METROLINK SAFETY PEER REVIEW PANEL FINAL REPORT

Transcription

1 METROLINK COMMUTER RAIL SAFETY PEER REVIEW PANEL SIX-MONTH REPORT CARD ON THE SCRRA S S PROGRESS ON THE PANEL S RECOMMENDED METROLINK ENHANCED SAFETY ACTION PLAN FINAL REPORT DECEMBER 31, 2009 Prepared for: SOUTHERN CALIFORNIA REGIONAL RAIL AUTHORITY Prepared by: METROLINK SAFETY PEER REVIEW PANEL

2 METROLINK SAFETY PEER REVIEW PANEL SIX-MONTH REPORT CARD ON THE SCRRA S PROGRESS ON THE PANEL S RECOMMENDED METROLINK ENHANCED SAFETY ACTION PLAN Final Report December 31, 2009 Prepared for the: Southern California Regional Rail Authority Prepared by the: Metrolink Safety Peer Review Panel

3 Table of Contents Introduction Safety Culture SCRRA Organizational Structure System Safety Program Plan (SSPP) Safety Performance Measurements Infrastructure Maintenance Analysis of Metrolink Short-Term Safety Projects Strategic Plan Governance Summary of Panel Recommendations APPENDIX A Matrix of SCRRA s Six-Month Progress of the Panel s Metrolink Enhanced Safety Action Plan APPENDIX B Summary of Recommendations Metrolink Enhanced Safety Action Plan APPENDIX C Metrolink Safety Peer Review Panel Members Biographies APPENDIX D Panel s Six-Month Progress Report Presentation to SCRRA Board September 11,

4 Metrolink Commuter Rail Safety Peer Review Panel Six-Month Report Card on SCRRA s Progress on the Panel s Recommended Metrolink Enhanced Safety Action Plan Introduction Metrolink Enhanced Safety Action Plan January 2009 Panel Report: The Southern California Regional Rail Authority's (SCRRA) Chairman appointed an Ad Hoc Subcommittee to establish an independent Metrolink Commuter Rail Safety Peer Review Panel (Panel) that was tasked with analyzing the Metrolink operating function through interviews and data analysis. A listing of the Panel members and their bios are included in Appendix C. A report of the Panel s observations and recommendations was published on January 5, The report included recommendations for short, medium, and long term safety and operating enhancements to the Metrolink system, which the Panel named the Metrolink Enhanced Safety Action Plan. This Plan is included in Appendix B. The Panel focused on two areas during the course of this study: 1. Metrolink s operating system, including Operating Contract Service Providers; and 2. SCRRA s organization structure and staffing levels. The Panel developed a milestone action plan organized by the eight major issues. Specific recommendations for improvement in each area were provided and categorized as to their implementation timeframes as follows: 1. Short-term within six months (February 2009 July 2009); 2. Intermediate-term - within 18 months; or 3. Long-term - within four years. Following the presentation of the report in January 2009, the SCRRA Board directed that a sixmonth progress report or report card be prepared on the Panel s recommendations. Metrolink Enhanced Safety Action Plan Six-Month Report Card: The Panel presented an initial six-month report-card to the SCRRA Board at its meeting on September 11, This presentation summarized how SCRRA was progressing in meeting the action items included in the Panel s recommended Metrolink Enhanced Safety Action Plan. A copy of the presentation is included in Appendix D. [[The Panel s final six-month report card is presented in this report. For the six-month report card, the status of each action item is categorized as: 1. Actions completed; 2. Actions being implemented or in progress; or 3. Actions that have yet to be started. 1 Metrolink Commuter Rail Safety Peer Review Panel Final Report, January 5, 2009; prepared for the Southern California Regional Rail Authority; prepared by HNTB Corporation in collaboration with the Metrolink Commuter Rail Safety Peer Review Panel members. Final Report 1

5 Note that although initial implementation may be short or medium term, each action item requires continuous follow-up or maintenance to achieve its objectives. This report is organized into the following Metrolink Enhanced Safety Action Plan sections: 1. Safety Culture 2. SCRRA Organizational Structure 3. System Safety Program Plan (SSPP) 4. Safety Performance Measures 5. Infrastructure Maintenance 6. Analysis of Metrolink Short-Term Safety Projects 7. Strategic Plan 8. Governance The six-month status for each of these areas is discussed on the following pages. The Panel has highlighted any progress that has been made since the end of the six-month period through the date of this report. A summary of the Panel s six-month report-card recommendations is included in Section 9. The following table provides a high-level summary of the progress made on the major action items presented in the Metrolink Enhanced Safety Action Plan: Actions Completed Short-Term Operational Recommendations Actions being implemented/ in progress Development of an Enhanced Safety Culture Update of System Safety Program Plan Actions yet to be started Comprehensive Organizational Assessment Update of Strategic Plan Board Governance At the beginning of each section, a chart is included which summarizes the status of each recommended action and whether the action is short-term, intermediate-term or long-term. A more detailed chart on the status of each action item for the six-month report card is presented in Appendix A. Final Report 2

6 1. Safety Culture a. Develop stronger and more unified safety culture In progress Long-term b. Develop vision for safety In progress Intermediate-term c. Develop long-term measurable objectives for safety In progress Intermediate-term d. Form a Strategic Safety Leadership Team Completed Short-term a. Develop a stronger and more unified safety culture among SCRRA and its contractors The SCRRA has made great strides in creating a stronger safety culture by: Elevating the safety department to report directly to the CEO; Forming a Strategic Safety Leadership Team and holding meetings; Establishing a risk assessment process; Creating a committee structure throughout all levels of the organization involving contractors and staff to support the safety program; and, Enhancing Metrolink s operational safety performance measurement system. As goals are adopted and tracked, this culture will become stronger. It is the Panel s observation that the SCRRA has made great strides in creating a stronger safety culture. b. Develop a vision for safety The agency needs to develop a vision for safety that describes the desired future state for each appropriate level of the organization, including a clear list of safety behaviors. c. Define long-term measurable objectives for safety The Panel recommended that SCRRA staff establish long-term, measureable objectives for enhanced safety. The safety of SCRRA passengers, employees, contractors and the general public is SCRRA s top priority. The specific goals and objectives will provide a framework to further reduce the incidence of customer, employee, rail corridor users and contractor accidents/incidents. The Strategic Safety Leadership Team (SSLT), which was developed as recommended by section 1e of the Metrolink Enhanced Safety Action Plan, is focused on developing the recommended safety vision, goals and objectives as part of Metrolink s Strategic Plan for FY 2010/11. In the short-term, the SCRRA staff has accomplished a number of measurement benchmarks reflected in this report. The Panel supports SCRRA s efforts and recommends that it move forward with its long-term safety goals development. The Panel would also like to see a methodology which applies measurements to safety goals so that safety progress can be measured and tracked for success. This approach and methodology has been discussed with SCRRA staff. For example, the list below shows examples of the types of measurements that the Panel suggests that the SCRRA consider as part of its goals development. These are not meant to be Final Report 3

7 inclusive of all goals, but illustrative of the kinds of goals and measurements that the Panel recommends that the staff and Board consider. Examples of Panel-Recommended Monthly and Annual Measurements Training Show tracking of all training for SCRRA and contractor staff on a monthly performance level. Efficiency Testing Show increases in number of efficiency tests versus previous testing; list goals by department and track the 6-months review and analysis Rule Violations - Decrease annual rule violations by X% Injuries - Decrease annual injuries by X% Audits / Inspections Show total number of performed inspections and audits on a monthly basis and track / compare this against hazard tracking documentation for effective hazard elimination and management and results. The Panel recommends that SCRRA staff present these safety goals to the SCRRA Board for discussion at its Board workshop scheduled for June, 2010, and that review and updating of the safety goals be a part of the SCRRA s annual budget process. d. Form a Strategic Safety Leadership Team The Strategic Safety Leadership Team (SSLT) has been created and has started to meet. The Panel recommends the addition of appropriate administrative and finance staff to the team, as needed, to address issues that these additional staff may be able to resolve. 2. SCRRA Organizational Structure a. Keep pace with critical operations oversight In progress Intermediate-term b. Perform organizational analysis Yet to be started Intermediate-term c. Implement immediate organizational changes Completed Short-term d. Clarify roles and responsibilities Completed Intermediate-term a. The SCRRA organization should keep pace with critical operations oversight as the complexity of Metrolink's contract and train volume increases (a. i) SCRRA has satisfied the short-term operational recommendations of the Panel. Key Executive and Operational positions have been realigned and staffed with qualified and experienced personnel. The Operations and Mechanical organizations are much stronger and better able than before to oversee the contractor's compliance with contractual requirements, the System Safety Program Plan, and observations of contractor personnel as related to operating rules compliance. Furthermore, SCRRA has not only increased the number of personnel involved in operational and safety oversight, but it has also recruited personnel with good railroad operational experience. As a result of these additions in personnel, the Panel believes that the SCRRA Operational Staff is in a much better position long-term to improve the oversight of SCRRA s contractors. Final Report 4

