National Academies Press: OpenBook

Improving Safety Culture in Public Transportation (2015)

Chapter: Appendix B - Transit Agency Mini Case Study Detail

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Suggested Citation:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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:"Appendix B - Transit Agency Mini Case Study Detail." 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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111 A P P E N D I X B Transit Agency Descriptions Transit Agency A (No Union; Small) Safety culture is on a positive track and probably now at its highest point. Safety is the number-one emphasis, even if it means that employees and supervisors have to interrupt schedules. Management believes safety is a “moving target”—“the only way you are going to keep up with it is to continue to move with it.” The current positive safety culture is attributed to: • A comprehensive training program emphasizing safety, • Top leadership commitment, • Employee involvement through joint safety and training committee work, • Using data for safety decision making, • An operator review program, • New technologies that enhance safety, and • External safety audits. After a series of pedestrian accidents, the focus on safety assumed new urgency. Employees still remember these acci- dents as shocking experiences that affected “everyone, from serviceperson to operations to the top managers.” Some operators stopped working for a while, and some simply quit. “That really started the great emphasis on safety at all times,” a manager said. “It’s in the back of my mind when someone is not following the safety procedures.” Employees started to brainstorm how they could prevent such accidents. Since then, drivers have been retrained, strobe lights for turning movements installed on the entire fleet, and audible signals sounded during right-turn movements on 60-foot buses. A campaign encouraging pedestrians to use cross- walks and look both ways before crossing the street was also implemented. On the maintenance side, the safety culture is considered to be very strong. Maintenance employees identify safety haz- ards on a daily basis. Management maintains an open-door policy on safety issues and addresses issues immediately. Transit Agency B (Medium) Following a series of pedestrian collisions, the agency launched a renewed effort to advance its safety culture in order to arrive at lower customer and employee injury rates. A recent internal survey shows that safety culture is consid- ered by management to be positive. Contributing to building this culture are: • Top leadership commitment, • A no-blame culture, • Employee participation, • Extensive safety training, • Near-miss reporting system in rail, • Data-driven safety decision making, • Implementation of new technologies, and • A sense of vulnerability about safety and the importance of being diligent at all times is conveyed throughout the organization. The union sees a significant deficiency in the agency’s han- dling of operator safety issues. Assaults on operators are up, especially around holidays, resulting in a high volume of oper- ator absences. Transit Agency C (Small) There is an overall positive safety culture that struggles to balance pragmatic considerations of operations and cost, a history of mistrust, and an expressed desire to improve con- ditions and outcomes. Transit Agency Mini–Case Study Detail

112 In the organizational work environment and on the part of leadership, there is an open commitment to safety as a top priority; “no conflict on operations—safety trumps every- thing, even if a customer complains.” On the whole, management and labor agree that, while not perfect, the safety culture has improved compared with its state a few years earlier, when there was a notable lack of will- ingness to take personal responsibility. Key factors contributing to this positive safety culture include: • Top management commitment and especially openness on the part of the COO; • Reduction of blame and liability as motivators for safety, with less intimidation of operators; and • The role of key individuals in spearheading aspects of the program and thinking creatively about communications, metrics, and incentives. The current safety culture incarnation was generated fol- lowing a series of serious accidents involving pedestrians. In response to public scrutiny, top management stepped up to identify problems and improve conditions. When assessing and responding to public concern about the accidents, with the input of a community advisory board, the agency identi- fied more than 60 initiatives to improve the safety of workers and the public. There is still a need for “reiterating the basic safety culture principles and reinvigorating the program.” Some initiatives are seen as having lost momentum. Not all are on board, and, by playing down safety, they may influence others. This may be attributed to a history of con- flict and mistrust at the agency. To some the organization is safety-minded “almost to a fault.” Hourly workers may feel that some initiatives go over- board and ignore practical aspects of operations. Less attention is paid to worker health, including ergonomics and musculo- skeletal disorders, and conditions that might affect vehicle and passenger safety, such as fatigue, lack of sleep, and the impact of split shifts. Transit Agency D (Large) Management considers safety to be ingrained in organi- zational culture, especially in operations. Safety receives sig- nificant support from top executives in the form of policies and resources. The commitment to safety is reflected in the continuing operation of joint safety committees at all operating bases when a number of other joint committees had to be elimi- nated due to declining funding. The safety program is a bottom-up program driven by the employees, primarily transit operators. According to a safety officer, employees “make great use of the safety incident reports, and they have always been vocal through communi- cation channels on what they feel is safe and unsafe. One of the strengths of this agency is this bottom-up leadership from the drivers about safety.” Constrained budgets continue to pose a dilemma. It “makes it harder for companies to keep the necessary invest- ments in things that don’t pay off instantly but surely have a long-term payoff like safety and training.” The union’s perception of safety culture is mixed. Some feel that vehicle safety is recognized as an organizational priority and that operator safety training is strong. Others say that safety culture has been “difficult and challenged” and that “there is a level of laissez-faire where rules are not enforced due to fear of stepping on toes.” Management is sometimes seen as not providing adequate responses to operators who express concerns and not sympathetic to union concerns— for example, on vehicle design. Another problem union rep- resentatives identified is that when the budget gets tight, the agency tends to hire more part-time employees with a higher turnover rate and higher accident rate. Efficiency sometimes takes precedence over safety and service, and the personal safety and health of operators can be compromised when the pressure to be on time is high. The operators hope to receive better training on customer relations, especially in dealing with difficult customers who may create hazardous situa- tions. Recently, however, the union has seen some improve- ment in management’s approach to safety issues, and the union’s concerns are taken more seriously with the installa- tion of a new safety officer. Transit Agency E (Large) Managers feel that safety is taken exceptionally seriously in bus and rail operations and in maintenance. Top manage- ment shows a commitment to safety by “making it clear at the beginning of the day that safety is at the top of the list of priorities.” Senior managers from rail consider the safety culture in their divisions to be very strong. The rail operation is trying to steer away from “the command-and-control environment.” Relentless safety training, frontline worker participation through open feedback and joint committees, and a recently implemented confidential near-miss reporting system bring- ing together labor and management interests are cited as key contributors to the positive safety culture. Labor representatives view the culture of safety in rail as “in the middle” but say that it “has come a long way.” Before, safety policies and rules were seen as forced on workers, and primarily as a tool for disciplinary actions. In more recent years, “[management has] been more inclusive in form-

