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Public Transportation: Identifying Lessons Learned Could Help Improve FTA's Process to Manage Safety Risks

GAO-21-104029 Published: Sep 14, 2021. Publicly Released: Sep 14, 2021.
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Fast Facts

After a series of high-profile accidents, the Federal Transit Administration was tasked with playing a larger role in overseeing safety for public transportation. It now works with transit agencies to develop data-driven safety plans, among other activities.

We looked at several aspects of FTA's involvement, such as:

  • FTA's efforts to reduce risks—including a pilot project that put cameras in rail transit cars to help determine accident causes
  • FTA's assistance to transit agencies
  • How the agencies responded to new planning mandates

We recommended that FTA craft a plan to implement lessons learned from the camera pilot.

A Southeastern Pennsylvania Transportation Authority Trolley

The front of a trolley on a busy street.

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What GAO Found

Of the twelve selected transit agencies GAO spoke with, most faced challenges incorporating the Federal Transit Administration's (FTA) requirements to develop and document its Safety Management Systems (SMS) in their new agency safety plans. SMS is a performance-based, data-driven framework to manage safety risks throughout an organization. Some rail transit agencies noted difficulties transitioning from the former 21-element safety plan to SMS and its four required components. However, most transit agencies said they benefited from FTA's assistance. FTA's assistance included guidance documents, webinars, and training. Upon request, FTA also reviewed transit agencies' draft safety plans, providing lessons learned from those reviews.

FTA established a Safety Risk Management (SRM) process to identify, assess, and mitigate safety risks across the nation's transit agencies. During the initial implementation, FTA selected four safety concerns to review (see fig. below). According to FTA, the use of cameras on rail transit was a pilot project, and FTA has completed four of the five steps in its process for the camera safety pilot. Though FTA continues to evaluate that pilot and work on the other three safety concerns, it has not completed actions to prepare for future rounds of the SRM process. In particular, FTA has not identified and documented lessons learned from the pilot. Documenting and incorporating such lessons could enhance the effectiveness and timeliness of FTA's SRM process and thus FTA's ability to address transit-wide safety risks.

GAO's Assessment of the Status of the Safety Risk Management (SRM) Process for Four Safety Issues under Review by the Federal Transit Administration (FTA)

GAO's Assessment of the Status of the Safety Risk Management (SRM) Process for Four Safety Issues under Review by the Federal Transit Administration (FTA)

FTA continues to gather information while it considers whether to mandate certain transit safety standards. FTA has issued safety bulletins for rail cameras and end-of-railcar signage. These bulletins suggest but do not require certain actions related to the installation of cameras and signage in rail transit cars. FTA, however, has not yet initiated a rulemaking for any mandatory federal safety standards. While the diverse nature of the transit industry can make setting federal safety standards challenging, transit agencies GAO spoke with were generally open to mandatory safety standards for some safety issues. For example, many of the selected transit agencies expressed support for requiring medical examinations of employees, as well as other so-called human-factor safety risks.

Why GAO Did This Study

In recent years, new laws gave the Department of Transportation's FTA additional requirements and authorities to oversee transit safety. In turn, FTA now requires, among other things, transit agencies to develop new safety plans that incorporate SMS to manage and mitigate safety risk. FTA also incorporated SMS in its transit agency oversight to better identify and assess safety risks, and determine appropriate mitigation efforts, including mandatory safety standards.

GAO was asked to examine how FTA is implementing its new responsibilities and authorities. This report examines (1) selected transit agencies' experiences in incorporating SMS in their new safety plans; (2) steps FTA is taking to identify, assess, and mitigate safety risks; and (3) FTA's status on mandating safety standards and stakeholders' views on the benefits and challenges of such standards. GAO reviewed FTA documents on safety oversight policies and practices and interviewed officials from 12 transit agencies and their 9 respective state oversight agencies. GAO selected transit agencies to reflect a variety of modes, sizes, age, and geographic diversity.


GAO recommends that FTA identify and document lessons learned from the camera pilot, including a plan to implement needed changes. DOT concurred with this recommendation and provided technical changes to the draft report, which we incorporated as appropriate.

Recommendations for Executive Action

Agency Affected Recommendation Status
Federal Transit Administration The Administrator of FTA should take steps to identify and document lessons learned from the camera safety concern pilot project, including a plan for implementing those lessons in the SRM process. (Recommendation 1)
Closed – Implemented
After a series of high profile accidents, especially on rail transit systems, the U.S. Department of Transportation (DOT) was charged with playing a larger role in transit safety oversight. Within DOT, the Federal Transit Administration (FTA) is responsible for implementing these authorities . To enhance the safety of public transportation, FTA adopted the principles and methods of Safety Management Systems (SMS), which is a process for safety management that incorporates systematic procedures, practices, and policies. As part of FTA's efforts to implement the SMS, FTA developed a five-step Safety Risk Management (SRM) process. In 2021, we reported that FTA has not completed a key step necessary to improve the SRM process-identifying, documenting, and implementing lessons learned from its pilot project. We have previously reported that, among other things, identifying and documenting lessons learned are leading practices for pilot projects. By not developing and documenting lessons learned, as well as how the agency planned to incorporate those lessons into the SRM process, FTA may miss opportunities to improve the timeliness and effectiveness of a relatively new SRM process that is essential to implementing SMS. Accordingly, we recommended that FTA take steps to identify and document lessons learned from the camera safety concern pilot project, including a plan for implementing those lessons in the SRM process. In 2023, we confirmed that FTA conducted an evaluation of the pilot project that identified and documented lessons learned to better understand what aspects of the SRM process worked well and what could be improved to make the SRM process more effective . Further, FTA implemented changes to the SRM Standard Operating Procedures based on those lessons learned from the pilot evaluation. Having made those changes based on its analysis of what aspects of the SRM process worked well and what could be improved, FTA has likely made the SRM process for other safety concerns more effective, and therefore better mitigate transit safety issues in the future.

Full Report

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Accident investigationPublic transportationRisk assessmentRisk managementSafety concernsSafety standardsTransit safetyTransit systemsTransportationTransportation safetyWorkforce protectionLessons learned