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Improving Safety Culture in Public Transportation (2015)

Chapter: Chapter 8 - Improving Safety Culture at Four Transit Agencies

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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 8 - Improving Safety Culture at Four Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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67 Improving Safety Culture at Four Transit Agencies Introduction This chapter uses four success stories to reinforce the iden- tification of elements that improve safety performance and safety culture in public transportation systems so that they may be considered for application throughout the transit industry. These elements were previously identified in Chapters 1, 2, 3, and 4 and Appendices A, B, and C. Their application, however, is best shown in accounts of transit agencies that have made sig- nificant improvements in safety culture. Please note that having “made significant improvements in safety culture” is not syn- onymous with having achieved a perfect state of safety culture. The research team examined two categories of transit agen- cies that made significant improvements in safety culture: • Safety culture improvement in response to a major acci- dent or incident. The first category consists of transit agen- cies whose efforts to improve safety culture were undertaken in reaction to a major accident or incident. Examples of tran- sit agencies in this category are NYCT and the Washington Metropolitan Area Transit Authority (WMATA). • Safety culture improvement without a major accident or incident. The second category includes transit agencies that have improved safety culture without the spur of an incident or accident. Examples of transit agencies in this category are LACMTA and OCTA. A New York City Transit Case Study Background On April 24, 2007, a New York City Transit track worker, while setting up flags on the IRT Line express tracks just north of Columbus Circle Station, was struck and killed by a southbound train. Five days later, on April 29, 2007, another track worker was struck and killed by a train proceeding eastbound on the IND Line while he was moving equipment across the tracks within the bounds of Hoyt-Schermerhorn Station. His partner was also struck but ultimately survived serious injuries. Fatalities were not uncommon at NYCT, as indicated in Figure 7. From 1950 to 1959, an average of 6.7 employees were killed per year. From 1970 to 2009, a 40-year period, the average dropped to 1.7 deaths, which still amounted to five fatalities every 3 years. The higher number of average annual fatalities from 1946 through the 1960s resulted from less emphasis on employee safety as reflected by safety rules, faster train speeds, train- ing deficiencies, and failure to delineate safe areas adequately. (In many tunnel stretches, there is insufficient space between the tunnel walls and the track to prevent employees from being struck by trains.) Fatalities dropped significantly as improvements were made in these areas. However, track fatal- ities continued at a rate of roughly three every 2 years for the last two decades. These fatalities continued to occur despite the establishment of: • An office of system safety, which reported directly to the NYCT president; • Separate safety units reporting to the vice presidents of the Department of Buses and Department of Subways; • An elaborate longstanding system safety program plan with defined responsibilities and investigative, reporting, and tracking systems; • A longstanding practice of weekly and monthly safety meetings; and • Relatively detailed contractual provisions for joint labor– management cooperation to monitor and resolve safety problems and disputes. Immediate Executive Action Letter to All Employees Immediately after an employee’s death on one of its lines, the NYCT president sent a message to all employees, discussing C H A P T E R 8

68 the recent fatality, other fatalities and injuries, and strategies, such as an emergency stand-down, to be taken to improve safety. Emergency Safety Stand-Down The emergency safety stand-down at NYCT for all employees who worked on the tracks lasted from April 30 to May 10, 2007. In conjunction with the president of TWU Local 100, the NYCT president also added labor representatives to the boards of inquiry investigating the fatalities. This was the first time in NYCT history that labor had been included in the formal investigation process. A number of changes in rules, regulations, and proce- dures were instituted on an interim basis subject to review and further revision. The first major initiative undertaken by the NYCT and TWU Local 100 presidents was to establish a Joint Track Safety Task Force (JTSTF). Management and labor representatives were named to the JTSTF representing all personnel involved in any way on the track. The chair of this task force was the vice president of system safety for NYCT. The task force was charged with answering five key questions: 1. To what extent are rules/procedures ignored? 2. Is risk taking inherent in the maintenance-of-way culture? 3. Have measures following previous fatalities or serious injuries positively changed the culture and employee behavior? 4. Is the workforce invested in the safety mission? 5. What short- and long-term changes are needed? The TWU Local 100 and NYCT presidents recognized early on that the response to these tragedies required challenging both the existing formal system and the prevailing culture. They enlisted individuals with background and expertise in special- ized labor environments to inform their leadership approach. Presentation briefings were conducted for top NYCT manag- ers and TWU representatives, and the science, complexity, and enormity of tackling systems and culture simultaneously were discussed. They decided that a survey would be the quickest and most reliable way to gain meaningful insights into the culture at NYCT. Safety Culture Survey A consultant was hired to design, conduct, analyze, and summarize the safety culture survey in conjunction with NYCT task force members. In June 2007, focus groups were conducted with groups of train operators, maintenance-of- way workers, and supervisors. The purpose of the focus groups was to identify issues for inclusion in the survey. The task force then developed the survey with the consultants’ assistance. It included questions about participants’ assessments of the work culture, safety conditions, training and safety measures, and communications. The survey contained 105 questions and took an average of 37 minutes to complete. The target population for the safety culture survey was approximately 11,000 employees. NYCT and TWU records were reviewed to obtain home telephone numbers. Between July 12 and August 2, 2007, at least five attempts were made to contact each individual. In addition, flyers were distributed to prospective survey participants, informing them about the survey and providing a toll-free phone number to call. Survey Findings Of the 756 completed surveys (margin of error ±3.6%), 114 were supervisors, 247 were train operators, 361 were maintenance-of-way workers, and 34 were construction flag- gers. The margin of error means that it is 95% likely that the results from the survey were within plus or minus 3.6% of reality. The surveys were designed to get behind the ideas verbalized by responders to underlying perceptions and base thinking about safety behavior. The cross-tabulations of the survey results revealed the various subcultures embracing different titles and groups of workers. This survey proved critical in formulating NYCT’s comprehensive response to the employee fatalities of April 2007. The results of the survey revealed that, while rules, regu- lations, and procedures needed revising, the major prob- lem was the existing safety culture at NYCT. That, in turn, meant dealing with multiple subcultures that defined atti- * No records before 1946 0 10 20 30 40 50 60 70 *1946- 1949 1950- 1959 1960- 1969 1970- 1979 1980- 1989 1990- 1999 2000- 2009 43 67 53 19 29 10 9 Figure 7. NYCT employee track fatalities by decade, 1946 to 2009.