8 (a. ii) The Panel had recommended to management that oversight staffing requirements be evaluated as part of the service expansion / modification process. From discussions with senior management, it appears that there is agreement on this recommendation. The ability of SCRRA staff to properly manage and oversee changes in train service will be considered as part of the service expansion/modification analysis. (a. iii) The Panel further recommended that SCCRA staff perform a formal analysis of its current business and organizational model to determine if it still meets the needs of its mission and goals. The organizational analysis and evaluation should be part of the strategic planning development process the Panel recommends in Section 7. At the time of the Panel s six-month assessment, SCRRA management staff had not initiated any action on this recommendation. Circumstances related to the Connex contract have resulted in SCRRA reviewing the option of bringing train and engine (T&E) employees in-house as SCRRA employees, but this is not as a result of a formal strategic business analysis and process. The Panel understands the reasons for not addressing the T&E issue at the present time. However, the Panel also recommends that once this issue is resolved, senior management and the Board revisit the underlying issue to ensure that senior management and the Board are in agreement. As of the date of this report, the SCRRA board has approved Amtrak as the operating contractor, starting July 1, SCRRA staff is presently holding ongoing transition meetings with Amtrak. b. Perform an organizational analysis/ d. clarify roles and responsibilities The Panel s recommendation was that the Organizational Analysis be performed as part of SCRRA's review of its Strategic Plan and current business and organizational model. Senior management has performed a short-term organizational analysis to clarify roles and responsibilities and to determine additional staffing resources and skills. As noted in section a. iii. above, the Panel believes that SCRRA management still needs to undertake a more formal review of its business and organizational structure, and that it should include the Board and other stakeholders in the process review. SCRRA has changed and grown significantly since the business model was originally created in the early 1990's, so there is a clear need for a review of this model. Subsequent to the Panel s September 11, 2009, presentation to the Board, SCRRA staff asked that the Panel give more details on an organization assessment. The Panel recommends a study with the following scope of work: 1. Document the history of ridership, service levels, and the size, age and condition of the rolling stock and infrastructure over the course of Metrolink s history. 2. Identify all functions required to operate Metrolink administrative, operational and oversight functions. 3. Identify the resources dedicated to each function over Metrolink s history, in-house and through contracts. 4. Identify alternative operating and contracting models. 5. Determine optimal resource and staffing levels for each model, broken down by function. 6. Evaluate the alternatives in terms of safety, reliability, cost, and responsiveness to stakeholders. 7. Conduct a process involving the Board to select the preferred alternative. Final Report 5

9 8. Develop a program to implement the preferred alternative. Either: a. Maintain the current model, but reallocate resources among functions in line with the optimal scenario. b. Transition to a new model, developing a time line for contracting as needed and reallocate staff resources within the agency in line with that model. c. Implement immediate organizational changes (c. i) Enhance interdepartmental communications to prevent the "silo" effect. This is a long-term and continual process. In the short timeframe between the final report and the six-month assessment, it is not possible to determine if there has been any improvement in interdepartmental communications. However, based on the Panel s discussions with staff, it appears that progress is being made in this area. Senior management must continue to focus on stressing the importance of preventing the formation of silos in the organization and encourage better interdepartmental cooperation and communications. (c. ii) Examine near term infrastructure and facilities, fleet, and service enhancements for oversight staffing needs. SCRRA management has made significant progress in addressing this recommendation. Examples of changes that the Panel agrees with are: Realignment of Manager, System Safety, reporting to the CEO; The creation and staffing of an Operating Rules Management function; The separation of infrastructure maintenance and capital program functions; The creation and filling of an Assistant Director, Operations, position putting all field operational oversight under a single accountability; and, The creation of Assistant Director, Maintenance of Equipment, position putting all rolling stock maintenance under a single accountability. (c. iii to c. vi) The reassignment of Safety Department from AEO, Operating Service, to CEO, the establishment of an Operating Rules Department, the enhancement of the Contractor's field testing programs and the strengthening and defining of responsibility of field operations management has been completed and appears to be working well. (c. vii) Strengthening the role of the Qualified Mechanical Person (QMP) function remains an open issue and an area of concern for the Panel. The Panel requested more information on the process and controls for assuring the QMP role in authorizing train movement and that the dispatchers are aware of the same. The Panel requested that the process being followed be formalized according to its review. A more detailed discussion on this issue is found under Action Plan #5, Infrastructure Maintenance. (c. viii) SCRRA management has filled the key positions of Director of Operations and Manager of Operations, as recommended by the Panel. As noted above, the Panel agrees with the reorganization of the Operations Department. Final Report 6

10 3. System Safety Program Plan (SSPP) a. Redraft the SSPP In progress Intermediate-term b. Develop organization-wide risk assessment process In progress Intermediate-term a. Redraft the SSPP The review and redrafting of the System Safety Program Plan (SSPP) is underway. According to the Manager, System Safety, management has created a Strategic Safety Leadership Team structure that involves all organizational layers (both SCRRA and contractors). The senior executive SCRRA staff, which includes the CEO and his immediate staff, will take the lead in the redrafting of the SSPP. The FRA is in the process of developing a rule on the specifications of a System Safety Program Plan which includes a hazard analysis process. The panel recommends that a Metrolink representative participate on the RSAC panel to ensure that a modification to its SSPP is in line with the draft rule. At a minimum, the Strategic Safety Leadership Team should review the FRA draft rule for guidance. b. Develop organization-wide risk assessment process The Risk Assessment Process is underway as part of the Hazard Resolution Committee (HRC) process. In discussions with senior management, it appears that this process is working well. The Panel recommends that the Strategic Safety Leadership Team periodically review the work of the HRC and that, once the ability to analyze the data and trends collected from the Operating Efficiency Testing Program is available, the HRC use this data to identify potential risks. 4. Safety Performance Measurements a. Enhance Operations Testing Plan In progress Short-term b. Define responsibility and analyze Efficiency In progress Short-term Testing i. Define responsibility for Efficiency Testing Completed Short-term ii. Analyze tests to ensure safety critical rules are being tested In progress Short-term c. Acquire an Electronic Efficiency Testing System In progress Short-term d. Increase observations of engineers, conductors, others Completed Short-term e. Review safety critical employee training Completed Short-term f. Assess impact of operating contract s liquidated damages provisions In progress Intermediate-term g. Establish goals for observations/ analysis In progress Intermediate-term Final Report 7

11 a. Enhance the Operations Testing Plan According to the documents submitted to the Panel, Metrolink has updated its Operational Testing Program effective August 1, The updated plan addresses all the key areas required of an effective plan. The revised plan contains specific requirements for testing officer qualifications, as required by revised 49 CFR 217, which went into effect January 1, The plan goes beyond the requirements of 49CFR 217 by requiring a monthly testing plan based on incidents, injuries and rules violations. SCRRA should proceed with the actions currently in progress, including performing a Rules Hazard Analyses, requiring a quarterly review of efficiency testing results for every safety critical position, adopting Amtrak s event review program and requiring crews to record safety briefing information on a daily basis or before each trip. b. Define responsibility for Efficiency Testing; analyze tests to ensure safety critical rules are being tested (i.) Define responsibility for Efficiency Testing SCRRA has hired a fully CFR/GCOR qualified individual and assigned this position with responsibility for the operational testing program and efficiency testing. SCRRA has assigned SCRRA personnel to be responsible for the efficiency testing compliance of contractors. These individuals will manage contract department operational testing plans. The review officer responsibilities are broken into four key areas Transportation (T&E), Dispatch, Mechanical, and Engineering with a subject matter expert (SME) identified to oversee compliance for each department. The Operating Manager of Rules has been assigned responsibility for oversight of the entire program. This is a model approach to provide SME oversight to ensure compliance with operational testing plans. A flow chart of the SCRRA operational testing model, as presented in Figure 1, notes the responsibilities for the divisions and system. The Operational testing plan has been updated to agree with this model and will become effective January 1, SCRRA has identified safety critical rules for required efficiency testing in SOP #1-Operations- Train Operating Rules. In addition, it has added a testing requirement for testing alertness in the audit area of fatigue, including testing the effect of circadian rhythm. In SOP #2 and #4, it has identified and requires testing in the CFR required safety critical areas of Drug and Alcohol use and Emergency Preparedness, respectively. The revised plans identify testing officers with clear responsibilities for efficiency testing, including joint testing with contractors and tenants who operate in Metrolink territory. (ii.) Analyze tests to ensure safety critical rules are being tested. The Panel has reviewed the CFR Part 217 six-month review documentation for Operations and Dispatch. The reviews were audited by local FRA and PUC inspectors and found to be in compliance with the regulation. The SCRRA maintenance of way and mechanical department are being audited to ensure regulatory compliance. Please note that programs have not only been reviewed to ascertain compliance with 49 CFR (e) (2), but the entire 49 CFR Part regulation. A standardized system of auditing has been initiated for monthly, six-month and annual reviews for each department. The monthly review is the foundation of the six-month and annual reviews. The review process is in place and will be used for the six-month review due January 30, Final Report 8

12 Figure 1: SCRRA/Metrolink Operations Testing Program Model Operating Rules Manager System Program Administrator (Authority for Overall Oversight of Program) Assistant Director, Operations Transportation Division Administrator (Responsible for oversight of division sub-program) Manager, Dispatching Operations Dispatch Division Administrator Rolling Stock Maintenance Manager Mechanical Division Administrator (Responsible oversight of division sub-program) MOW Compliance Officer Engineering Division Administrator (Responsible oversight of division sub-program) Contractor Plan Administrator (Responsible for sub-program implementation) Contractor Plan Administrator (Responsible for sub-program implementation) Contractor Plan Administrator (Responsible for sub-program implementation) SCRRA Field Managers (Responsible to test: Foreign Crews, Contractor testing officers and employees Contractor Field Managers (Responsible to test Contractor train and engine employees) SCRRA Chief Dispatchers (Responsible to test Train Dispatchers) SCRRA Field Managers (Responsible for oversight of Contractor testing officers) Contractor Field Managers (Responsible to test Contractor employees) SCRRA Field Managers (Responsible for oversight of Contractor testing officers) Contractor Field Managers (Responsible to test Contractor employees)

