Yet because his repeated safety violations — in 1997, 2006, 2011, and 2013 — stretched out over many years, they did not trigger MBTA rules that require the authority to fire employees after three safety infractions in two years.

In the most serious case, in 1995, David Vazquez’s train derailed in the maintenance yard after he failed to follow instructions and operated the train on the wrong track.

The veteran Red Line driver whose train took off without him late last year had previously compiled 13 Massachusetts Bay Transportation Authority rules violations, including five related to safety, according to a report released Tuesday by the Department of Public Utilities and the T.


The new report follows an investigation into the dramatic events of Dec. 10, when Vazquez’s Red Line train rumbled through four stations and more than 5 miles without him, after he exited the train to flip a switch.

There were about 50 passengers on board.

He admitted his wrongdoing in a statement to investigators: “It was operator error, my fault,” he wrote.

According to the investigation results, Vazquez had wrapped a microphone cord from his announcement system around the throttle of his train and forgotten to set the handbrake, as the Globe reported in December.

In the report, Vazquez told officials he had rigged the switch in order to put on his gloves.

Meanwhile, because a signal failure was preventing his train from moving forward, Vazquez requested permission to set the train in “emergency bypass” mode to override the signal system. That required him to climb out and throw a toggle switch under the train. But because he had tampered with the throttle and forgotten to set the handbrake — both in violation of the T’s rules — the train accelerated to 25 miles per hour after he flipped the switch.


At one point, passengers on the driverless train used the radio to call for help.

“Hello, hello, is anybody there? I am on the train with no driver,” a passenger said, according to the report. One rider asked whether there was anything he could do; the dispatcher responded that help was on the way.

Vazquez told officials he had forgotten he had rigged the throttle because the lights were off in the cab and he had been talking to a dispatcher.

No one was injured except Vazquez, who was grazed by the train as it took off without him.

Globe Staff

The MBTA fired Vazquez, but his lawyer said he would seek to fight the ruling. The lawyer, Philip Gordon, and Vazquez did not respond to requests for comment Tuesday.

According to the report, T officials reviewed several aspects of the December incident and ruled that the train did not malfunction.

The MBTA’s general manager, Frank DePaola, said officials are taking steps to make sure nothing similar will happen again.

“While the MBTA is grateful that no one was harmed, the safety of our passengers and employees is something we take very seriously,” DePaola said in a statement.

The staff is considering closed-circuit video monitoring of drivers to observe whether they’re following the rules. New Red and Orange line cars coming online beginning in 2018 will have cabs equipped with cameras, according to officials.

In addition, the T has reminded all drivers about the rules against tampering with safety equipment and has established a new process for dealing with faulty signals.


The 73-page report on December’s incident, which includes pictures of the rigged switch, said Vazquez “violated a number of safety rules, including safety critical violations that led to the unattended train event, which MBTA Safety asserts posed a catastrophic risk to life, property and the train system.”

“MBTA has taken prompt disciplinary measures to address the egregious safety violations perpetrated by the operator,” the report said.

Vazquez had been cited for numerous violations in the past. In addition to the 1995 derailment, his other four safety violations included driving his train through areas for which he didn’t have proper clearance and changing his train’s operational settings without permission. The remaining violations of the 13 he compiled were related to attendance, courtesy, and failing to make announcements to riders.

Under its collective bargaining agreement, the MBTA can punish drivers with suspensions for their first two safety violations and can fire a driver after a third violation, spokesman Joe Pesaturo said.

If employees go two years without a violation, they are essentially able to act as if their violations had been wiped clean. In other words, the next violation would lead to a suspension, rather than to a recommendation for firing.

In all, Vazquez worked for the MBTA for 25 years after being hired in March 1987. Initially, he worked on the Red Line before moving to the Blue Line later that year. He worked on the Blue Line until resigning in 1991, and then was rehired for the Red Line in 1994.


In the aftermath of the December incident, Governor Charlie Baker and his transportation secretary, Stephanie Pollack, sought to portray the event as an unacceptable but highly unlikely anomaly that was largely caused by “operator error.”

Still, the MBTA has disciplined at least two other employees for tampering with the throttle of a train in the last 16 years. Officials also say they are looking into the possibility of redesigning the throttle, so that it would be less susceptible to tampering.

Nicole Dungca can be reached at nicole.dungca@globe.com. Follow her on Twitter @ndungca.