113 requires vigilance and ongoing commitment. The work will never be done. Safety culture is transparent to all employees. Initiatives are driven top down and bottom up to help reinforce various aspects of the safety culture. Emphasis is not just on vehicle operation safety but also on workplace safety in maintenance, facilities, and administrative functions. Top management believes that safety campaigns are nec- essary but that safety culture runs much deeper than cam- paigns, slogans, and posters. Following a serious pedestrian accidents, the agency responded immediately to address system problems revealed by the accident investigation and implemented a number of measures to make operators more aware of surroundings, particularly pedestrians at intersections and crosswalks. It focused on annual operator retraining, onboard messages to provide safety tips, and message boards at dispatch to scroll safety metrics, messages, and statistics on performance. The idea is that operators can see them when they pick up their information. The union rates the safety culture as fair. Scheduling of ser- vice and operator involvement in problem solving are cited as two major areas of improvement the union hopes to see. According to some union members, drivers constantly feel caught between the pressure of on-time performance and the emphasis on safety, especially when budget cuts result in tighter schedules. In maintenance, the union and management concur that the safety culture is strong, and that belief is confirmed by an excellent record. The top operations manager conducts semi- annual base inspections and believes that safety starts with the employees. Ample lighting, proper tools, and an emphasis on preventive maintenance all contribute to keeping the shop and employees safe. Transit Agency H (Large) The general consensus is that a positive safety culture exists in the organization but that there are areas that need improvement. A recent board resolution endorsed the concept of safety being the highest priority and recognized the importance of a positive safety culture—among other reasons, to help avoid the problems experienced by other transit agencies. That pri- ority is communicated constantly to the workforce. The new board initiatives lead the way in effecting safety culture improvements. An executive committee on safety initiatives has also been established, focusing on engineering improvements, educating the public, and enforcement. Spe- cial emphasis is also being placed on “controllable collisions.” Hitting fixed objects, hitting pedestrians with the front of the ing safety committees. Employees can bring issues up to management.” The union representatives rank safety culture in the bus division as “pretty strong,” particularly in terms of manage- ment encouraging union members to participate in safety activities. However, management senses a general lack of trust between labor and management, which may have deterred employees from reporting certain unsafe behaviors of their peers, such as using a cell phone while driving. Transit Agency F (Medium) Safety is an important organizational priority—built into all levels of training and reinforced by systems of safety com- mittees, periodic safety reporting and reviews at all levels, and employee surveys. Leadership is strong on the part of agency executives and union leaders. The priority of safety is reinforced in interac- tions with all employees. Safety statistics are required as part of periodic reports (monthly, quarterly, annual) and internal reviews. There are system-wide safety committees for bus, rail, and maintenance that include union representatives. Employees are expected to interrupt work to ensure that safe conditions are in effect. In practice there is pressure for service schedules to be maintained, particularly in rail opera- tions, where holding up one vehicle can result in holding up an entire line. That pressure is less evident in bus operations and in maintenance. Union leaders see the need for a greater emphasis on safety and for greater engagement by frontline employees in identi- fying and correcting actual or potentially unsafe conditions. Union leaders report that safety problems identified by union members may or may not be addressed. They see the system as needing to be more oriented to identifying hazards and improving risk profiles in advance of incidents. They claim that frontline worker input is not sought out in developing safer procedures and practices. They see the safety commit- tees as operating at a high organizational level but not always responding to issues identified by frontline workers. In rail operations in particular, the union feels that maintaining the schedule often takes precedence over solving safety problems. The union reports that frontline workers can sometimes resolve safety hazard issues directly with their supervisors, although this is reported to be more likely in maintenance than in rail or bus operations. Transit Agency G (Small) Management considers safety culture generally positive but in need of improvement. Maintaining a safety culture

114 There is a formal written procedure that directs employees to stop work or interrupt service if an unsafe condition arises. The procedure is part of general work practices and is covered in training. It also was addressed in a video by the CEO that was made as part of the recent safety rededication program and campaign. Examples are buses being taken out of service because of a threat of fire and fueling operations being closed down because of suspected faulty equipment. Transit Agency Components Strong Leadership, Management, and Organizational Commitment to Safety Top leadership and mid-level management at the nine agencies are strongly committed to ensuring that safety is emphasized at all times. This is reflected not only in constant communication of safety messages but also in the dedication of adequate personnel and financial resources to ensure safe operations. Most CEOs and GMs at these organizations are personally involved in reviewing key safety indicators with safety and other senior managers on a regular basis. When it comes to managing safety responsibilities, larger agencies have a dedicated safety staff, while smaller agencies tend to have safety officers who also have other tasks, including training, risk man- agement, and health. Board members, for the most part, serve a supporting role that helps reinforce safety culture. Employees are recognized as the ultimate safety champions across the case study locations. Table B-1 summarizes responses. Employee/Union Shared Ownership and Participation Employee participation and engagement are pervasive among the best-practice agencies. The most commonly used structure for employee participation is a joint safety commit- tee involving managers, supervisors, and frontline employees. In the agencies where there is union representation and where safety committees exist, all but one has union representatives on the committee. Many times, the committee chairperson and employee members are either appointed by the union leadership or elected by union membership. Other than the regular safety committees, ad hoc joint labor–management task forces have been established to address particular safety concerns, such as in the event of a significant safety failure. Even though labor is not typically involved in the initial accident investigation, a joint accident review committee is sometimes in place to validate findings. At the only nonunion agency, the employee–management committee structure has become a well-established norm. Employees participate in multiple committees, including safety and training, and their bus, and running red lights are classified as events that should never occur. The agency has traditionally used indicators such as the quality and quantity of safety reporting by employees and the results of safety audits and unannounced bus rider checks to estimate the state of safety culture. A safety culture survey and regular group discussions with hourly operations employees indicate the presence of a posi- tive safety culture. Unsafe conditions, hazards, and near misses can be reported by employees using a standard form, which can be submitted anonymously. Upon receiving a completed near-miss 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 elimina- tion or mitigation of the hazard or near miss. All agree that workers would have no hesitation with respect to stopping work if they perceived that there was a hazardous situation, but no one could cite a formal proce- dure to that effect. Transit Agency I (Medium) Safety is accorded the highest priority by top executives, the board, and the union. A separate board safety committee is planned to get the board more directly involved in safety. The agency is a highly functional organization with a low accident rate and a good union–management relationship, but it does not pretend to be a zero-defects organization. The agency recognizes that people make mistakes but says, “just don’t make the same mistake twice.” Ninety-nine percent of the focus is on a proactive approach to safety. The commitment to safety is organized from both the top down and the bottom up. Hourly employees take great pride in the quality of vehicles and are actively involved in all aspects of safety through joint teams. Employees are deeply and actively involved in all aspects of safety and safety culture. The three main structures for this involvement are: • Teams made up of management, supervisory, and hourly employees to determine root causes of vehicle and passen- ger accidents/incidents and to recommend steps to prevent a recurrence; • Safety committees in each base with employee representa- tives; and • Designation of an employee on each shift as the “safety cap- tain” who assists management and supervision in ensuring a safe workplace and sits on safety committees. The agency has a near-miss reporting program; there is no discipline associated with honest self-reporting.

115 Transit Agency Leadership, Management, and Organizational Commitment A Commitment to safety starts with the CEO and board and moves throughout the organization. It is demonstrated not only in “spoken words and posters, but also budgetary commitment.” The CEO and top safety and training manager assume distinct yet complementary roles in cultivating a positive safety culture. The CEO “cheerleads” and encourages the staff to keep safety at the forefront. The safety and training manager is provided with resources and tools and works directly with supervisors and frontline employees to ensure system safety. The company holds safety banquets and award dinners each year to recognize safety champions among employees. B The CEO and executive management team employ actions and practices to set the tone and climate for a visible commitment to safety through candid and consistent communication. Initiatives at the leadership level include: Safety leadership training; Quarterly management meetings; An executive safety committee that meets monthly to review various statistics, including leading and lagging indicators and logs from hazard reports and the safety hotline; near misses (rail only) are submitted by employees and are also discussed, with an emphasis on addressing reported issues and implementing recommendations satisfactorily; and Quarterly safety updates to the board and regional leader, with comprehensive data, including vehicular and employee injury rates. C The COO maintains a strong interest in and commitment to safety. The safety director was also recognized by management and labor as a key champion. Other staff in human resources and administration contribute ideas for improving safety communication. D Safety starts at the top, with the CEO, deputy GM, and senior managers, as well as the executive board members of the union. The CEO makes sure to keep communication open with the chief safety officer (CSO), who oversees a relatively large department. The rail side has additional safety personnel. The risk management unit is actively involved when problems arise and helps with passenger awareness campaigns using grant programs. E Safety responsibilities are embedded in the two modes. There is no corporate CSO. A director of risk management oversees any corporate-level safety initiatives. F The CEO is clearly seen as the top advocate for safety and safety culture. Since a serious pedestrian accident, the agency has moved to upgrade the CSO position and have that officer report directly to the CEO rather than to the COO, and the safety department is being reorganized. The agency’s goal for the new CSO will be for the officer to work him- or herself out of a job “by integrating safety into every person’s • • • • responsibilities.” The CEO receives and reviews quarterly safety statistics with all senior staff. There are weekly meetings with top bus and rail managers, and every month business unit managers meet with the CEO and COO and report on safety statistics, safety problems, and best practices. Table B-1. Leadership, management, and organizational commitment. (continued on next page)

