SafeTrack. FTA has other efforts to improve the safety and performance of public transportation systems. For example, in July 2016, FTA issued its final rule establishing a National Transit Asset Management System in accordance with section 20019 of MAP–21. Transit agencies are required to have an initial transit asset management plan completed by October 2, 2018. Transit agencies’ plans must include an inventory of the number and type of capital assets and a condition assessment of those inventoried assets for which a provider has direct capital responsibility, among other elements. In August 2016, FTA also issued a Public Transportation Safety Program final rule establishing rules to support its administration of the public transportation safety program. The rule provides the framework for FTA to monitor and enforce transit safety. WMATA’s planning of SafeTrack did not fully align with leading project management practices, including some that are focused on projects for rehabilitating transit assets. Specifically, while WMATA’s efforts to coordinate with local stakeholders after SafeTrack began have generally been in line with such practices, WMATA did not (1) comprehensively collect and assess data on its assets, (2) analyze alternatives, or (3) develop a project management plan before starting work. WMATA did not follow these practices because it believed it needed to start work immediately to address critical safety issues. However, by not following these leading practices, WMATA lacks assurance that the accelerated approach taken with SafeTrack is the most effective way to identify and address safety issues. WMATA also lacks a policy that requires, and relevant procedures specifying how, it follow these leading planning practices for large-scale rehabilitation projects. Without such a policy and procedures in place, WMATA lacks a framework to comprehensively plan future large-scale rehabilitation projects to meet their objectives. Leading management practices for transit rehabilitation projects state that transit agencies should collect and use data on assets when planning projects. Public transit agencies have a wide variety of assets to maintain, including track and third rail infrastructure. The TCRP report on prioritizing the rehabilitation of capital assets states that transit agencies should collect detailed information on assets, including data on the age and condition of infrastructure. The TCRP report also states that agencies should use data to assess the conditions of assets. This assessment should then form the basis of prioritizing rehabilitation work. Indeed, according to TCRP, “the process of evaluating and prioritizing rehabilitation and replacement work starts with collecting data on existing transit capital assets.” Though WMATA collected data on its track assets through inspections when planning SafeTrack, those inspections were not comprehensive because they focused on specific items like rail crossties and did not cover all track-related infrastructure. Specifically, in 2015, WMATA conducted inspections of its Metrorail track to collect data on the condition of its track infrastructure and identify the work necessary to bring the track to a state of good repair. The inspections were carried out by a contractor for WMATA’s Track and Structures department as part of WMATA’s Track Quality Improvement Program (TQIP). According to WMATA officials we spoke with, these inspections were necessary under TQIP because they could not rely solely on track condition data in WMATA’s existing asset database. Indeed, WMATA’s OIG recently found that WMATA’s asset database does not have adequate controls and oversight in place to properly manage assets, among other concerns. WMATA used the data collected in its 2015 inspections as the primary source for identification of the most degraded areas of track, which would be subject to SafeTrack surges. However, the data collected during the inspections focused on the rail crossties and did not cover all infrastructure in the Metrorail track area. For example, according to WMATA officials, the inspections did not include an examination of all interlockings or of all track power systems, including the electrical cables that power the third rail system. According to WMATA officials we spoke with, these systems were not included in the inspections because the Track and Structures department leading the TQIP effort is not responsible for the maintenance of other systems. Electrical cables, for example, are managed by WMATA’s Power Engineering department. Data on the condition of assets in non-track systems has generally been collected by the responsible department, but according to WMATA officials, these data were not used to identify areas for SafeTrack work. Officials with other transit agencies we spoke with said that accurate and comprehensive data on assets are crucial to identifying and prioritizing rehabilitation efforts. For example, NYCT officials told us that they rely on data from their transit asset management database to identify track sections with the greatest number of defects, or areas in need of repair, to prioritize sections of tracks for rehabilitation activities. MBTA officials we spoke with said that their agency has developed a state-of-good-repair database that includes an inventory of the age of assets that managers can use to prioritize rehabilitation and replacement projects. Officials from CTA said they use a new asset management system, which has detailed information on the condition of CTA’s assets, to better identify and prioritize capital projects. WMATA’s planning of SafeTrack relied on limited data regarding the condition of Metrorail assets, in part because the agency lacks internal requirements governing the collection and use of asset information in planning projects. More specifically, WMATA does not have a policy or procedures requiring it to collect and use asset data, and coordinate with other departments on the collection of such data when planning large- scale rehabilitation projects. To ensure that such proper management practices are consistently carried out, the COSO internal control framework used by WMATA states that management should set policies establishing what is expected and relevant procedures specifying the necessary actions to carry out the policy. As we reported recently, asset management can help transit agencies optimize limited funding so that they receive the “biggest bang for their buck” when rehabilitating and replacing assets. By not gathering and using detailed data on all aspects of the track