13 c. Acquire an Electronic Efficiency Testing System SCRRA has pursued acquiring an electronic system from Metro-North Railroad. Due to unforeseen contract issues between Metro-North and Metrolink, SCRRA is behind schedule. At the time of this report, the contracts have been signed, the software has been forwarded, and SCRRA is in the process of filling the databases for their use. SCRRA s Information Technology (IT) department will continue working with staff, gathering specific application requirements and user needs to support the SCRRA environment. SCRRA should continue to aggressively pursue the use of an electronic system by setting specific objectives to implement, with timelines for completion. SCRRA has made progress in establishing an electronic database, but has not provided any direction on the intent to use PDA s, rather than paper, to conduct efficiency testing. The panel strongly recommends that SCRRA consider using PDA s for this function. The report is due soon from the programmer that will set the timetable for completing the project. A project plan is on file with assigned responsibilities and implementation dates. The dates for implementation will be updated following the receipt of the programmer s report. d. Increase observations of engineers, conductors, and other safety critical employees SCRRA s Program of Operations Testing and Standard Operating Procedures for Safety Critical Functions documents clearly identify testing officer responsibilities, including a minimum number of testing in safety critical areas with timelines for completion and submission. There have been increased observations of engineers, conductors and other safety critical employees, as well as joint testing with other operators on the corridor. e. Review safety critical employee training and establish process to update training The Panel has received documentation that this action item has been completed with regards to Testing Officer Qualifications and Locomotive Engineer Certification. The Panel has received documentation that an evaluation of safety critical employee training has been completed in other key areas, such as identification of and movement of passenger equipment with en-route running gear defects. The first rules (revision) class was taught on November 24, The planned published date for the Maintenance of Way Operating Rules and Instructions document for the field staff is January 1, f. Assess impact of operating contract's liquidated damages provisions for rules violations In 2008, SCRRA modified the Liquidated Damages (LD) assessment contract language in its Equipment and Maintenance of Way contracts. The modification implies that rules violations that are caught and reported by the contractor do not result in assessment of Liquidated Damages. However, the SCRRA Operating Contract with Connex retained the LD provisions for reported violations whether by SCRRA or the contractor. The Panel questioned the provision on the basis that it might be a disincentive to reporting rule violations. While SCRRA has not modified the Connex contract, SCRRA is administratively giving Connex the opportunity to protest Liquidated Damages. In instances where Connex reports the violation and is acting appropriately in handling the violation, SCRRA can exercise its discretion to waive the Liquidated Damages. The Peer Review recommends that this sort of language be inserted into any new Operating Contract and SCRRA staff concurs. Final Report 10

14 g. Establish goals for observations and analysis with quarterly reports to Board SCRRA staff has set up monthly testing requirements for SCRRA and Contractor testing officers. These testing requirements pertain to all efficiency testing done by each department. The testing requirements are tracked and measured within the SCRRA efficiency testing plans. The Panel recommends that these requirements be reported to the SCRRA Board, Safety Operations Oversight Committee and to the Strategic Safety Leadership Team. These testing requirements and goals must be consistent with the CFR 49 Part 217 regulations and consistent with future safety objectives described in section 1c of this report. 5. Infrastructure Maintenance MAINTENANCE OF WAY a. Implement an electronic asset mgmt system In progress Intermediate-term b. Evaluate adequacy of quals testings Completed Intermediate-term VEHICLE EQUIPMENT MAINTENANCE a. Designate a site manager at CMF Completed Short-term b. Perform staffing analysis and hire, as needed Completed Intermediate-term c. Establish a Qualified Maintenance Person at MOC In progress Short-term d. Fully integrate the Mechanical Dept into systemwide Risk Management analysis In progress Intermediate-term e. Conduct a staffing analysis on increasing fleet In progress Short-term f. Conduct training for train operators on equipment troubleshooting In progress Short-term g. Improve inter-departmental coordination In progress Short-term h. Strengthen the contractor s document control policies INFRASTRUCTURE SAFETY IMPROVEMENTS a. Continue to work with local and state stakeholders to implement grade crossing safety education and enforcement b. Continue to upgrade the vehicle fleet, including CEM technology c. Re-evaluate intermediate and long-range goals to construct further grade separations d. Continue and expand SCRRA s Sealed Corridor Program to enhance overall safety and security e. Double track to improve operations and increase commuter/ freight capacity and reduce train conflicts Completed In progress In progress In progress In progress In progress Intermediate-term Long-term Long-term Long-term Long-term Long-term Final Report 11

15 Maintenance of Way a. Implement an electronic asset management system The Metrolink railroad tie inventory system is over 40 % completed. Following a complete inspection, the tie inventory will be complete. The Track Inspection project is underway as a pilot program. SCRRA Maintenance of Way (MOW) is scheduled to go paperless on January 1, System integration with Asset Works and Maintenance of Way Information System (MOWIS) software is now in progress. b. Joint inspections by SCRRA and contractors This item has been completed within the short-term timeframe. c. Evaluate the adequacy of qualifications testing This item has also been completed within the short-term timeframe. Vehicle Equipment Maintenance a. Designate a site manager at Metrolink Central Maintenance Facility (CMF) SCRRA Operations management filled the Site Manager position at the CMF. Management actually went beyond the Panel s initial recommendation; as part of their organizational analysis, SCRRA decided to create a full-time position solely for the management of vehicle (cars and locomotives) maintenance. b. Perform a staffing analysis and hire people as needed The recommended personnel changes have been addressed. c. Establish a Qualified Maintenance Person (QMP) at Metrolink Operations Center (MOC) The Qualified Maintenance Person (QMP) process has been strengthened, but the Panel is recommending additional changes to ensure efficient communications and to ensure that all necessary parties understand what communications have occurred. Metrolink s initial response was to continue to provide QMP support from the Central Maintenance Facility which is allowed under CFR part 238. However, consistent with the Peer Review recommendation and to address ongoing mechanical concerns, Metrolink will establish in January 2010 a pilot program to utilize a QMP at MOC. One QMP will work a split shift to provide direct and recorded interface with train crews experiencing mechanical difficulties. The QMP will work off a recorded telephone line and will have access to a recorded Maintenance of Way radio line. A mechanical desk has been established within the dispatch office that will record all conversations between QMPs, train crews and dispatchers. Metrolink will monitor train performance to see if this change also improves mechanical performance. Part of the pilot program for the QMP at MOC will be to refine the standard procedures of the desk and the MOC personnel. The Panel has not been shown any documentation of instructions, training or procedures for effected personnel in operation of passenger trains with en-route defects. However, regular mechanical troubleshooting meetings between Connex, Operations and the Mechanical Department have been occurring since May of Minutes of all meetings have been distributed amongst meeting participants. The Panel recommends that this area be evaluated and required training be identified and implemented for QMP s, dispatchers and Train and Engine crew for identification of and rules / procedures to follow when encountering running gear defects en-route. Final Report 12

16 d. Fully integrate the Mechanical Dept into system-wide risk management analysis This action item is in progress. e. Conduct a staffing analysis on increasing fleet This action item is in progress. f. Training for engineers on equipment troubleshooting SCRRA has begun a program of training and qualifying crews on equipment troubleshooting. Its Equipment and Operations Departments are meeting monthly to discuss equipment concerns, on time performance issues and train delays. Both departments will work jointly in developing the necessary training modules for new and leased equipment by identifying CFR 49 Part 238 and 239 safety critical training elements needed for the operating crews. g. Improve inter-departmental coordination This action item is in progress. h. Strengthen contractor's document control policies SCRRA has worked with Bombardier to revise the document control policies. The policies have been strengthened consistent with the recommendations of the Panel. Infrastructure Safety Improvements a. Grade crossing safety education; reduction in grade crossings This is part of an ongoing process. Grade crossing standards have been completed. b. Crash Energy Management SCRRA has completed the testing on the new coaches that are on order. These are state-ofthe-art in crash energy management. The delays in delivery have been addressed and the cars should be shipping by the end of In additional, 400 frangible tables have been ordered. Existing passenger vehicles will be retrofitted with this equipment as it is delivered. c. Grade separations While SCRRA does not take the lead on grade separations, it does support grade separations by cities within its member agencies. This process continues with several more grade crossing studies to begin by the end of d. Sealed Corridor (including Grade Crossings) The Flower St. crossing in Glendale is open and another four crossings are under design. There are an additional 51 crossings in the Sealed Corridor that are under construction or under study. The grade crossing program is moving forward with construction. In addition, SCRRA has released a comprehensive standard on the design and construction of grade crossings within the Metrolink system. This document will set the standard for grade crossings in many agencies. Requests for federal stimulus money have been made to further funding of additional grade crossing upgrades. e. Double tracking SCRRA is continuing to look for opportunities for funding sources to support double tracking. Currently, they are moving forward with specific double tracking projects on the Antelope Valley Line. Final Report 13

