Violations have typically been relatively minor, and safety measures like automatic braking mean there's been little chance of the collisions or derailments the rules are intended to prevent.
But the agency has concluded operators are too reliant on the backup measures, while managers have failed to follow up on violations after the fact.
TriMet said that there's only been one collision resulting from a rule violation of this type, when a MAX train entered a Hillsboro rail crossing in February 2013 before the arm gates were fully down and struck a car. No one was seriously injured in the incident.
Still, the agency plans to implement all 41 recommendations from the audit, which was conducted by a former investigator from the National Transportation Safety Board. Doug Kelsey, TriMet's chief operating officer, presented the findings to the agency's governing board on Wednesday.
"We want to do this now, before we have a big incident," Kelsey said. "The other side is a very different phenomenon. This way, we get to shape it on our terms."
Kelsey, who arrived at TriMet a year ago, said he ordered the audit earlier in 2016 after reviewing logs of safety rule violations and observing them as a MAX rider.
The most frequent rule violations include errors such as speeding, leaving a station before getting a "green light" signal or following too closely behind another train. On a per-mile basis, error rates at TriMet exceeded other transit agencies with light-rail systems.
The audit was conducted by a team led by Michael T. Flanigon, a former National Transportation Safety Board investigator who in that role oversaw teams that assessed rail transit crashes nationwide.
It found that MAX operators, as well as their supervisors, have come to view safety violations as normal part of operation. Follow-up with operators is inconsistent and slow, while there's little formal supervision in the field.
Flanigon's team also found the agency wasn't regularly investigating recorded rule violations. Supervisors, he said, are overwhelmed by the number of incidents. As a result, some investigations fall to the wayside until after data records had been purged or it was too late to discipline the operator responsible.
"A number of these cases didn't get investigated at all," Flanigon said.
It's not clear why the rate of safety rule violations continues to increase.
But the MAX system has grown in size and complexity over the 10 years examined in the audit. And nearly a third of TriMet's MAX operators have been on the job for less than two years, in part because of the opening of the Orange Line in September 2015.
Kelsey said TriMet plans to adjust its training regimen to put more emphasis on safety. It's considering purchasing a MAX train simulator, similar to one it introduced for training bus drivers earlier this year.
It will also consider lengthening the probation period for MAX operators, who under TriMet's labor contract must work as bus drivers first. It could also increase penalties for rule violations, which Kelsey described as more lenient than other agencies. (Those changes would require negotiating changes to the contract with its union, Amalgamated Transit Union Local 757.)
And Kelsey said the agency will increase oversight when violations do occur. The rail operations manager placed on leave will be replaced, Kelsey said.
In the meantime, Flanigon said the light-rail system is safe.
"There's a lot of safeguards built into a system like this," he said. "All these violations chip away at that, but they don't defeat it. Statistically, transit is very safe, and TriMet is no exception."
-- Elliot Njus
http://www.oregonlive.com/commuting/index.ssf/2016/12/trimet_audit_finds_max_safety.html
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