infrastructure when planning SafeTrack, WMATA decision-makers may not have had sufficient information to develop project objectives and properly prioritize SafeTrack work. Indeed, serious safety incidents have continued to occur on the Metrorail system during SafeTrack on assets that were not being addressed in the project. On July 29, 2016, a train derailed near the East Falls Church station. This derailment occurred on an interlocking, a part of track not scheduled at that time for rehabilitation under SafeTrack. As a result of this incident, WMATA modified the scope of future SafeTrack surges to include the rehabilitation of interlockings. Additionally, FTA has directed WMATA to complete safety critical work both prior to starting and during SafeTrack, resulting in changes to the scope and schedule of SafeTrack, as discussed later in this report. Though WMATA did not utilize comprehensive asset information in planning SafeTrack, it is developing a new inventory, as required by FTA’s 2016 Transit Asset Management final rule. More specifically, WMATA is currently conducting a Transit Asset Inventory and Condition Assessment, and is working with FTA to develop its new transit asset inventory. According to WMATA, this effort will help ensure that it has a complete, consistent, accurate, and centralized repository of relevant asset-related data. A reliable repository of asset data can then facilitate data-driven maintenance and capital investment decision making. WMATA has completed the first of two phases for this assessment. In the first phase, WMATA sought to conduct an initial asset inventory and condition assessment. In the second phase, WMATA plans to further develop how it will manage its assets and collect additional data, among other things. Leading management practices for transit rehabilitation projects state that transit agencies should have a policy in place for evaluating project alternatives. The TCRP report on prioritizing the rehabilitation of capital assets states that agencies should generate alternative plans for achieving a state of good repair and quantify the costs and impacts of those alternatives. As noted above, the COSO internal controls framework used by WMATA also states that management should establish policies and procedures to help ensure that proper practices are carried out. Though WMATA considered different plans for improving the state of repair of its track infrastructure, it did not quantify the costs and impacts of each alternative. WMATA currently lacks a policy requiring alternatives analysis for large-scale rehabilitation projects. After collecting data from track inspections in 2015, WMATA developed three alternatives for improving the state of repair of its track infrastructure. These alternatives included 8, 10, and 22-month work schedules. According to WMATA officials, these alternatives included different levels of service disruptions, including extensive single-tracking and track section closures, but generally included the same work tasks. According to WMATA officials, they ultimately settled on the initially announced 10-month plan, dubbed SafeTrack, because it best balanced rider disruption with addressing the urgent safety needs of the system. Additionally, they said that WMATA’s ability to make effective and efficient use of time on the track was also a primary consideration. However, WMATA did not fully assess the alternatives to improving the state of its track infrastructure. In particular, WMATA did not quantify the effects of the various alternatives on extending the life of the track assets, on reducing maintenance costs, and on Metrorail ridership. WMATA also did not quantify the costs or establish a detailed budget for its alternatives and still has not determined the final funding sources for its selected alternative. Although WMATA estimates that the SafeTrack project will cost approximately $120 million to complete, it has identified funding sources for about $80 million of these costs and has yet to determine how it will fund the remaining $40 million. Other transit agencies we spoke with described detailed considerations of alternatives to carrying out large-scale rehabilitation projects. For example, CTA officials we spoke with said they developed and assessed different plans to rehabilitate its Red Line South track, including estimates of the costs and impacts of each alternative. Further, officials at PATH told us that they selected a particular approach to upgrading a tunnel they use for trains that travel from New Jersey to Manhattan, New York, because it balanced rider disruption and work efficiency. The PATH officials told us that they conducted approximately one year of planning in advance of this project and developed seven different scenarios before finally settling on the current approach. WMATA did not fully assess alternatives to rehabilitate its track assets because it believed it needed to start work immediately to address critical safety issues. At the time SafeTrack was planned, according to officials we spoke with, WMATA leadership was making critical decisions on how to address systemic deferred maintenance. Indeed, according to WMATA’s Chief Safety Officer, in a call on May 10, 2016, a senior official within FTA’S FWSO office notified WMATA that FTA was considering taking action to “shut down” the entire Metrorail system due to safety concerns. According to WMATA officials, SafeTrack was conceived as WMATA’s unique and necessary response to the state of its track infrastructure. Further, WMATA officials noted that the agency is committed to devoting the resources necessary to bring the track to a state of good repair, and to developing preventative maintenance programs that would prevent similar safety-critical situations in the future. Nevertheless, by not having a policy and procedures in place requiring analysis of alternatives for future large-scale rehabilitation projects, WMATA lacks a framework to comprehensively plan such projects to meet their objectives. WMATA plans to spend over $56 million a year on track rehabilitation projects alone starting in fiscal year 2018. If WMATA were to make decisions about the scope and prioritization of these projects without full information about the various alternatives, it may not select an approach that best balances costs and impacts. Leading project management practices emphasize the importance of developing project management plans. The PMI PMBOK® Guide states that a comprehensive project management plan should be developed before a project begins so that it is clear how the