69 tudes and accepted norms of behavior for that particular part of the organization. At NYCT, the subcultures were distinguished by: • Organizational role (e.g., board, management, supervi- sion, hourly employee), • Operating mode (e.g., rail, bus, paratransit), and • Specific functional specialties within the organization (e.g., rail transportation superintendent, bus maintenance foreman, rail dispatcher, bus driver, train operator, track worker, signal maintainer, bus mechanic). The interactions of all of these elements representing dif- ferent safety subcultures are affected by the imperatives and constraints inherent in the physical operation of each spe- cific mode and drive overall organizational behavior, which behavior defines safety culture in the organization. Further investigation revealed that: • Safety culture was expressed only by behavior. • Attitudes and norms of behavior were not necessarily uni- form even within single subcultures. • A safety subculture existed within every part of the orga- nization; it might be unified and extraordinarily effective, or it might be disorganized, non-uniform, and completely ineffective at preventing accidents, incidents, and/or inju- ries, but it existed. Actions to Improve Safety Culture at NYCT JTSTF Wide-ranging initiatives were undertaken to improve the safety culture at NYCT. The JTSTF implemented the follow- ing actions: • Stand-down reform. The traditional method of assessing safety problems and general safety conditions for pub- lic transit track workers is the safety stand-down, during which all but emergency work is suspended and manage- ment, supervision, and hourly workers gather together for an off-site seminar on track safety. In the past, these sessions had largely consisted of supervisors reading the rulebook to hourly employees. However, in 2007, a major effort was undertaken to transform these sessions into active discussions of safety issues involving managers, supervisors, and hourly workers. • Analysis of past accidents and responses as a whole. While thorough investigations had been conducted of NYCT accidents and incidents as each occurred, no one had done an analysis of all accidents and incidents that had occurred in the previous 20 years. Such an analysis was performed in 2007 and was very useful in highlighting recurring factors that were not evident in the individual investigations. • Joint union/system safety on-site inspections. Un- announced inspections were instituted for all three shifts on a weekly basis using a safety checklist covering 21 areas. Inspections covered in-house track construction projects, track maintenance and cleaning, capital construction projects, signal maintenance, and lighting. The NYCT and TWU presidents tracked the results closely on a weekly and monthly basis. The number of unsatisfactory findings declined steadily. Joint Presidential Actions The NYCT president and the president of TWU Local 100 used numerous strategies to influence safety culture and sub- cultures positively within the organization. These included: • Priorities: Establishing safety as highest priority by board, management, and union leadership and evidencing com- mitment to that priority by support for and dedication of sufficient resources to safety; • Rules: Developing realistic rules, regulations, and proce- dures with involvement of all levels of the organization; • Training: Improving the quality of initial and refresher training; • Communications: Allocating significant additional resources to effective communications; and • Oversight: Dramatically increasing oversight of all track- related operations by managers, supervisors, and joint union–management teams. Other Actions Other actions included: • Near-miss investigations: The System Safety Department received an additional headcount to accomplish a number of previously unfunded functions, to include the thorough investigation of near-miss incidents. • Inspections: Frequent inspections were instituted both by the System Safety Department and joint management– labor teams of all aspects of system operation. • Performance indicators: An accurate system of metrics to track safety-related incidents and to determine and reveal emerging patterns and trends was instituted. • Follow-up surveys: A periodic, anonymous survey to track changes in attitudes and norms of behavior within the separate NYCT subcultures and for the organization as a whole was planned.

