Improving Safety Culture in Public Transportation (2015)

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131 A P P E N D I X C Strong Leadership, Management, and Organizational Commitment to Safety Table C-1 lists key points related to leadership, management, and organizational commitment to safety that were raised during the interviews with the organizations. Company Mini–Case Study Detail Table C-1. Key leadership and organizational commitment points. Company Key Points AA Each employee performs safely and accepts responsibility for his or her role. A line of distinction is not drawn according to position or title; from the CEO to the rank and file, each person is responsible for safety. This practice has created a sense of company unity among all employees. BB The company believes that when safety is put in the hands of employees, and systems and tools for employee feedback are provided, feedback will come, and employees will be invested in company safety practices. Every year in an annual performance evaluation, safety criteria (which employees helped create over the years) are reviewed with individuals and managers. Employees are responsible for managing their own roles on the job site without close oversight, with safety being the core value. CC This company’s positive safety culture stems from the chairman and executive council. Some years ago, the safety office was moved to work directly with manufacturing and engineering to ensure that the highest levels of standardization were being followed. Safety is under the purview of the chief technology officer, supporting a collaborative environment among technology, engineering, and manufacturing. DD Operates with five core values; safety is number one. Believes in developing a committed employee rather that a compliant employee. In 2004 there was a shift: safety was no longer the sole responsibility of the safety department; it became the responsibility of the supervisors, who use the safety department as a resource. A new emphasis has been placed on having no fatalities and lessening the severity of incidents. (continued on next page)

132 Employee/Union Shared Ownership and Participation Table C-2 lists key points related to employee/union shared ownership and participation that were raised during the interviews with some of the organizations. Company Key Points EE The company believes that safety must be in the CEO’s DNA. Accountability for safety concerns/incidents has to be placed front and center with corporate leadership. This company does not tolerate leaders putting production or quality above safety. FF The culture of safety is ingrained in its leadership, structure, and key processes. Ownership of an incident is assumed by all stakeholders, especially the CEO. Employees are encouraged to participate in behavioral observations, incident investigations, employee training, and the creation of safety policies and procedures. Accountability begins with the hiring process. Individuals are evaluated on risk taking through critical tasks and are weighted against key performance indicators. GG The chairman would say he is the chief safety officer; the plant manager in each town would say he or she is chief safety officer, and so forth. It is a role that everyone plays. HH The company has a cross-office functional group that includes eight offices, with safety people in each; the CEO interacts directly with this group. The company does not impose punitive sanctions on employees involved in near misses/safety incidents but instead encourages people to share information about them and use them as learning experiences. II The CEO is very visible and spends a minimum of 2 days in the field each month. He communicates regularly and often with the safety manager, who also has a regular and strong presence in the field. Table C-1. (Continued). Company Key Points BB The organization takes great pains to ensure that employees hired from the union hall (which by contract is how the company is required to hire employees) choose to remain on their jobs. The company has made a significant investment in safety training. It recognizes that employees can choose to return to the union hall at any time to be reassigned to another job site at the same wage and benefit level. It is understandable that the company takes pride in high retention levels, which it attributes to its strong safety culture orientation. The interviewee highlighted two union hall employees, each retiring from the company with 36 years of continuous service. Those individuals were active members of the company community and played important roles training new employees and union members, and they felt great loyalty to the company and to its safety culture. The fact that so many employees choose to stay with the company supports the finding that a positive safety culture leads to improved retention. At the same time, the company is reaping a major return on its investment in safety training. The company uses joint safety committees to help monitor safety performance, improve safety programs, and generally promote safety. Table C-2. Key employee/union shared ownership and participation points.

