Improving Safety Culture in Public Transportation (2015)

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81 C H A P T E R 9 Guidelines for Improving Safety Culture Introduction To better illuminate the steps of improving safety culture, what follows is a hypothetical example of a general manager in a transit agency following these steps. Once upon a time, a new general manager named Char- lotte Trueheart arrived to take over the Central State Transit Authority (CSTA). Charlotte had begun her career at a smaller transit agency in the Midwest that only operated buses and paratransit vehicles. She had, however, made such significant improvements in safety, on-time performance, efficiency, reliability, customer satisfaction, and employee morale that she had rapidly gained recognition within the transit indus- try as an outstanding talent and was eventually recruited and selected to head CSTA. CSTA, however, was much larger than her former transit agency. It had three times as many employees and operated heavy- and light-rail lines as well as bus and paratransit services. It therefore represented a much greater set of management challenges in terms of number, scope, scale, and complexity than Charlotte had previously experienced. Of these challenges, the most urgent was the reality that CSTA had been plagued with a continuous series of accidents, resulting in a significant number of employee and passenger injuries and two employee and three passenger fatalities in the previous 10 years. Luckily for CSTA, Charlotte was not only an avid practi- tioner of what is known as managing by walking around but had also recently participated in a transportation industry seminar on safety culture. In her frequent visits to maintenance shops, crew rooms, and other employee facilities, Charlotte found that many hourly workers and supervisors felt that CSTA’s dominant management philosophy was one of “my way or the high- way.” Many with whom she talked were concerned with CSTA’s poor reputation within the local area because of its less than stellar safety record and numerous operational problems, such as poor on-time performance, faulty heating and air conditioning, equipment breakdowns, and so forth. As she talked to more and more people, she began to suspect that CSTA’s safety problems might be related to the lack of a strong, positive safety culture. She resolved to investigate this possibility as part of a safety initiative that she intended to launch as one of her highest priorities. Steps To Improve Safety Culture Step 1: Secure preliminary commitment from management and union leadership at the highest levels to improve safety culture As she had learned during the safety culture seminar, she first needed to meet with her senior managers and solicit their views on the sources and causes of their safety problems. Her primary purpose in these meetings was not to seek imme- diate solutions but to build a consensus among the manag- ers that something needed to be done and an understanding that her managers had to be actively involved in crafting and implementing the proposed solutions. These meetings took considerable time since many of the managers were fixed in their ways and unaccustomed to innovation. She also met individually with the president (Roger John- son) and vice presidents of the union that represented CSTA’s hourly employees. The union meeting was far more difficult than the management meetings because union–management relations had never been very good at CSTA, and Charlotte’s sincerity with respect to wanting to solicit union views with respect to the sources and causes of CSTA’s safety problems was suspect. At the end of these sessions, however, she had largely convinced Roger that there was much to gain and little to lose in putting her sincerity to the test. As she said to him and later reiterated to her managers, “listening to union views in no way compromises management’s control of this tran- sit agency. Decision making remains entirely management’s Guidelines for Improving Safety Culture and Recommendations for Additional Research

82 prerogative. If we can make better decisions, however, by incorporating union concerns and input into those decisions, we would be fools not to do so.” She ended these sessions by explaining that “everyone will benefit from improving the safety culture of this transit agency—the customers, the community, and all of the transit employees.” And, in fact, Roger soon became convinced that Charlotte in fact was completely sincere about enlisting the union as a full partner in improving safety culture and safety at CSTA. Step 2: Identify, consult, and secure the preliminary com- mitment of all other key stakeholders to improve safety culture In CSTA’s case, key stakeholders included the CSTA board, the county political structure, the FTA regional office, the state oversight agency, and three separate organizations rep- resenting rail, bus, and paratransit riders. All appropriate meetings were held, and Charlotte was surprised that the significant consensus was that something had to be done. Step 3: Collectively determine the problems to be addressed (subject to regular revision as more information is received) It then was time to collectively determine the problems to be addressed, subject to regular revision as more information was received. To implement this process, Charlotte created a joint task force (JTF) headed by the CSTA chief safety officer. Other members of this task force were senior representatives of all of the major operating and supporting departments and representatives of the union. Departments were repre- sented by deputy department heads or above, and the union by vice presidents and shop