70 flaggers (a total of 7,852 people) attended one of 51 training sessions lasting 8 hours that were presented for employees. Each session consisted of a 2-hour auditorium presentation conducted by the NYCT and TWU Local 100 union presi- dents and a 6-hour small group discussion on implementa- tion of the 63 JTSTF recommendations. In the auditorium session, the NYCT and TWU Local 100 presidents reviewed the results of the survey with an emphasis on the danger- ous attitudes and norms of behavior revealed and made the case for continuous refinement of a set of applicable rules, regulations, and procedures until all employees embraced that set and lived it on a daily basis or faced censure from their coworkers. Rapid-transit operating personnel attended a similar program, with 4,540 people attending 3-hour ses- sions. The fact that these sessions were personally led by the NYCT and TWU Local 100 presidents captured the attention of the participants, conveyed the necessary sense of urgency and shared management and labor commitment, and under- scored the message that nothing was more important to lead- ership than safety. Safety Culture Improvements About 3 years after an employee’s death, a track supervisor was killed on the NYCT tracks. This represented the second longest period between track deaths in recorded NYCT his- tory. About 6 years after his death, another hourly worker was killed on the tracks at NYCT. This is by far the longest period between hourly worker deaths. The steps taken to bring about this improvement in safety culture at NYCT represented an instinctive application of Reason’s principles by the presidents of TWU Local 100 and NYCT, neither of whom happened to have any previous knowledge of Reason’s work. A Washington Metropolitan Area Transit Authority Case Study Background WMATA had experienced 10 serious accidents in the pre- vious decade, which resulted in 17 employee and passenger fatalities and nearly 100 passenger injuries. Two of the most serious accidents occurred on WMATA’s Red Line rail service. On November 3, 2004, 20 passengers were injured when an out-of-service Red Line train rolled backward into the Woodley Park station and hit an in- service train that was at the platform servicing the station. On June 22, 2009, two Red Line trains collided when a south- bound train stopped on the track and another southbound train hit the rear of the first train. The lead car of the second train telescoped into the rear of the stopped train, killing nine • Legislation: Joint agreement was reached on New York State legislation that established a New York State Track Safety Task Force consisting of two state commissioners (transportation and labor) and the presidents of NYCT and Local 100 with oversight over any “material modifica- tions” in the track safety program, and that legislation was passed. Changing Behavior Basic Approach Understanding how to bring about positive improve- ments in safety-related behavior was critical to improving the safety culture at NYCT. John Law, an earlier TWU Local 100 president, was fond of an ancient Irish saying that “paper never refused ink.” In this context, what that meant was that the greatest safety experts in the world could write a book containing the best set of rules, procedures, and regulations ever devised, but unless the employees for whom the book is written completely absorb, internalize, and live by those rules, procedures, and regulations on a daily basis, that effort is worth nothing. The NYCT president and the president of TWU Local 100 facilitated the process of bringing about translating the writ- ten word into changed behavior by stressing: • Employee involvement in developing revised rules, regula- tions, and procedures; • Continual refinement of that set of rules, regulations, and procedures; • Development of a “marketing plan” for selling NYCT employees on the merits of following the rules, to include use of “commercials” made by family and friends, an idea borrowed from New York City’s Consolidated Edison (which has successfully improved its safety climate), on the importance of employees coming home safely every night; and • Direct involvement by senior management and union leaders in carrying the message that change is essential. Using Communication and Training to Foster Changes in Behavior The JTSTF developed 63 recommendations, of which 13 were rule changes and 50 were process and procedural changes. The necessity for significant changes in attitudes and norms of behavior and the rationale for these changes being imple- mented were the subject of training sessions conducted from May through July of 2008. All maintenance-of-way personnel who worked in the right-of-way and on road car inspection and all construction

71 • Safety as a priority: added safety to the WMATA mission statement. • Reorganization: moved the safety department to under the general manager. • Resource allocation: increased the number of employees and resources committed to the safety department. General Manager Initiatives First Steps Focus on Operations Department The new general manager’s efforts to improve WMATA’s safety performance and safety culture initially focused on the Operations Department. • Clarification of responsibilities: The Operations Depart- ment was assigned primary responsibility for safety. • Operations manager experience: The new general man- ager hired additional experienced managers for both bus and rail operations. • Worker Protection Program: This program, which defines procedures for protecting all employees who work on the track, was completely overhauled, with employee buy-in and involvement incorporated and extensive initial train- ing administered and periodic refresher training required. • Organizational learning: The general manager established a formal lessons-learned program (“Looking back to effec- tively move forward”). All departments are required to prepare a lessons-learned bulletin for any significant safety incident. The bulletin is to contain an incident summary, lessons learned (what happened versus what should have happened), a root cause analysis, and recommendations for further action. These bulletins are distributed to all affected employees by e-mail and by the chain of command. • Oversight: Safety officers were assigned to the field to provide greater oversight of operations. Rather than sit behind desks and manage safety operations through their in-baskets, these officers are constantly observing field operations. Safety Culture Survey The general manager initiated an employee safety culture survey. The initial survey had a 97% participation rate. • The survey was contemporaneous with initiation of the upgraded Worker Protection Program. • The results reaffirmed disconnectedness and fear of reporting because of peer pressure and possible management action. • Respondents, however, were not convinced that the changes that had been made were permanent. passengers and injuring more than 70. The train operator of the second train was killed. In addition, there also were eight fatal accidents involving track workers during this decade. • In October 2005, an employee was struck and killed at the Braddock Road station on the Blue and Yellow Lines. • In May 2006, another employee died after being hit by a Red Line train at the Dupont Circle station. • On November 30, 2006, two employees were struck and killed while performing routine track maintenance on the Yellow Line near the Eisenhower Avenue station. • On August 9, 2009, an employee was struck and killed by a ballast regulator between the Dunn Loring–Merrifield and Vienna/Fairfax–GMU stations on the western end of the Orange Line. • On September 10, 2009, another employee was struck between the Braddock Road and Ronald Reagan Washing- ton National Airport stations and subsequently died from his injuries. • On January 26, 2010, two workers were killed when they were struck by a piece of track equipment at the Rockville station. Board Initiatives Evaluation In response to this series of accidents and mishaps, the WMATA board asked several separate consultants to exam- ine WMATA operations. The general consensus of these con- sultants was that WMATA rail in particular suffered from a poor safety culture. Management was not emphasizing safety sufficiently; existing safety and operating procedures were frequently ignored, and employees were often establishing their own procedures; operations were dominated by orga- nizational silos; train operators were not sufficiently mindful of the safety of maintenance workers on the roadway; the rail transit system was physically in poor condition (with track conditions being particularly bad); and communications within the organization were poor. Board Responses The WMATA board was criticized by the NTSB for lack of safety oversight in a July 27, 2010, report. Board organizational change: In response, the board created a Safety and Security Subcommittee on September 30, 2010. The board also took the following specific actions: • Management changes: hired a new general manager and chief safety officer.