project will be executed, monitored, and controlled. More specifically, the plan should include the critical information for managing a project’s scope, schedule, and cost, according to established baselines and in consideration of project risks, quality standards, and other items. As discussed below, federal law also requires that recipients of federal financial assistance for major capital projects prepare a project management plan. According to WMATA officials, WMATA did not develop a comprehensive project management plan before beginning SafeTrack because they believed a project management plan was not appropriate for such a project. WMATA considers SafeTrack to consist of accelerated but normal maintenance activities. According to WMATA officials, a project management plan is best suited for new construction projects. WMATA therefore chose to manage SafeTrack using tools that they considered more appropriately suited for managing coordinated maintenance tasks. For example, WMATA uses detailed “march charts” to plan and coordinate its various maintenance tasks within surge work areas. However, according to WMATA officials, they did not develop a plan that clearly defined the budget, execution, monitoring, and control of the project before beginning SafeTrack. According to FTA officials we spoke with, FTA has discretion regarding when it determines a project is major and when a project management plan must be submitted. As discussed later in this report, WMATA developed a project management plan during the initial months of SafeTrack implementation, though FTA has not yet approved WMATA’s plan. Other transit agencies we spoke with said that they generally developed extensive plans for their large-scale rehabilitation projects. For example, CTA officials we spoke with said that they conducted extensive planning, and developed a project management plan, for their Red Line South reconstruction project, even though they did not use federal funds and therefore were not required by FTA to develop such a plan. Additionally, in planning for the shutdown and rehabilitation of the Canarsie tunnel, NYCT is developing a detailed plan that reflects its risk assessments and analysis of lessons learned from previous work, according to the officials we spoke with. Though WMATA developed SafeTrack as a unique response to the state of its track infrastructure, future large-scale rehabilitation projects undertaken by the agency would benefit from the development of a comprehensive project management plan prior to the start of the project. As discussed above, WMATA officials told us that they implemented SafeTrack to respond to a critical safety situation and that they could not postpone this track work to develop a project management plan. SafeTrack, though, involves an unprecedented amount of track work performed over an extended period, significantly disrupts ridership, and is estimated to cost well over $100 million. WMATA currently lacks a policy and procedures requiring the development of a project management plan for large-scale rehabilitation projects like SafeTrack, according to WMATA officials, regardless of whether the work is to be completed in response to an emergency situation or within WMATA’s normal state of good repair efforts. The COSO internal controls framework used by WMATA states that management should have policies establishing what is expected of management and employees, to help mitigate risks to achieving goals. Although WMATA told us that it has a manual on project implementation that is focused on the implementation and close-out phases of a project, it does not yet cover the planning phase. Further, although a project management plan is required for public-transportation-related major capital projects receiving federal financial assistance, WMATA may undertake future large-scale rehabilitation projects that do not meet the major capital project definition or that do not use federal funds at all. Such projects could still benefit from having a project management plan in place before beginning the project—consistent with leading practices—to manage the project’s scope, schedule, costs, and other factors. Without a policy and procedures that require the development of a plan for future large-scale rehabilitation projects, WMATA lacks a key tool to ensure its projects are completed on-time, on-budget, and according to quality standards. Leading management practices and other transit agencies we spoke with state that identifying and coordinating with external stakeholders is part of proper project planning. The PMI PMBOK® Guide states that agencies should identify stakeholders for their projects, communicate and work with stakeholders to meet their needs, address issues as they occur, and foster stakeholder engagement in project activities. FTA project guidelines also note that communication with the public can be crucial for receiving the necessary buy-in to move a project forward. Other transit agencies we spoke with said that they generally began stakeholder engagement weeks, if not months, prior to the beginning of projects. For example, the PATH officials we spoke with said that they began communicating with government officials and the public about the proposed tunnel weekend shutdowns 2 months before the project started. Similarly, according to NYCT officials, they presented various schedule alternatives for rehabilitating the Canarsie tunnel to the local communities directly affected by the tunnel’s closing to explain NYCT’s rationale for completing the work, as well as to discuss the benefits and challenges of different plans. According to WMATA officials, urgent safety concerns necessitated an accelerated planning process, which precluded advanced notice of SafeTrack to local jurisdictions, other regional transit agencies, and the public. Officials from one local county we spoke with said that they had about a month between when they first heard about SafeTrack and when the first surge began in June 2016. According to local officials we spoke with, little advanced notice of SafeTrack caused some miscommunication between local jurisdictions as well as difficulty identifying funding for mitigation efforts. Specifically, one local county official told us that the county had to quickly develop a plan to bring 25 recently retired buses back into service to provide options to Metrorail riders affected by SafeTrack surges. The county estimated that it incurred approximately $1 million in bus driver labor and other costs as a result of SafeTrack. The county official told us that it expects to be