The Death-Based Model of Organizational Learning: Accident, Pandemic,

and Workplace Change in New York Public Transit

Noah McClain*
mcclain1@gmail.com

Forthcoming 2021, American Behavioral Scientist vol. 66

Submitted March 29, 2021; accepted June 25, 2021.

Abstract

The public transportation workers of New York City lost their lives to COVID-19 at a shocking
rate in the spring of 2020, likely abetted by their employer’s resistance to allow workers to wear
masks until mere days before a region-wide lockdown was declared. We might see this death toll
as a tragic outcome of uncertainty in the face of the unprecedented, yet the stance of the
employer (the Metropolitan Transportation Authority, or MTA) was consistent with its
longstanding reluctance to assimilate – much less pursue – signals that suggest need for safety
reforms until a worker dies. This article terms this pattern a death based model of organizational
learning, and situates the virus’ toll on transport workers from three angles: first, from workers’
experience of existential precarity in their workplaces, rooted in dangers they readily
problematize which are not addressed by management; second, by showing how the MTA may
modify rules following an employee fatality, at least when that death cannot be explained by
individual failures alone; and third, by exploring the MTA’s longstanding disinterest in health
and safety research conducted in its physical and institutional bounds. These prior patterns
articulated in the MTA’s response to COVID-19, such as in passivity in the face of general
public health guidelines, disinterest in obvious founts of expertise to tailor response to the
pandemic, and in the eventual acceptance of a nascent public health role in light of the mounting
death toll of employees.

Introduction
Just two weeks before the New York City
region entered a lockdown period in
response to the emerging COVID-19 crisis
in March 2020, the Metropolitan
Transportation Authority – which operates
the city’s subways, busses, and the region’s
commuter railroads - issued a memorandum
to its uniformed employees reiterating a
standing policy. The memo read, “Since
masks are not medically necessary […] and
not part of the authorized uniform, they
should not be worn by employees” (Warren
et al., 2020). About a month later, MTA
employees began to lose their lives to the
virus at numbers and rates far higher than
comparable workforces serving the serving
the city (DiLorenzo, 2020), totaling 127
fatalities by the end of May 2020.
The MTA was not wholly alone in its
initial response to masks. Of the mass
transport authorities serving major U.S.
cities, like Chicago, Washington, D.C.,
Boston, Philadelphia, San Francisco, and
Seattle, several also reiterated the CDC’s
official skepticism in the efficacy of masks
prior to mid-March 2020. But several
anticipated a reversal of the CDC’s position
– such as the Washington, D.C. Metro and

1
Bay Area transit authorities, which began to
stockpile masks by the end of January and
February 2020, respectively (Metro, 2020;
Reyes, 2020). More fundamentally,
however, there is no record that any of those
other public transit agencies actively forbade
masks to workers. In this respect, MTA was
unique. MTA did pivot, however, first to
allow workers to wear masks, and then - on
the cusp of expected changes in Centers for
Disease Control (CDC) guidance - to
provide and eventually to require workers to
wear masks. But the delay may have cost
some workers their lives.
One way of thinking about MTA’s many
COVID-19 deaths is as the result of true
uncertainty in the face of circumstances
unprecedented in living memory. In arguing
– as MTA’s March memorandum did – that
the benefit of masks for the uninfected had
yet to be established, and that masks might
even be detrimental to the already-infected,
the MTA drew from official guidance. Later,
MTA indeed made an appropriate
adjustment to its policies in response to a
growing death toll on its workforce, and in
light of evolving wisdom. Yet, in facing the
initial uncertainty over the utility of masks
and deferring to rules which stipulate the
proper workplace uniform, without
apparently seeking expertise to situate
public health recommendations in relevant
contexts, MTA was following one of its
well-worn organizational pathways. That
pathway is characterized by a lack of
proactive investigation of safety issues for
its employees; resistance to the production
of new health and safety knowledge specific
to its domains; deep attachment to rules, and
the confrontation of the dangers of mass
transit labor through the regulation of
workers rather than structural mitigation --
all leading to a reluctance to introduce safety
reforms unless a death of an employee
produces a signal which cannot be ignored.
2
This article situates the deaths of transit
workers from COVID-19 in a longer
organizational trajectory in which death is
the most significant engine of their
employer’s engagement with workplace
hazards. I demonstrate that MTA’s meager
early response to COVID-19 is consistent
with how, in matters of employees’ safety,
that organization learns – that is, how it
notices, interprets, and assimilates feedback
and information as retrievable knowledge
(March, 1991; Owen-Smith 2005; Aldrich &
Ruef, 2006). With safety reforms driven
principally by past fatalities, it is appropriate
to describe MTA as following a death-based
model of organizational learning.
To make this case, I examine the MTA as
a workplace and an organizational actor at
three registers. The first, that of tunnel-level
work in the subway, uses ethnographic and
interview data to illustrate worker’s concern
for, and problematization of, evident risks
which are undiscovered or unacknowledged
by their employer. At a second register, I
examine official MTA accounts of
accidental deaths of employees, how those
accounts relate to evidence of learning, and
show how MTA’s efforts towards change
are prompted by deaths of workers, albeit
only when those deaths cannot be blamed on
individual error, unfitness, or deviance. At
the third register, I detail MTA’s resistance
to scrutiny, and its lack of cooperation with,
and disinterest in, health and safety research
conducted in its organizational or physical
confines. This resistance comes into high
relief, I show, when we compare MTA to
one of the few peer entities also responsible
for the mass transit of a global capital,
Transport for London (TfL) which – unlike
MTA - not only allows, but actively
commissions research on epidemiological
questions.