116 voices are not only heard but also given serious consideration by management. In these organizations, employees become the frontline champions of the safety culture. By actively engaging in problem identification, fact finding, and problem resolution with their managers, employees feel empowered and motivated to take on personal responsibilities to ensure the safety of the system (see Table B-2). Effective Safety Communication The best-practice cases demonstrate that communication is the principal means through which safety culture norms and expectations are transmitted to all employees and rein- forced throughout the organization, thus establishing safety culture as an informed culture. The most successful com- munication of safety culture is consistent, frequent, and per- vasive. As found in these best-practice cases, safety culture Transit Agency Leadership, Management, and Organizational Commitment G The agency has a check-and-balance system organizationally when it comes to safety. Reporting to the CEO are two deputy CEOs. While the vast majority of the operators and mechanics work under the deputy CEO for operations, engineering, and construction, where every employee’s job is safety, the hard-line safety and security functions are the responsibility of the deputy CEO for safety. The deputy CEO for safety is given the authority to call a service stop when unsafe conditions are detected. The CEO and deputy CEO for operations advocate for a safety culture by providing tools, resources, and training—for example, making investment in bus simulators for annual recertification of operators. The safety officer is more conversant with the details, looking at specific cases or examples and grading accidents or examining the workplace for unsafe conditions. Top management stresses the need for “commitment throughout the organization from all levels—entry-level to the boardroom—and everybody has to be committed to safety.” This belief is carried out in the structure of a joint safety task force that meets every month and addresses safety issues primarily related to bus operations. The board is considered as playing a supporting role in creating a positive safety culture. It understands that safety is critical, and that is important in its deliberation of policies, particularly if resources are scarce. The board and CEO celebrate safety, conferring awards on deserving workers from both operations and maintenance. H The safety champions include the board, the CEO, the COO, the CSO, the executive officers for maintenance and transportation, and the local safety committee and subcommittee chairs. The CEO, the COO, and the chain of command have primary responsibility for safety and safety culture. The CSO acts as the eyes and ears for and provides direct staff support to the CEO in all matters pertaining to safety and safety culture. The chain of command and union leadership all understand and promote safety as the first priority. The board has exhibited strong leadership by passing a resolution that makes it clear that board members intend to play a significant role with respect to safety and safety culture. I The CEO and other top executives, the senior managers from each base, and the employee safety captains all regard themselves as safety champions. The CEO, the COO, and the senior managers in the bases have line/program responsibility for safety. The corporate safety officer provides oversight and staff support on safety but also oversees other functions, such as health and environmental compliance. Table B-1. (Continued). communication is conveyed across multiple media—written, oral, and electronic. Successful communication is embed- ded in training, management directions, problem solving, and analysis of lagging and leading indicators. In this case, aligned safety communication is built into annual, quarterly, monthly, weekly, and daily interactions among employees at all levels. Safety is deeply embedded in general organizational interactions and in specific structures such as dedicated com- mittees and through well-defined safety captain roles (see Table B-3 for summary of comments). Proactive Use of Safety Data, Key Indicators, and Benchmarking Agencies with positive safety cultures use a variety of meth- ods to improve safety performance for all employees, foster- ing an informed, learning, and flexible culture. Traditional

117 A A safety and training committee is in place to ensure employee participation in safety decision making. The committee is made up of full-time and part-time operators and supervisors who meet once a month with the director of safety and training. In maintenance, mechanics hold monthly safety meetings with the director. The committee members are elected by their peers to serve a 1-year term. Several committees operate much like the safety and training committee to engage employees. They include the route schedule committee, the policy and procedures committee, the social committee, the newsletter committee, the fitness committee, and the sustainability committee. Both managers and frontline workers believe that this type of structure is helpful. As a manager puts it, “communication within a transit system is very difficult because of the different schedules. Having that interaction with the employees is a good way to communicate.” Since the agency is a nonunion shop, this structure puts more emphasis on management to listen to and adopt feedback from rank-and-file employees. B Safety committees in each service district meet on a monthly basis to discuss any concerns. Hourly employees are included in these meetings and are encouraged to provide input. Items discussed during the district meetings are referred to the executive committee that meets once a month with a large number of participants. Each committee has a log of safety issues that it tracks, and one measure of achievement is the speed with which issues get resolved and taken off the log. Union representatives have been invited to both district and executive council safety meetings. There have also been ad hoc joint safety task forces when major safety problems were identified. For example, a union–management task force was convened to evaluate and reduce bus–pedestrian collisions that resulted from similar causes. A joint labor–management committee reviews performance statistics for 1 year and sets goals for the next year. Every employee can get a bonus if safety goals for preventable vehicle accidents and on-the-job injuries are achieved on a semiannual or annual basis. C Under the direction of the COO, bus operators were recruited for a period of 7 hours to assess the internal ergonomics of a new bus design. The union was not formally or systematically involved. D The agency institutes several layers of formal structures for employee participation in safety. At the top leadership level, a joint labor–management committee meets quarterly, bringing together senior local union officials and executive management. This is the opportunity for management and the union to raise broad issues, such as changes to vehicle design, to improve operator health and safety. Transit Agency Employee/Union Shared Ownership and Participation Each operations base has a safety committee primarily staffed by a handful of bus operators elected by the union membership. Operators get paid time off to perform committee work. Representatives from base management, including one of the chiefs, attend the safety meetings. These committees are tasked with reviewing accidents and safety performance data and with being part of the process for making recommendations for corrective actions. Vehicle maintenance also has a labor- management committee within which safety issues are discussed. The base security committee meetings are structured much like those of the safety committee, the difference being that the transit police attend. These meetings are active and instrumental in helping communicate the concerns of the operators, and they provide an opportunity for police to offer drivers tips on making themselves safer operators. When specific problems arise, special committees or work groups are formed with representatives from the union and discrete sections within the agency to address and solve them. With recent accidents potentially caused by poor sight lines from the driver’s seat and other design issues, management and labor have mounted an intensified effort to address concerns about safety defects in equipment. Procurement of nonrevenue vehicles will soon follow the same process. “[Operators] will have a lot more input in safety.” The union helps push for solutions to many of these design and procurement problems and is actively involved in the discussion and fact-finding process. The agency holds an annual safety summit—“an effort to try to drive safety from the bottom up, with leadership from the top.” It is a self-managed work group, and the mission is to “excite colleagues and empower them to start thinking safety-wise.” Participants engage in role-playing games using subjects such as route qualifications and safety rules. Table B-2. Employee/union shared ownership and participation. (continued on next page)

