TriMet reviews operations during Oct. 31 rainstorm: “We will be a better agency”

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TriMet is releasing its findings from its review into operations during the intense Halloween rainstorm, along with changes we are making – including steps already underway – to prevent a reoccurrence. More than two inches of rain fell in downtown Portland in just a few hours. The heavy rain, along with falling leaves and other debris, led to clogged drains, standing water and flooded streets.

The rapidly deteriorating conditions led to challenges: MAX trains had difficulty climbing the grade on SW 5th Avenue, traffic signals went out at 2nd and Morrison, cars were crossing into the restricted trackway along Interstate Avenue to get around stalled autos and water levels beneath the Morrison Bridge rose to the highest level in our 30-year history.

Our focus was to keep service operating, but the conditions required us to take a different course of action. Our findings demonstrate the need to improve communications, protocols and procedures. We have learned from this incident and are implementing changes to improve our operations during emergencies and in our daily operations.

Findings

  1. Communication from rail operators and field supervisors to the Command Center and between field operations and management was not precise regarding the fast-changing weather conditions and unprecedented rapid water accumulation.
  2. The Train Order, which advised rail operators that if there was standing water they should reduce operating speed to 10 MPH, did not provide enough guidance for operators as conditions rapidly worsened. No updated Train Order was issued to better address the worsening conditions.
  3. There is a conflict between the Train Order (slow to 10 mph) and the Rail Operation Rule Book, which states:
    “Stop train if you observe any standing or moving water above the rail.
    Notify Control and await further instructions. Do not proceed if the rail
    is not visible.”
  4. There are no specific rules or pertinent Standard Operation Procedures (SOP) that precisely describe acceptable standing water levels that trains can safely travel through. Rail operators continued to operate trains as directed by the Train Order. However, the Train Order should not replace rail operators as the eyes and ears for the Controller. They must work together to understand changes in the operating environment.
  5. Notwithstanding rules and procedures, errors in judgment and imprecise communication occurred that resulted in trains traveling through high water levels when service should have been halted.
  6. Many areas in the city were impacted by high water. As a result, the Command Center experienced long wait times on the telephone when requesting assistance in pumping of standing water.
  7. While the section of Right Of Way (ROW) beneath the Morrison Bridge is a low area, no one can recall impassable water levels in our 30-year history of operating light rail.
  8. Only one rail supervisor was assigned to the most affected area. That supervisor’s area of responsibility extended from Gateway to the CBD and up to the Expo Center.
  9. Supervisors are equipped with camera technology. Photographs could have been sent directly to Control, which would have provided greater information to Control and Field Operations management.
  10. Radio communications between operators and the Command Center are handled by controllers who cover a specific territory. Operators do not hear all of the messages delivered on the various channels.

Short-Term Action Items

  1. Provide feedback and training to staff (Operators, Controllers and Supervisors). Use current rail operator recertification training to further instruct operators of proper procedures. Review protocols and staffing levels for Field Operations. Allison/Jackson, 2 wks
  2. Review management oversight and protocols (see more details in Longer-Term Action Items below). Nelson ongoing
    Develop General Guidance for SOP 410 (and others) and Rule Book; assess the conflict between Rule Book and SOP (stopping versus slow order). Temporary guidance will be issued within a week followed by formal adoption and issuance of a revised SOP. Nelson/Van Dyke, 4 wks
  3. Define “standing water,” and “an acceptable level of standing water that is safe to operate through”. Develop protocols that change operations when water levels rise to a particular level. For example, with less than two inches of standing water, slow speeds of trains further, such as 5 mph. Van Dyke, Heilig, 2 wks
  4. Develop controller “high water” evaluation checklist. Van Dyke, 2 wks
  5. Assess communication protocols and procedures between Transportation and Maintenance of Way, and implement changes. Van Dyke/Jackson/Kindig/Blair/Allison, 2 wks
  6. Maximize flexibility in staffing deployment during an emergency event. Jackson, 2 wks
  7. Arrange for on-call emergency pumping services (contractors). Wilkinson, 2 wks
  8. Follow-up with City of Portland regarding emergency response/maintenance concerns. Jackson, 2 wks
  9. Integrate the use of technology into SOP, such as sending cell phone photos and video to the Command Center and Field Operations management to better understand operating conditions. Van Dyke, 4 wks
  10. Enlist outside expertise team to assess and conduct a review of our Operations Command Center structure to improve communications, response and incorporate industry best practices (additional detail below). Nelson/Lomax/Vinci, 2 wks
  11. Review radio communications protocols to improve information between operators and controllers. Nelson/Van Dyke, 2 wks

Longer-Term Action Items

With the help of outside expertise, the General Manager’s office will have oversight of the actions listed below. While a complete assessment is expected to take three to four months, interim reports and action items will be issued as they are completed.

  1. Assessment and review of the Operations Command Center structure, i.e. procedures, response and recovery, accountabilities, and initial and refresher training for controllers, etc.
  2. Assessment of initial and refresher training for rail operators, to include communication protocols, operating rules and procedures.
  3. Assessment of field operations – management structure, deployment, activities and duties, communication protocols, response and recovery, and accountabilities.