Almost two months before a Massachusetts man allegedly killed seven people in a crash, a Registry of Motor Vehicles employee opened an alert from Connecticut warning that the driver had refused a chemical test during a traffic stop.
The electronic notification should have triggered the suspension of Volodymyr Zhukovskyy's Massachusetts commercial license, but the RMV employee took no action and closed out of his driving record after only seven seconds.
The employee would later tell investigators that he had never before performed such a task and was not trained to do so.
His inaction was one of several missed opportunities and "line of defense" failures leading up to the June 21 crash that killed seven motorcyclists in New Hampshire, auditors said in a Friday report examining the crisis at the RMV.
Interim findings from national audit firm Grant Thornton, which the Department of Transportation released publicly Friday, built off of what internal reviews and testimony before lawmakers already revealed to be a pattern of system management failures at the RMV.
The newest report, however, outlines in greater detail how multiple contemporaneous breakdowns across different departments within the RMV allowed Zhukovskyy to keep his license and a years-long backlog of other notices to build up unattended.
"The risks that the RMV faces in the ordinary course of business are diverse, consequential, and not only limited to safety," auditors wrote.
As RMV officials have detailed in their own explanations since the crash, the Registry had for years failed to handle both electronic and printed notices from other states about Massachusetts drivers who committed a range of violations in other jurisdictions.
The electronic notification alerting the RMV about Zhukovskyy's arrest on OUI charges in Connecticut earlier that month and his refusal to take a chemical test came on May 29. The message, categorized as requiring an employee to "add conviction," was marked for action at a later date, so it was automatically sorted into a queue for manual review before any license suspension could occur.
Within the RMV, the SPEX department had been responsible for handling such items since the ATLAS software was launched in March 2018. But — per information released publicly for the first time with Friday's report — it took workers about 10 months before they began to address electronic notices of violations in other states, and Susan Crispin, the unit's leader, believed that some of them had been categorized in error.
She reached out to Fast Enterprises, the vendor who designed the software, in March to request a fix, but none came before the crash.
"Ms. Crispin appears to have been aware that even if certain items may have been erroneously labeled as items requiring posting on drivers' records, other items in that queue were not being erroneously labeled," auditors wrote. "As such, Ms. Crispin and the SPEX unit should have been completing any items in the manual intervention queue pending any new guidance from FAST regarding a possible system configuration change."
That, Grant Thornton wrote, was the first missed opportunity. The second came on the day that Connecticut alerted the RMV itself.
Michael Norohna, an employee in the SPEX department, ran a search for outstanding items in the manual queue and then clicked on the then-new one concerning Zhukovskyy, pulling up his driving record. Seven seconds later, Norohna closed the window without making any changes.
Norohna told auditors that, while he does not know why he clicked on Zhukovskyy's record, he had never been trained on processing such cases and would not have known what to do with it.
"Grant Thornton has not seen any information to indicate that Mr. Norohna brought this work item to the attention of his supervisor, Ms. Crispin, or to anyone else who could have evaluated whether the out-of-state violation should have been posted to Mr. Zhukovskyy's record," the report stated.
The RMV also repeatedly failed to handle printed warnings from other states, as officials previously discussed, the auditors confirmed.
While former Registrar Erin Deveney — who resigned four days after the crash — told lawmakers that she was not aware of any formal protocol for processing those alerts until 2016, auditors found several past employees in the Driver Control Unit (DCU) who said they handled at least egregious violations between 2008 and 2014.
Confusion grew in the years that followed.
When Keith Constantino was hired as the new DCU head in 2015, he did not understand the department was responsible for handling out-of-state notifications. He soon discovered a backlog of about 10,000 that had never been addressed, and suggested assigning responsibility for them to the Merit Rating Board, which already conducted data-entry.
"It can be convincingly argued that while the MRB was a suitable candidate for data entry for these paper out-of-state notifications, it was not so for adjudicating the inevitable processing exceptions, which would require additional expertise that ultimate resided within the DCU," auditors wrote.
Despite that, Deveney signed off on the proposal and the task was transitioned. The MRB soon found itself unable to keep up with the new task, and amid challenges with the ATLAS software changeover in 2018, it essentially stopped processing notices from other states.
Auditors said the RMV failed to develop clear operational controls and risk management practices, leading to the slow-moving breakdown. Management practices and oversight, what the auditors described as the first and second lines of defense, were both "deficient," the report said.
RMV officials have frequently said that they triaged the situation in the wake of the crash and worked through the backlog of missed notices — and more than 2,400 drivers have since had their licenses suspended — but Grant Thornton on Friday raised several red flags with the response.
Five boxes of warnings from other states sent in 2017 and 2018 — which auditors believe contained an unspecified number of alcohol-related offenses — "appear to not have been included in the remediation process," Grant Thornton wrote.
Four other "egregious" notifications that may have resulted in a suspension were improperly categorized non-egregious, and more were "processed in a manner inconsistent with the remediation plan described by the RMV," the firm found.
The auditors wrote that they communicated those findings to Interim Registrar Jamey Tesler, who "provided us with an overview of the steps he is taking to address these findings."
A MassDOT spokesman said the five boxes have since been fully addressed and noted that an earlier status report indicated that additional work remained to handle alcohol-related violations.
Grant Thornton is also expected to produce a final report next month unless the firm and transportation officials agree to extend its work.
The Joint Committee on Transportation is simultaneously conducting its own investigation. Members grilled RMV workers and administration officials for more than seven hours last month, and the chairs have been pressing Transportation Secretary Stephanie Pollack to release a full swath of records they want, going as far as to hint at subpoenas.
Lawmakers have also expressed skepticism about Pollack and Gov. Charlie Baker's explanations that they did not know about the failures at the RMV until after the crash.
Auditors said that Pollack and administration officials had been involved in conversations about workflow struggles the Merit Rating Board had adjusting to the new software, but Pollack reiterated in her interview with Grant Thornton that she was not aware of the full extent of the problem.