72 • Parts availability: There was a major parts problem for both buses and rail that took 2 years to fix. Employees can see that parts are available and get the message that things have changed. • Radio system: A major problem with the radio system has been fixed. • Communications: The general manager does a weekly employee message. It always has a safety component. • NTSB backlog: There were 400 NTSB open items when the new general manager arrived; only a few now remain. • Accident investigation backlog: There were 220 back- logged accident investigations when the new safety officer arrived; few remain. The goal is to close out most investi- gations within a 72-hour limit or to explain to the general manager why they were not closed out. • Tri-State Oversight Commission (TOC) relationship: There was a poor relationship between the TOC and WMATA; that relationship has improved. Results of Initiatives After 3 years: • Employees say that things are better. • Key statistics have improved. • There has been only one serious injury to a WMATA employee; it occurred in a maintenance shop on May 29, 2012. • An FTA review found “considerable progress.” • WMATA has completed another employee survey (64% participation) in which 85% of respondents reported that they were no longer afraid to report close calls. • WMATA has implemented a Good Faith Challenge Pro- gram under which employees can stop work. • Employees can get rules changed through: – LSCs, – A safety hotline, and – An operator group, which has been working on red sig- nal violation rules. • Single tracking train speed has been reduced to 15 mph, thereby increasing available reaction time for employees working on the adjacent track and reducing braking dis- tance for trains. • The general manager’s greatest fear going forward is com- placency. Looking to the future, the following initiatives are under way: • The safety officer is setting up a safety measurement sys- tem (SMS), which will resemble the New York City police department COMSTAT system. Additional Actions to Improve Safety Culture at WMATA Additional actions taken to improve the safety culture are discussed in the following: • Feedback: The general manager set up a safety hotline to serve as a feedback channel. All employees, contractors, and patrons can contact the safety hotline by e-mail, telephone/ voice mail, or in person. Approximately 43% of the calls in the first year of operation concerned facility problems, 20% were employee personal safety issues, 9% were vehicle defects and problems, and 7% concerned environmental issues. • Reporting: The general manager also established a WMATA non-punitive close call program. – The BTS takes calls while protecting the confidentiality of the caller. – The BTS conducts a confidential interview of the report- ing employee or employees. – The BTS provides a report to a joint Metro/Local 689 group on the cause of the close call and recommends appropriate action to the deputy general manager for operations (DGMO). – The DGMO reviews and accepts the recommendations and provides oversight of the implementation. – Agreements to implement the system were signed with BTS and the ATU. • Employee involvement: The previous general manager had brought DuPont onto the property and set up LSCs. The performance of these committees was uneven. The new general manager and safety officer have reinvigorated the LSC program by empowering the LSCs to make changes and by providing effective oversight of LSC activities: – The LSC motto is “Identify locally; solve locally.” – Department Safety Committees oversee the LSCs. – The Executive Safety Committee oversees the Depart- ment Safety Committees. – The WMATA approach is to “listen, say what we are going to do, do it, and solicit feedback.” • Infrastructure: A major problem at WMATA had been the deterioration of the infrastructure, with no resources pro- vided for a return to a state of good repair. The supporting jurisdictions have significantly increased capital support: FY 2010: $400 million, FY 2011: $600 million, FY 2012: $770 million, and FY 2013: $900 million. • Availability: Major improvements made in track and car availability: FY 10: 836 cars on average available; FY 11: peak requirement is 896. There are now 940 to 950 cars available, on average. • Engineering support: WMATA has hired back car engi- neers and integrated them into operations, making engi- neering support directly available to operations managers.

73 Recent Board Initiatives Safety Culture Assessment In 2012, the LACMTA board commissioned an evaluation of safety culture, which included a safety culture survey and group discussions with hourly operations employees. The results of the survey and the discussions indicated the pres- ence of a positive safety culture. However, it also was clear that there was room for improvement in many departments. Board Resolution The LACMTA board passed a resolution requesting the evaluation and making it clear that the board endorsed safety as its highest priority for public transportation in Los Angeles County. The board recognized the importance of a positive safety culture in avoiding the safety problems that have beset other transit agencies. The resolution specifically cited the criticism of another transit agency board by the NTSB for not taking a sufficiently active leadership role with respect to safety and safety culture: The top priority for the MTA Board of Directors has been and must always be exercising vigilant oversight of MTA’s bus and rail system to ensure the safety and integrity of our transit system for every one of our 38 million monthly passengers. As a Board we must remain committed to this priority and continually strive to improve the safety culture at MTA in a proactive manner, rather than in a reactive manner after suffering a major accident, such as the one on June 22, 2009, that claimed [deleted] lives and injured [deleted] other passengers on the [deleted] subway system. In its report on this tragic accident, the National Transportation Safety Board (NTSB) determined that this accident was not just the result of operator error or faulty equipment, but rather served as “an example of a quintessential organizational accident.” In short, the NTSB directly called into question [deleted] safety culture and the effectiveness of the [deleted] Board’s oversight responsibility for sys- tem and organizational safety. Organizing for Safety The safety champions at LACMTA include the board; the CEO; the chief operating officer (COO); the executive officers of corporate safety, maintenance, and transportation; and the local safety committee and subcommittee chairs. Since being hired in 2009, the CEO has consistently emphasized the impor- tance of safety performance and a positive safety culture. At LACMTA, the chain of command (the CEO, the COO, managers, and supervisors) has primary responsibility for safety and safety culture. The executive officer of corporate safety acts as the eyes and ears for and provides direct staff sup- port to the CEO in all matters pertaining to safety and safety culture, thereby assisting the CEO in discharging his command responsibility for safety. • All accidents and incidents are investigated in a timely fashion. • WMATA’s biggest current safety effort is fatigue management. • The safety office elicits regular feedback from management and union personnel. • The general manager and safety officer are not satisfied with current accomplishments because pockets of employ- ees still remain unconvinced in the changes. • The safety officer reports monthly to board safety and security committees (safety one month, security the next). WMATA has shifted capital work from midday on week- days almost entirely to weekends: 8:00 p.m. Friday to 5:00 a.m. Monday. This minimizes the number of employees working on the track during weekdays. Operations uses bus bridges paid by capital funds to replace rail service on the affected tracks. The safety department: • Has increased from 28 to 61 positions, • Provides coverage for 20 hours per day, • Is involved in project planning from its inception, • Makes hazard management a priority, and • Participates in the daily operations call, which starts with a safety report. Safety Culture Improvements Since the arrival of the new general manager and safety officer, there has been only one serious employee accident; it occurred in a shop on May 29, 2012. There have been no rail collisions, and no track workers have been hit by trains. On October 6, 2013, however, there was an explosion in a Red Line tunnel that killed a contractor’s employee. No WMATA employees were reported as being seriously injured. A Los Angeles County Metropolitan Transportation Authority Case Study Background LACMTA (Metro) has not experienced significant acci- dents similar to those that led to initiatives to improve the safety culture at the NYCT and WMATA. The process of improving safety and safety culture at LACMTA was started in 2001 when DuPont was hired to assist in reducing workers’ compensation accidents, injuries, and costs. More recently, further progress has been made as a result of determination by the Metro board and senior management to improve safety performance and safety culture in order to reduce the likeli- hood of accidents on the order of those that had occurred at NYCT and WMATA.