133 Effective Safety Communication Table C-3 lists key points related to effective safety communication that were raised during the interviews with some of the organizations. Table C-2. (Continued). Company Key Points CC Unions play a huge role in shaping safety culture at the company. The company negotiated separate agreements with unions based on their commitment to working together, creating the collaborative environment needed to achieve a zero-injury mind-set and to incorporate necessary safe standards to ensure consistency at all worksites. From these agreements, the company created numerous improvements and safety programs. The company’s largest union, the International Association of Machinists, partners with the company on a joint health and safety institute, whose mission is “[t]o ensure continuous improvement of workplace health and safety for the IAM bargaining unit of employees of the company and to create an environment characterized by open-minded communication and mutual trust between workers and management on issues of health and safety.” One example is a program called Safety with Technology, which uses technology such as iPads and handheld devices to accomplish tasks, allowing for real-time information to reach the labor force and real-time organizational learning to take place, improving safety records. DD The company has developed its labor–management relationship to a point where 22 full-time union officers serve as safety officers and trainers. There is union involvement at every level, up to the international president of their largest union. Union officers conduct ride reports and respond to requests from the safety department to support employees with performance difficulties. The 22 full-time union officers are employed in the operations department. The company was forthright about the difficulty of improving labor–management relationships while working toward a just culture. Over time, the company’s leadership acknowledged that safety improvements would only be made with increased participation from the union. The company’s program was initially introduced by consultants and developed slowly. Consultant involvement unintentionally insulated management and union leadership, preventing them from accepting ownership of the program. Early union and management safety meetings were stressful and less than productive, but over the years the program evolved into real contributions and solutions from managers and union members at various sites working together one-on-one. This cooperation and progress grew into appointment of the 22 union officers as full-time safety officers in operations. Direct communication with employees, emphasizing safety training and elements, dramatically increased the program’s credibility. The company uses joint safety committees. GG The company uses joint safety committees to help monitor safety performance, improve safety programs, and generally promote safety. II The company also uses joint safety committees to help monitor safety performance, improve safety programs, and generally promote safety. Company Key Points BB Many companies use messaging in facilities and on equipment to reinforce the safety message. At this company, all equipment, whether trucks, trains, or signs at facilities, displays the message “safety first.” Employee input and feedback are key ingredients in message development, and many companies reported having safety programs that were created and are monitored by employees specifically. Weekly management calls at the company are conducted and led by the CEO and begin with a review and discussion of safety performance and safety incidents. The company also conducts quarterly meetings in which all employees are invited to participate. Key performance indicators, goals, and objectives, and any training needs that might be unmet, are discussed in an open forum. After all safety issues are addressed, other teams, such as sales and operations, are given the opportunity to address issues they deem necessary. While the company is union organized, and attendees at the meetings are not compensated monetarily for this time (meetings are after hours, typically lasting from 4:30 p.m. to 6:30 p.m.), the attendance rate is approximately 85% of available workforce in any region. Table C-3. Key safety communication points. (continued on next page)

134 Company Key Points CC The company communicates safety points and investigation results at morning stand-up meetings at a local level. These meetings are typically conducted in manufacturing facilities and include reviews of any safety issues or activities that are relevant from the preceding 24 hours. The company believes that the best way to communicate safety information is employee to employee. Supervisor–employee discussions are viewed as a positive tool to communicate safety information. DD Company supervisors conduct a weekly locker-room talk that uses actual case studies of past incidents. GG The company believes that open and available information is key to safety success. It communicates with employees regularly by e-mail and shares safety concerns, issues, and solutions in regular e-mail correspondence. HH The company believes that open and available information is key to safety success. It communicates with employees regularly by e-mail and shares safety concerns, issues, and solutions in regular e-mail correspondence. The company worked with a development company to create a smart-phone application that puts crisis management flowcharts at people’s fingertips. From the company’s corporate safety director: My smart phone has all of our area office information on it, but if you’re the area safety director in our Albuquerque division, it has your protocol as the area safety director—what you need to do in a crisis. You can scroll down, all the numbers are live, our media statements are there, the protocol on how to handle an incident is right there at their fingertips so they know what to do in case of an emergency. The next stage of this should roll out within the next few months; it will be able to send out notifications, just like any other iPhone app, to everybody in the company, similar to our e-mail that we send at the end of the day to tell everybody something has happened, whether it is good or bad. . . . people will find out about something through YouTube quicker than we can get it through our company. Well, the reason it kind of started was, we had a job site and we had a very small crane rollover. Nobody was hurt, nothing like that, and actually our Corporate VP, Business Development and Marketing just stepped out for a second—she was at a meeting in Kansas City and this happened in Oklahoma City; and she heard about it from somebody else within ten minutes of it happening because they saw it on YouTube before we could even get to the job site to get it secured and see what happened. That’s how fast all of this stuff happens. . . . so, our crisis flowchart worked at the local level in that incident, but not at a corporate level. She should never be blindsided by something and neither should one of our division presidents around the country. So, we tried to streamline that process, which is why the app was invented and we’re going to expand on it over the next few years; right now it’s a tool that we hope that we never have to use. II The company uses 55 leading safety culture indicators and measures them in real time, also monitoring them daily. When results warrant it, issues are identified collaboratively and discussed, and all parties work together toward addressing the problem. Each month, the CEO informs the board of directors of all safety issues addressed. Causation is explained, with the goal of monitoring for improvement and accountability in the field as well as at management levels. There are also open lines of communication, and this company is viewed as the industry leader in safety. Table C-3. (Continued).