stewards. Step 4: Identify outside professionals and assessment tools to evaluate the transit agency’s current safety culture Since CSTA did not have the expertise necessary to design and implement a safety culture assessment survey, the JTF’s first order of business was to identify outside professionals and assessment tools to evaluate the transit agency’s current safety culture. Under the JTF’s oversight, a safety culture survey was prepared and administered to all operations employees. The survey results were a surprise to management and even to Roger, who had been considerably more negative about CSTA operations than representatives of any other stake- holder group. Roger was quoted as saying: “I knew things were bad, but I had no idea how bad.” The results, organized in accordance with the eight components of safety culture as initially set forth in Table S-2, can be summarized as follows: • Leadership, management, and organizational commitment to safety: 60% of all employees agreed or strongly agreed with the statement “management talks the talk about safety but does not walk the walk.” • Employee/union shared ownership and participation: 75% of all hourly employees agreed or strongly agreed with the statement “management’s primary philosophy is ‘my way or the highway’” and 68% with the statement “employees cannot get rules and procedures changed no matter how strong their case is for doing so.” • Safety communication: 80% of hourly employees agreed or strongly agreed with the statement “there is no effec- tive communication within CSTA about safety problems and issues” and 90% with the statement “employees are kept in the dark about the results of accident investigations.” • Proactive use of safety data, key indicators, and bench- marking: 78% of all hourly employees agreed or strongly agreed with the statement “management’s analysis of safety data is not shared with hourly employees.” • Organizational learning: 65% of all employees agreed or strongly agreed with the statement “too many of the same kind of accidents occur over and over again.” • Consistent safety reporting and investigation for preven- tion: 61% of all hourly employees agreed or strongly agreed with the statement “employees never report near misses because those who do are usually subjected to discipline” and 85% with the statement “management is not interested in determining the real cause of an accident in order to pre- vent recurrence; they only want to find someone to blame and impose discipline.” • Employee recognition and rewards: 73% of all hourly employees agreed or strongly agreed with the statement “there are employees in the organization who have safely performed hazardous duties for 20 years or more who have never been recognized for their achievements.” • High level of organizational trust: – 55% of managerial employees agreed or strongly agreed with the statement “hourly employees cannot be trusted to do their jobs properly unless they are closely watched and 32% with the statement “supervisors cannot be trusted to see that the necessary rules and procedures are followed at all times.” – 40% of supervisory employees agreed with the state- ment “managers cannot be trusted to see that supervi- sory employee decisions are supported” and 15% with the statement “hourly employees cannot be trusted to follow instructions from their supervisors.” – 45% of hourly employees agreed or strongly agreed with the statement “managers cannot be trusted to ensure hourly workers are adequately protected when working in hazardous locations” and 25% with the statement “supervisors will not protest when a manager orders a group to do something that is inherently unsafe.”

83 Step 8: Implement outreach to all appropriate employees to introduce the safety culture improvement program, obtain input, and act on that input in a highly visible manner Charlotte and Roger presented the safety culture improve- ment plan to every CSTA operations employee. They accom- plished this in a series of meetings small enough for group discussion and generated a great deal of feedback. As a result of this feedback, several substantial amendments to the plan were made. Immediately after the meetings were concluded, Charlotte summarized the changes to the plan that had been made as a result of employee input at the meetings in a letter sent to all employees. Step 9: Ensure that management and union leaders collabo- rate to carry out safety culture improvements and serve as organizational role models She and Roger were able to ensure that senior leaders were noticeably involved by assigning responsibility for imple- mentation of each element of the plan to a two-person team composed of one manager and one union leader. Their guid- ance to these two-person teams was: • Strive for cooperation, avoid arbitrary imposition of changes if at all possible, and use discipline only as a last resort; • Exert constant oversight, anticipate problems, and give special attention to problem areas; and • Jointly establish litmus tests for success, including ensuring that employees are remaining engaged, key safety problems are being tracked, progress is being made, and leaders are constantly recalibrating the program. Step 10: Report back to employees on a regular basis and continuously obtain feedback As the 3 years passed, she first noticed some improvements in CSTA’s leading indicators and then, gradually, the lagging indicators, which initially had moved in a negative direction because of more accurate reporting, began to move in the right direction. At the end of the 3-year plan, Charlotte and Roger repeated the original safety culture survey. The results did show solid improvement across the board. However, significant