Former NTSB investigator conducts audit and recommends changes to improve safety
TriMet’s Chief Operating Officer Doug Kelsey today reported to the TriMet Board of Directors on a safety audit he requested on operational rule violations, or recordable safety events. Each year, MAX trains travel 9.2 million miles a year, carry 40 million trips safely and delivers this with few collisions or close calls.
Increase in recordable safety events
Earlier this year, Kelsey did a deep dive into data related to on-time performance, and has since put changes in place to move TriMet to achieve 90 percent OTP in the years ahead. A contributor to OTP is how well our operations are performing. The data revealed a growing trend of a high number of recordable safety events that demonstrated that we needed to take immediate action to improve how we manage our rail system.
Examples of an operational recordable safety event includes:
- going above the posted speed limit, even by 1 mph
- departing a station platform before the signal fully turns “green”
- entering a rail segment while another train is in the same trackway (Kelsey noted that a train automatically stops and the vehicles do not even come close to each other if a vehicle enters another train segment, demonstrating another safety feature designed into the system).
Kelsey assured the board that “MAX is a safe system with design and engineering checks and balances in place to prevent collisions, close calls, and for much of the system, override human error. We also have extensive rules and Standard Operating Procedures in place to augment those checks and balances to keep it a safe system.”
Former NTSB investigator hired for independent audit
The examples above rank as the top three incident categories in 2015. In the past year, there were nearly 1,200 recorded incidents, which have nearly doubled over the past four years with a 10-year upward trend. It’s typical that during the year leading up to and the first year of operating a new line that there is an increase in rule violations, due in part to new infrastructure and new operators. While the numbers are high, there has only been only one minor collision with a vehicle in 10 years stemming from a rule violation.
To understand the scope of the problem, TriMet hired a former National Transportation Safety Board (NTSB) investigator to conduct an independent audit. We provided Mike Flanigon with 10 years of data and asked him to focus on operational issues incidents related to: Passing a Stop Signal, overspeed events, and train doors being opened on the wrong side of the platforms or outside the platform.
We received the final audit on Monday, we welcome the outside review and agree with all of the findings. We will implement all 41 of the recommendations over a short, medium-term and long-term timeline.
At a high level, Kelsey said that the audit found that our high number of recordable safety events stem from:
- Years of being too comfortable and reliant on the redundant safety features built into the MAX system.
- Accepting these incidents as the norm and not following through on investigations, oversight and adequately managing performance.
- Infrastructure issues, such as design and placement of sensors along the rail line, a recently discovered warranty issue with defective equipment is now being replaced, and extending the recording time of the “black box” on the train to preserve data.
We have already begun implementation to improve our management, training and oversight, including making personnel and structural changes, assigning project leads with specific deliverables.
We will report monthly to the TriMet Board of Directors for the next six months, and then report quarterly. We’ll also post our progress on our website for our riders and the public can keep track as well.