 Taken together, evidence from these
registers suggests that MTA evolves its
safety measures principally as a response to
death. Of course, we expect employers to
seek correctives when the demise of an
employee forgrounds theretofore-
unassimilated dangers. Organizations often
do “discover” new risks which were in some
sense always there (see Douglas &
Wildavsky, 1982; Weick 1998). A death on
the job can signal a danger that should not
be ingored while demonstrating the
concsequences which arise because the
danger apparently has been ignored.
Certainly, organizations should learn from
such tragedies. Why, then, is the MTA case
different? While Hutter and Power (2005)
point out that organizational encounters with
new risks “emerge from the cracks in
institutional thinking” (p. 11), the MTA
illustrates how those cracks in thinking can
be broad chasms when an organization
actively resists their discovery, and fails to
heed actors eager to identify and
problematize its gaps in awareness of safety
and health problems in a working
environment. As I show, this willful
ignorance indeed helps explain deadly
outcomes suffered by front-line MTA
workers at the dawn of the COVID-19
pandemic. Those deaths are both
consequences of, and datapoints for, a death-
based model of organizational learning.
Research Contexts for Death-Based
Learning in the MTA
By studying existential precarity in the
workplace, this article lends fresh context to
Nelkin and Brown’s (1984) interviews with
workers’ experience of heath precarity in an
era when the causal connections between
low-dose chemical exposure (such as they
experienced on the job) and creeping
illnesses were evident but almost universally
3
unproven. I echo Desmond’s (2007)
examination of how an employer– the U.S.
Forest Service - accounts for the deaths of
wildland firefighters: while a “public
eulogy” frames the deceased as self-
sacrificing heroes, an “internal eulogy” finds
evidence of incompetence in the death itself,
supporting a mythology - necessary to
deploy workers agaisnt vast danger - that
firefighting is not dangerous to the
competent. As I show, MTA’s way of
addressing death on the job tends towards
this pattern. Yet workers’ deaths are
sometimes capable of sparking crisis for
MTA because the contributing factors are
vastly under the MTA’s jurisdiction - for
example, any train hitting a track worker
was purchased and maintained by MTA,
operated by an employee hired and trained
by MTA, in a tunnel owned by MTA. With
so few elements of an accidental death
extrinsic to its purview, deaths MTA cannot
reduce to incompetence or deviance are able
to create a signal which can lead to
organizational learning and change.
This perspective reflects arguments on
organizational learning from accidents.
Haunschild and Sullivan (2002) observed
that airlines may learn little from accidents
with simplistic explanations because, for
example, there are no further problems to
solve once the “incompetent pilot” has been
fired. Accidents identified with
heterogeneous causes, however, prompt
internal probing for latent causal factors,
perhaps leading to organizational learning.
For the MTA, deadly accidents with
heterogeneous causes indeed correlate with
evidence of learning, likely for the same
reasons.
By documenting how the MTA reacts to
death, but declines to seek signals of
looming dangers, I suggest that the death toll
of COVID-19 on transit workers is a system
accident rooted in organizational failure. A
line of case-studies at the juncture of
organizations and accidents (e.g., Vaughan,
1996; Beamish, 2002; Snook, 2000; Weick,
1995, Clarke 1999) poses the question: how
do actors in an organization discount,
overlook, or misinterpret signals of
underappreciated risks, looming dangers, or
crucial information, in ways that precipitate
calamity? What features or practices of an
organization can help us understand those
missed signals ? This article advances that
agenda by jointly posing an inverted
question: what are the minimum conditions
in which a specific organization searches for
or assimilates crucial signals? What patterns
best explain how risks are recognized and
given impact by an organization? Through
this inversion, this article seeks to exemplify
a means of confronting organizational habits
- and even forms of willful ignorance
observable in its past - as a model for
studying, and developing a politics over, its
future capacities to effectively protect its
workers.
Data and Research Strategy
This article stems from a research program
focused on the MTA as a work setting, as an
organizational actor, and as an administrator
of key public goods in an epicenter of U.S.
urban life, spanning the mid-2000s to the
present. With an operating budget of $17
billion, MTA provides about one-third of all
public transit trips taken in the U.S. each
year, mainly through the New York subway,
which is operated along with the city’s
busses by the MTA subsidiary New York
City Transit. Controlled by the State of New
York, critics contend MTA avoids
accountability to its ridership and the city in
which its riders principally dwell.