118 Transit Agency Employee/Union Shared Ownership and Participation E At the corporate level, the top safety officer holds regular update meetings with the two safety managers as well as their union counterparts. In the bus division, each garage has safety committees for operators and mechanics. The business agent at each bus local union appoints the safety committee chairpersons, and management usually agrees to those choices. The chairpersons run the meetings on safety every month and are paid by the company for their time. Minutes are shared with management with regard to safety issues to be addressed. Certain concerns, such as operator safety and bathroom breaks, then go through negotiation. This structure has worked effectively for more than 10 years. On the rail side, cross-functional joint labor–management safety committees are used to identify and correct hazardous conditions and unsafe work practices. The committee members identify possible safety hazards at maintenance facilities, rail yards, terminals, and stations, along with rights-of-way and equipment. The committees also conduct monthly on-site inspections following the committee meetings and recommend corrective actions as required. The committee structure and process are detailed in the agency’s FRA-mandated Rail System Safety Program Plan. Any safety issue that cannot be rectified at the committee level is pursued through the senior manager of the division and the rail safety department. Senior management also makes a commitment to attend “at least one safety committee meeting (round-robin) just to make sure that things don’t get lost in translation.” F Bus and rail have safety committees that deal with problems as they come up. Membership on these two broad committees includes labor representatives. G The joint safety task force is chaired by the director of bus operations and consists of the top executive of operations, the transportation superintendents from both bases, the maintenance director, the safety officer, the training manager, the route planner, the union president or secretary-treasurer, and four to five bus operators. This joint forum was established over 15 years ago and continues to follow a congenial and rigorous process. Topics discussed include route planning, time points, road hazards, equipment, and any type of operator safety concerns. The process is taken seriously by managers and is considered by management to be a real part of the culture. It is a hands-on committee that drives concrete decision making and actions. The union considers the task force an effective way to involve employees in safety discussions: “Each party is given an opportunity on how to resolve issues. It is because of the cooperation and joint effort to bring the union in and have discussions relating to safety issues [that we have] created an environment where our issues are addressed.” To encourage employees to report safety issues and concerns, photos of individuals who are part of the task force are posted at the bases so that operators and mechanics know how to communicate with them when safety issues arise. Management considers the union to be its partner in safety. A manager describes the union role in the joint task force: “They encourage operators to report accidents immediately. We don’t have many conflicts in terms of safety. They are on the accident review committee to determine preventability of the accident and also on the joint training committee.” The union president also has access to data related to changes in training subjects or methods or safety concerns. In between the task force meetings, the agency encourages employees to report route and other related problems using a service change request form. According to a union representative, it is “a way to document those issues and get them to management so that those issues can be addressed.” Table B-2. (Continued).

119 no consistent standards as to specific measures. The types of leading indicators used by such agencies include: • Degree of employee participation in programs, • Employee opinions on safety culture through stand-alone or integrated surveys, • Quality and quantity of employee safety reporting, • Percent closure of safety entries in reporting system, • Walk-through and on-site inspections, and • Safety audits—internal and external. Many managers expressed frustration with industry benchmarking for safety performance because of ill-defined lagging indicators are used across the board and are vigor- ously analyzed and reported on throughout the agencies. Many are also used for standardized reporting to the NTD. They include: • Preventable and nonpreventable accidents, • Vehicle collisions (left or right turn, fixed object, vehicle, passenger, and pedestrian), • Incidents, including near misses in several agencies, and • Employee on-the-job injuries. Some agencies consider leading indicators to be as impor- tant as the lagging ones, if not more so. However, there are Transit Agency Employee/Union Shared Ownership and Participation • The committees normally meet once per month at a regularly scheduled date and time and at a fixed location to review the status of local safety performance and safety programs and activities. Meeting minutes are e-mailed to members and posted on division bulletin boards to inform employees of committee activities. Committees use data analysis to: Review accident and occupational injury data and implement strategies and programs to reduce workplace incidents, Ensure that the subcommittees are analyzing all appropriate data/metrics and key performance indicators, and Review subcommittees’ programs and recommendations for improvements. The three subcommittees deal with injury and accident reduction, hazard identification and correction, and program activities and recognition. The chairpersons are normally assistant managers. I Teams are established to determine the root cause of bus and passenger incidents. The teams are made up of management as well as supervisory and hourly employees. The team goal is to analyze all the facts pertaining to the accident and to recommend steps to prevent a recurrence or, if recurrences cannot be absolutely prevented, to reduce frequency. Employee representatives are selected by management to represent fellow employees on the safety committees at each base. There are separate safety committees for maintenance and operations. Base managers appoint a minimum of two operators to the operations safety committee and appoint a separate representative from each shift for mechanics, service workers, parts clerks, and facility maintainers. Safety committees meet monthly. A representative from the health and safety 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 at each base. They may be coach operators, maintenance employees, or management. There are no restrictions. Any employee can initiate a review of rules that need to be changed by working through a safety employee representative. • • H The primary avenue for employee participation in safety is the local safety committee. The committees provide the primary means of coordinating safety activities at the local level. They are responsible for: Reducing the number of injuries and incidents within the division or department; and Verifying, via measurements, the degree of compliance with established safety policies and guidelines, implementing appropriate corrective action, and reducing the number of lost workdays due to injuries The chair of the committee rotates every 6 months between the transportation and maintenance division managers. Other members include the division assistant managers, corporate and division safety specialists, representatives of the local unions, • • the subcommittee chairpersons, and other local staff as needed. Non-division departments have an equivalent membership structure. Table B-2. (Continued).

120 Table B-3. Effective safety communication. A Safety expectations are communicated via a company intranet, bulletin boards, monthly newsletters, e-mails, and safety meetings at different levels of the organization, including weekly management meetings, monthly safety and training committee meetings, and quarterly all-hands meetings chaired by the GM. Management maintains an open-door policy and encourages employees to walk in any time safety issues arise. Safety is a focus during initial training and is reinforced through annual employee reviews and retraining. B Safety is communicated through quarterly management meetings, executive committee meetings, updates to the board, and monthly committee meetings at each district involving hourly workers. C The safety program began with monthly meetings to establish the concept of “safety first.” A safety culture statement was posted and disseminated, setting the guiding principles of commitment at all levels, safety as the top priority, adequate resources and incentives, a responsible and accountable environment with free reporting of breaches, and analysis of actions and establishment of individual accountability. D Frequent communication is perceived as the number-one factor leading to a positive safety culture. Safety personnel attend the GM’s staff meetings and monthly staff meetings at the base operations level. A series of weekly posters displayed throughout the operations building, including on the backs of bathroom stall doors, is seen by both management and union as an effective channel through which to communicate safety to employees at all levels. New electronic bulletin boards have a section dedicated to safety and are programmed by the bases and the transit control center to display customized messages. The local union also contributes to spreading safety by placing messages and articles in its newsletter or on its website. Employees attempt to resolve disagreements about work safety rules at the lowest level possible, initially through the section safety committee. If that fails, the issues are forwarded to the joint safety committee for resolution. E In addition to the employee safety rulebook, every operator bulletin or communication sent to bus operators stresses safety. Monthly safety meetings are held at each bus facility. The meeting time is changed from month to month to give most people the opportunity to fit the meetings into their schedules. In rail, the safety department publishes a quarterly newsletter that includes news; a spotlight on employee safety champions; announcements of safety-related training, improvements to station and equipment safety, and safety incidents; and performance data for the past quarter, such as total injuries and descriptions of Transit Agency Effective Safety Communication injuries. Rail employees have an opportunity to raise concerns through a safety hotline. Rail safety contacts appropriate departments immediately to resolve issues and maintains a monthly log to track calls and corrective actions. Rail safety also uses safety alerts, advisories, informational brochures, job briefings, and safety meetings to issue weekly areas of focus and quarterly themes. F The agency makes a special effort to solicit safety procedures around new rail and bus services. All employees are urged to identify any problems they see and bring them up for discussion. This can lead, for example, to new signage, curbs, and changes to the physical environment. In the maintenance shops, there are daily stand-up meetings with safety as a component. The safety committees deal with wide-ranging issues in a process managed by administrators in each mode. They review performance against goals. The committees identify problems and deal with them, often proposing solutions that combine engineering improvements and people issues—new rules or procedures.