compensated by the state for these expenses. Nonetheless, as the SafeTrack project has progressed, WMATA’s efforts to coordinate with local stakeholders have generally been in line with leading practices. WMATA officials identified stakeholders for the SafeTrack project, including local transit agencies and elected officials. WMATA utilized a variety of methods to communicate and coordinate with local transit agencies and jurisdictions during SafeTrack. For instance, one local official we spoke with said that WMATA’s Joint Coordinating Committee—which brings local officials together to plan for major events affecting regional transportation—is an effective mechanism for sharing information, such as local plans for the use of shuttle buses in areas affected by surges. Local officials also said that communication and coordination between WMATA and jurisdictions has been effective, especially after the first few months of SafeTrack. For example, one local official told us that WMATA has provided the jurisdiction with prompt information about the upcoming surges through weekly planning meetings at WMATA headquarters, as well as through informal coordination with WMATA staff on specific surges. WMATA has also effectively communicated with the public, according to the local officials we spoke with. WMATA officials told us that they have used a variety of measures to communicate SafeTrack plans to the public including press releases issued to local news media outlets; postings on social media, such as Facebook, YouTube, and Twitter; and a SafeTrack web page that includes details about the overall project and each surge. Officials from one jurisdiction said that WMATA has provided good information on its website and that having additional WMATA staff at SafeTrack-affected stations and bus areas has also been useful. As a result of such efforts, one local official told us that Metrorail riders have demonstrated a high level of awareness about SafeTrack. WMATA’s implementation of SafeTrack generally aligns with leading project management practices. Specifically, during the course of each SafeTrack surge, WMATA officials collect and document information about the work performed and the condition of assets. WMATA officials also develop lessons learned during and after each surge period, and use those lessons during subsequent maintenance and planning efforts. Last, WMATA developed a new organization-wide quality control and assurance framework that it is implementing for the first time through SafeTrack. Leading project management practices emphasize the importance of collecting and monitoring work performance data and information. The PMI PMBOK® Guide states that throughout the lifecycle of a project, organizations will generate a significant amount of work performance data and work performance information that is collected, analyzed, documented, and shared with stakeholders. This data and information is typically created and documented after a project begins, and is a key element in controlling a project’s scope, schedule, cost, and risk. Organizations can collect work performance data and information to identify trends and process improvements. Work performance data are also a key factor in an organization’s overall quality management for projects, as they provide a foundation for implementing quality control and quality assurance practices, as well as stakeholder engagement, since they inform discussions on project performance. The TCRP report on prioritizing the rehabilitation of capital assets also states that transit agencies should define data collection and inspection protocols, and ensure the data are detailed and current enough to support decisions on asset rehabilitation or replacement. Based on procedures WMATA has established, officials have collected and documented information about the work performed and the condition of WMATA’s assets in SafeTrack surge areas, consistent with leading project management practices. Prior to each surge, WMATA officials from relevant departments have conducted inspections on the conditions of both the track infrastructure and other non-track assets. WMATA officials have used this pre-surge inspection data to develop the overall scope of work for each surge, as well as to identify each component planned for maintenance or replacement. According to WMATA officials, although prior to SafeTrack inspections focused solely on track assets such as the condition of crossties, pre-surge inspections have since included assessments on the condition of both track and non-track assets, such as power cables. However, the number of assets planned for maintenance or replacement in each surge varies depending on the conditions of the assets in question. WMATA officials told us that during each surge, they regularly discuss progress with departments that are responsible for ensuring completion of scheduled work, as well as monitoring teams’ work quality and site safety. At the end of each surge, WMATA officials have compiled totals for all work completed, after verification and completion of the various departments’ quality control processes. WMATA has then compared the completed work against the pre-surge work plan. WMATA has used the completed work data to develop its surge progress reports, which it issues to stakeholders and makes available to the public at the end of each surge. However, although WMATA is collecting information on the condition of assets repaired through SafeTrack, WMATA does not have a policy or procedures requiring it to use asset data when planning future large-scale rehabilitation projects, as previously discussed. WMATA has also used work performance data and information to identify the amount of rehabilitation work that can be performed during a given maintenance window. For example, WMATA is not replacing all crossties within a given SafeTrack segment; rather, its goal is to ensure that 75 percent of the ties in a surge area are in good condition so that it will not need to replace all of them at the same time in the future. WMATA officials stated they believe that this approach will allow them to move to a more sustainable crosstie replacement model, eliminate maintenance backlog, and achieve a state of good repair for those assets. WMATA has also incorporated other types of data, such as logistical constraints for available work crews and equipment, to inform its assessment of how work will be accomplished during each surge. See figure 3 for select track assets that have undergone repair or replacement during SafeTrack. The work performance data collected by