4
This article draws from fieldwork in the
subway, and from one hundred interviews
with subway employees, conducted by
myself and my fellow investigator in the
latter 2000s studying the “securitization” of
subway work, in which workers’ existential
precarity emerged as a central theme. Those
research steps are detailed elsewhere
(Molotch and McClain, 2012). I examine
how MTA has accounted for and responded
to the deaths of employees on subway tracks
through MTA fatality reports made available
by a federal oversight body (National
Transportation Safety Board, 2019). Further
data comes from MTA rule books, reports
and memoranda which indicate continuities
and change in MTA safety policies and
measures. A rule-change is not itself
necessarily a change in practices; rules are
central to the repertoires to propagate
practical and symbolic action alike. Rule-
changes may be purely symbolic (Meyer and
Rowan, 1977, Scott 1995), but can also be
sincere efforts to transform organizational
practice, or both at the same time. Yet, in
either case, rules are “codings of
organizational history” (March. Shulz and
Zhou, 2000 p. 2) which betray, at the very
least, an organization’s encounter with some
problem, and effort to distill a form of
knowledge (including knowledge of a
symbolic solution perhaps constituted by the
rule itself) or solution in official codes.
Rule-changes reflect scrutiny of existing
rule systems (Kieser, 2008), and thus reflect,
at least, learning that prior rules were
somehow inadequate.
I study MTA’s engagement with
independent health and safety wisdom
through email correspondence, telephone
conversations, and questionnaire responses
conducted or obtained between summer
2020 and early 2021 from scientists
involved in six prior research agendas
focused on health and safety issues
specifically in the New York subway,
published in the past two decades. As I
show, MTA’s disengagement with health
and safety-related research projects
conducted in its environments can help us
understand the organizational failure to
protect the MTA workforce as an era of
pandemic arrived. To study how MTA
interfaced with scientists and health
researchers to inform its confrontation of
COVID-19, I engaged in email
correspondence with eight scientists with
relevant, subway-specific research
accomplishments, or who were identified in
media reports as having special expertise to
matters critical to subway operations during
the pandemic.
I. Precarious Transit Work, MTA
Learning, and the Asymmetrical
Recognition of Risks
In 2003, subway conductor Janell
Bennerson was killed when her head struck
a metalwork barrier on a subway platform as
she leaned out of her cab’s window as the
train pulled out of the station. Conductors
are required to observe their train doors as
trains depart to make sure that no one is
being “dragged”, which can readily maim or
kill (Gershon et al., 2008). MTA’s report on
Bennerson’s death noted she had leaned out
of her cab too long; her train had travelled
more than 300 feet when her head hit the
barrier, apparently out of compliance with a
rule requiring conductors to observe train
doors for the shorter of three subway car
lengths (about 150 feet), or until they reach
the end of the platform. Yet Bennerson also
faced a blinding early-morning sun behind
the barrier in that open-air station, likely
making the barrier hard to see; also, because
1
Rule 107[t] in 1969; renumbered as rule 97[r] in
1992; modified as rule 9.01[r] in 2003 (Metropolitan
Transportation Authority, 1969/1979/1992/2003).
5
of earlier mechanical problems with her
train’s doors, Bennerson may have been
extra watchful against dragging. Lastly, of
course, MTA constructed a barrier on a
station platform just eighteen inches from
the pathway of trains, giving deadly
consequences a required task performed one
moment too long. (Smith, 2003).
Soon after, MTA lowered the barrier. It
also modified the door-observation rule,
which had been unchanged in any way since
at least the 1960’s, to specify that
conductors shall now observe the doors until
the train travels seventy-five feet. 1 As a
station agent commented in an interview,
After she [Bennerson] got killed, they
changed the rules. No more ‘three car-
lengths.’ No more ‘observing to the end of
the platform.’ Now its seventy-five feet.
That’s it. But it took her getting killed for
them to change the rules.
The rule-change was borne of tragedy but
led to a lesser victory agaisnt a danger that
has long persisted for conductors, from
surprise attacks while leaning defenselessly
out of their cab windows as the train moves.
In precisely those moments, conductors may
be victimized by opportunists who hit or
slash them, or spit into their faces (Molotch
and McClain, 2012). The MTA has proposed
to address the problem through means which
are non-preventative, like enhanced criminal
penalties or using body cameras to capture
the assaults (Barone, 2018). In responding to
death by at least limiting conductors’
exposure to one sort of hazard, MTA learned
something addressing the vulnerability of
conductors’ heads that it had failed to
address from their recurrent victimization.
 Such examples build towards workers’
belief – pervasive in my interviews - that
even persistent dangers flagged by
employees were discounted or unnoticed by
management, reinforcing a general sense
that MTA has not discovered - and was not
interested in discovering –threats that loom
as obvious to workers. Supporting this belief
is a long heritage of reports, such as one
which found that the subway’s safety office
was not compiling injury statistics to
identify correctable hazards and was instead
only “reactive to problems disclosed by
accidents and oversight agencies” (Prichard,
1988).
One rich vein of dangers comes from what
workers identify as MTA’s inadequate
provision for emergency, creating what may
be unmanageable, deadly circumstances in
their midst. One example, from the mid-
2000s, came after MTA eliminated staff
from many stations, leaving service exits
locked, and body-encompassing turnstiles
(Fig. 1) as the sole means of emergency
egress. As posed by a train operator in a
discussion of emergency evacuation,
Can you imagine in the subway rush hour,
people trying to go through the turnstile in
New York one at a time, two at a time?
You’re gonna get one person that’s gonna
trip and that gate is gonna be shut down.
And that’s gonna be it. It’s gonna be over.