121 Transit Agency Effective Safety Communication G New technologies are used to announce affirmative safety messages to drivers based on their real-time locations. The messages are recorded by trainers or superintendents and are triggered by the onboard GPS system. Managers feel that the system has received strong favorable reactions from the operators since its implementation. Clear procedures and policies also contribute to safety culture communication. An operations manager said, “the first thing you want to eliminate in safety culture is ambiguity.” Standard operating procedures (SOPs) and rulebooks are rigorously maintained and regularly updated. Serialized operational notices are issued to advise operators of particular safety concerns and can be incorporated into an SOP or rulebook. Union officers provide a regular newsletter and e-mails to drivers and also use social networking sites such as Facebook to help communicate safety to members. If an operator or maintenance person has a concern, he or she will bring it to the union, and a union representative will contact the operations manager to try to resolve the issue. H The board’s commitment that board members intend to play a significant role with respect to safety and safety culture has been delivered by the CEO consistently throughout the organization. The message is transmitted to employees through initial training, refresher training, letters, bulletins, quick review sessions with managers, and the local safety committees and subcommittees. Risks of and rationale behind safety rules are effectively conveyed. This is primarily accomplished as part of training, starting with initial training and continuing through refresher training and informal training in the field. I Methods for communication with employees range from labor-management meetings to safety committee meetings, videos in the driver’s room, tailgate meetings, and bulletin boards. The CEO recently did an introduction to a “rededication to safety campaign” video. In order to ensure that effective and open communication is maintained among all organizational levels and all employees, the agency implemented a computerized system accessible to employees at each base. Employees can submit any concern on any issue at any time, and management must respond in a timely manner. The system was originally designed for operators to enter route-specific information based on daily experience, but its use has been expanded to all employees to deal with safety problems and issues. It is an effective and innovative approach to employee safety communication and participation. The local union also uses newsletters and flyers and holds a safety fair each year. Table B-3. (Continued). data or lack of data-sharing across various transit systems and in vastly different operating environments. Agencies have instead resorted to using their own past performance as the benchmark. Several transit CEOs and safety officers interviewed expressed interest in a forum for similarly situ- ated agencies (by mode and size) in which safety experience and practices might be compared (see Table B-4 for summary of comments). Organizational Learning Organizational and individual learning is deeply ingrained in the everyday operations of these transit agencies. Recruit- ment strategies and practices to seek employees with a safety mind-set and filter out high-risk individuals help the orga- nizations establish the technical competence required to achieve safety. Initial and continuing safety-focused training and education keep employees vigilant and build up their technical knowledge and skills to ensure safety. More broadly, these organizations constantly learn from information collected and are willing to implement changes to procedures and equipment based on their learning. Recruitment. Identifying potential new hires who are likely to make safety a personal priority is an important emerging development in the transit industry. Many agen- cies review DMV records of applicants for operator posi- tions, looking for accidents and traffic violations. This is a continuation of the practice commonly applied to current operators. Following best practices in other industries and countries, a few of these nine transit agencies are beginning to use personality test profiles to identify high-risk individuals

122 Transit Agency Safety Data, Key Indicators, and Benchmarking A In the previous 8 years, the agency went from no analysis of accidents at all to performing monthly and annual analysis of all accidents using a centralized database. Measures tracked include collisions and injuries (fixed object, vehicle, passenger, and pedestrian) and associated costs. The monthly safety performance reports are not only shared among managers but are also the basis for safety awareness programs for operators (bulletin board, newsletter, etc.), communicating constant information about how the agency is doing. When data analysis identified a high collision rate among first-year operators, for example, the information was immediately brought to the attention of the CEO, and a series of measures were implemented, including the institution of a 6-month review of new operators and a new mentoring program. Another analysis revealing a high rate in right-side and fixed-object collisions led to targeted training to address these issues. These data-driven safety measures have had dramatic effects on safety records and overall safety climate. The agency participates in APTA’s bus safety audits. This initiative was begun after a spate of serious accidents. The agency is also part of an insurance consortium; there are three other properties in the region. It is critical to ensure safety in order to keep the premium in check. Safety personnel from all four agencies meet quarterly to make sure that things are done properly and to learn from each other. B The agency places great emphasis on conducting regular safety performance data tracking and root cause analysis when issues arise. For example, following a period of concentrated bus–pedestrian collisions, the safety department and training department conducted thousands of field observations and evaluations on left-hand and right-hand turns. The analysis report was presented at the executive safety committee, and the following actions were taken: Continue observations—play video in the employee lounge, Continue covert ride checks—place video on the agency intranet, and Refreshers on left-hand turns using training video. Like most transit agencies, the agency performs benchmarking against its own past performance, but it does so more frequently than other agencies, exceeding the industry average. Statistics from the NTD are sometimes but not regularly analyzed. C The agency is trying to go beyond on-street accidents and events to assess and analyze other accident rates, as well as injury, illness, and workers’ compensation costs. It returned to a basic assessment of accidents—what is an accident, what makes it preventable rather than what is the liability. Management credits the human resources manager, who focuses on costs and benefits of safety. The agency’s health claims and insurance brokers provide advice to help lower rates and premiums. To achieve better OSHA compliance, especially in the shops, the agency did a safety audit based on a walk-through, which showed where improvements were needed. D Success is measured using a number of lagging performance indicators, such as • • • preventable and unpreventable accidents, industrial injuries, and delays in reporting. The CEO reviews safety performance indicators weekly. There are monthly reports from the safety section on the basic statistics as well as comparisons to the industry standards for each base. The agency holds an annual safety breakfast for whichever base has reduced its accident rates the most. Agency conducts safety audits internally and externally through APTA and the state safety oversight agency. E The bus division measures safety performance based on OSHA reportable incidents and NTD required reporting in categories such as vehicle collisions per 100,000 miles and employee injuries per 200,000 hours. Safety statistics are also analyzed to target specific issues such as high frequency of collisions due to similar causes. Data from onboard cameras are used to assist with the analysis. Rail operation establishes the yearly injury reduction goals by department based on a 5-year average. These goals are published in the Rail Safety Program at the beginning of the year. A monthly report is published no later than 10 days after the end of the month. Reports are also produced to reflect trends, type, and location of rail accidents/incidents/injuries. When specific safety concerns arise, relevant parties such as rail operations and mechanical managers, representatives of the federal and state safety oversight agencies, and equipment manufacturers are engaged in extensive data collection and root cause analysis to resolve issues. The joint labor–management safety committees in rail operations conduct monthly on-site inspections following the committee meetings and recommend corrective actions as required. Table B-4. Safety data, key indicators, and benchmarking.

