Practices for Wayside Rail Transit Worker Protection (2012)

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49 INTRODUCTION This chapter explores the processes agencies use to evalu- ate the effectiveness of their ROW worker protection pro- gram. The most obvious measure of effectiveness is the number and type of accidents that occur within an agency. As investigation reports reveal, accidents do not just happen; they result from what could be a simple failure to a complex combination of a variety of situations and circumstances. Agencies that experience accidents conduct investigations to understand what happened and learn how to prevent similar events from occurring. All the agencies studied had baseline policies and procedures in place to provide for the ongoing evaluation of their program. Some had implemented more comprehensive approaches to data collection and analysis to enable the ongoing refinement of their efforts. STATE SAFETY OVERSIGHT PROGRAM In 1991, Congress required for the first time that the FTA establish a program providing for the state-conducted oversight of the safety and security of U.S. rail systems not regulated by the FRA. In April 2005, the FTA issued a Final Rule making changes to the substance and format of the existing 49 CFR part 659. The intent of the changes was to improve the perfor- mance of the State Safety Oversight Program and to ensure the following outcomes: 1. Enhance program efficiency; 2. Increase responsiveness to recommendations from the NTSB and emerging safety and security issues; 3. Improve consistency in the collection and analysis of accident causal factors through increased coordination with other federal reporting and investigation programs; and 4. Improve performance of the hazard management process (12, Part IV, p. 22563). Under the 2005 Final Rule, rail transit agencies must develop a system safety program plan, review it annually, and modify it as needed. As part of the process, all elements of the system safety program must be reviewed in an ongoing manner over a 3-year cycle. The agency’s chief executive must submit a statement of compliance or noncompliance with its system safety program plan, along with the agency’s annual report, to the oversight agency. If an agency is in noncompliance, the report must identify the areas that do not conform to the system safety program plan, and must list measures being taken to bring these areas into compliance. In addition, rail transit agencies must have a hazard manage- ment process in place that includes the ongoing identification of hazards, the evaluation and prioritization of elimination or control measures, a mechanism to track identified hazards to resolution, thresholds for notification and reporting hazards to the oversight agency, and ongoing reporting of hazard resolution activities to the oversight agency (13, pp. 32–38). The State Safety Oversight rules apply to all of the agencies interviewed for this study, except TTC. The primary responsi- bility for demonstrating compliance with 49 CFR Part 659 rests with System Safety. The Office of System Safety serves as the primary liaison between the State Safety Oversight orga- nization and the agency. System Safety develops the System Safety Program Plan with input from the rest of the organiza- tion and conducts the internal auditing. Generally, the auditing consists of ensuring that rules, policies, and procedures are in place and are effectively communicated to employees, and tracking employee and customer accidents and incidents. ACCIDENT INVESTIGATIONS Rail transit agencies investigate any accident that involves a collision with an individual on a rail ROW. Usually, safety department personnel conduct the investigation with assistance from the operating department where the accident occurred. In general, the investigators: • Question all witnesses; • Compile all documentary evidence; and • Ascertain all applicable safety rules. Upon completion of the investigation, the investigators prepare a written report that sets forth the material facts lead- ing to and causing the incident; determines the principal and contributing causes; reaches conclusions as to the persons, policies, procedures, and practices responsible for the inci- dent; and provides recommendations for changes in safety rules, work rules, or other policies, practices, and procedures to prevent the occurrence of similar incidents. The recom- mendations are vetted through the affected departments. A set of corrective actions are agreed upon and planned to be CHAPTER FOUR SAFETY AUDITS, INCIDENT REPORTING, ANALYSIS, AND FOLLOW-UP ACTIONS