To the degree this issue has been
corrected, change came only when MTA
was notified that the situation violated state
fire codes and was forced to add exit gates
(McClain, 2019). Scepticism in provisions
for any sort of evacuation is not limited to
the obstacles posed by the turnstile. A
simple process of a train crew guiding
passengers off a disabled train is hard
enough, according to another train operator,
but if there is “a smoke condition or fire,
6
then you have pandemonium […] People
with [flash]lights, even experienced track
workers have tripped and fell and been
burned and electrocuted. So imagine
passengers who’ve never walked through
the tunnel before […] your chances are very
slim.”
Transit workers’ descriptions of precarity
and deployment against possible dangers
unacknowledged by management was
validated in field work, such when I
witnessed a group of subway cleaners being
required to remediate an underground
subway station of a fine powder that coated
all station surfaces, reportedly dust from a
distant tunnel rehabilitation project (see Fig.
2). At street level, supervisors insisted that
the task was required, while workers
protested that their simple dust masks were
inadequate protection from this mystery
powder. We can situate the workers’
skepticism in evidence of the known health
dangers already pervading the air they
breathe, such as steel dust – a product of a
century of steel rails, wheels and brakes
griding each other into a particulate which
oxidizes and blows through subway air –
which subway employees breathe
throughout their work lives (Chillrud et al.,
2006), or in incidents such as when
asbestos-laden dust accumulated in homes
adjacent to elevated subway tracks from a
botched removal job, and MTA
representatives told locals that no, the dust
did not contain any asbestos at all (Flinter,
1995). Back at the station full of mystery
powder, I recorded one cleaner yelling “I
just don’t feel safe!”, before he and several
others decided to “book off sick” rather than
face the task and risk exposure to the
undefined particulate.
These examples illustrate risks workers
have readily identified, but which sit in their
employer’s blind spots for all practical
purposes, perhaps awaiting tragedy before
they can be “discovered” by MTA. By
looking at deaths on subway tracks and their
relationship to formal organizational change
we can see that learning process in detail.
II. Organizational Learning and
Death on the Tracks
Subway track and signal repair are
predictably dangerous, not least because
they are historically organized to allow the
continued passage of trains within the
confines of a tunnel or upon an elevated
track while work is underway. A subway
train engaging its brakes at just twenty miles
per hour needs more than one hundred feet
to come to a stop, so workers can be left
with nowhere to go at all if precautions fail
and a train barrels into a work zone. A
complex web of rules and regulations
govern track work and the movement of
trains in its midst. Ideally, those rules define
safe procedures and coordinate the
perceptions and actions of all relevant
workers. A compatible way of thinking
about these rules is also as instruments
which transfer the liability of dangerous
labor onto workers; as instruments which
perform legitimately for regulators and
others; and which are more or less
successful as practical guidelines to stave off
accidents. These rules and procedures have
generally avoided critical examination or
substantive revision by the MTA even in the
face of employee deaths so long as the
victim or other low-level worker could be
assigned blame. Yet, when a death cannot be
explained by the failures of individuals, it
can be followed by organizational learning
in the form of revisions to rules, procedures,
and equipment.
In the span of 2001-2013, nine MTA
employees lost their lives while working on
7
or adjacent to tracks; Table 1 summarizes
the findings of each official MTA report
made in its wake and the evidence of MTA
learning stemming from each incident. Each
and every fatality report cites some failure
of the victim as a primary cause, but some
lend weight to additional factors. Some lead
to evidence of learning, overwhelmingly in
the form of a new or modified rule.
Between 2001-2004, only one death led
learning: that of Joy Antony who was struck
and killed by a train from behind when he
had to lean over an active subway track to
access a signal he was testing. MTA’s
official report nonetheless cited him for
violating rules which required him to expect
trains from either direction at any time and
to “be prepared to take a safe position at all
times” (New York City Transit, 2003, rule
3.71[f]) - a rule seemingly violated by any
worker hit by a train. Nonetheless, the
incident brought a sliver or organizational
learning in the modification of “flagging”
rules. Flagging involves the placement of
warning lamps or flags, and human
“flaggers” positioned upstream and
downstream from a work zone to
communicate through signals with
oncoming trains, and with work crews, to
make way for trains passing through the
work area. Antony’s demise led to the
modification of a rule to stipulate that work
between two narrowly-separated tracks
should be protected by flagging on both
tracks, not just one (New York City Transit,
2010).
MTA’s deeper engagement with systemic
problems in track safety was prompted by
the deaths of two workers in 2007. Track
worker Marvin Franklin was killed when a
supervisor promised to act as a flagger but
then abandoned his post, leaving Franklin to
be struck by a train. Just five days earlier,
Track worker Daniel Boggs had been hit by
a train while setting up flagging protection
lamps for a repair project. A plan for
alternate service – under what is known as a
General Order (G.O.) was planned to route
all trains onto a local track to allow work on
the adjacent express track. A slow, diesel
work train had already passed Boggs,
usually indicating the G.O. was now in
effect, and that the express track would be
free of passenger trains for hours. But just
when the G.O. was scheduled, an upstream
local train was momentarily disabled, and
the train behind it was re-routed to the
express track, and right into Daniel Boggs.