123 retraining. In the real world, unions maintain that such test- ing can lead to problems of perceived or even actual discrimi- nation. Somehow recruiting safe employees, however, is an important first step toward having a workforce that is con- sistently committed to safety (see Table B-5 for summary of comments). and exclude them from being hired as operators or in other safety-related occupations. Concern has been voiced, how- ever, by union leaderships that such tests lead to an over- emphasis on psychological testing and an underemphasis on (1) systems redesign and engineering efforts to eliminate or mitigate hazards, and (2) the importance of training and Table B-4. (Continued). Transit Agency Safety Data, Key Indicators, and Benchmarking F The agency has thorough tracking and reporting of safety incidents and a good system for analyzing and responding to incidents as they occur. With the exception of safety attitude questions on periodic all-employee surveys, the safety statistics used are mostly backward-looking. G Top management conducts a monthly safety review, which includes operations, maintenance, administrative, and workers’ compensation data. When the monthly chargeable accidents are considered too high, a mini–stand-down is initiated to “make sure everyone makes a recommitment of safety.” The maintenance department keeps a performance matrix. Superintendents are required to provide safety briefs to the maintenance director at least once a month. The top operations manager also conducts semiannual inspections at the maintenance base. The agency participates in APTA’s annual bus safety audits. Six months after the safety audit, it performs an internal check on its progress to correct problems. Due to lack of consistent industry benchmarking standards or data, the agency considers its current best benchmark as being against its own past performance. H The leading safety indicators include corporate safety rule compliance checks, quality and quantity of safety reporting by employees, and internal unannounced audits on bus rides. Recently, the board commissioned an outside evaluation of safety culture, which included a survey of hourly operations employees and group discussions with those employees. The results of the survey and discussions indicated the presence of a positive safety culture at the agency. I The agency examines trends in hours lost and other metrics and puts 99% of its focus on a proactive approach to safety. This includes the degree of employee participation in programs, the percent of closure of safety entries in the computerized reporting system, and inspection and audit results as leading indicators. B The agency evaluates points on drivers’ licenses and reviews annual DMV/accident records to check for safety violations committed by new hires and existing operators. It provides annual safety certification for operators, and the safety department conducts ride-alongs to check for good habits and conduct. The human resources department is exploring predictive statistical modeling to determine if certain parameters have a high correlation with safety issues and to determine if any existing bus operators fit that model. It is hoped that the model can be used on a continuing basis to evaluate operators before and after hiring to identify high-risk behavior patterns. G The agency conducts a full background check and verifies DMV driving records when hiring new operators. It also uses an industry-qualified analysis from standardized tests that probes candidates’ risk-taking attitudes. On the mechanical side, background checks are performed and potential employees are interviewed; questions are structured around safety. During the hands-on assessment that follows, the mechanical staff on the interview panel can observe the behavior of the mechanics to see if they are working safely. Note: No Table 5 input received for transit agencies A, C through F, H, and I. Transit Agency Recruitment Table B-5. Recruitment.

124 Such retraining is not generally carried out in most transit agencies (see Table B-6 for summary of comments received.) Consistent Safety Reporting and Investigation for Prevention A reporting culture exists where workers feel free to con- tribute to the informed culture through various safety report- ing mechanisms. Four of the nine case study agencies use a codified system for near-miss reporting, a relatively new prac- tice in the transit industry based on success in aviation and Training and education. Training is the foundation of all knowledge and understanding underpinning safe operations and a culture of safety. It is how organizational learning is pre- served and promulgated. With their strong leadership commit- ments to safety as a top priority, it is not surprising that these nine transit agencies invest heavily and effectively in workforce training. These agencies generally have strong technical train- ing systems (instruction in how to do one’s job correctly and safely) as well as training that emphasizes that safety always comes first. Many of these transit agencies have mandatory annual or biannual retraining in safety and for technical skills. A The director of safety and training conducted a full evaluation of the training process. The training program has been greatly expanded and lengthened. Standardized documentation was developed for classroom, equipment, commercial driver’s license (CDL), and line instruction training. The agency has a relatively complex bus system; it takes a significant amount of time and effort to get new operators trained. Over the years, total training hours and drive hours have increased by roughly one-third. Several years ago the agency incorporated the Smith system of defensive driving into its new-hire training program and started a summer review program for all operators, later to include a roadeo, with emphasis on safety. Given safety concerns, new drivers are restricted from driving routes near schools in their first 6 months. The agency implemented a mentoring program for first-year operators, with a minimum of six safety ride evaluations and follow-up if necessary. The director also conducts random safety ride evaluations on an ongoing basis. Judging from the feedback during interviews, this comprehensive system of operator training is considered highly effective by managers and workers in boosting the culture of safety. The maintenance department prepares a training matrix for each employee, tracking training needs and completion status. Employees work with original equipment manufacturers to train on equipment and safety in the workplace. For PPE, outside experts are brought in to train employees. A certified forklift trainer provides in-house training. The maintenance department also provides a mentoring program; each new employee is partnered with an experienced mechanic, one for each subsystem. B Training is mentioned as a major contributing factor in ensuring a positive safety culture at the agency. A new left-hand-turn training module was completed recently. It focused on operator “inattentional blindness” and the need for operators to make a mental note of pedestrians in the crosswalk and on street corners. The module also described the importance of waiting 2 seconds before making a left-hand turn to search the corners and the crosswalk for pedestrians. The module further described the “rock-and-roll” technique to eliminate blind spots. The left-hand-turn training module was also added to the biennial refresher training. A talking bus reminds operators that they must be alert for pedestrians while making a turn while also alerting pedestrians about the oncoming bus. The safety department is the lead player for all safety training in the organization. According to a safety manager, “much of the root cause analysis will determine deficiencies in the procedures, and we will drive the training to that end. When we were doing an investigation and found an employee was not responding appropriately to an accident, we will drive the training. As part of the safety review process, departments have to send their training to us for review.” The union considers some of the training to be effective, particularly the road instructor observation and training. This training is not based on discipline but rather is focused on improving driver skills and safety performance. The local union has started working with the safety department to develop a safety training video for brake rebuild mechanics. The business agents contribute by providing subject matter information such as a list of PPE and a description of the work environment. Transit Agency Training and Education According to the union, this is part of the overall effort to ensure member safety. Table B-6. Training and education.

125 Table B-6. (Continued). Transit Agency Training and Education D Beyond the initial training at hiring, drivers receive 8 hours of safety refresher training every 3 years. The safety department also designs and delivers special topic training, the most recent one being a pedestrian awareness session. Some base superintendents also established mentoring programs for employees working night shifts. E In the bus division, training programs are essentially driven by components of safety. The agency provides 19 days of training for new hires, covering all safety rules and regulations and defensive driving. It evaluates employee safety records at set intervals. When a part-time operator is converted to full-time, 1 additional day of training is offered. Incumbent operators also receive refresher modules of training on customer service, vehicle collisions, bus simulation, and so forth. The bus division has a state- of-the-art training facility and a joint training committee that periodically meets with the union, with safety being one of the topics. In the rail division, the training department typically focuses on technical training for maintenance and transportation employees, and safety is embedded in all its programs. The safety department provides 3 days of training to new hires on the basics of railroad safety and OSHA topics in both the classroom and field environment. The agency offers 6 hours of safety training on a quarterly basis for all supervisors hired or promoted during the previous year, or as requested by departmental supervision. In addition, rail safety developed a basic training program for foremen and other frontline supervisors on their safety responsibilities. It has three sections: how to properly conduct a safety job briefing, personal protective equipment, and injury reporting procedures. This training is provided on a monthly basis. The engineering department has a 2-day class every year for its employees that covers basic road-worker safety, bridge-worker safety, and OSHA requirements (fault protection, lockout/tag out, confined space, etc.) for which other employees are normally trained only once. For maintenance employees who work night and weekend shifts, the maintenance department also provides e-learning on various subjects. Labor is involved in making training recommendations through the joint labor and management fact-finding and problem resolution process of the accident/incident review team. F Agency officials emphasize the importance of well-designed safety training and training components in technical job training. Training of new hires and apprenticeship training (for those going through apprenticeships solely in maintenance occupations) are widely seen as exemplary. C The Smith system is a cornerstone of the safety environment. It focuses on driver behavior and training, was provided to all staff, and is refreshed with periodic videos and quizzes. All hourly employees and supervisors are required to qualify for the CDL license and must meet training requirements, even if they do not operate vehicles on the road. Drivers need 10 hours of in-service training annually to stay on status. Trainers may be peer trainers or subject matter experts—state troopers to talk about winter driving, physical therapists to talk about wheelchairs. The special training needed for paratransit drivers recently included dealing with clients with developmental disabilities. Employees may also receive video-only training if their route schedules conflict, and roadeo participation may also qualify. Safety training includes biannual review of material safety data sheets and check-in on how to use equipment. Accidents are key indicators for retraining. A dedicated training department is being developed. Operator training is provided by a strong group of behind-the-wheel trainers who have a good safety record from all operating divisions. They are held to a high standard of performance and provided with uniforms and training, and they participate in quarterly training roundtables. Other drivers reach out to them since they are recognizable resources. Training is designed to allow drivers the freedom to challenge what they may see as nonsense. They do not use a top-down lecture format. (continued on next page)

