Fiscal belt-tightening, a lack of trust in leadership, and frequent lapses in maintenance and inspections all contributed to a "questionable" approach to safety at the MBTA, an independent panel concluded in an explosive new report.

The three outside experts, tapped to review the T after a string of derailments this summer, found that many existing safety issues likely go unreported and that the MBTA does not have a culture in place that focuses enough on avoiding hazards on its core transit system.

"In almost every area we examined, deficiencies in policies, application of safety standards or industry best practices, and accountability were apparent," the safety review panel wrote. "The foundation for safety is also not obvious as the agency has not identified or adopted a comprehensive vision, mission, values or set of strategies and goals to guide the agency’s actions to achieve a safe work environment and to deliver quality service."

The problems identified by the experts are both operational and cultural in nature, from insufficient maintenance staff to a "deflated, helpless and in some cases hopeless" sentiment among leadership to employees who do not report issues because they fear retribution, according to an executive summary of the report.

"In essence, safety is not the priority at the T, but it must be," the experts wrote.

MBTA General Manager Steve Poftak told reporters Monday that the report was "sobering."

"We understood the gravity of the report and everyone understands the need to change the culture here at the T," he said.

Despite the criticisms in their report, the trio — former U.S. Secretary of Transportation Ray LaHood, former acting administrator of the Federal Transit Administration Carolyn Flowers and former New York City Transit President Carmen Bianco — stressed Monday that MBTA trains are still safe for passengers.

"The T is safe, but the T can be safer, like all points of transportation," LaHood told reporters at a Monday morning press conference.

Experts said the challenges are limited to the MBTA's subway system. The Keolis-operated commuter rail "is performing well and does not face many of the challenges that were identified on the transit side of the house," they wrote.

Gov. Charlie Baker, whose administration has come under fire for frequent service disruptions on the T, said he is "fully confident" that Poftak can oversee implementation of the group's recommendations.

"One of the reasons you do a deep dive review like this is to find out where your issues and your opportunities are and that’s exactly what this report represents," Baker told reporters. "That’s why we’re so glad to have it and so anxious to implement it."

The group conducted more than 100 interviews, hosted six focus groups and visited sites across the MBTA network as it researched the T's safety culture.

Running through every concern, the panel wrote, is frequent turnover at the top: since 2010, the MBTA has had nine different general managers.

"We believe that part of the problem with the culture that exists today is the revolving door of GMs," Bianco said at the Monday board meeting. "The longevity of a general manager is just about 13 months, hardly enough time to begin to put in place or to understand the strengths and weaknesses of the organization, to understand what's the strategy we're going to follow going forward."

In their final report released Monday, the experts made 34 recommendations and suggested 61 corrective actions, several of which are already underway. The T must also draft a written safety policy and transit safety plan by July 2020 under federal regulations.

The most important step, Flowers told the Fiscal and Management Control Board, is to ensure the MBTA is "resourced properly" so there are enough qualified employees to conduct preventative maintenance and inspections. Those regular checks have not been performed as often as necessary in recent years, and the T is also failing to collect data to support that oversight.

"You've got good people here," LaHood said. "You just don't have enough."

Several factors contribute to that gap, the panel found, including a complex and lengthy onboarding process as well as budgetary obstacles.

The report drew a clear connection between the Baker administration and FMCB's focus on reducing the persistent operating budget deficit — while simultaneously pushing major capital projects — and failures to keep precautionary measures up to speed.

"The FMCB has put a significant focus on fiscal control of operating expenses, while at the same time increasing the throughput of the capital program," authors wrote. "The outcome of this emphasis on capital delivery has been detrimental to Operations. The result is sharing of critical operational resources and stretching those resources to serve multiple functions."

Jim Evers, president-elect of the Boston Carmen's Union that represents thousands of MBTA employees, said in a statement that the findings did not come as a surprise.

"Management has made decisions that have compromised safety for far too long. The Boston Carmen’s Union has raised concerns related to MBTA safety for years, both publicly and behind closed doors — about insufficient staffing, deficiencies in leadership, and prioritizing cost savings at the expense of safety. Our concerns have consistently been ignored by MBTA management."

Former MBTA Chief Safety Officer Ron Nickle filed a federal complaint this year alleging that higher-ups at the agency attempted to "undermine" safety regulation enforcement and fired him for raising concerns.

The panel found that employees struggle to contact agency leaders and that, in some cases, they refrain from reporting issues because they fear retaliation.

Poftak told reporters Monday that the T would look into enhancing its safety hotline's confidentiality, something the panel suggested, and will work to rebuild trust.

"I want our employees to feel they can reach out to their supervisors, reach out to the control center, utilize the MBTA's safety hotline, email me," Poftak said. "There are a number of different ways we want them to reach out. We want people to feel they can report these things and that their concerns will be heard and responded to."

Another problem the panel identified is a lack of quality control or quality assurance. The T currently has "no meaningful QA/QC strategy or system in place," they wrote, but Poftak said Monday that the MBTA would add staff and resources to a new department dedicated to that task.

A common thread in several of those suggestions is funding, and while Baker renewed calls for the Legislature to approve $50 million in short-term MBTA funding he sought, he did not say whether he supports new forms of transportation revenue.

During Monday's FMCB meeting, board member Brian Lang asked if the T needed more money for its operating budget. LaHood answered, "Talk to the governor. Talk to the Legislature."

Lang then replied that the MBTA "need(s) the Legislature now."

Poftak said at Monday's board meeting that improving safety "will require additional financial resources." He told reporters that he plans next week to request a reallocation of about $10 million for safety improvements from the $127 million the Legislature appropriates to the T every year.

However, he said that transfer combined with the $50 million Baker proposed for an accelerated "flex force" will likely be enough to meet the T's needs.

"That's something we'll review in the budget process," Poftak said. "But right now, we believe we have the resources between the appropriation and the potential for this flex force money to address what's in the (safety) report."

The panel also criticized the frequency of FMCB meetings for diverting attention from the top away from crucial needs. By statute, the board is required to meet 36 times a year, many of which last for several hours with a dozen presentations or more and are "overwhelming" for staff.

Experts suggested petitioning the Legislature to lower that requirement. Baker said Monday he plans to file legislation next month that would impose a lower threshold for MBTA meetings.

MBTA officials convened the panel in June after a Red Line derailment outside JFK/UMass Station — the 24th on a passenger train since the beginning of 2015 — set off months of delays.

The T agreed to pay $35,000 per month for LaHood's work on the panel, $499 per hour for Flowers, and a total of $812.50 for Bianco and two of his staffers, according to copies of the contracts provided by an MBTA spokesman.