MTA’s death report accused Boggs, who
had been struck from behind, of breaking a
rule requiring him to expect trains from any
direction at any time. It also noted, however,
that Boggs’ supervisors had not been
required to confirm with the Rail Control
Center (which manages all train traffic) that
the G.O. was in effect, and even if someone
knew to warn Boggs to still expect
oncoming trains, MTA did not issue radios
to titles held by Boggs or his supervisor.
Boggs’ body ended up in contact with an
electrified train component. When his co-
workers, rushing to help him, first threw a
switch on an emergency box to cut power to
the third rail, they only avoided
electrocution themselves by triangulating
that the third rail was still live; it turned out
that the emergency box was fed by faulty
cables which had sat on a repair list for two
years but had not even been marked as
nonworking.
In response, a task force formed jointly
between MTA and the workers’ union (the
Transport Workers’ Union-Local 100, or
TWU) documented that near-miss accidents
are frequent but are rarely reported for fear
of discipline or reprisal; many track workers
believe their jobs are “not very” or “not at
all” safe; that safety procedures cannot be
8
followed while also meeting production
expectations, and that there is little
interpersonal or intergroup agreement over
how flagging rules should even be
interpreted in practice (Joint Track Safey
Task Force, 2007).
The task force made more than sixty
substantive recommendations, including for
modification of rules and procedures and
new training requirements. Management
reported acceptance of many of those
recommendations (Department of Subways,
2010) suggesting it was learning from death,
though no means for workers to
confidentially report near-misses existed
twelve years later (National Transportation
Safety Board, 2019). However, changes to at
least sixteen rules or clauses speaking to
track safety matters followed. Most were
explicitly cited by MTA as responses to
prior accidents or the recommendations of
the task force. Around 2010, MTA
instituted, for large-scale maintenance
projects, a full shutdown of segments of the
subway system to allow repair projects to
proceed without making way for trains
(Nieminem et al., 2016). Moreover, MTA
has also collaborated with TWU in efforts
mitigate the vulnerability of flaggers during
the deeply dangerous minutes they are
actually setting up flagging protection and
are not yet able to signal their presence to
oncoming trains (Track Safety Task Force,
2010).
This learning has not necessarily impacted
other aspects of subway work. Certainly
unchanged is the MTA’s general
suppression of information betraying
internal issues and processes relevant to
safety matters, and lack of engagement with
independent researchers who might offer
guidance on dangers to the public and the
MTA workforce.

III. Avoiding Scrutiny, Avoiding
Learning: MTA Opacity, and
Hostility Towards Independent
Research
MTA avoids the active production of
knowledge of new risks – and perhaps how
to manage them – through secrecy,
noncooperation with researchers seeking to
understand its environs and work contexts
from safety and health perspectives, and
through marked disinterest in relevant
findings.
Advocates for government transparency
have accused the MTA of acting more like a
spy agency than an operator of public
transport, with a “habit of shading statistics
[and] telling partial truths” (Fauss &
Kaehny, 2019). Requests under Freedom of
Information law can face yearslong delays
before the MTA categorically rejects them.2
Reportedly, MTA does not maintain an
organization chart through which the public,
researchers, or even its own leadership
might navigate its intricacies (Guse, 2020).
This secretive disposition and
inaccessibility are especially hostile to the
work of researchers who indeed might
inform the MTA’s operations of all types.
Nineteen studies of the New York subway
relevant to epidemiological concerns have
been published in the past two decades,3 but
none indicate that MTA offered any sort of
cooperation. Health and safety researchers
2 3
See e.g., two FOIL requests issued to the MTA in
May 2018: # 2018-5 (still open at the time of writing)
and FOIL Incident # 180614-001599, rejected after
two years due to unspecified “technical limitations”.
See https://www.muckrock.com/foi/new-york-
16/memoranda-and-correspondence-related-to-
swipers-55056/ and
https://www.muckrock.com/foi/new-york-
16/memoranda-and-correspondence-related-to-
swipers-55738/.
9
involved in six different subway-focused
research agendas shared their experience
with me through emails, conversations and
an informal questionnaire circulated in
summer, 2020. Four said they had
approached MTA for cooperation with their
research. In one case, MTA was
nonresponsive. In three cases, MTA
responded but was non-cooperative -- for
example, refusing to allow epidemiologists
to analyze used subway air filters before
they were thrown away. Five researchers
believed that their findings had immediate
benefit for safety and health conditions in
the subway and attempted to share those
findings directly with the organization, but
the MTA expressed no interest in any case.
The MTA’s disinterest in safety and health
research is readily illustrated through
contrasts with a global peer, Transport for
London (TfL), which also oversees
numerous mass transit entities, including
London’s subway, the Underground, which
had a 2019 ridership three fourths that of the
New York subway, and London’s bus
system – operated by ten private companies
in contract with TfL - which had a ridership
about twenty percent greater than the busses
of New York. Unlike MTA, TfL is under
control of the city it principally serves.
Twenty-five years ago, the London
Underground actively commissioned the
foundational research on suicide in mass
transit, partly out of concern for the
debilitating trauma suffered by the operators
of trains used as instruments of suicide. The
This number reflects distinctive health and safety-
related non-review scholarly publications with partial
or exclusive focus on the New York subway,
abstracted in the PubMed database, or previously
known to the author, produced between 2000-2020.