17 6. Analysis of Metrolink Short-Term Safety Projects a. Investigate, specify, procure and install inwardlooking video technology in the operating cabs b. Accelerate the implementation of PTC over the entire Metrolink system and work with BNSF, UPRR, Amtrak, FRA on cost-effective design & deployment c. Implement short-term actions of Panel s Metrolink Enhanced Safety Action Plan, which can replace the Second Set of Eyes program. d. Expedite plans to transition from the Digicon system and implement action plan for maintenance and other emergencies in the interim e. Implement medical evaluations prior to placement of contractor employees in a safety covered position at least every three years f. Participate in the Hours of Service issue with FRA s Rail Safety Advisory Committee process g. In cooperation with its operating contractor, conduct a review of SCRRA operator s Hours of Service Split Shift schedules to determine any risk factors Completed In progress Completed Completed In progress In progress In progress Short-term Long-term Short-term Short-term Intermediate-term Intermediate-term Intermediate-term a. Forward and inward-facing video cameras Metrolink has completed and activated the inward and forward-facing cameras on all its existing locomotives. The system has been activated in each of the Metrolink 52 locomotives and all 58 Crash Energy Management (CEM) Cab Cars will also have cameras equipped to view inward and forward-facing. b. PTC and replacement of dispatch software system SCRRA is proceeding expeditiously on the implementation of Positive Train Control (PTC) and its dispatch software system. Currently 52 staff members and consultants are at work developing the system. In addition, SCRRA has been participating in the FRA Rail Safety Advisory Committee (RSAC) in the development of the system. Current plans are to have the PTC implementation plan completed by April 16, Specifically, SCRRA has completed the following work: Assigned SCRRA staff and a consultant team; Issued $16M in engineering contract task orders; Established a contract and legal support team; Submitted numerous grant applications; Met with associated stakeholders, government agencies and operating railroads; and Is developing up-front, high level engineering and contract procurement documents. Final Report 14

18 SCRRA is preparing to issue a Request for Proposal for a PTC vendor/integrator. This will be the first large public PTC solicitation. SCRRA has installed Automatic Train Stop (ATS) at 49 new locations throughout the system. This was completed in October This brings the total to 105 ATS inductors on the system. The Panel believes that SCRRA has done a good job in making sure that the installation of ATS has not conflicted with expediting PTC. c. Implement short-term actions of Panel s Metrolink Enhanced Safety Action Plan which can replace the Metrolink Second Set of Eyes program. SCRRA has implemented the short-term operational actions in the Panel s Metrolink Enhanced Safety Action Plan. Since the short term safety improvements in the Panel s recommended Action Plan have been implemented, those improvements can replace the Second Set of Eyes program. Those actions completed include: Implementation of a Strategic Safety Leadership Team; Organizational Re-structuring; Enhanced Operations Testing Plan; Increased observations of safety critical employees; and Installation of in-cab video technology. It is also recommended that SCRRA perform a Hazard Analysis under its SSPP including research and analysis of accident data where there has been a Second Set of Eyes program in order to better inform its decision on this issue. d. Expedite plans to transition from the Digicon system and implement action plan for maintenance and other emergencies in the interim SCRRA has completed the plans to transition from the Digicon system. e. Triennial medical evaluations for safety covered positions refer to FRA RSAC process SCRRA is participating in Federal Railroad Administration (FRA) Railroad Safety Advisory Committee s (RSAC) Triennial Medical Evaluations issue. The FRA has provided notification that they will be presenting a Notice of Proposed Rulemaking (NPRM) on Medical Standards to the RSAC Work Group at a meeting in Washington, D.C. scheduled for December 8 and 9, SCRRA has a staff representative on the FRA Medical RSAC Working Group and is participating. SCRRA will reevaluate contractor medical qualifications efforts in 2010, based on the resulting FRA RSAC recommendations. f. FRA Hours of Service (HOS) RSAC and APTA HOS Study SCRRA has identified a qualified supervisor to attend and participate in the FRA Commuter Rail and Intercity Passenger Hours of Service (HOS) Rail Safety Advisory Committee (RSAC). SCRRA has also directed this supervisor to participate in the American Public Transportation Association (APTA) HOS working group. Current federal law (SEC. 108 of the RSIA -08) allows for the formation of an FRA RSAC to determine if existing hours of service requirements suffice to combat fatigue with Train and Engine Crew (T&E) employees of passenger railroads. The FRA RSAC has met and FRA consultants are conducting a survey/log study with T&E) employees of various commuter railroads. Final Report 15

19 An APTA work group was formed to work closely together on this high impact issue. APTA hired a fatigue consultant to advise the group. SCRRA has submitted its Metrolink schedules for fatigue analyses to the APTA work group for evaluation, as did other passenger commuter railroads. The schedule information is being evaluated by utilization of the FAST model and analyzed by a subject matter expert under contract to APTA. The FAST model is the same model utilized by the FRA. The Metrolink schedule analysis by the APTA work group has been completed with a result of 0.0% risk of fatigue for existing train and engine service assignments. The analysis included evaluation of so called swing assignments with interim release. For interim release assignments, the APTA work group wanted to determine the worst case scenario and inserted the assumption into the FAST model that employees with a scheduled rest period took no rest. With and below being an unacceptable risk for fatigue, Metrolink scheduled assignments evaluated to the following average effectiveness scores: Non-interim release schedules Interim release schedules Overall average effectiveness score These preliminary findings by APTA demonstrate that for scheduled assignments, fatigue is not an issue with commuter railroads in general and with Metrolink specifically. However, extra list assignments and working relief days do have potential for risk of fatigue, according to preliminary findings by the APTA study. The APTA work group has yet to complete their analysis in these areas. g. Review contractor's Hours of Service Split Shift schedules SCRRA has authorized the Panel to perform an Hours of Service (HOS) analysis. The Panel has engaged Dr. Patrick Sherry to perform this work and the kick-off meeting was scheduled for Friday, September 11, This meeting was deferred until after an informational conference call could be scheduled with the Connex and SCRRA attorneys with the facilitator of the Panel. That conference call was held on November 3, 2009 and the consensus was to schedule a meeting in late January, 2010, of Dr. Patrick Sherry with both Connex and labor representatives to explain the study process. Once this meeting is held, the study will proceed to the survey and data collection phase. Final Report 16

20 7. Strategic Plan a. Update Strategic Plan to include strategic operational and safety issues b. Seek buy-in at multiple levels on funding commitments, flexible budgeting processes, and rigorous project evaluation and prioritization c. Explore new technologies, wider markets and more effective operational safety strategies during the strategic planning process Yet to be started Yet to be started Yet to be started Intermediate-term Intermediate-term Intermediate-term a. Update Strategic Plan, with added emphasis on safety, flexible budgeting processes, and new technologies b. Seek buy-in at multiple levels on funding commitments, flexible budgeting processes, and rigorous project evaluation and prioritization c. Explore new technologies, wider markets and more effective operational safety strategies during the strategic planning process The development of a comprehensive Strategic Plan still needs to be initiated. The Panel recommends that the strategic planning process begin as soon as possible. The plan should Include strategic operational and safety issues; Seek buy-in at multiple levels on funding commitments, flexible budgeting processes, and rigorous project evaluation and prioritization; and Explore new technologies, wider markets, and more effective operational strategies. The Panel recommends that SCRRA should begin its strategic planning process immediately, with the understanding that there are many items to be determined. This will help SCRRA s stakeholders to have a firm understanding of how their initiatives will function in relation to SCRRA s safety culture and overall operational needs. The Panel s recommended that the SCRRA proceed with strategic planning even if several uncertainties would cause SCRRA to hold up its plan. Overall, the Panel recommends that SCRRA should be an active proponent of its vision for commuter rail service in the region rather than respondents to stakeholder activities. However, SCRRA has placed its strategic planning process on hold pending the outcomes of several efforts including the Metrolink contract operator status, member agency funding and budget plans and High Speed Rail. For example, now that the SCRRA board has approved Amtrak as the operating contractor, effective July 1, 2010, this removes one of the uncertainties that was holding back the initiation of the strategic plan. In addition, SCRRA leadership is working with its member agencies and others regarding passenger and commuter rail service in the Los Angeles area. The passage of Measure R in Los Angeles County has created opportunities with regards to rail funding. However, the current state of the economy is posing operational funding threats that may result in significant service Final Report 17

21 cuts, fare increases and significantly higher member agencies subsidies in order to sustain the safety and service expansion goals. Although Measure R was recently approved in Los Angeles County, the loss of transit funding throughout the state and the dramatic reduction in sales tax revenues are challenging all Metrolink member agencies to provide a stable funding base for Metrolink in the near and medium term. Finally, new funding for High Speed Rail (HSR), with an emphasis in the Southern California region, creates opportunities and challenges for the current and planned Metrolink service. SCRRA should take a pro-active stance in its strategic plan on HSR s relationship to Metrolink commuter rail service. The Panel also recommended that the strategic plan emphasize system safety. In the January 2009 Peer Review report, the Panel reported that that system safety was addressed in the strategic plan by a discussion of the System Safety Program Plan (SSPP). It was also addressed in the member agency capital programs regarding grade crossing safety programs and grade separation programs. SCRRA has not taken action yet to incorporate its additional safety goals and updates to the SSPP within the Strategic Plan as recommended by the Panel. System safety and the strategic plan are complementary and should be advanced at the same pace. The Strategic Planning process is a dynamic process and the plan produced from this process is a dynamic document. By proceeding with this document while simultaneously working with its member agencies on their pending actions, SCRRA will enhance the strategic position of Metrolink regarding system safety. Final Report 18