74 are e-mailed to LSC members and posted on division bulletin boards to inform employees of LSC activities. LSCs use data analysis to: • Review accident and occupational injury data and imple- ment strategies and programs to reduce workplace inci- dents, • Ensure that the subcommittees are analyzing all appropri- ate data/metrics and key performance indicators, and • Review subcommittees’ programs and recommendations for improvements. The LSCs therefore provide a vehicle for direct employee involvement in matters pertaining to safety and safety culture. Mutual Trust The degree of mutual trust within the organization is rela- tively good. However, it varies from department to depart- ment, with employees in some departments much less trusting of their management than those in other departments. The United Transportation Union general chairman describes it as more of a state of mutual understanding than one of mutual trust. Reporting LACMTA does have an effective system for encouraging employees to report safety issues and concerns and is rela- tively successful at doing so. It is called the SAFE-7 Report of Unsafe Condition or Hazard and Near-Miss form (also described in Chapter 7). This form is one of the primary means by which employees can report hazards and near misses. It can be submitted anonymously and without fear of reprisal. Departments and divisions are required to maintain records of these reports of hazards or near misses, track the status of corrective actions taken or planned, and ensure that appropriate corrective action has been taken within estab- lished time limits. SAFE-7 tracking is accomplished using a SAFE-15 form. Upon receiving a completed SAFE-7 form, department or division management is required to analyze the reported hazard or near miss, identify all of the factors involved, and develop recommendations for timely elimi- nation or mitigation of the hazard or near miss. These rec- ommendations may include modifications of equipment or facilities design, maintenance schedules or practices, operat- ing rules and procedures, employee training, bus stop loca- tions, rail station layout, traffic control devices, road design, traffic signs, and markings. Management must inform all other involved employees of the existence of and circum- stances surrounding the hazard or near miss. Hazardous or near-miss situations involving more than one department The union leadership at LACMTA also promotes safety as the first priority. The general chairman of the United Transportation Union confirmed that, in his opinion, safety is the highest priority for the Metro board, management, supervision, and hourly employees, and that priority is com- municated constantly to the workforce. The importance of safety is emphasized to employees through initial safety training, refresher safety training, letters, bulletins, “rap ses- sions” with managers, and the local safety committees and subcommittees. Importance of Training LACMTA effectively conveys the risks and rationale of its safety rules. This is primarily accomplished by training, starting with initial safety training and continuing through refresher training and training in the field. Employees inter- viewed at LACMTA agreed that workers would not hesitate to stop work if they perceived a hazardous situation; however, they could not cite a formal procedure to that effect. Employee Involvement As previously detailed in Chapter 7, the primary vehicle for employee participation in safety is their membership on local safety committees. These LSCs were established during an earlier successful intervention by DuPont to control rap- idly escalating workers’ compensation costs. LSCs provide the primary means of coordinating safety activities at the local level at LACMTA. LSCs are responsible for: • Evaluating the number and type of injuries and incidents within any given division or department and identifying measures for mitigating them; • Verifying, via measurement, the degree of compliance with established safety policies and guidelines and implement- ing appropriate corrective action; and • Reducing the number of lost workdays due to injuries. The chairperson of the LSC rotates every 6 months between the transportation division and maintenance division man- agers. Other LSC members are the transportation and main- tenance assistant managers, a senior safety specialist from corporate safety, division safety coordinators, representatives of three different unions, the subcommittee chairpersons, the return-to-work coordinator, a sheriff ’s representative, and other local staff as needed. Non-division departments, such as rail wayside systems, have an equivalent membership structure. LSCs normally meet once per month to review the status of local safety performance and safety programs and activities at a regularly scheduled date, time, and place. Meeting minutes