With several of those studies credited to one or more
of the same authors, those publications constitute a
smaller number of research “agendas”, as I term them
here.
results were disseminated through a half-
dozen journal articles which explicitly
benefitted from direct access to the
Underground’s information and staff (see
O'Donnell et al., 1994; see also Coats &
Walter, 1999). While health researchers
have been long interested in the problems of
death, injury and trauma resulting from New
York subway incidents, there is no record of
any such collaboration in extant research
(e.g. Guth et al., 2006; see also Haberman,
2000). For example, if MTA had indeed
gathered data on struck-by-subway fatalities
in the 2000s, the data were not obtained by a
group of researchers who instead sorted
through forty thousand files held by the city
coroner to calculate their own statistics
(Gershon et al., 2008).
Publications by scholars in a wide range of
fields indicate beneficial contact or
provision of important information by TfL
(e.g. Greenham et al., 2020). While no study
of airborne contaminants in the New York
subway indicate MTA’s cooperation, TfL
has solicited advice on air-quality issues in
the Underground and elsewhere from
university researchers (Transport for
London, 2017). While MTA’s public
datasets are deeply limited and contain no
data on matters of health and safety at all
(see New York State Office of Information
Technology Services, 2021), TfL has
publicly posted its own air-quality datasets
for open analysis (Smith et al., 2016).
TfL’s disposition carried over into the era
of COVID-19. For example, when TfL
sought to understand high fatalities of bus
drivers to COVID-19, it commissioned a
direct study by a university center for health
equity (Goldblatt and Morrison 2020). When
TfL pondered the efficacy of bus drivers’
anti-assault barriers to also protect against
the virus, it commissioned a joint report
from researchers in the areas of
10
transportation, fluid mechanics, and “safety
infrastructure” (Malki-Epshtein et al. 2020).
Another research group was commissioned
to measure COVID-19 viral particles on
Underground surfaces or in Underground air
(Green, Zhou, Desouza, 2021). This
disposition surely did not give TfL an
unblemished record in confronting COVID-
19. Reportedly, some of the private bus
companies operating for TfL were slow to
institute COVID-19 precautions, likely
contributing to the 42 London bus drivers
who were killed by the virus by early 2021,
part of TfL’s overall toll of 57 employees by
that time (Edwards, 2021). While tragic, the
number was less than half the toll of the
virus on the comparably-sized MTA
workforce by that point (Guse, 2021), and
indeed prompted TfL to invite scrutiny on
its practices, and examine means of doing
better.
MTA’s contrasting disengagement with –
or even hostility towards - health and safety
research of all types heralds a broader
deposition: a disinclination to scan for --
much less accept proffers of -- new wisdom
from outside sources, which help it avoid
learning until a sudden death brings a crisis
requiring a response. This had significant
consequences when COVID-19 arrived at
MTA’s doorstep.
IV. COVID-19 and MTA’s Death-
Based Model of Organizational
Learning
MTA achieved something of a proactive
disposition towards the safety of its
workforce in the face of the pandemic crisis,
but the route was indirect. The
organizations’ initial approach manifested
its well-worn institutional disposition,
marked by failure to search for new sorts of
information, disinclination to expose itself to
research scrutiny, and defense of its status
quo.
MTA responds to COVID-19, winter-spring,
2020
In January, 2020, MTA and TWU officials
met to discuss the looming potential for
pandemic to develop in New York City.
Reportedly, a single physician participated
and advised the use of masks, but only for
those who had been infected (Goldbaum,
2020). Transit workers wearing personal
masks as the crisis began to unfold in New
York were told to remove them because they
are not allowed as part of the MTA’s official
uniforms, demonstrating how organizational
perception in unusual circumstance draws
from traditions formed in the mundane. As
an agency long oriented to perceive
workers’ activities, concerns and even
deaths in relationship to formal rules, MTA
determined what was allowable in an
emerging global pandemic by consulting
rules proscribing workers’ pants, shirts, and
boots.
The MTA memo which justified a no-
masks policy cited the most general
guidelines issued by the CDC (Warren et al.,
2020). While the CDC’s mask-related
advice of the moment was widely
acknowledged to be better rooted in politics
than epidemiology, MTA’s chief safety
officer declared that its mask policy would
be reevaluated only in light of new federal
or state guidelines (Offenhartz, 2020).
Effectively, MTA – with a workforce of
seventy thousand public employees and host
to nine or so million passengers on an
average pre-pandemic weekday - declared it
would passively consume the most general
public health guidance, not actively pursue
wisdom that might speak to the unique
challenges of COVID-19 in New York’s
mass transit settings and workspaces.
11
Under pressure from TWU, however,
MTA’s ban on masks was reversed in
increments, first allowing workers to use
personal protective equipment of their own
(Fama, 2020), and, just days before the CDC
made long-expected modifications to its
mask recommendations, MTA began to
distribute them to workers (White, 2020;
Rubinstein, 2020). Yet, while a standing
MTA policy anticipating an influenza
pandemic mandated a six-week stockpile of
N-95 masks at least for some subway and
bus job titles (Pendegrast, 2012), the policy
had not been adequately heeded, and the
MTA faced the same scarcities as the
broader public obtaining sufficient or high-
quality masks as the pandemic spread
(Metropolitan Transportation Authority,
2020).