126 common than financial rewards for hourly employees, most of which are covered by union contracts that do not allow for individual financial awards. Positive individual safety evaluations can lead to public recognition, badges, and other nonfinancial symbolic awards, while in these agencies safety performance deficiencies generally lead to focused retrain- ing. While exempt employees often have safety built in as a discrete element in their annual performance reviews, non- financial incentives for hourly employees are more typically (and more productively) focused on positive group perfor- mance and competition among teams, garages, depots, and so forth, leading to shared benefits such as paid days off or public recognition in the workplace and at awards banquets. In these transit agencies, rewards are generally not offered for reporting near misses or safe behavior (see Table B-8 for summary of comments). High Level of Organizational Trust The transit best-practice cases illustrate a core finding that Reason and others have emphasized: mutual trust is an essen- tial feature of a positive safety culture. Trust is built on a foun- dation of past performance. It cannot be given but only earned. This is accomplished when people consistently keep promises and act in good faith to solve problems rather than just assign blame. Transit agencies with positive safety cultures under- stand that trust is closely tied to what Reason calls a just and informed culture (see Table B-9 for summary of comments). new FRA initiatives. Among these four agencies, three are large, one is medium-sized, and all operate rail transit. Within the agencies at which a near-miss reporting system has been fully implemented, it is perceived as an exceptionally effective tool to improve the organizations’ safety culture and safety performance. Agency E provides a good example in this area. In other locations, even though employees are encouraged to report unsafe conditions or near misses, they may not be fully shielded from discipline due to lack of a completely no- fault, anonymous system. Employees sometimes consider the agency’s effort lacking in taking actions to resolve issues. Recognizing the potential value of employee safety reporting without fear of retribution or discipline, several agencies have started to explore experimenting with such systems. Accident and incident investigation systems are robust across all nine agencies. These agencies in general put a heavier emphasis on identifying system failures, rectifying the problem, and retraining employees rather than blaming and disciplining. Unions are normally not involved in the initial investigation stage but are asked to review findings as part of an accident review committee. Root cause analysis is used in at least three agencies (B, E, and I). See Table B-7 for sum- mary of comments received. Employee Recognition and Rewards Safety recognition and reward systems play a role in virtu- ally all these best-practice agencies. Recognition is much more Table B-6. (Continued). Transit Agency Training and Education G The agency has an extensive training and retraining program for bus operators. A staff of full-time instructors performs about 4 hours of classroom instruction, including in SOPs and its rulebook. All instructors are certified by the National Safety Council, the Transportation Safety Institute, and the state DMV as examiners. Bus operators are put through 9 weeks of behind-the-wheel instruction that includes fundamentals and route training. They then spend the tenth week picking up passengers while the trainers are on the bus advising them. The student–instructor ratio is no more than three students per instructor. Union trainers are also used for peer training when new equipment is purchased. Peer-to-peer training facilitates the introduction of new equipment into the workforce. When operators are due for their annual recertifications as required by the state DOT, they are provided with more than the legally required minimum training. Simulator training is focused on skills and is complemented by ride checks, gate checks, and safety messages during the course of an operator’s work. In maintenance, labor and management established a joint maintenance training committee to direct a combination of classroom, on-the-job, and mentor training targeted to areas of greatest need, as identified through a skills gap analysis. I Joint accident reduction teams and safety committees recommend the appropriate levels of safety training and retraining for employees. The agency ensures that employees are adequately trained on safety matters by constantly reviewing performance and mounting frequent safety campaigns. There is annual safety refresher training for frontline employees after initial orientation safety training. Note: No Table 6 input received for transit agency H.

127 Table B-7. Consistent safety reporting and investigation for prevention. A When accidents or other safety problems occur, the agency sends frontline supervisors to assess the scene, take photos, conduct interviews, and get employees involved. Video cameras are installed on all buses. A real-time GPS system tracks vehicle speed. The safety and training committee is generally not involved in investigation. If an employee is subject to discipline due to wrongdoing, he/she can initiate an appeal process. The accident review board will then be assembled and will consist of two operators, two supervisors, and a representative from local law enforcement. This board is a subset of the safety and training committee and will make a final ruling. B The agency promotes and encourages all employees to identify and report hazards or potential hazardous conditions in the workplace and operating environment without fear of reprisals. Management considers it important to mold a positive safety culture that is non-punitive. Instead of blaming the last person who touched the equipment, management conducts root cause analyses to determine which organizational factors—procedures, human engineering, training, supervision, communications— may have contributed to the accident. The agency is among a handful of transit agencies that implement a near-miss reporting system in its rail operations. Unsafe activities or conditions can be reported immediately and anonymously via a safety hotline. This is followed by a thorough investigative process. C Management reports an open-door policy all the way to the top. The intent of accident assessment is to eliminate the blame process and replace it with a corrective- action approach. The program includes progressive discipline. To resolve conflicts with the union, this includes initial warnings, but second infractions can lead directly to discipline. If accident assessment indicates a need for retraining, the required training following incidents is paid overtime. Accidents (and appeals) are evaluated by a team of supervisors and operators who look at the facts, make their case, and vote. The process is educational for drivers and managers. Findings that an incident was preventable can be appealed. There is an anonymous comments box along with anonymous accident reporting forms, a general open-door policy, and state whistleblower regulations. On the street, incident reporting goes to the dispatcher. A safety director and risk manager go to accidents and work with supervisors who are trained to do scene-of-accident investigations. Incident reports are submitted on a page with room for comments in response; this is turned in to the dispatcher. Because of the no harm, no foul approach, people are encouraged to report even small property damage; this is used as information to direct improvements rather than as a club for punishment. If no response is received after 14 days, the employee can inquire about follow-up. For urgent safety issues, employees are encouraged to go to the safety manager. A near- miss reporting system has been discussed but is not yet fully in place. An onboard road observation form is used by all administrative staff when traveling on public transit; they may list positive and negative observations but are limited to commenting on areas in which they have experience. The categories are not limited to safety but include customer relations and other issues. D Employees use a system to tag a piece of equipment that is considered unsafe or Transit Agency Safety Reporting and Investigation for Prevention report an unsafe condition. Once tagged, a machine is shut down. The base manager will then send a copy to the safety department to resolve the issue. Drivers can also convey concerns to the joint safety committees or bring up concerns to the union, which in turn introduces them at a joint committee. E A unique feature of the agency’s safety system is the recent implementation of a near-miss reporting system in rail operations, modeled after a system used by the airline industry. This agency is the only one among the FRA pilots to implement a system-wide program to include all services (main tracks and yards). For the process to work, confidentiality must be maintained. The agency has a written agreement with all of its local unions to implement and maintain the process. This agreement provides for a joint labor–management peer review team and a senior management support team. Labor and management team members go through training on how to maintain confidentiality and on conducting root cause analysis. This training is facilitated by a third-party consultant who is paid by the agency to sit in on team meetings. Under this new system, employees can report any incidents they witness to a central data center where their data are combined with information from other railroads participating in the pilot. Information then passes to two federal agencies for technical analysis. Those agencies scrub the data of train numbers, locations, and information that could identify employees involved in mistakes. The data sheets are then returned to the joint peer review teams on each property. Each peer review team (continued on next page)