22 8. Governance a. Conduct a self-assessment of the Board s performance with particular emphasis on safety and operational oversight b. Develop Board and Board responsibilities and actions Yet to be started Yet to be started Intermediate-term Intermediate-term a. Conduct a self-assessment of Board performance on safety and operational oversight The Panel still recommends that SCRRA conduct a self-assessment of its performance with emphasis on safety and operational oversight. While the Board established a new Safety Operational Oversight Committee for briefings, reporting progress, and discussion of operational and safety issues, it has not set up a committee to assess Board performance. In additional, the rest of the Panel s recommendations on Board governance have not been initiated. The Panel recommends that the Board consider the broader issue of governance which includes: Developing and implementing long term strategies and goals oriented towards enhancing Metrolink s safety performance; and Providing the financial resources necessary to implement the agreed upon strategies and goals. b. Develop specific Board responsibilities and actions, including briefings, duties of Board members, committee structure, safety performance measures, monitoring of action plans In its report, the Panel suggested that the Board take a look at its role in governing the SCRRA and how its role interplays with the safety culture of the organization. The Panel recommended that the Board develop Board responsibilities and actions in the following areas: More rigorous briefing sessions for new Board members; Board-adopted statement of duties and responsibilities for Board members and for the Board as a whole; Board-adopted performance safety and operational performance measures; Guidelines for the addition of safety and operational staff positions as new services are introduced; Revised, more comprehensive strategic plan that addresses safety and operational issues; and Direct board involvement in developing and updating the Enhanced Safety Action Plan and monitoring its implementation. Final Report 19

23 The Panel is aware of some suggestions for Board governance which we think is a good start. Some of these are listed below. 1. The Board, at this year s annual workshop, should conduct a self-assessment of its roles and functions within the organization. Staff should be directed to prepare and administer the assessment at the workshop. 2. New and existing Board members should have an understanding of the operations of the organization, the role that they play as Board members in the development and promotion of a safety culture within the organization, and a working understanding of the SCRRA. Both new and existing board members, if they have not done so already, should be strongly encouraged to participate in the following educational events. a. Within a certain amount of time after becoming a Board member (no more than two months), new members should participate in an educational briefing about the SCRRA, including, but not limited to, how the agency operates, key safety initiatives and measures, key personnel, contractors and their relationship with the agency, key contracts the agency has with outside providers and other items believed to be critical to effective Board governance. The orientation/educational briefing should be at least one half day in length, with a curriculum to be developed by the staff and reviewed and approved by the Board, or its subcommittee. b. Within a four-month period of assuming Board membership, each Director should arrange to visit the Metrolink Operations Center for a briefing on its operation and role within the organization. c. Within the same four-month period, each new Director should also visit the Central Maintenance Facility (or upon its opening, the new Eastern Maintenance Facility), to see how the trains are serviced and maintained. d. Finally, within a six-month timeframe, each new Director should be required to complete a high-rail tour of a portion of its rail line, as determined by maintenance staff, to bring to their attention any unique or other operating areas that staff believes they should be aware of. The Panel believes that these are good initial steps to have the Board Members familiarized with Metrolink, its service, and some of its facilities. However, the recommendations do not address the longer term issue of governance; and that is the Board responsibility in supporting and requiring management to develop longer term strategic plans, goals and measurements to both guide management and to hold them accountable for their performance. This is particularly important when there is the potential for conflict between SCRRA staff and the staffs of the member agencies that the Board Members represent. The Panel also recommended that the Board establish committees for briefings, reporting progress and discussion of Operational and Safety issues. The Panel recommends that the board hold a facilitated board workshop on governance to implement the Panel s recommendations on board governance. Final Report 20

24 9. Summary of Panel Recommendations The Panel commends the SCRRA for completing and having in progress many of the short term actions in the Panel s recommended Metrolink Enhanced Safety Action Plan. The Panel would now like to see SCRRA focus on the intermediate and longer term actions where the agency has not yet started. These include setting long term, measurable safety goals, performing an organizational assessment, updating the Strategic Plan and improving Board governance. Specifically, the Panel recommends that the SCRRA take the following actions in these four areas. Develop Long-Term, Measureable Safety Goals (Action Item 1c) The Panel recommends that the Board authorize SCRRA staff to develop and the Board to approve long term, measurable safety goals. The Panel recommends that these goals be presented to the SCRRA Board for discussion at least by the time of the Board workshop scheduled for June, Perform an Organizational Assessment (Action Item 3b) The Panel recommends that the Board authorize SCRRA staff to perform an organizational assessment study with the following scope: 1. Document the history of ridership, service levels, and the size, age and condition of the rolling stock fleet, the scope infrastructure over the course of Metrolink s history. 2. Identify all functions required to operate Metrolink administrative, operational and oversight functions 3. Identify the resources dedicated to each function, both in-house and through contracts, over Metrolink s history 4. Identify alternative operating and contracting models. 5. Determine optimal resource and staffing levels for each model, broken down by function. 6. Evaluate the alternatives in terms of safety, reliability, cost, and responsiveness to stakeholders. 7. Conduct a process involving the Board to select the preferred alternative. 8. Develop a program to implement the preferred alternative. Either: a. Maintain the current model, but reallocate resources among functions in line with the optimal scenario. b. Transition to a new model, developing a time line for contracting as needed and reallocate staff resources within the agency in line with that model. Update the SCRRA Strategic Plan (Action Item 7) The Plan recommends that the Board direct SCRRA staff to update the SCRRA Strategic Plan, especially in light of the Metrolink Enhanced Safety Action Plan and the Board s recent decision to change service providers. The plan should: Final Report 21

25 1. Include strategic operational and safety issues; 2. Seek buy-in at multiple levels on funding commitments, flexible budgeting processes, and rigorous project evaluation and prioritization; and 3. Explore new technologies, wider markets, and more effective operational strategies. Implement Panel s Board Governance Recommendations (Action Item 8) The Panel recommends that the Board direct the SCRRA Executive Officer to develop and hold a facilitated Board workshop to implement the Panel s recommendations on Board governance. This workshop should develop policies and actions for: 1. More rigorous briefing sessions for new Board members; 2. Board-adopted statement of duties and responsibilities for Board members and for the Board as a whole; 3. Board-adopted safety and operational performance measures; 4. Guidelines for the addition of safety and operational staff positions as new services are introduced; 5. Revised, more comprehensive strategic plan that addresses safety and operational issues; and 6. Direct Board involvement in developing and updating the Metrolink Enhanced Safety Action Plan and monitoring its implementation. If the Board believes that it is advantageous and value-added, the Panel or experts within the Panel could serve as an advisor on each of the four areas listed above. The Panel could also serve a continuing role to monitor the Panel s recommended Metrolink Enhanced Safety Action Plan. Appendices Appendix A: Appendix B: Appendix C: Appendix D: 6-month Report Card Matrix The Metrolink Enhanced Safety Action Plan Panel Member Biographies The Panel s September 11, 2009 presentation to the SCRRA Board on SCRRA s six-month progress in accomplishing the Metrolink Enhanced Safety Action Plan. Final Report 22

26 APPENDIX A Matrix of SCRRA s Six-Month Progress of the Panel s Metrolink Enhanced Safety Action Plan Final Report 23

27

28 APPENDIX B Metrolink Enhanced Safety Action Plan Included in Metrolink Safety Peer Review Panel Report, dated January 5, 2009 Final Report 24

29 Metrolink Enhanced Safety Action Plan Issue 1. Safety Culture 2. SCRRA Organizational Structure Summary of Recommendations Metrolink Enhanced Safety Action Plan a. Develop a stronger and more unified safety culture at SCRRA (including its contractors) leading to operational excellence, increased ridership and revenues, lower operating costs, stronger employee and public relations, and fewer accidents. b. Develop a vision for safety that describes the desired future state for each appropriate level of the organization, including a clear list of safety behaviors. c. Define long-term, measurable objectives for safety. Progress toward meeting these objectives should be part SCRRA s management process for annual budgeting and performance evaluation. d. Revise Metrolink s System Safety Program Plan (SSPP) to reflect the output of the work on the strategic role, vision, and goals. e. Form a Strategic Safety Leadership Team. This team will lead the culture development effort, provide leadership for SCRRA, and be accountable for the effective execution and integration of the SSPP. The Strategic Safety Leadership Team should be led by the CEO and include the participation of all SCRRA Senior Managers with input from SCRRA s major contractors. a. The SCRRA organization should keep pace with critical operations oversight as the complexity of the Metrolink contracting environment and the volume of train operations have increased. i. Compare the historical growth in the volume of train operations with the trends in the numbers and skills of oversight personnel at SCRRA and make adjustments to maintain critical operations oversight. ii. Require increased contract oversight and SCRRA staff when there are increases in train service, fleet size and infrastructure. iii. Undertake an analysis of SCRRA s current business and organizational model to determine if it still meets the needs of its mission. b. Perform a detailed Organizational Analysis that identifies all responsibilities and tasks associated with system safety. Then determine, in priority order, any omissions in the current structure and whether the responsibilities are sited appropriately. i. Emphasize SCRRA s operations organization and contractor oversight. ii. Require increased contract oversight and SCRRA staff when there are increases in train service, fleet size and infrastructure. iii. Review the distribution of resources for all operational functions and determine whether staffing levels appropriately cover necessary duties to implement necessary safety programs. iv. Empower the Assistant Executive Officer, Operating Services to transfer resources from one area to another within his or her span of control in order to address the most safety critical positions and trends. v. Consider the annual budget process an opportunity to reallocate staff among functions on a routine basis to determine if the staffing levels and skills are sufficient to manage an operating commuter railroad. Final Report 25