135 Proactive Use of Safety Data, Key Indicators, and Benchmarking Table C-4 lists key points raised related to the proactive use of safety data, key indicators, and benchmarking that were raised during the interviews with the organizations. Company Key Points AA The company measures progress against its own performance and the performance appraisals of its employees. It attributes much of its safety culture success to closing the gap between union and management. Employees are provided information about safety data, expectations, company targets, and milestones. The idea that performance can be improved through accountability serves as the foundation for its favorable position within the markets serviced. BB The company does not perform individual performance evaluations since employees are unionized. CC The company benchmarks against internal facts and figures and against other industry leaders. DD The company benchmarks against Class 1 railroads. It also benchmarks against the airline and trucking industries, which are viewed as competitors. Performance indicators are used in every manager’s evaluation. EE The company is constantly looking globally at how standardized practices across businesses affect the drive to zero incidents. At the local level, facilities measure hazard causation and proactive or leading indicators to evaluate overall risk mitigation. It benchmarks against its own diverse business interests, other petrochemical companies, and other industries that face similar levels of potential hazards. Performance feedback is given to all employees, whether union or not; benchmarking and feedback have given employees the confidence to establish zero tolerance as an achievable goal for 2015. FF Benchmarks are established from the results of a safety perception survey. The company is large enough globally and varied enough in its industry involvement that it primarily benchmarks against its own business. Table C-4. Information, metrics, and benchmarking. (continued on next page)

136 Company Key Points HH Because the safety program and culture is so successful, it is being used as the model for other business areas (quality, schedule, budgeting, etc.). The company believes in educating subcontractors as well as employees, because it believes that creating a safer industry is the overall goal. Benchmarking includes annual award competitions and working with the Associated General Contractors of America, to which statistics can be submitted and analyzed for feedback about the position of the company in relation to peers and industry standards. Senior management is active on several peer group committees through various industry organizations. Since the company views itself as an industry leader in safety, its leadership focuses on continuously improving existing programs that work rather than developing new ones. With respect to information and data collection, the company relies on: Orientations—get valuable information about how to better prepare workers to go out into the field. Audits—not just conducted by safety directors but also by superintendents and employees. Employee observations—What are they seeing out there every day that can help make the company better? Are they satisfied that they are working in a safe environment every day? Communication within the company—open doors to all with no repercussions for reporting near misses or safety incidents. II The company is considered the industry leader in safety because for the previous 50 years no loss of life could be directly attributed to safety incidents. Strong emphasis on leading safety indicators in addition to a risk index. This company relies on more than 50 leading indicators, the largest number of leading indicators mentioned by any company interviewed. • • • • GG The company uses other industry safety incidents to learn more about what it needs to do to improve its culture. It is working on risk tolerance and on encouraging employees to actively care and to approach others, encouraging workers not to hesitate when intervening if someone is putting him- or herself at risk. The company benchmarks performance as well as best practices with oil and gas companies and trade groups (such as the American Petroleum Institute) at a minimum of annually, but ideally on a quarterly basis. At the corporate level, there are few leading metrics, because leading metrics tend to be process-specific. OIMS assessments provide ratings at the corporate level, but most leading metrics are at the local level, where there could be a dozen or more. Examples: What is the percentage of employees who are on track for their training for the year? What is the timeliness of follow-up on incident investigation findings? What is your maintenance status versus your ongoing maintenance schedule? What is the status of the number of drills you’re supposed to have conducted versus your target for the year? • • • • Table C-4. (Continued).