While MTA was still prohibiting the use
of masks, its workers were dying - almost
exclusively from MTA’s subway and bus
divisions. In the same week that MTA began
distributing masks to employees, its
employee death toll totaled at least 41
(Goldbaum, 2020). A subway conductor’s
op-ed – authored when surface contact was
suspected as a major vector for the virus –
described a lack of running water in her
crew room, and the ration of three single-use
sanitary wipes expected to last for several
shifts (Gidla, 2020). By late March 2020, the
deep impact of the pandemic on MTA
workers – apparently far greater than any
comparable public workforce in the New
York region – became a recurrent theme in
the mass media.
MTA leadership responded to criticism
that it had been slow to act for its employees
by pointing instead to global and national
public health agencies and rejecting that it
might have a wider role to play in critically
evaluating appropriate safety measures. The
MTA’s CEO argued in a public letter
directed agaisnt media criticism that, “[t]he
only ‘sluggish’ response has been on part of
the World Health Organization and CDC,
whose guidelines agaisnt widespread use of
masks the MTA (a transportation
organization, not a medical provider)
initially followed but has since disregarded”
(Foye, 2020, emphasis added). By late May,
2020, MTA’s death toll had risen to include
83 employees from divisions operating
subways, 40 from those operating busses,
and several from other MTA entities
(Martinez, 2020).
The MTA’s Limited Probe for Useful
Knowledge
MTA’s disposition towards
independent researchers with potential
insight repeated in times of COVID-19. I
found no evidence the organization sought
any advice from scientists with mass-transit
research experience at all, including what is
likely the sole research team to have
modelled the movement of airborne threat
agents specifically in the New York
subway’s chaotic atmospheres (Richmond-
Bryant & Wittig, 2009) who might have
offered vital insights, or directed the MTA
to appropriate expertise.4
Relatedly, when an epidemiologist who
has led a longstanding subway-focused
research program (e.g. Gershon et al., 2008)
undertook to study why COVID-19 was
having such a powerful toll on transit
workers, the scholar found a willing partner
in the TWU but not the MTA (nyu.edu,
4 7
Email correspondence, J. Richmond-Bryant, July
22, 2020; B. Wittig, Feb 19 – 22, 2021.
5
The distinction between subways and busses as
modes of transport, versus as work settings with
attendant procedures, exposures, and congregation
environments is crucial (Levy 2020).
6
Email correspondence, R. Löhner; L. Marr; D.
Milton; K. Pollitt, March 10-11, 2021.
12
2020). When the scholar announced that
one-quarter of surveyed transit workers said
they had been infected with COVID-19 at
some point, the MTA besmirched the survey
basis of the statistic (Eyewitness News,
2020), but has not granted any researcher
access to study the impacts of the virus on
transit workers on other methodological
grounds.
In August, 2020, the New York Times
published an interactive feature article
reporting that, according to high-profile
university researchers in bioaeresols,
virology, fluid dynamics, and indoor
environmental exposure, the subway may be
safer for riders than was widely believed.5
The ventilation and filtration systems of
subway cars, according to the article, can
reduce airborne viral particles at a rate much
superior to ventilation systems in office
buildings or schools (Gröndahl et al., 2020).
Yet, as I discovered through correspondence
with four of the five researchers cited in the
article,6 the Times - not MTA - had
empaneled the experts and had given them
the relevant technical details and
specifications to make their evaluations. The
newspaper produced knowledge which there
is no evidence MTA had even sought.7
In late May of 2020, the MTA announced
several initiatives to address COVID-19.
One was a research contract with
transportation consultants who, in turn,
consulted with an occupational-health
practitioner affiliated with Johns Hopkins
University. Yet the consultants were not
assigned to investigate potential ways to
Moreover, three of these experts received no
subsequent contact from the MTA to inform its
operations; the fourth could not specifically recall
any such inquiry but stopped short of stating the
MTA had not attempted to reach them.
combat the virus in New York mass transit.
Rather, they were asked to summarize
measures deployed in other global transport
contexts towards that end (mtainfo, 2020,
100:16). The short report (Gasparine et al.,
2020) offered case-studies of measures
which, the report cautioned, may be neither
appropriate nor even legal in New York.
Thus, the MTA’s sole major research
initiative in the face of COVID -19 was to
commission a highly general pamphlet
containing ideas without any particular link
to New York’s mass transit, and its material,
social or legal contexts.
The MTA’s second research-adjacent
initiative involved investigating the use of
ultraviolet light to kill COVID-19 in empty
mass transit vehicles. The MTA’s CEO
officially announced that the director of the
center for radiological research at Columbia
University’s medical school was serving as
the MTA’s “technical advisor” for the
project (mtainfo, 2020, 45:21). In the
scholar’s own words, however, the MTA
“never ‘worked with me’ in any substantive
way. There were a few phone calls, I
provided some advice over the phone, and
that was it.”8 I have not found evidence of
any other occasion in which the MTA
sought advice directly from independent
health, safety or related scientific
researchers in recent years.9
The MTA Begins to Learn from COVID-19
Deaths
The shocking death toll of the virus on
MTA employees has brought gestures
towards action. Temperature checks were
8
Email correspondence, D. Brenner, March 2, 2021.