30 Issue Summary of Recommendations Metrolink Enhanced Safety Action Plan c. Implement Immediate Organizational Changes: i. Enhance interdepartmental communication to prevent the silo effect. ii. Examine near term infrastructure and facilities, fleet, and service enhancements for oversight staffing needs. iii. Re-assign the Safety and Security Department from the SCRRA Assistant Executive Officer, Operating Services to the SCRRA Chief Executive Officer (CEO). iv. Establish an Operating Rules Department reporting to the Assistant Executive Officer, Operating Services. v. Enhance the contractors Field Testing Programs consistent with SCRRA s restructured Operating Rules Program. vi. Define the overall responsibility for field operations management. vii. Strengthen the Qualified Mechanical Person (QMP) function whether in the Metrolink Operations Center (MOC) or elsewhere to better manage and respond to real time locomotive and rail car failures. viii. Fill key positions in the SCRRA Operations Department, specifically: (a) Director of Operations; and (b) Manager of Operations. d. Clarify Roles and Responsibilities i. Review the operating rules, standard operating procedures and contracts to identify provisions affecting or affected by observations of the organizational analysis. ii. Direct the Transportation contractor to: (a) Perform all required operational testing in compliance with the SCRRA approved operational testing plan. (b) Establish a schedule of tests and training to meet all required criteria. (c) Report regularly on actual versus scheduled training and testing. Identify failures and act promptly to correct such deficiencies. iii. Direct the SCRRA Operations staff to audit contractor testing programs as the primary oversight function. iv. Provide training for en-route vehicle troubleshooting for train and engine crews. 3. System Safety Program Plan (SSPP) a. Redraft the SSPP based on the conclusions of the Organizational Analysis, with particular attention to: i. The oversight functions for in-house and contractor operations. ii. All essential components and the Agency s functions, which must be accountable in the System Safety Program from the Board of Directors through the CEO to all departments. iii. Contracts and SCRRA policies and procedures, which must be conformed to the updated SSPP and related Standard Operating Final Report 26

31 Issue 4. Safety Performance Measurements 5. Infrastructure and Maintenance Summary of Recommendations Metrolink Enhanced Safety Action Plan Procedures. iv. Continued conformance with APTA standards and maintained as a control document. b. Develop a broadened organization-wide hazard assessment process and incorporate that process into the updated SSPP. a. Enhance the Operations Testing Plan i. Produce an Efficiency Testing Plan ii. Perform a signal hazard analysis: iii. Require a quarterly review of efficiency testing results for every safety critical position; iv. Adopt Amtrak s event review program; and v. Require crews to record safety briefing information on a daily basis or before each trip. b. Define responsibility for and analyze Efficiency Tests. i. Define responsibility for Efficiency Tests. ii. Analyze tests to ensure that safety critical rules are being observed. c. Increase observations of all Engineers, Conductors, and other safety critical employees with primary focus on safety critical operating rules. d. Review safety critical employee training and establish a process to update training. e. Assess impact of operating contract s liquidated damages provisions for rules violations to determine any real or perceived conflicts of interest. f. Acquire an Electronic Efficiency Testing System to manage data collection and analysis of observation and testing data. g. Establish goals for observations and analysis and report results quarterly to the SCRRA Board. Maintenance of Way (MOW) a. Implement an electronic right-of-way asset management system that identifies trends and assists in hazard analysis b. Require joint inspections by Metrolink staff and the contractor, which act as a check and balance in the system. c. Evaluate the adequacy of qualifications testing. Rail Vehicle Equipment Maintenance a. Designate a site manager with clear responsibility over all aspects of operations within the CMF. b. Perform a staffing analysis and hire additional personnel as needed. c. Establish a QMP for the dispatching center. d. Fully integrate the Mechanical Department into the system-wide risk management analysis effort. e. Conduct a staffing analysis of the impact of increasing the fleet prior to its Final Report 27

32 Issue 6. Analysis of Metrolink Short Term Safety Projects a. In-cab video recording b. ATS/PTC c. Second set of eyes d. DigiCon Dispatch Issue e. Annual Medical & Psychological Evaluations f. & g, Railroad Industry Hours of Service/Split Shift Issue Summary of Recommendations Metrolink Enhanced Safety Action Plan introduction. f. Conduct training for train operators on equipment troubleshooting. g. Improve inter-departmental coordination. h. Strengthen the contractor s document control policies. Infrastructure Safety Improvements a. Grade Crossing Safety: Continue to work with local and state stakeholders to implement grade crossing safety education and enforcement, and reduce grade crossings. b. Crash Energy Management (CEM): Continue to upgrade the vehicles fleet, including CEM technology. c. Grade Separations: Reevaluate intermediate and long range goals to construct further grade separations. d. Sealed Corridor: Continue with and expand SCRRA s Sealed Corridor Program to enhance overall corridor safety and security. e. Double Tracking Program: Double track to improve operations and increase commuter/freight capacity and reduce train conflicts. a. Investigate, specify, procure, and install inward looking video technology in the operating cabs of SCRRA passenger equipment. Technology should include a software application for facilitating real time observations. b. Accelerate the implementation of Positive Train Control (PTC) over the entire Metrolink System and work with BNSF, UPRR, Amtrak, and FRA on cost-effective design and deployment. i. The implementation of ATS should not be a priority over or take resources away from the implementation of a PTC system. c. If the short term safety improvements in the Panel s recommended Metrolink Enhanced Safety Action Plan are implemented, then those improvements will replace the Second set of eyes. Those actions include: i. Strategic Safety Leadership Team; ii. Organizational Re-structuring; iii. Enhanced Operations Testing Plan; iv. Increased observations of safety critical employees; and v. Installation of in-cab video technology. It is also recommend that SCRRA perform a Hazard Analysis under its SSPP including research and analysis of accident data where there has been a second set of eyes to better inform its decision on this issue. d. Expedite plans to transition from the DigiCon system and develop action plan for maintenance and other emergencies in the interim. e. Implement medical evaluations prior to placement of contractor employees in a safety covered position and at least every three years. This recommendation is consistent with the preliminary studies by the FRA Railroad Safety Advisory Committee (RSAC). The Panel did not find any evidence that psychological evaluations for Final Report 28

33 Issue Summary of Recommendations Metrolink Enhanced Safety Action Plan train crews would reduce exposure to risk for Metrolink. However the Panel does recommend that SCRRA perform research in this area to determine if psychological exams would increase safety on its Metrolink system. f. Since SCRRA s Transportation contractor uses split shift assignments in its train and engine crew schedules, it is the Panel s recommendation that SCRRA participate actively on the Hours of Service issue as part of the FRA RSAC process. g. The Panel also recommends that SCRRA, in cooperation with its operating contractor, conduct a review of its contractor s Hours of Service Split Shift schedules for their train and engine crews and determine if fatigue is a factor in the use of Split Shifts. In addition, SCRRA should evaluate whether any relevant rules and their particular application require any short term measures pending the results of the FRA RSAC process regarding Hours of Service. 7. Strategic Plan a. Update the strategic plan to include strategic operational and safety issues. b. Seek buy-in at multiple levels (staff, board, Member Agencies), including funding commitments, more flexible budgeting processes, and more rigorous project evaluation and prioritization. c. Maintain through the strategic planning process a continuous exploration and evaluation of new technologies, wider markets, and more effective operational safety strategies during the strategic planning process. 8. Governance a. Conduct a self-assessment of Board performance with particular emphasis on safety and operational oversight. b. Develop a more explicit definition of Board and Board member responsibilities and actions that might include: i. More rigorous briefing sessions for new Board members; ii. Board-adopted statement of duties and responsibilities for Board members and for the Board as a whole; iii. Establishment of new or rechartered standing subcommittees with added focus on operations and safety oversight and possibly, a subcommittee devoted to assessing Board performance; iv. Board-adopted performance safety and operational performance measures, and guidelines for the addition of safety and operational staff positions as new services are introduced; v. Revised, more comprehensive strategic plan for the agency that addresses safety and operational issues; and vi. Direct board involvement in developing/updating the Panel s recommended Enhanced Safety Action Plan and monitoring its implementation. Final Report 29

34 APPENDIX C Metrolink Safety Peer Review Panel Members Biographies Final Report 30

35 Metrolink Commuter Rail Safety Peer Review Panel Members Panel Facilitator Linda Bohlinger Vice President, National Director of Management Consulting HNTB Corporation Transportation Agency Management, Including Commuter Rail; Contract Systems and Contracts Oversight Linda has over 30 years experience in the transportation industry. As Vice President of HNTB, she is responsible for leading HNTB s national Management Consulting practice. Her previous public sector experience was as the Executive Director of South Florida s Tri-County Commuter Rail Authority (Tri-Rail), now named the South Florida Regional Transportation Authority (Tri-Rail). Tri-Rail is a 71-mile commuter rail system that runs from Miami to Ft. Lauderdale to Palm Beach. Similar to Metrolink, Tri-Rail contracts out its operations and maintenance and has multiple freight and Amtrak users on its rail corridor. Previous to running the Tri-Rail system, Linda had fifteen-year tenure with the Los Angeles County Metropolitan Transportation Authority (Metro), where she held positions of CEO, Deputy CEO and planning executive officer. She also served as Deputy Director for the California Transportation Commission in Sacramento, CA. Linda helped start up Metrolink in the early '90's when she worked for Metro. She helped purchase the railroad right-of-way, negotiated all the funding agreements with the five counties and secured the initial grants. Linda has a Master of Public Administration from the University of Southern California. Linda is active in the transportation industry and is currently the Vice Chair for Research and Technology for the American Public Transportation Association (APTA) and serves on the APTA Executive Committee. Lead Panel Members Don Sepulveda Senior Project Manager HNTB Corporation Track, Signals and Vehicles Inspection and Maintenance (Grade Crossing, Corridor Safety Specialist) Don has had extensive experience in railroad safety issues, specifically the application of advanced technologies to railroad applications, the analysis, design, and permitting of highway-rail grade crossings and grade separations. He has worked with local agencies on grade crossing improvements and improvement strategies for the enhancement of rail corridors in particular, the Alameda Corridor project. In addition, Don has developed comprehensive standards and procedures for the design, permitting, and construction of highway-railroad grade crossing in addition to Final Report 31