WMATA demonstrate that WMATA has renewed or replaced a substantial amount of track infrastructure, as well as other non-track assets, during the course of SafeTrack. According to WMATA officials, SafeTrack work crews have been able to complete work more efficiently than is possible during normal, shorter, maintenance windows. For example, WMATA reported that by limiting service for 13 days on the Red Line from Shady Grove to Twinbrook, it was able to replace over 3,500 crossties; this work would have taken more than 2 years to complete if performed only after the end of the rail system’s service each day. As shown in table 1, through the first 10 surges, WMATA has replaced more than 26,000 crossties, with its goal being to replace over 45,000 crossties when the project is complete. Through surge 10, WMATA has also replaced more than 4,300 insulators, which support the third rail. WMATA plans to replace more than 11,800 insulators through SafeTrack, and has replaced over 700 power cables as well. The collection of lessons learned is a key project management step that helps inform an organization’s planning and evaluation of its projects, programs, and portfolios, as well as supports process improvements. The PMI PMBOK® Guide states that organizations should identify and collect lessons learned during the course of executing a project to complement their overall knowledge base, particularly with respect to project selection, performance, and risk management. FTA Quality Management Systems Guidelines also state that corrective actions for nonconforming work common to most projects should be recorded as lessons learned and disseminated throughout an organization. In accordance with leading project management practices, WMATA officials have developed lessons learned during and after each surge period, and have used those lessons during subsequent maintenance and planning efforts. For example, WMATA officials said that over the course of the initial SafeTrack surges, they evaluated their work procedures and refined their approach to replacing rail crossties. In particular, they acquired new machines to remove ties and install rail spikes, and implemented better scheduling of the machines and work crews to facilitate more efficient crosstie replacement. As another example, during the course of the initial SafeTrack surges, WMATA officials learned to define clear work limits prior to each surge to improve work efficiency. More specifically, during the initial planning of SafeTrack, officials did not clearly define surge work areas by specific chain markers and instead labeled the ends of the surge areas by Metrorail station. Furthermore, WMATA officials recognized the need to make detailed scope and work plan documents available before the start of each surge in order to prevent confusion regarding expectations, work inefficiencies, and unachieved objectives. WMATA has also used project meetings to capture and disseminate lessons learned among its work teams. Before every surge period, WMATA stakeholders have met to discuss the intended scope of work for the surge, prioritize work tasks, and agree upon a work plan. WMATA officials have then incorporated this information into a 90-day “look ahead” schedule that is used to plan material purchases and verify track rights for work crews. According to WMATA officials, once a surge has ended, WMATA holds “closeout” meetings with its internal stakeholders (including quality assurance officials) to discuss the work performed and lessons learned, which are then included in an official closeout report. The use of closeout meetings after a project work period ends is also consistent with leading project management practices. Leading project management practices emphasize the importance of the management, assurance, and control-of-quality issues. The PMI PMBOK® Guide states that organizations should establish policies and procedures that govern quality management for their projects and deliverables. Quality management refers to key processes that comprise a quality framework, including identifying quality requirements and standards, performing quality audits, and monitoring and recording results of executing quality activities in order to assess performance and recommend necessary changes. PMI notes that having a quality management framework in place can ensure that project requirements are met and process improvement initiatives are supported. WMATA has developed an agency-wide quality control and assurance framework that is in line with best practices. According to WMATA officials, the agency is implementing a new quality assurance framework for the first time during SafeTrack. In March 2016, WMATA officials established a new, independent quality team called Quality Assurance, Internal Compliance, and Oversight (QICO) that reports directly to the WMATA General Manager. In addition to serving as an independent reviewer of the SafeTrack project, the QICO team is responsible for developing and implementing a new quality framework for the entire organization. According to WMATA officials, this framework has three levels of review for work performed by maintenance groups. Maintenance groups are to provide the first level of review, with managers assessing the quality of the work completed by crews, such as installation and maintenance of assets, and documenting their findings on quality control checklists. Second, QICO is responsible for assessing the overall quality of completed work by reviewing a sample of work tasks competed during the surge, and providing feedback for work teams on quality and safety concerns. This feedback includes preparing surge closeout reports that document any quality, safety, or other concerns and reporting them to WMATA leadership and the relevant work teams involved. The work teams must then address and close out any quality deficiencies through ongoing maintenance activities. Last, the WMATA OIG and Board of Directors are responsible for monitoring internal performance at the agency and approving manager-level decisions regarding quality control and assurance. In addition to this review structure, the QICO team is also developing an enterprise-wide Quality Management System, in accordance with the FTA’s Quality Management Systems Guidelines, that is intended to clearly define WMATA’s organizational objectives with respect to quality assurance. The QICO team has also developed training programs for maintenance supervisors as well as certification requirements for quality assurance staff. In implementing procedures, WMATA’s QICO team has identified