TRA developed, executed, and reported on four discrete but related areas: The first area was a holistic assessment of the five safety incidents, wherein TRA reviewed their relationships and implications for overall VTA safety effectiveness. TRA then refined three further tasks, including a broad assessment of operations and maintenance safety issues, a review of safety department effectiveness and resources, and an assessment of VTA-wide management and measurement tools as they relate to safety.

TRA’s work at VTA involved detailed, on-site examination of incident and accident sites, documents, and equipment; multiple interviews with operations, maintenance, and safety personnel; and close examination of existing organizational and reporting structures. The operations, maintenance, and safety assessment tasks also involved detailed business process assessments and analyses, and related on-site verification.