36 many presentations to the engineering community on the diagnostic analysis, design, and construction of highway-railroad grade crossings. He has analyzed railroad safety practices for several railroads in the development of the products for which he has been responsible. Don is active in the industry and is currently President of the American Society of Civil Engineers (ASCE), Los Angeles Chapter. He is a registered professional engineer. Peter A. Cannito, Sr. Transportation Consultant Railroad and Transit Management Professional, with experience managing all aspects of Railroad Operations, Maintenance, and Engineering. Peter retired as President of Metro North Railroad. He has a lengthy background in the railroad industry, including freight, intercity, and commuter railroading. At Metro North, Peter was responsible for the management of one of the largest commuter rail systems in the United States. He managed annual operating budget of $1.2 billion and an annual Capital Program of $320 million. He also had a long tenure with Amtrak, where he was directly responsible for Amtrak s Northeast Corridor and National Operations as well as its Engineering and Maintenance function for infrastructure and vehicle fleet maintenance and acquisition. He spent 7 years with Penn Central Railroad in field operating positions prior to joining Amtrak. Other Panel Members Gerald R. Hanas General Manager Northern Indiana Commuter Transportation District Railroad Operations and Systems Safety Jerry has a broad range of technical and operating experience with the Commuter rail industry. He is familiar with NTSB and FRA accident investigation procedures. He is active in APTA and has chaired the Commuter Rail CEO committee. He has served as General Manager for the District since Since that time he has managed the District s activities in refurbishing the passenger assets of the former Chicago South Shore and South Bend Railroad. Those activities include managing a Capital budget of over $380 million. The District also directly operates the passenger rail service between South Bend, Indiana and Chicago, Illinois. The services provide forty-one (41) weekday trains carrying approximately 14,000 passengers a day and special event ridership topping 20,000 passengers a day. The District employs 340 people in a variety of disciplines. Final Report 32

37 Bill Parsons Director of Operating Rules Metro North Commuter Railroad Railroad Operations Bill is the Director of Operating Rules for Metro North Commuter Railroad and is the former chair of the Operating Rules Association of North America, the industry organization for all railroads, including freights. He is active on the FRA RSAC (Rail Safety Advisory Council) operating committees. He represents Metro-North and APTA on the Railroad Safety Advisory Committees. Bill has participated on the NORAC Safety Committee. He also participated on an APTA peer review for Washington Metropolitan Area Transit Authority. He interfaces with the American Association of Railroads (AAR) and APTA on regulatory issues. Robert E. Skinner, Executive Director Transportation Research Board The National Academy of Sciences Contract Systems and Contracts Oversight Bob Skinner represents a policy, research and technology perspective for all transportation modes for the Panel. As head of TRB, Bob sits on several Panels, including the recent Boston Big Dig peer review Panel. Mr. Skinner joined the Transportation Research Board as a Senior Program Officer in 1983, and was named Director of the Studies and Information Services Division in 1986 before becoming Executive Director in Prior to joining the board, Mr. Skinner was the Vice President of Alan M. Voorhees and Associates in McLean, Virginia, a transportation consulting firm specializing in services to local, state, and federal transportation agencies. Mr. Skinner holds a Bachelor of Science degree in civil engineering from the University of Virginia and a Master s degree in civil engineering/transportation systems from the Massachusetts Institute of Technology. He is a registered professional engineer. Robert E. Gallamore Chair, Committee for Review of the Federal Railroad Administration Research and Development Program Systems Safety Robert represents an academic perspective for the Panel, with a freight railroad background. Robert E. Gallamore is the former Director of The Transportation Center and Professor of Managerial Economics and Decision Sciences in the Kellogg School of Management at Northwestern University, Evanston, IL. Prior to joining Northwestern University in August 2001, Gallamore was on executive loan from Union Pacific Railroad to the Transportation Technology Center, Inc., in Pueblo, Colorado. There he was Assistant Vice President, Communications Technologies and General Manager of the North American Joint Positive Train Control Final Report 33

38 Program. This partnership of the Association of American Railroads, the Federal Railroad Administration, and the State of Illinois DOT is establishing railroad industry interoperability standards and deploying an operational positive train control system enabling rail passenger train speeds of up to 110 mph between Chicago and St. Louis. Before the industry assignment, Gallamore was General Director, Strategic Analysis for the Union Pacific Railroad in Omaha and an executive with UP Corporation in New York City. Gallamore has also served in several positions with the federal government. As Deputy Federal Railroad Administrator under President Jimmy Carter, he led the Executive Branch development of recommendations for railroad deregulation and revitalization. In this capacity President Carter awarded him one of the first Senior Executive Service Awards. Earlier, Gallamore was Associate Administrator for Planning of the Urban Mass Transportation Administration and System Plan Coordinator with the United States Railway Association (which established Conrail out of the facilities of the bankrupt Northeast railroads). After 9/11, Gallamore served on a National Academy of Sciences Panel, "Science and Technology for Countering Terrorism: Transportation and Distribution Systems," whose report is included in Making the Nation Safer: The Role of Science and Technology in Countering Terrorism. Subsequently, Gallamore chaired the National Research Council / Transportation Research Board Committee on Freight Transportation Information Systems Security, which addressed issues, threats, and research priorities in this difficult area. He subsequently chaired other NAS / TRB Panels on hazardous materials transportation and on railroad research priorities. He was made a Lifetime Affiliate of the National Academies in Dr. Gallamore received his A.B. from Wesleyan University with high honors. He earned an M.A. in Public Administration and a Ph.D. in Political Economy and Government from Harvard University. His dissertation on railroad mergers remains a standard reference. Among Gallamore's numerous publications is a chapter on railroad innovation and regulation in Essays in Transportation Economics and Policy: a Handbook in Honor of John R. Meyer, published by the Brookings Institution (1999). Bart Reed Executive Director The Transit Coalition Passenger Rail Advocate Bart Reed is the Executive Director of The Transit Coalition, a Sylmar, CA based nonprofit. In this capacity, he is a nationwide advocate for effective transportation systems and solutions. Reed addresses citizen and community groups about public transportation issues, including autos, rail, bus, bicycles, roads, toll lanes, ADA, goods movement and rail / pedestrian safety. Reed frequently travels to Washington, DC and Sacramento to educate elected representatives on rail and bus transportation issues. He produces and conducts outreach programs and meetings to demonstrate support for public transit initiatives and investment. Reed developed and manages a transit list with 5,000+ transportation Final Report 34

39 contacts and edits and publishes a weekly e-newsletter and a monthly print newsletter Moving Southern California. Reed maintains an extensive community presence with involvement in organizations including: Valley Vote, Friends4Expo, Friends of the Green Line, Friends of the Red Line, Sylmar Neighborhood Council, Sierra Club Transportation Committee, Pacoima Community Coordinating Council and TUG-NET: the computer users group. Anne Herzenberg Transit Consultant Contract Systems and Contracts Oversight Anne is a transit consultant who has recently performed organizational reviews and other transit consulting work for the Tren Urbano rail line in San Juan, Puerto Rico, the Regional Transportation Commission of Southern Nevada (RTC), the Dallas Area Rapid Transit District (DART), the Bay Area Rapid Transit District (BART) and the New Orleans Regional Transit Authority. Anne was the Massachusetts Bay Transportation Authority (MBTA) Chief Operating Officer for several years. She was head of two of MBTA s subway lines and of the mechanical back shop before becoming deputy Chief Operating Officer (COO) and COO. She is familiar with commuter rail. Like the SCRRA, the MBTA contracts out their entire commuter rail service. She graduated from Yale University and has a Master of Science in transportation from MIT. Anna M. Barry Director of Subway Operations Massachusetts Bay Transportation Authority Systems Safety Anna is the Director of Subway Operations for the MBTA, the fourth largest transit agency in the United States. She oversees the operation of about 2500 trains each weekday, with an annual budget of $150 million, employing 2,000 persons and using more than 500 pieces of revenue rolling stock. She brings to this position over 30 years of experience in the transportation field, including more than 25 years in railroad and transit operations. Prior to assuming responsibility for the MBTA Subway system in October of 2005, Anna was the first woman appointed as Director of Railroad Operations, a position she held for eight years. In that capacity, she had responsibility for the management of the sixth largest commuter rail system in the country, and the largest contract operation, with an annual operating budget of more than $200 million. She managed the system through a complex series of operating agreements, trackage rights agreements and other contractual and deeded arrangements with multiple railroads and contractors. As Director of Railroad Operations, Anna served as Project Manager for the $1.1 billion procurement of the commuter rail services contract, the largest in North America and the largest single contract in the history of the Authority. At the same time, she led Final Report 35

40 negotiations of a 30-year trackage rights agreement with Amtrak providing dispatching and maintenance services at no cost to the MBTA. She also oversaw successful opening and operation of 70 mile New Old Colony Railroad, 8 mile Newburyport Extension and transition to new state of the art $200 million Commuter Rail Maintenance Facility. During 20 years with the Authority, she also has been Chief of Operations Support, responsible for the management of the entire Authority s buildings, structures and power systems. She worked in subway vehicle maintenance for nine years as Assistant Superintendent and Superintendent on the Red and Orange lines. Anna also worked at the Boston and Maine Railroad, in both freight and passenger services. She holds an A.B. from Boston College and a Juris Doctor from Suffolk University. She is admitted to the Bar of Massachusetts and is an active, founding member of the Boston Chapter of the Women s Transportation Seminar. She currently is a member of the WTS Boston Board of Directors. She was the Boston Chapter s Woman of the Year for She is active in APTA, COMTO, Transportation Research Board, and is a past President of the New England Railroad Club. Final Report 36