prob- lems remained in a number of departments, and mutual trust, while somewhat improved, was far from ideal. More years of “management walking the walk” were clearly going to be required before virtually every employee would be con- vinced that change had come to stay. Table 9 summarizes the steps that Charlotte and Roger took and outlines a possible path for others. Step 5: Create a road map for improving safety culture and estimate the necessary financial resources to solve identi- fied problems and make required changes In response to the survey results, Charlotte called a meet- ing of the JTF and asked that they prepare a plan within 90 days for her consideration, to include assigning a priority to each element of the plan and determining the resources required for implementation. While waiting for the plan to be developed, she shared the results with her board and the other stakeholder groups. It was clear to all that the problems were too pervasive to con- tinue to be ignored or to be resolved without a serious and long-term commitment. Step 6: Jointly create a road map for rollout and implemen- tation of the safety culture improvement plan and secure commitment of the necessary resources After 90 days, the JTF presented its plan. Included in the plan was implementation of a comprehensive review of CSTA’s safety rules and procedures. The plan also called for an overhaul of the CSTA safety performance indicators, to include incorporation of more leading indicators. There was also a call for identifica- tion of all current CSTA safety practices and a determination as to how those practices might be improved and amplified in order to improve the state of safety culture at CSTA. Possible adoption of practices from transit authorities with reputations for positive safety cultures was also contemplated. Over the next 2 weeks, Charlotte conducted an intensive series of consulta- tions with her senior management team, the board, and Roger and the union leadership. The result was a 3-year plan, with the highest-priority elements to be funded in the current budget and the remaining elements to be funded in the second and third years of the plan. Charlotte was pleasantly surprised at how much input by Roger and the union had strengthened the plan. This satisfied the need to create jointly a road map for rollout and implementation of the plan and to secure commit- ment of the necessary resources to solve identified problems and make required changes. Step 7: Meet with employee leaders (supervision and hourly) at all levels and secure their buy-in for the safety culture improvement plan In a series of meetings, Charlotte and Roger met with the formal and informal leadership at all levels of CSTA, explained the safety culture improvement plan, encouraged honest feed- back, and discussed how to best communicate the plan to all employees. Despite the huge investment of their time that would be required, she and Roger decided that a series of meet- ings, which they would personally lead and which every CSTA operations employee would attend, would be the optimal way to kick off the program.

84 produce strong bottom-line results would provide a signifi- cant incentive for improving safety culture across the public transportation industry. The second is development of a fully validated safety cul- ture survey and establishment of an associated confidential public transportation industry database. The third is development of a proposed standardized set of key performance indicators for the transit industry. The advantages and disadvantages of such a set of indicators could be determined. Both leading and lagging indicators could be proposed for standardization. The use of technology to produce real-time leading indicators, such as those found in the airline industry, could be explored. Recommendations for Additional Research The research team believes that there are three areas in which further research could provide important addi- tional tools for the improvement of safety culture in public transportation. The first is an econometric study (a practical application of mathematics and statistical methods) of the benefits and costs of improvements in safety culture. Such a study would require extensive collection of data that currently is not rou- tinely available. However, the effort would be justified in that a demonstration that improvements in safety culture 1. Secure preliminary commitment from management and union leadership at the highest levels to improve safety culture 2. Identify, consult, and secure the preliminary commitment of all other key stakeholders to improve safety culture 3. Collectively determine the problems to be addressed (subject to regular revision as more information is received) 4. Identify outside professionals and assessment tools to evaluate the transit agency’s current safety culture 5. Create a road map for improving safety culture and estimate the necessary financial resources to solve identified problems and make required changes 6. Jointly create a road map for rollout and implementation of the safety culture improvement plan and secure commitment of the necessary resources 7. Meet with employee leaders (supervision and hourly) at all levels and secure their buy-in for the safety culture improvement plan 8. Implement outreach to all appropriate employees to introduce the safety culture improvement program, obtain input, and act on that input in a highly visible manner 9. Ensure that management and union leaders collaborate to carry out safety culture improvements and serve as organizational role models 10. Report back to employees on a regular basis and continuously obtain feedback Table 9. Steps to improving safety culture.