75 • An executive committee on safety initiatives has also been established. This committee focuses on the “3 Es”: engineer- ing improvements, educating the public, and enforcement. • Special emphasis is also being placed on “controllable col- lisions.” Hitting fixed objects, hitting pedestrians with the front of the bus, and running red lights are classified as events that should never occur. • There is an understanding at LACMTA that while there is a positive safety culture at work, there is always room for improvement. Safety Culture Improvement LACMTA continues to operate with no major accidents similar to those that have occurred at NYCT and WMATA. An Orange County Transportation Authority Case Study Background OCTA has had a positive safety culture for over two decades. Its culture has improved incrementally and become increas- ingly stronger as a result of dedicated leadership and a com- mitment to safety that permeates the entire workforce of represented and non-represented employees. OCTA Approach to Safety Culture Priority A recently retired CEO told the research team that safety was accorded the highest priority at OCTA by himself and by the board. The new CEO has proven to be as dedicated to safety as the former CEO. The first thing he did, upon assuming the CEO position, was to request an APTA peer review of OCTA’s overall safety programs. The executive director of human resources and organizational development indicated that OCTA has a strong and positive safety culture because safety starts at the top. He indicated that both the past and present CEOs made safety paramount and allowed nothing regarding safety to be sacrificed for other priorities. He said that OCTA is a highly functional organization with a low accident rate and a good union–management relationship. He noted that the unions work hard on safety and distribute union-generated safety initiatives. When the president of Teamsters Local 952 was asked if safety was the highest organizational priority at OCTA, she replied, “absolutely.” Its value has been recognized and embraced for over 20 years, as seen through a dedicated staff of safety representatives and the entire employee base. A former CEO told a story about answering his cell phone while touring a maintenance yard and being told by an hourly worker that it was against OCTA rules and regulations to use that cannot be resolved by the department working by itself will be reported to corporate safety, and corporate safety will resolve the situation by working with all involved depart- ments. The responses to SAFE-7s are distributed to the indi- vidual submitting the report and to the appropriate LSC. In the opinion of the research team, the only improvement that could be made to the reporting system would be to imple- ment disciplinary immunity for employees reporting near misses. Investigations LACMTA has a detailed procedure for investigating accidents and incidents. Investigations are initiated at the supervisory level, with support from other staff as neces- sary. The corporate safety department is involved if the severity of the accident warrants investigation by acci- dent reconstruction experts. The Accident Review Board reviews the reports and determines if the accident was avoidable. Labor representatives do not play a significant role in accident investigations. Other Ongoing Actions Leading indicators: LACMTA reports 17 leading per- formance indicators. In doing so, it reports far more lead- ing indicators than most public transportation agencies and more closely resembles the airline industry. Deterioration in these leading indicators could provide specific warnings about given areas of operation and a general warning about the overall state of safety culture in the organization as a whole. Technology: LACMTA also leverages technology, such as video camera recording systems on its buses, to screen out risk-taking employees who exhibit unsafe behaviors. Training: The appropriate levels of training and retraining have been determined by years of trial and error. Based on the independent safety culture evaluation referenced earlier, safety training is rated as being very good. Safety in performance appraisals: Appreciation of safety culture is not a factor in performance appraisals at LACMTA. Safety performance, however, is an evaluation factor for man- agers and supervisors. Assessing safety culture: Until the safety culture survey, there was no attempt to gauge safety culture on an annual basis or otherwise. Recent Changes • In terms of improvements, the new board initiatives lead the way.

76 a maintenance supervisor who serves as a safety captain, any employee can use the safety captain program to get a procedure changed that needs to be changed. A machinist and safety captain confirmed this. Another machinist who serves as a safety captain said that OCTA is much more seri- ous about safety than where he used to work. He said that employee well-being is very important to OCTA. Stop-Work Procedure OCTA has an informal procedure that directs employees to stop work or interrupt service if an unsafe condition arises. The executive director of human resources and organizational development said, “Anyone and everyone can say ‘stop.’” The procedure is covered in training. It also was covered in a video by the CEO that was made as part of the recent Rededication to Safety campaign. Examples are taking buses out of service because of a threat of fire and closing down fueling operations because of suspected faulty equipment. Organizing for Safety Culture The CEO, deputy CEO, executive directors, general man- ager for transit, base managers, and safety captains all regard themselves as safety champions. The CEO, general manager for transit, and the base man- agers have line/program responsibility for safety. The chief safety officer (the manager of the Health, Safety, and Envi- ronmental Compliance Department) provides oversight and staff support. Communication Most of the conventional methods for communication with employees are used, including formal training programs, labor–management meetings, safety committee meetings, vid- eos in the drivers’ room, tailgate meetings, and bulletin boards. The former CEO approved the introduction of a Rededication to Safety campaign video. Teamsters Local 952 also uses news- letters and flyers and holds a safety fair each year. In order to ensure that effective and open communica- tions are maintained between all organizational levels and all employees, OCTA has what is called the Ri2 system. It is a computerized system accessible to transportation employees at each base. Employees can submit any concern or any issue at any time, and management must respond in a timely man- ner. The Ri2 system was originally designed for operators to enter route-specific information based on daily experi- ence, but its use has been expanded to all employees to deal with safety problems and issues. It is an effective and inno- vative approach to employee safety communication and participation. a cell phone in the yard. He said that when a mechanic cor- rects the CEO on a matter of safety, you know safety culture is alive and well. Assessing Safety Culture With respect to measuring safety culture, OCTA has con- ducted an employee survey, with positive results. OCTA also looks at trends in hours lost and other metrics and puts 99% of its focus on a proactive approach. Employee Involvement The CEO emphasized the importance of establishing a positive safety culture by including managers and employees, resulting in a strong and sustainable culture over time. He stated that encouraging and welcoming input and communi- cating on a regular basis are essential to maintaining OCTA’s safety culture. OCTA employees are deeply and actively involved in all aspects of safety and safety culture. The three main structures for this involvement are: • Accident reduction teams: These teams are made up of management, supervisory, and represented hourly employ- ees. The teams focus on determining the root cause of bus and passenger incidents. The team’s goal is to analyze all the facts pertaining to an accident and to recommend steps to prevent a recurrence or, if recurrences cannot be abso- lutely prevented, to reduce frequency. • Configuration Control Committee: This committee is made up of department directors, managers, engineers, and base representatives from both the operations and mainte- nance departments. The committee assesses all proposed OCTA bus service configuration changes prior to imple- mentation. In doing so, it reviews proposed changes for potential hazards and possible threats to OCTA employees or patrons. • Safety captain program: Captains are selected by OCTA management to represent fellow employees on the com- mittees at each base (depot). There are separate safety committees for maintenance and for operations (transpor- tation). Base managers appoint a minimum of two operators to the operations safety committee and appoint a sepa- rate representative from each shift for mechanics, service workers, parts clerks, and facility maintainers. Safety com- mittees meet monthly to address problems. A representative from the Health, Safety, and Environmental Compliance Department attends each of these meetings, reviews the meeting minutes, and ensures that all outstanding issues are addressed. The safety committee chairpersons are elected from the membership of each committee. According to