a number of work-related issues (referred to as “discrepancies”) during its quality control and quality assurance inspections of SafeTrack work, discrepancies that WMATA is working to address. Specifically, according to SafeTrack surge’s closeout reports through the first eight surges, QICO inspectors identified a total of 413 discrepancies for WMATA teams to address. Officials are to document these discrepancies in “punch lists” of work tasks that WMATA workers must complete during the course of upcoming routine maintenance. FTA officials told us that the QICO closeout reports are useful in order to see work completed during each surge as well as to inform post-surge inspections. Through surge 8, WMATA has closed 231 of the 413 discrepancies identified by QICO, including 93 percent of the safety concerns, 57 percent of the quality concerns, and 53 percent of site condition concerns (see table 2). Prior to WMATA’s announcement of SafeTrack in May 2016, FTA conducted many inspections of WMATA’s track infrastructure and internal inspection program. These have informed its oversight of the project. As previously discussed, FTA established the FWSO office in October 2015 to provide temporary and direct safety oversight of WMATA in the absence of an effective state oversight authority, according to FTA. When WMATA first notified FTA of its plans to implement the SafeTrack project on May 6, 2016, the FWSO had been conducting inspections on the integrity of WMATA’s track since March 2016. The FWSO was in the process of developing a directive requiring WMATA to take corrective actions to address concerns with its track construction, maintenance, and inspection resources, among other issues. According to FTA, FWSO inspectors conducted 76 inspections of WMATA’s Metrorail system from October 2015 through May 2016. For example, in March and April of 2016, FTA inspected over 60 miles of track on all six Metrorail lines, with additional follow-up inspections between late April and June. FTA found that WMATA’s track inspection program did not fully account for differences in track types, locations, and train traffic volume when WMATA prioritized its inspections. In addition, FTA found that WMATA maintenance departments did not jointly review inspection results to develop coordinated mitigations and assign limited resources to highest priority issues. Since the start of SafeTrack work in June 2016, FTA has conducted additional inspections and observations of SafeTrack work for each surge. According to FTA inspection data from June 2016 through September 2016, FTA inspectors conducted a total of 102 individual inspections of WMATA rail assets, including 49 inspections that covered SafeTrack-related work. For example, FTA officials told us that from the first SafeTrack surge, FTA officials accompanied WMATA staff on pre- surge inspections to identify repair items and observe work tasks during each surge to assess the quality of the repairs. FTA officials said they also conferred with WMATA staff after each surge to identify work not completed, which WMATA compiles into a prioritized “punch list” of critical repairs to be completed during the course of upcoming routine maintenance. FTA officials told us they have been monitoring WMATA’s completion of punch list items and were working with WMATA to ensure progress in completing these tasks. As a result of its inspections, FTA directed WMATA to complete safety critical work both prior to starting and during SafeTrack, specifically: In response to WMATA’s initial SafeTrack plan provided to FTA on May 6, 2016, FTA sent a letter on May 11, 2016, directing WMATA to make urgent repairs to reduce the risk of smoke and fire events and the occurrence of arcing insulators on certain sections of the rail system. FTA’s letter directed WMATA to repair power cables, insulators, and the electrified third-rail system on certain portions of the Red, Blue, Orange, and Silver lines, before beginning SafeTrack. In response to WMATA’s proposed schedule changes after the July 29, 2016 derailment of a Silver Line train near the East Falls Church station, FTA sent WMATA another letter on September 1, 2016, encouraging WMATA to also include additional safety-related work in SafeTrack, including: (1) prioritizing additional repairs to arcing insulators on the Red Line; (2) completing unfinished track work from the third surge on the Blue and Yellow lines; and (3) addressing poor tie and fastener conditions on certain sections of the Orange and Blue lines, including a section of the Orange Line that was not originally part of WMATA’s SafeTrack surge plan. WMATA took several actions to address FTA’s concerns. First, WMATA adjusted the order of early surges in its initial SafeTrack plan and has replaced insulators, repaired power cables and third-rail components, and assigned a dedicated work crew to improve drainage on the sections of the Red Line between Medical Center and Van Ness stations, as cited in FTA’s May 11 and September 1 letters. Second, WMATA officials told us that Metrorail completed unfinished work from the third surge on the Blue and Yellow lines during an additional single-tracking event. Finally, in January 2017, WMATA scheduled an additional surge from May to June 2017 to address FTA’s concerns regarding poor track condition on a certain section of the Orange Line. FTA reported that WMATA’s actions taken in response to FTA’s concerns have helped reduce safety incidents. According to an FTA report, WMATA has reduced the prevalence of electrical arcing incidents on the Red Line between Medical Center and Van Ness station as a result of WMATA’s additional maintenance activity in that section of track. Specifically, FTA reported that between March 1, 2016, and June 14, 2016, WMATA had experienced 18 electrical arcing incidents between Medical Center and Van Ness, including 4 major events at the end of April and early May. Since taking additional maintenance actions, WMATA experienced 8 arcing events over the 4 month period from mid- June 2016 through mid-October 2016, and FTA has characterized these events as relatively minor. In addition to FWSO inspections of WMATA infrastructure and safety procedures, FTA has also exercised its project management oversight authority over SafeTrack since July 2016. FTA’s project management oversight includes monitoring a major capital project’s progress to determine whether a project is on time, within budget, and in conformance with design criteria, and whether it is constructed to approved plans and specifications, and is efficiently and effectively