implemented. Progress on the actual implementation of the corrective actions is usually tracked and reported to agency management and the oversight organization. NEAR MISSES NYCT was the only agency interviewed that followed a structured process for reporting near miss incidents. The process includes an analysis of Potential Employee Contact (PEC)-type near miss incidents and Non-PEC-type near miss incidents. A PEC-type near miss incident is an incident involv- ing a train or a ROW operation that could have resulted in an employee fatality or serious injury. A Non-PEC-type near miss incident is an incident involving a train or a ROW oper- ation that could have resulted in a customer injury or prop- erty damage but does not present the potential for an employee fatality or serious injury. PEC near miss incidents include: • General Order violations; • Improper flagging; • Potential employee contact with trains while working on the roadbed; • Portable trip overruns; • Failure of train to blow horn when passing yellow caution lights; and • Train passing work area at excessive speed. NYCT Division of Subways personnel are required to report all PEC near miss incidents immediately to their super- visors. The reporting protocol for supervision is as follows: • Notify RCC immediately; • Notify the Divisional Chief Officer immediately; • Notify the Office of System Safety immediately; and • Initiate an investigation within 24 h of the incident to determine the causative factors involved. An incident report must be issued within 30 days of the incident to the Divisional Chief Officer of the employees involved and submitted to the Office of System Safety. That office produces and distributes quarterly reports that analyze the incidents by type, department, and operating division (14, p. 10.6). The NYCT Office of System Safety shared a copy of its 2010 Year End Near Miss Trend Analysis with the study team. During the calendar year 2010, 15 PEC-type near miss incidents were reported, the same amount as in calendar year 2009 (15, pp. 1–2). The report provided a detailed analysis of the different types of incidents (i.e., portable trip overrun, improper flagging, potential employee contact/miscellaneous) and a review of the incidents, contributing causes, and departmental responsibilities. It also requested corrective action plans from departments with multiple related incidents. 50 RULES VIOLATIONS None of the agencies interviewed had a structured process for employees reporting rules violations. Generally, reports and complaints would be made by MOW employees about train operators violating speed restrictions, or by train oper- ators about improper flagging arrangements or unprotected employees on the tracks. These reports are made verbally to the Control Center or supervisory personnel. The reports are investigated by management, and disciplinary actions are taken when warranted. Several agencies have implemented structured manage- ment processes to identify and take corrective actions on rules violations. These approaches go beyond what is required by the State Safety Oversight program to audit job sites. The MBTA Safety Department conducts approximately 100 ran- dom safety audits of work sites each year to check for proper use of equipment and flagging procedures. If inadequate flag- ging protection or equipment is observed, work is stopped until the situation is corrected and a determination is made on how work may proceed safely. Employees cited for violating rule book procedures can be subject to discipline. The TTC has a Quality Assurance unit within its Safety Department. It includes seven staff members and a unit super- visor who focus on safety performance in operations, ROW maintenance, and vehicle maintenance. The information from their audits and evaluations is used to develop reports and analyze trends in rule compliance and overall system safety. The NYCT Office of System Safety conducts 350 to 400 safety inspections of on-track work each year in conjunc- tion with union representatives. The purpose of these surprise inspections is not to “catch” workers doing the wrong thing, but rather to identify safety issues and take corrective actions. The inspections are executed primarily at night when most construction and maintenance work is performed and includes work with both NYCT and contractor crews. An inspection report is completed and reviewed with the job supervisor and forwarded to management. Issues identified through the inspection process are investigated to determine if system-wide measures are needed (e.g., rules changes, employee infor- mation). Feedback from the inspections is also funneled to training personnel so information can be incorporated into existing courses. In 2010, supervisors who received consis- tently good marks on safety inspections were recognized. In addition, to the Office of System Safety efforts, the Department of Subways has implemented auditing initiatives. The Senior Vice President of Subways convenes a quarterly audit team that conducts inspections of work activities on the tracks. The results of the inspections are forwarded directly to him or her for corrective actions. The MOW Division also recently began conducting weekly “Safety Blitzes.” The blitz team usually consists of about 26 management (superintendent and manager level) representatives from inside the various

51 disciplines within the MOW Division. The team is broken down into small groups of three to four people from different disciplines (i.e., track, signals). Each small group conducts multiple inspections during its safety blitz tour of duty. If rule violations are discovered during an inspection, the team instructs the workers on proper procedures. If there are blatant violations jeopardizing the safety of the workers, the work is stopped and the job site is shut down. The results of the Safety Blitz inspections are reviewed with the supervisors in charge of the work sites. The intent of the program is to improve the safety culture. MOW management believes there have been many benefits. The cross-discipline teams have promoted understanding and knowledge-sharing across the different work classifications. Management’s commitment to the program and its focus on correcting behav- iors, not administering disciplinary actions, demonstrates to employees that the organization is serious about safety. Finally, management’s direct observation of work sites has led to the realization that certain work rules are not feasible in the “real world.” MOW management reviews accident statistics, near miss incident investigations, safety inspections, Safety Blitzes, and other relevant trend analyses at quarterly Safety Enhancement Briefings for all employees. ONGOING DATA EVALUATION AND CONTINUOUS IMPROVEMENT All the agencies interviewed strive continually to improve safety through everyday experiences, inspections, audits, investigations, and the like. NYCT’s Office of System Safety stresses data analysis as a tool for identifying problem areas and determining the effectiveness of practices to reduce hazards and enhance safety. The office maintains and updates a variety of databases to generate reports, provide data to reg- ulatory agencies, and to support data analysis. Those relevant to ROW worker protection include: • Employee Accident Database System; • Employee Fatality Database; • Near Miss Database; and • Contractor Accident Database (14, pp. 9.1–9.5). The data analysis enables the organization to identify common trends and problems and to determine if the number of incidents is increasing or decreasing over specific time periods. Trend analyses focus on employee and customer accidents, near miss incidents, fire incidents, and common deficiencies resulting from inspections, audits, investigations, reviews, and surveys. CONCLUSION The challenge of getting employees to make reports that would incriminate fellow workers was raised frequently. Each agency had specific reporting procedures for accidents and accident investigation processes. However, structured processes for reporting near miss incidents or rules violations did not exist, with the exception of NYCT’s near miss reporting require- ments. All the agencies took swift and corrective actions when rules violations were uncovered but some, excluding NYCT, acknowledged that they could do more with regard to data tracking and analysis. NYCT personnel, including representatives from the Office of System Safety and the Department of Subways, viewed the data tracking and trend analyses put in place as the result of their Track Safety Task Force initiative as significant improvements and valuable tools in addressing ROW worker safety.