77 • New-hire screening: OCTA attempts to screen out risk- taking employees by reviewing department of motor vehi- cle (DMV) and criminal records prior to employment and continuously thereafter. • Training: The factors used to determine the appropriate lev- els of training and retraining for employees are experience and the recommendations of accident reduction teams and the safety committees. OCTA ensures that employees are adequately trained on safety matters by constantly review- ing performance and mounting frequent safety campaigns. There is annual safety refresher training after initial orien- tation safety training. • Safety incentives: Incentives include presenting safety awards to deserving employees at awards ceremonies. The only safety-related financial incentives at OCTA are con- tractual bonuses for reduction in annual workers’ com- pensation costs. • Safety outside the workplace: OCTA also focuses on safety as a complete employee experience. Factors outside the work environment, such as safety at home, are treated as equally important. Safety Culture Improvement OCTA continues to operate with no major accidents. The improvements with respect to safety and safety culture that OCTA is attempting to make include developing more mea- surable leading indicators, enhancing the agency’s safety train- ing program, and further formalizing an industrial hygiene exposure control program. OCTA rates its approach to safety culture compared with that of other transit organizations as outstanding and prob- ably in the top 10% of the industry. That said, OCTA is aware that improvements need to be made and that continuous refinement of the safety program is a never-ending pursuit. Comparison with Previous Research Table 8 compares the four case studies to the eight compo- nents of safety culture developed in this project. Strong Leadership, Management, and Organizational Commitment All of the team’s research suggests that the process of improving safety culture begins and is driven by top leader- ship that is fully committed and willing to bring the necessary resources to bear on problems and to lead by example. Intel- ligent, strong, decisive, and persevering leadership is required to resolve or remove obstacles and to stay the course. Such leadership is demonstrated in all four case studies. Reporting The Ri2 system successfully encourages employees to report problems and raise issues. It is easy for employees to use and to track responses with. The problems and issues raised and the actions taken are also visible to all employees. OCTA has a near-miss program, which it calls the Good Catch Program. It is described in Chapter 7. This program has no discipline associated with honest self-reporting. OCTA is looking for feedback from people who are involved in an inci- dent in which they experienced a near miss and from anyone who observes an unsafe condition or act. The accident reduction team program also ensures that all of the relevant issues are addressed, that all levels of employ- ees, including union representatives, are engaged in problem solving, and that the workforce understands the basis for any new process or procedure. Importance of Training The primary method used to ensure that employees under- stand the risks and the rationale behind OCTA’s safety rules is training. Mutual Trust According to both the executive director of human resources and organizational development (HROD) and the president of Teamsters Local 952, there is a strong state of mutual trust among managers, supervisors, and employees at OCTA. The HROD executive director said that, because OCTA has significant employee involvement and because management is open to questions and criticism, the system works with a high degree of mutual trust and respect. The union pre- sident said that OCTA management always handles safety matters professionally. One of the safety captains said that there was too much at stake for there not to be mutual trust and respect. Other Ongoing Actions Other ongoing safety actions are: • Safety assistance: Resident trainers are also available for employees to approach with safety problems. • Accident investigation: In investigating accidents or other safety and health problems, discipline and prevention of recurrences are balanced by dealing with prevention first. • Leading indicators: OCTA includes, as leading indicators, the degree of employee participation in programs, the per- cent closure of Ri2 safety entries, and the number of out- standing inspection and audit findings.

78 case, affirming Reason’s dictum that informed culture is syn- onymous with safety culture. Assessing Safety Culture The starting point of any safety culture improvement pro- cess is determining where the transit agency stands—both with regard to its existing safety culture and in comparison to other agencies. A transit agency needs to be able to answer the following questions: • What are managers and employees actually saying and doing when no one is looking? • What are the areas and special problems that require work? • Which particular processes and assessment methods yield the greatest information and allow the best view inside the organization, and which simultaneously contribute the most to shared ownership and buy-in among stakeholders? Obviously, employing unthreatening methods that are free of any threat of retaliation and that promote candor and encourage shared responsibility and accountability is the pre- ferred, necessary, and most productive approach. In this regard, it is better to have more rather than less information to go on. Employee/Union Shared Ownership and Employee Involvement When a safety culture improvement program is being intro- duced, it is essential that every effort be made and specific processes be implemented to enlist the active participation, involvement, and shared ownership of all key stakeholders, including labor union representatives; employees; governing boards; lower, middle, and upper management; and funding partners and funding sources. The more challenging and dif- ficult the transformative change required, the more important will be the buy-in required, and the more likely the process will encounter and have to overcome barriers—including problems of cynicism, suspicion, distrust, and lack of enthusiasm—and will be imperiled by grudging compliance or even noncompli- ance. Even with strong leadership, progress cannot be sustained without buy-in by all levels of management and employees; it must be evident up and down the organization. The degree of shared ownership and employee participation varied from case study to case study but existed in all four organizations. Effective Safety Communication The emphasis given to communication and the methods employed varied somewhat from case study to case study. However, communication was more than adequate in every COMPONENTS NYCT WMATA LACMTA OCTA Strong leadership, management, and organizational commitment Yes*** Yes*** Yes*** Yes*** Employee/union shared ownership and employee participation Yes** Yes** Yes** Yes*** Effective safety communication Yes** Yes** Yes** Yes*** Proactive use of safety data, key indicators, and benchmarking Yes** Yes** Yes*** Yes** Organizational learning Yes** Yes** Yes** Yes** Consistent safety reporting and investigation for prevention Yes** Yes** Yes** Yes*** Employee recognition and rewards and just disciplinary system Yes* Yes* Yes* Yes* High level of organizational trust Yes* Yes* Yes* Yes*** Notes: The number of asterisks assigned to each component is based on the research team’s interpretation of information provided by the individual transit agencies. *** Exceptional ** Achieved * In progress Table 8. Components of safety culture evidenced in case studies.