128 Table B-7. (Continued). Transit Agency Safety Reporting and Investigation for Prevention meets monthly to review incidents and recommends corrective action to the senior management support team. The support team meets independently to review these recommendations and makes a decision on final actions. The confidential near-miss reporting system “allows us to gather data that we need to hopefully improve what we never would have gotten unless there was a major incident, which is a positive for us. It’s a positive for [employees] because it allows them to report things without the fear of it affecting their certification. And it has strengthened the labor union relationship.” Union representatives see how this has brought management and labor closer together. Instead of discipline, what employees can expect when they report an incident is a veil of confidentiality and a promise of protection from retribution from the railroad or the union. They are thoroughly interviewed by investigators, who will elicit a description both of the circumstances leading up to the accident and of the employee’s frame of mind before, during, and after the incident. G When incidents occur, transportation and safety staff trained and certified in accident investigation and reconstruction conduct firsthand investigations. A joint labor– management accident review committee then grades the accident as either preventable or nonpreventable. The committee consists of two union representatives, two management representatives, and one mutually agreed-upon neutral party. If there are extenuating circumstances or a recurring issue, or if an operator brings up concerns that are not properly addressed, these factors are taken into consideration when determining whether to grade the accident as preventable or nonpreventable. Any concerns or issues that stem from daily operations may be referred to the safety task force for further action. The accident review committee can also make recommendations for system changes. The company provides accident review training to new union leadership to help them carry out their responsibilities as members of accident review committees. The training covers accident investigation, documentation, and evaluation. The union believes that it is to the agency’s benefit to have union officials involved because it cuts down the cost of arbitrations. Operators and mechanics can appeal the accident review committee decisions if they are not satisfied with the outcomes. If there are frequent customer complaints regarding an operator or if the operator is involved in an accident, management gives that operator 4 hours of retraining, regardless of the accident grading. Operators used to be automatically suspended pending investigation, and if the accident was deemed nonpreventable, it was removed from the operator’s record and lost wages were reimbursed. The new policies allow the operator to go back to the original post right after the retraining, even if the investigation results are pending. The commuter rail side of the operation has a formal near-miss reporting system, and the bus division is discussing how it might be adapted. H Employees use a standard form to report unsafe conditions, hazards, and near misses. It can be submitted anonymously. 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 established time limits. On receiving a completed near-miss 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 elimination or mitigation of the hazard or near miss. These recommendations may include modifications of equipment or facility design, maintenance schedules or common practices, operating rules and procedures, employee training, bus stop locations, rail station layout, traffic control devices, road design, traffic signs, and markings. Management must inform other employees of the existence of and circumstances surrounding the hazard or near miss. Hazardous or near-miss cross-departmental incidents that cannot be resolved will be reported to agency-wide safety staff, who will resolve the situation by working with the departments involved. Responses to near-miss reports are distributed to the individual involved and to the appropriate local safety committees. The agency has a detailed procedure for investigating accidents and incidents. Investigations are initiated at the supervisory level, with support from other staff as necessary. Agency-wide safety staff are involved if the severity of the accident warrants. The accident review board reviews the reports and recommends disciplinary action.

129 Transit Agency Safety Reporting and Investigation for Prevention I The agency’s computerized employee reporting system is successful in encouraging employees to report safety problems and raise issues. It is easy for employees to use and to track responses. The problems and issues raised and the action taken are also made known to all. The accident reduction team program also ensures that all of the relevant issues are addressed, that all levels of employees, including union representatives, are engaged in problem solving, and that the workforce understands the basis for any new process or procedure that results. In investigating accidents or other safety and health problems, discipline and prevention of recurrences are balanced by dealing with prevention first and “figuring out who is to blame later.” The agency has a near-miss program, which has no discipline associated with honest self-reporting. The agency is looking for honest feedback from people who are involved in near misses as well as from those who observe an unsafe condition or act. Note: No Table 7 input received for transit agency F. Table B-7. (Continued). A All operators are involved in an annual summer review in which safety is a major component. Each operator goes through an obstacle course and gets rated for performance. The director of safety and training spends one-on-one time with operators to review safety issues, analysis, and actions. The company holds safety banquets and award dinners each year to recognize safety champions among employees. C Workers with injury-free periods are rewarded with badges, a safety banquet, and breakfasts prepared by management. Accolades are awarded for those who provide solutions to operations and safety problems. If a division achieves 90 days without an on-the-job reportable injury, supervisory staff prepare breakfast. D The agency has annual safety competitions wherein awards are given for bases with better records than others. Operators without preventable accidents for a certain number of years are also recognized. E For bus employees, safety culture is reinforced with safe worker awards; employees are recognized at annual award ceremonies for not causing preventable accidents (operators) or injuries (maintenance) for a certain number of years. System-wide in every division, awards are given for most safety improvements overall on three measures—customer safety, employee injuries, and vehicle collisions. The rail division has had safety programs tied to team performance where the team with the fewest reportable injuries would win incentives. However, budget constraints caused the program to end. The division also has an employee recognition program wherein employees can be nominated for “doing remarkable things,” including contributing to the safety of operations. Workers are recognized in front of their peers. Employees are also recognized in the safety newsletter for being safety champions. F Safety is a distinct factor in performance appraisal at the agency, at all levels of the organization. Managers and supervisors are held accountable for the performance of their groups. For bargaining unit employees, there are no performance appraisals as such, but there are team incentives and campaigns designed to improve safety performance. Winning teams, for instance, can get a paid day off. The agency also has safety award programs for operators—insignia for uniforms based on annual and multiyear accomplishments. In maintenance there are awards for not having injuries on a team. Transit Agency Employee Recognition and Rewards Table B-8. Employee recognition and rewards. (continued on next page)

130 A Managers and hourly workers believe that there is a good level of mutual trust when it comes to safety. A lot of that has to do with relationships developed through employee committees and an open-door policy. When employees see a genuine commitment from management, it makes it easier to achieve buy-in. D Top management considers there to be “a solid labor–management relationship” and “very good morale.” The management respondent said, “generally speaking, the rank-and-file employees like their jobs, and they are treated with respect, and that works in the more structured labor–management approach. Negotiations tend to be interest-based and they tend to be collaborative at a very good level.” E In rail, labor and management share a positive relationship that both enables and reinforces a range of joint activities, including safety committees and the near-miss reporting system. One of the managers said, “[The union] wants to change the culture, they want their employees to work safely, and they want their employees to go home the same way that they came here. That is a very strong positive for management to work with union effectively.” The rail union representative shared a similar sentiment: “Over time, [the agency] has realized the value. Years ago they gave me a safety award for working so long without accidents. Crews were acknowledged in public for protecting the property and people. The more we do that, the mutual suspicions we have with regard to each other can dissipate because safety is a mutual interest that benefits our members and the public.” G Trust is established through multiple layers of interaction. Supervisors are asked to consistently follow the open-door policy and interact with employees so that the latter feel comfortable talking to their supervisors. “Trust is established by being available, open, interacting, and doing what you say you are going to do. Even if the answer isn’t what they want to hear, you have to make sure you get back with the employee and explain to them why it is not feasible and show them that you researched it and did what you said you were going to do.” Note: No Table 9 input received for transit agency B, C, F, H, and I. Transit Agency High Level of Organizational Trust Table B-9. High level of organizational trust. Table B-8. (Continued). Transit Agency Employee Recognition and Rewards G The safety culture is reinforced with safe worker awards for not having preventable accidents (operations) or workplace injuries (maintenance) for a certain number of years. There are also annual safety competitions between maintenance facilities. Awardees are invited to board meetings, and the board members present the awards. This underscores the importance of the investment made in training and equipment. Beyond the formal safety awards, employees are also given bonuses of $50 to $75 for meeting the yearly safety performance matrix. H Safety performance is an evaluation factor for managers and supervisors. I Employee incentives include presenting safety awards to deserving colleagues at award ceremonies. The only safety-related financial incentives are contractual bonuses for reduction in workers’ compensation costs. Note: No Table 8 input received for transit agency B.

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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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