137 Consistent Safety Reporting and Investigation for Prevention Table C-5 lists key points about safety reporting and investigation that were raised during the interviews with some of the organizations. Company Key Reporting and Investigation Points AA The company uses an open reporting system. Safety meetings provide an open and safe forum to voice and address safety issues. BB There is no such thing as loss-time action for the report of a safety issue. Safety reporting is not a fault-finding process. The reporting, investigation, and determination of preventability are separate from any consequence of a disciplinary finding. Employees are kept active during investigations, if at all possible, allowing them to continue in their roles while safety issues are investigated and addressed. When an incident happens before noon anywhere in the country, it is reported to corporate loss control no later than close of business; incidents that occur after noon must be reported no more than 24 hours after the fact. Root call analysis is employed to identify facts and suggest solutions. The members of the safety committees, which exist in each territory, participate in these root call analyses. When this process has been employed, 30, 60, or 90 days after the incident (depending on its severity), changes are analyzed to gauge effectiveness. CC Root cause investigation and analysis are used for safety incidents and near misses. Investigation teams are formed at a local level, steered by supervisors, and include key employees and staff who are knowledgeable about the incident and the techniques of root cause analysis. The company has a dedicated Internal Reporting System (IRS) that includes OSHA-demanded reporting and company standards for reporting near misses, accidents, and incidents. The IRS houses data collected daily, weekly, and monthly driven by leading and lagging indicators. The IRS also drives the analysis process and performs quality checks for corrective action. Specific safety professionals are brought in to assist investigations when necessary. DD The board will be dissatisfied with the company’s having the most improved safety record in history if there is a single fatality. The company has developed a “potential for injury” assessment as a leading indicator to supplement “injuries per 100,000 miles of railroad.” The CEO and VP of operations and engineering review every reportable accident investigation every Monday at 7:00 a.m. The CEO begins every earnings call with a review of the safety record for the quarter. Every board meeting begins with a report on the condition of the safety culture for the prior month. Table C-5. Key reporting and investigation points. (continued on next page)

138 Company Key Reporting and Investigation Points FF The company employs a centralized reporting system across all continents and regions, with data entered monthly. The company documents major incidents involving a fatality or serious injury and reports them to the CEO immediately; lesser medical incidents are reported to the local president. The company values employee participation and encourages involvement and input for creation of policies, procedures, and investigation processes. EE The company uses the Apollo Root Cause Analysis method and employs facilitators who have undergone specialty training. Formal reports are filed for each incident and are published and available to employees. The company encourages open reporting environments and benchmarks safety performance against peers in the industry. The company uses climate assessment tools to measure employee engagement and review global employee opinion every 2 years. The company uses a simple system (red, yellow, green) when asking employees to assess safety factors. GG The company’s Operation Integrity Management System includes 11 key elements, one of which is incident reporting and analysis. This element lays out the expectations and processes involved for people to report safety incidents within their organizations. All incidents and near misses that are reported are investigated. Lower-level, less complex incidents are analyzed with a fairly simple root cause analysis flowchart that includes five or six key questions used to identify contributing factors. More complex and significant incidents are addressed using more complex tools, in particular Tap Root, a computer-based tool that drills down in very fine detail to find root causes and contributing factors. All information is entered into a database; each incident is assigned an “owner” and “follow-through due date” and is tracked until closed. HH Within 24 hours of any safety incident, there is a conference with all parties: leadership from that office, operations from that office, people involved in the incident, the CEO, and the corporate safety director. Daily e-mails are sent out to all staff at 4:05 p.m. to review and address relevant issues, allowing safety to be the last thing on people’s minds each day. E-mails are a major tool; easy to read and graphically concise, they allow employees to identify key points easily. Every single employee, including upper management, is evaluated on safety performance in annual reviews. Safety is a part of every person’s job description and goals for the year. II Fifty-five performance indicators are measured by the hour. Safety culture is measured using a survey developed by an Australian university; the survey uses open-ended questions, allowing employees to answer at length if so desired. The company has an open occurrence reporting system that is accessible to everyone in the organization. Reporting can be done anonymously or openly. Overwhelmingly, employees choose to report openly. All departments have a small safety cell that promptly investigates each occurrence. These cells make recommendations to resolve issues, change procedure, and/or change policy. Table C-5. (Continued).