79 at each of these transit agencies indicated that the inher- ent conflict and tension between maintaining privacy and providing sufficient transparency in the administration of the disciplinary system make it difficult to demonstrate to employees that the disciplinary system in fact is generally just. High Level of Organizational Trust (Mutual Trust) Within one of the transit agencies studied in this chapter, the level of trust was exceptional. This was probably due to the number of years that a positive safety culture has existed at the agency. In the other three, building trust is a work in progress. Our research indicates that trust must be earned by consistent performance over a long period of time. Employees will not begin to trust based on the rollout of a flashy new safety program and vague promises of reform. They will not begin to trust management until they have observed manage- ment “walk the walk” through good times and bad. And it is equally important for management to trust employees to do the right thing at all times. Conclusions: Guiding Principles An analysis of the similarities among these four case studies produces the following essential elements for transit agencies seeking to improve their safety cultures. Strong Leadership Truly committed leadership is essential to building a posi- tive safety culture. There is no hope of improving safety cul- ture without top management commitment, direction, and support. Leaders must “walk the walk,” fight for adequate resources to be budgeted to support safety and safety culture programs, hire and promote managers and supervisors who are similarly minded, and be willing to support innovative ideas that occur within the organization that will positively affect safety culture. Employee/Union Shared Ownership and Employee Involvement Truly committed union leadership and significant employee involvement and buy-in are equally essential to building a positive safety culture at any transit agency with represented employees. Management cannot go it alone. Even the most committed CEO will not succeed in improving safety culture without the support and involvement of union leadership and the represented employees. Management and union leader- ship, as well as represented and non-represented employees Gathering perceptions as well as factual data is important. While perceptions are not conclusive, they are valuable— especially those of affected employees and other key stake- holders. For a trained observer or data analyst, the following are all potentially important clues and information that can be extracted from anecdotal and empirical information: understanding the relevance or efficacy of rules on the books; gauging the gap between rules and behavior; understanding degrees of differentiation that might exist within the work- force and among line employees, supervisors, and managers; fully grasping the level of cynicism, trust, or distrust; and dis- cerning the underlying beliefs and values of key players. Which tools best meet the actual requirements? What degree of anonymity should be provided? Interviews, surveys, focus groups, and role-playing exercises are all possible tools. Combined with raw data, all contribute to painting an accu- rate picture of the situation and existing conditions. It is hardly coincidental that safety culture surveys have been used at all four of the transit agencies discussed in this chapter. Organizational Learning Organizational learning clearly contributes significantly to improved safety culture. Joseph Carroll (1998) defined organizational learning as taking place “through activities performed by individuals, groups, and organizations as they gather and digest information, imagine and plan new actions, and implement change.” All of these transit agencies have institutionalized such activities. WMATA’s lessons-learned program is a good example, as is NYCT’s analysis, as a group, of all accidents and incidents that had occurred in the previ- ous 20 years. Consistent Safety Reporting and Investigation for Prevention All four transit agencies have effective reporting systems, and prevention of a recurrence is a high priority. Only one of these agencies, however, provides disciplinary immunity for employees reporting near misses or close calls. As might be expected, that agency has the highest percentage of near misses reported. Employee Recognition and Rewards and Just Disciplinary System The great majority of employees must feel that they are recognized and appreciated for their contributions to safety efforts and that the disciplinary system will treat employees fairly. In that respect, the safety culture surveys implemented

80 hazards and near misses. Reporting near misses and develop- ing strategies to reduce or eliminate these problems are integral to a positive safety culture. Recognizing employees represents a change from blaming employees for safety problems to respecting them and acknowledging that they understand the day-to-day hazards of their work. It will greatly improve safety performance, as has been demonstrated in other industries. Consistent and appropriate recognition and reward must be balanced by a fair and just disciplinary system. “Just,” how- ever, is not a synonym for “lax.” Good employees know that employees not meeting the standards of the organization will face appropriate correction and, if unable to come up to stan- dard, will be fired. Appropriate discipline administered swiftly and surely is important to everyone’s morale and well-being. In too many transit agencies, months or even years may elapse between charges and disposition of those charges. High Level of Organizational Trust (Mutual Trust) Mutual trust cannot be established overnight. It must be earned by all members of the organization (managers, super- visors, and hourly employees) through consistent performance. Employees must trust their managers and supervisors to do the right thing, and managers must trust their employees and each other to do the same. In order to begin a safety culture improvement process, it is mandatory to determine where a transit agency stands with respect to the components outlined. This requires a concen- trated effort, involving some combination of data collection and analysis, observations, interviews, focus groups, and sur- veys. In a world of generally limited resources, it is essential to first know what problems need fixing. throughout the transit agency, must establish an effective working partnership with regard to all aspects of safety cul- ture. Cooperation is essential. A “my way or the highway” approach will not work. Communication Effective safety communication is needed so that all employ- ees fully understand the hazards inherent in their jobs and will appreciate any progress being made. Failure to communicate sufficiently about safety is a common problem in the public transportation industry. Too often the assumption is made that communication can be handled as an unfunded additional duty. That assumption is false and guarantees poor communication. Organizational Learning Organizational learning is very important to improved safety culture. Transit agencies must learn from their experi- ence and adjust to changes in environment; failure to do so can be catastrophic. Reporting and Investigating Employees must have full confidence in the integrity of the reporting and investigating systems. If something is reported, they must be confident that it will be investigated and that appropriate action will be taken. Employee Recognition and Rewards Employees must be recognized for their contributions to safety culture, including contributions such as identifying of

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TRB’s Transit Cooperative Research Program (TCRP) Report 174: Improving Safety Culture in Public Transportation presents research on the definition of safety culture within public transportation, presents methods and tools for assessing safety culture, and provides strategies and guidelines that public transportation agencies may apply to initiate and build a program for improving safety culture.

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