9
In a prior decade, Rutgers researchers synergizing
and piloting “best practices” in H1N1 preparedness
training for the transport industry reportedly
consulted with the MTA on the adaptation of general
13
made mandatory at the start of work shifts in
late April, 2020. Fares were suspended on
all city busses to diminish surface and
human contact adjacent to the farebox, and
cash transactions were suspended for the
purchase of subway fares at token booths.
For a period of several months, passengers
entered busses from rear doors to give
distance to their operators.
Some of the steps taken in response to
COVID-19 deaths finally gave some indirect
relief to problems long faced by transit
workers. Over the second half of 2020, the
MTA installed plexiglass barriers in busses
to separate their operators from a passing
public (New York City Transit, 2021).
These new barriers may also offer some
protection from the longstanding, frequent
assaults on bus operators, including now
from passengers irate over mask
requirements to board a bus. Partitions once
promised by the MTA years earlier to
combat chronic assaults (AP, 2013) hadn’t
been installed on the full bus fleet, and were
inadequate to prevent, for example,
miscreants from bludgeoning a bus operator
with a padlock (McCarthy, 2020). While it
is unclear what – if any – research or
expertise informs the new design, learning
from COVID-19 may have prompted the
MTA towards inadvertent action agaisnt
longstanding assault.
The mandate for employees to wear masks
may also carry benefit in light of recurrent
findings of dangerous environmental
exposures in the subway (Chillrud et al.,
2006; Vilcassim et al., 2014) by which
transit workers are disproportionately
affected (ABC7NY, 2010). The COVID-19
guidelines for transport contexts. However, the
researchers do not report that MTA participated in
the training thus developed (Faass, Greenberg &
Lowrie, 2013).
crisis, and the legitimacy crisis brought to
the MTA by its workers’ death toll gives
workers protective equipment for airborne
hazards and may nudge the MTA to
normalize their use when – and if – the crisis
subsides. Like the case of bus partitions, a
program of action responsive to death
achieves what threats to transit workers’
quality-of-life, and length-of-life, did not.
In February, 2021, when appointments to
receive vaccines against COVID-19
remained elusive even for eligible
populations, the MTA announced that it had
procured an independent supply of vaccine
which it would make available to its
workforce. Less than a year earlier, it had
declared itself just a transit agency with no
particular healthcare role beyond following
the most general sorts of public health
guidance. The organization did learn, in this
sense, but it is long to be determined if it
will find a new way of learning.
Conclusion
Surely, we should expect for employers to
respond to the deaths of employees. Yet the
MTA’s pattern of inaction except in the face
of certain kinds of death, followed by its
encounter with a pandemic, show the
consequence - for all organizations - of a
willful ignorance of risks to workers
cultivated over decades, and of
consequences that can follow when an
organization oriented to correctives only
agaisnt precedented events encounters the
truly novel. A firmer analytic grip on how
routine patterns of organizational learning
create or diminish resources useful in new
crisis occasions might lead to an improved
politics of safety at work.
In early 2021, the MTA memorialized its
many lost employees with a video tribute - a
14
montage of photos of those lost to the virus,
captioned with their names and roles - which
solemnly plays on screens at many transport
locations (MTA, 2021). Yet that memorial,
though undoubtedly touching, risks framing
these as a tragedy which happened to the
MTA instead of a tragedy which,
significantly, happened through the MTA.
A more fitting tribute would be for the
MTA to search for gaps in its thinking about
the safety of its workforce - first for the
crevices and then for the cracks. Listening to
internal voices – like a cleaner who says
they do not feel safe with a task – is a good
step. So is allowing scrutiny from the press,
the public, and researchers to investigate
questions the MTA is not posing to itself for
one reason or other. Reversing the MTA’s
pattern of learning takes ongoing,
incremental effort; “practices” are so-named
because they require recurrent action and are
not just suddenly adopted and pasted-in to
organizational life when an emergency has
arrived. The institutional literature teaches
that organizational habits are hard to break;
combating a complacency that awaits death
to elicit change needs to become a habit of
its own before the next crisis someday
comes. Organizational safety models, such
as a “communitarian” safety culture (Hutter,
2001) or a “high-reliability organization”
(Weick & Sutcliffe, 2007) are at the ready
for experimentation. Even if they are over-
idealized, tinkering with those models surely
beats waiting for a death to figure out how
the death might have been prevented.
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Fig. 1: Example of turnstiles left as sole means of subway egress in unstaffed stations, circa mid-
2000s. Photo by author.

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Fig. 2: A fine particulate covering all surfaces of a subway station which workers were required
to clean while equipped with no more than standard dust masks. Photo by author.

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*
Noah McClain (PhD, New York University) is a sociologist and Chief Research Officer of
Emerald Studies in Media & Communications, where he also serves as Senior Editor for Science
and Technology Studies (STS). His interests span the sociologies of cities, law, inequality,
complex organizations, work, policing, and security, and how these intersect with technologies
high and low. He has been on the faculties of Illinois Tech, and the Bard Prison Initiative, where
he was also a postdoctoral research fellow. He is a former investigator of police misconduct for
the City of New York.

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