There were nearly 1,200 recorded incidents over the past year. The number of rules violations has nearly doubled over the past four years, with a 10-year upward trend, the audit found.

PORTLAND TRIBUNE FILE PHOTO - Increasing rule violations by MAX operators are prompting TriMet to launch safety improvements before a serious incident happens.More than six years after a fatal bus crash in Old Town prompted TriMet officials to overhaul the agency's safety programs, a new audit documents an increasingly high number of rules violations on its MAX system.

There were nearly 1,200 recorded incidents over the past year. The number of rules violations has nearly doubled over the past four years, with a 10-year upward trend, the audit found.

The audit was released at the TriMet Board of Director's meeting on Wednesday morning. General Manager Neil McFarlane told the board the findings "clearly demonstrate we need to take immediate steps to improve how we manage our rail system." Planned improvements include offering more training for train operators — many of whom were hired during the past few years to staff the new Portland-to-Milwaukie MAX line.

In a memo to the board, McFarlane said the agency's light-rail system is a national model, safely providing 40 million trips per year because of checks and balances to prevent collisions, close calls and override human error. Research found only one minor collision with a vehicle in 10 years stemming from a rule violation.

But TriMet Chief Operating Officer Doug Kelsey says even minor violations can come together to produce a significant event.

"We need to get out front on this now because significant rail events usually have multiple causes. We have not had one of those yet, and we need to keep it that way," says Kelsey, who was hired by TriMet a year ago from the TransLink system in Vancouver, B.C.

Kelsey discovered the increasing number of rule violations, also known as "recordable safety events," while reviewing data to improve MAX's on-time performance. They include trains going even one mile over the posted speed limit, departing a station platform before the signal fully turns green, and entering a rail segment while another train is on the same trackway, even though they are designed to automatically stop before colliding.

Because of Kelsey's findings, TriMet hired former National Transportation Safety Board investigator Michael T. Flanigon last summer to lead an independent audit to review 10 years of data. It concluded that although some of the increases were related to the opening of the new Orange line, others were the result of systemwide problems: the great majority of rules violations were human errors; noncompliance has become accepted as normal; follow-up with rail operators who violate rules is uneven and often not timely; not all incidents are investigated; and there is no regular ongoing comprehensive program of tests and inspections on rail operating rule compliance.

The audit includes 41 different recommendations for addessing the problem, from reviewing train operator training to aligning discipline to industry best practices.

"TriMet operators do their jobs well, but they're dealing with a system that has five lines and two departure points. We need to give them more support, especially the newer ones," Kelsey says.

In his memo, McFarlane blames the problems on years of being too comfortable and reliant on the redundant safety features built into the MAX system and infrastructure issues, such as design and placement of sensors along the rail lines.

The audit found that TriMet employees at all levels want to improve operating rule compliance. McFarlane says the agency has already begun improving management, training and oversight, including making personnel changes, and assigning project leads with specific goals and deadlines.

There is no estimated budget for implementing the recommendations yet. McFarlane says TriMet will report on the progress being made to the board every month for the next six months, then quarterly after that. The information will also be posted on the agency's website.

The Amalgamated Transit Union, which represented TriMet operators, and the Oregon Department of Transportation, which has oversight responsibilities over TriMet, are expected to respond to the audit after its release.

This is the second time that TriMet has initiated major safety improvements since April 2010, when a bus driver making a left-hand turn in Old Town killed two people and injured three others who were legally crossing the street. The agency fired the driver and settled a lawsuit against the agency and bus manufacturer for $4 million.

Three months after the crash, TriMet appointed a Task Force on Safety and Service Excellence to improve safety to the highest levels in all areas of the agency's operations. It released a report in October with 19 recommendations, including transforming TriMet's culture to make safety a value and appointing an executive director of safety, who will be responsible for developing and implementing a comprehensive safety program.

"Every TriMet employee is charged with embracing safety as a value," the agency says on its website.

TriMet Audit

To read the enitre TriMet Rail Transportation Compliance Audit, visit:

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