implemented. As noted previously, major capital projects include, among other things, projects involving the rehabilitation or modernization of an existing fixed guideway with a total project cost in excess of $100 million. FTA found that SafeTrack met the $100-million criteria for a major capital project when it approved an additional $20 million in safety- related federal funding for the project in mid-June 2016, during the first surge. As a result, FTA announced that it would exercise its project management oversight authority over SafeTrack in a July 1, 2016, letter to WMATA. After FTA designated SafeTrack as a major capital project based on criteria established in law, WMATA became subject to the statutory requirement to complete a project management plan. Federal law requires that recipients of federal financial assistance for a major capital project related to public transportation prepare a project management plan approved by the Secretary of Transportation, and carry out the project in accordance with the project management plan. FTA guidelines state that a project management plan provides a functional, financial, and procedural road map for the project sponsor to effectively and efficiently manage a project on-time, within-budget, and at the highest quality and safety. According to federal regulations, as a general rule, a major capital project’s project management plan must be submitted during the grant review process and is part of FTA’s grant application review. These regulations also state that if FTA determines that a project is major under its discretionary authority after the grant has been approved, FTA will inform the recipient of its determination as soon as possible. In the case of SafeTrack, due to WMATA’s desire to begin SafeTrack work immediately, and FTA’s determination of SafeTrack as a major capital project after work had already commenced, WMATA did not submit its project management plan to FTA until 4 months into the project. On July 1, 2016, FTA requested that WMATA submit its project management plan to FTA by July 29, 2016. WMATA requested and was granted an extension, and submitted its project management plan to FTA on September 30, 2016. As of January 2017, FTA has yet to approve WMATA’s project management plan because key elements lacked sufficient detail. FTA officials told us that WMATA’s plan did not provide adequate information on the SafeTrack budget and costs of the work being conducted, as well as information to identify and manage project risks, or assess the performance of the project against defined metrics. FTA provided WMATA with detailed comments on WMATA’s plan covering these and other issues. As previously noted, WMATA officials told us that they do not consider the project management plan to be the most appropriate tool to manage SafeTrack tasks, which are primarily maintenance activities. However, WMATA officials also told us that they were working closely with FTA to improve the quality and level of detail in the plan. WMATA’s recent record of significant safety incidents demonstrates that its Metrorail system faces serious safety and infrastructure challenges. Through SafeTrack, WMATA has accomplished a substantial amount of repair work to bring its track infrastructure closer to a state of good repair. WMATA is also learning some important lessons in implementing SafeTrack that could better equip it to identify and address issues in future large-scale rehabilitation projects. Perhaps more importantly, SafeTrack indicates that WMATA is now committed to preventative maintenance, including the repairing of track assets before they break and cause more cost and safety impacts on Metrorail riders. Though SafeTrack consists largely of routine maintenance work, the intensity, length, cost, and disruption of the effort distinguishes it from normal maintenance work. As a result of the urgent need for work on the track infrastructure and the unique nature of SafeTrack, WMATA’s planning of SafeTrack did not fully align with leading practices, and WMATA likely experienced some early challenges as a result. These challenges highlight the importance of comprehensive planning and project management for large-scale rehabilitation projects to minimize the impacts on riders and ensure work is completed efficiently and according to quality standards. Indeed, SafeTrack is not a comprehensive approach to addressing WMATA’s safety needs and additional efforts will be needed to bring the entire Metrorail system to a state of good repair. Without a policy requiring planning processes that are more consistent with leading project management practices, which call for thorough analysis, planning, and informed decision-making, WMATA’s ability to effectively address future infrastructure challenges may be limited. This situation is particularly true for future large-scale rehabilitation projects that may not be designated as major capital projects and subject to FTA’s project management oversight authority, but which could still benefit from having a project management plan in place before beginning the project, consistent with leading practices. Furthermore, documenting these planning requirements, and the relevant procedures for carrying them out, would help ensure that they are carried out consistently, in order that staff and management can be held accountable for them. To ensure future large-scale rehabilitation projects are in line with leading project management practices, WMATA should develop a policy that requires and includes relevant procedures specifying that the following three actions be taken prior to starting large-scale projects: use detailed data on the conditions of assets to develop project evaluate and compare alternative ways of accomplishing the project objectives, including estimates for the alternatives’ costs and impacts; and develop a comprehensive project management plan for the selected alternative—to include key elements such as detailed plans for managing the project’s scope, schedule, and cost—for those projects that may not be designated major capital projects. We provided a draft copy of this report to DOT, NTSB, and WMATA for review and comment. In written comments, reproduced in appendix I, DOT said that, since exercising oversight authority, FTA has guided and examined WMATA’s work toward improving its safety culture, infrastructure, and operations. DOT also said that FTA will continue to provide safety oversight of WMATA and help it build upon improvements made in the last year. In comments provided in an e-mail, NTSB noted that it shares our