41 APPENDIX D Panel s Six-Month Progress Report Presentation to SCRRA Board September 11, 2009 Final Report 37

42 12/31/2009 METROLINK COMMUTER RAIL SAFETY PEER REVIEW PANEL Six-Month Report Card Metrolink Enhanced Safety Action Plan Presentation to the Board of Directors of the Southern California Regional Rail Authority SCAG Offices, Los Angeles, CA September 11, 2009 Metrolink Commuter Rail Safety Peer Review Panel 1 Outline OUTLINE A. Overall Assessment B. Progress on Metrolink Enhanced Safety Action Plan 1. Safety Culture 2. SCRRA Organizational Structure 3. System Safety Program Plan (SSPP) 4. Safety Performance Measurements 5. Infrastructure Maintenance and Upgrade 6. Metrolink Short Term Safety Projects 7. Strategic Plan 8. Governance C. Conclusion Metrolink Commuter Rail Safety Peer Review Panel 2 1

43 12/31/2009 A. Introduction INTRODUCTION SCRRA Board Motion Metrolink Commuter Rail Safety Peer Review Panel Ad Hoc Subcommittee Panel Selection Process Panel Members Scope of Work Panel completed 1/9/09 Report on recommendations for short/medium/long term actions Six-month Report Card Hours of Service study Metrolink Commuter Rail Safety Peer Review Panel 3 B. Metrolink Enhanced Safety Action Plan Six-Month Progress Overall Progress Actions Completed Short-term t recommendations Actions being implemented and progressing Development of an enhanced safety culture Update of System Safety Program Plan Actions yet to be completed Comprehensive Organizational Assessment Update of Strategic Plan Board Governance Metrolink Commuter Rail Safety Peer Review Panel 4 2

44 12/31/2009 Issue 1. Safety Culture ISSUE 1 SCRRA has made great strides in creating a stronger safety culture. Elevated the Safety Department to report directly to the CEO. Created Strategic Safety Leadership Team. Established risk assessment process. Metrolink Commuter Rail Safety Peer Review Panel 5 Issue 1. Safety Culture Continued ISSUE 1 Created a committee structure throughout all levels of the organization involving contractors and staff to support the safety program. Enhanced operational safety performance measurement system. As safety goals are adopted and tracked, this safety culture will become stronger. Metrolink Commuter Rail Safety Peer Review Panel 6 3

45 12/31/2009 Issue 1. Safety Culture Continued ISSUE 1 Staff has developed draft goals: Training Efficiency Testing Rule Violations Injuries Audits / Inspections Panel recommends that goals be more specific as to metrics, measurable, timely, communicated and apply at all levels of organization. Metrolink Commuter Rail Safety Peer Review Panel 7 Issue 1. Safety Culture Continued ISSUE 1 The Strategic Safety Leadership Team (SSLT) has been formed and is meeting regularly. Panel recommends that the non-operating staff be included and participate in the process. Metrolink Commuter Rail Safety Peer Review Panel 8 4

46 12/31/2009 Issue 2. SCRRA Organizational Structure SCRRA has satisfied the short-term recommendations of the Panel. ISSUE 2 Key Executive and Operational positions have been further realigned and staffed with qualified and experienced personnel. The Operations and Mechanical organizations have further strengthened contractor oversight. Oversight staffing requirements are part of the service expansion and service modification analysis. Metrolink Commuter Rail Safety Peer Review Panel 9 Issue 2. SCRRA Organizational Structure Continued ISSUE 2 SCRRA management still needs to initiate the comprehensive organizational analysis to further clarify roles and responsibilities. However, SCRRA has done an in-house assessment for purposes of addressing the Operations Department staffing needs. Metrolink Commuter Rail Safety Peer Review Panel 10 5

47 12/31/2009 Issue 2. SCRRA Organizational Structure Continued ISSUE 2 SCRRA management still needs to undertake a more formal analysis and process of review of its business model. This analysis should include the Board and other stakeholders in the process of review. SCRRA has changed and grown significantly since the business model was originally created in the early 1990's. Metrolink Commuter Rail Safety Peer Review Panel 11 Issue 2. SCRRA Organizational Structure Continued ISSUE 2 The Panel made a series of recommendations to immediately address some organizational changes. SCRRA Management has implemented these recommendations and are continuing to improve on them. Metrolink Commuter Rail Safety Peer Review Panel 12 6

48 12/31/2009 Issue 3. System Safety Program Plan (SSPP) ISSUE 3 The review and redrafting of the System Safety Program Plan is underway. Management has created a System Safety Committee structure that involves all organizational layers, including contractors, in the process. The Strategic Safety Leadership Team will oversee the redrafting of the SSPP. The Risk Assessment Process is underway as part of the Hazard Resolution Committee (HRC) Process. Metrolink Commuter Rail Safety Peer Review Panel 13 Issue 4. Safety Performance Measurements SCRRA has updated its Operational Testing Program. ISSUE 4 SCRRA has hired a CFR/GCOR qualified operating rules manager responsible for Implementing an electronic efficiency testing system acquired from Metro North Railroad. Managing the efficiency testing program and ensuring compliance with operating rules and FRA regulations through periodic reviews and audits. Metrolink Commuter Rail Safety Peer Review Panel 14 7

49 12/31/2009 Issue 4. Safety Performance Measurements Continued ISSUE 4 Increased observations of engineers, conductors and other safety critical employees as well as joint testing with other operators on the corridor. Liquidated Damages for rule violations language remains the same within the current T&E contract. Performance goals are being developed and will be completed by the end of October Metrolink Commuter Rail Safety Peer Review Panel 15 Issue 5. Infrastructure Maintenance and Upgrades ISSUE 5 Maintenance of Way (MOW) Implementation of an electronic asset management system is in progress. Modified and strengthened the Qualifications Testing Program. Vehicle Equipment Maintenance The recommended personnel changes have been addressed. The Qualified Maintenance Person (QMP) process has been strengthened but the Panel is recommending additional changes. Metrolink Commuter Rail Safety Peer Review Panel 16 8

50 12/31/2009 Issue 5. Infrastructure Maintenance and Upgrades Continued ISSUE 5 Infrastructure Safety Improvements SCRRA has completed the testing on the new coaches that are on order. These are state of the art in crash energy management. Other infrastructure safety improvements are being implemented. SCRRA has worked with Bombardier to revise the document control policies. The policies have been strengthened according to the recommendations of the Panel. SCRRA has begun a program of training and qualifying crews for equipment troubleshooting. Metrolink Commuter Rail Safety Peer Review Panel 17 Issue 6. Analysis of Metrolink Short Term Safety Projects ISSUE 6 Capability for inward-facing cameras is being installed and tested. SCRRA is proceeding expeditiously on Positive Train Control (PTC) and its dispatch software system. All new ATS locations will be installed by early October Metrolink Commuter Rail Safety Peer Review Panel 18 9

51 12/31/2009 Issue 6. Analysis of Metrolink Short Term Safety Projects Continued ISSUE 6 SCRRA is participating in FRA RSAC s Triennial medical evaluations issue. SCRRA has authorized the Panel to perform the Hours of Service Study. The Panel has engaged Dr. Patrick Sherry to perform this work and the kick-off meeting is Friday, September 11, Metrolink Commuter Rail Safety Peer Review Panel 19 Issue 7. Strategic Plan The development of a comprehensive Strategic Plan still needs to be initiated. ISSUE 7 The Panel recommends that the strategic planning process begin as soon as possible. Include strategic operational and safety issues. Seek buy-in at multiple levels on funding commitments, flexible budgeting processes, and rigorous project evaluation and prioritization. Explore new technologies, wider markets, and more effective operational strategies during the strategic planning process. Metrolink Commuter Rail Safety Peer Review Panel 20 10

52 12/31/2009 Issue 8. Governance ISSUE 8 The Board established a new Safety Operational Oversight Committee for briefings, reporting progress, and discussion ssion of Operational and Safety issues. The rest of the Panel s recommendations on Board governance have not been initiated. The Panel has received draft suggestions on enhanced education of board members and believes those are a good start. Metrolink Commuter Rail Safety Peer Review Panel 21 Issue 8. Governance Continued ISSUE 8 These suggestions do not address the broader issue of governance to work with staff to: Develop and implement long term strategies and goals oriented towards enhancing Metrolink s safety performance; and Provide the financial resources necessary to implement the agreed upon strategies and goals. Metrolink Commuter Rail Safety Peer Review Panel 22 11

53 12/31/2009 Issue 8. Governance Continued ISSUE 8 Panel still recommends that the Board: Conduct a self-assessment of its performance with emphasis on safety and operational oversight. Develop Board responsibilities and actions: More rigorous briefing sessions for new Board members. Board-adopted statement of duties and responsibilities for Board members and for the Board as a whole. Metrolink Commuter Rail Safety Peer Review Panel 23 Issue 8. Governance Continued Board-adopted performance safety and operational performance measures. ISSUE 8 Guidelines for the addition of safety and operational staff positions as new services are introduced. Revised, more comprehensive strategic plan that addresses safety and operational issues. Direct board involvement in developing and updating the Enhanced Safety Action Plan and monitoring its implementation. Metrolink Commuter Rail Safety Peer Review Panel 24 12

54 12/31/2009 C. Conclusion Significant short term progress has been made for safety enhancements. Conclusion Many intermediate and long term initiatives are underway. Areas needing more attention are: Comprehensive organizational analysis and business model review; Strategic planning; and Board governance. Metrolink Commuter Rail Safety Peer Review Panel 25 13