concern that WMATA’s interlockings, and other track work, were not fully considered in planning SafeTrack. NTSB also said that FTA’s public transportation safety oversight approach lacks the necessary standards, expertise, and resources. This report focused on FTA’s oversight of the SafeTrack project specifically, so we did not evaluate FTA’s overall public transportation safety model. We do, however, have planned work to examine FRA and FTA safety oversight programs. In written comments, reproduced in appendix II, WMATA agreed with our findings and conclusions, and said that it is working to address the recommendations. WMATA also said that the draft report did not reflect the urgent safety state of the Metrorail system prior to beginning SafeTrack, which precluded comprehensive project planning. We acknowledge throughout the report that, at the time SafeTrack was being developed, WMATA faced significant safety issues and leadership was making critical decisions on how to address systemic deferred maintenance. Nevertheless, by not fully carrying out leading project management practices, WMATA lacked assurance that SafeTrack was the most efficient and least disruptive approach to accomplishing the track repair objectives. Having a policy and procedures in place requiring these project management practices for future large-scale rehabilitation projects will ensure that WMATA plans such projects so they best meet their objectives. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Transportation, Chairman of NTSB, General Manager of WMATA, WMATA Board of Directors, and the appropriate congressional committees. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-2834 or goldsteinm@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Individuals that made key contributions to this report are listed in appendix I. In addition to the contact named above, Matt Barranca (Assistant Director), Kyle Browning (Analyst in Charge), Jason Blake, Lacey Coppage, Hannah Laufe, Sara Ann Moessbauer, Malika Rice, and Michelle Weathers made key contributions to this report.

Summary: Recent inquiries into WMATA's Metrorail system have revealed a range of serious safety issues. In response to some of these issues, as well as a backlog of track maintenance, WMATA announced in May 2016 that it was undertaking SafeTrack, a large-scale rehabilitation project. The SafeTrack project is overseen by FTA. GAO was asked to review a range of safety and oversight issues regarding WMATA. This report examines the extent to which WMATA's (1) planning and (2) implementation of SafeTrack was consistent with leading project management practices as well as (3) the steps taken by FTA to oversee SafeTrack. GAO reviewed documentation on WMATA's planning and project implementation, and FTA's oversight of SafeTrack. GAO also interviewed officials from WMATA, FTA, and local jurisdictions, and compared WMATA's planning and implementation of SafeTrack to leading project management practices developed by professional organizations. The Washington Metropolitan Area Transit Authority's (WMATA) planning of SafeTrack did not fully align with leading project management practices. While WMATA generally followed leading practices to coordinate with stakeholders, it did not comprehensively collect and use data on the condition of its assets, analyze project alternatives, and develop a project management plan before starting work. WMATA did not follow these practices because it believed it needed to start work immediately to address critical safety issues. Although WMATA inspected its track assets when planning SafeTrack, those inspections were not comprehensive and did not collect detailed data on the condition of all track infrastructure, such as all “interlockings,” where trains cross from one track to another. As a result, WMATA's decision makers may not have used sufficient information to develop project objectives and to properly prioritize SafeTrack work. Though WMATA developed three alternatives for SafeTrack, it did not determine the costs and impacts of each alternative, or assess them to determine which approach may have resulted in greater efficiencies, lower costs, or less disruption for riders and local jurisdictions. Before WMATA began SafeTrack, it lacked a comprehensive project management plan, which is a key tool to ensure a project is completed on-time, within-budget, and according to quality standards. WMATA does not have a policy that requires, and includes relevant procedures for how to carry out, these planning activities for large-scale rehabilitation projects. Without such a policy and procedures, WMATA lacks a framework to plan future rehabilitation projects so that they achieve their objectives. WMATA's implementation of SafeTrack generally aligned with leading project management practices. Specifically, WMATA officials collected information on the work performed and the condition of assets repaired during SafeTrack. WMATA officials also collect lessons learned during and after each surge, and use those lessons during subsequent maintenance and planning efforts. Additionally, WMATA developed a new organization-wide quality control and assurance framework and is implementing it for the first time through SafeTrack. The Federal Transit Administration (FTA) has used safety inspections and other tools to oversee SafeTrack and direct WMATA to undertake safety-critical work. FTA has relied on two different authorities to oversee SafeTrack: (1) FTA's public transportation safety oversight authority, and (2) its project management oversight authority. Prior to the start of SafeTrack and during the project, FTA conducted safety inspections and directed WMATA to make repairs to reduce the risk of smoke and fires on the rail system. After SafeTrack work began and estimated project costs exceeded $100 million, FTA determined SafeTrack to be a major capital project, triggering the statutory requirement that WMATA prepare a project management plan. WMATA did not submit its project management plan until 4 months into SafeTrack. FTA found the plan lacked sufficient detail, and WMATA told GAO it is working to improve the plan. GAO recommends that WMATA develop a policy that requires and includes procedures for it to, prior to starting future large-scale rehabilitation projects: (1) use asset data to develop project objectives; (2) analyze alternatives; and (3) develop a project management plan for those projects that may not be designated as major capital projects. WMATA agreed with GAO's findings and said that it is working to address the recommendations.