Improving Safety Culture in Public Transportation (2015)

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1 S U M M A R Y Introduction Safety in the workplace—any workplace—is not accomplished through the simple act of posting a sign noting the number of days that have passed without an injury or accident. It is a matter of the culture of that workplace. Culture has been called the personality of an organization. It consists of the assumptions, values, norms, and tangible signs (artifacts) of organization members and their behaviors. The goal of TCRP Project A-35 was to help transit agencies improve safety culture in public transportation. The research team needed to answer a number of key questions designed to provide insight into safety cultures inside and outside the public transportation industry: • What is safety culture? • How do key transit agency stakeholders perceive safety culture? • How are safety values and safety information communicated throughout the agency— that is, from the board to the shop floor and the worker? • What key components affect safety culture? • What methods do transit systems use to assess, improve, and monitor safety culture? • Are there transit agencies with positive safety cultures? • What factors set these agencies apart from their peers? • How are improvements in safety culture made? • What methods do organizations outside the public transportation industry use to assess, improve, and monitor safety culture? • What industries and organizations outside the public transportation industry have posi- tive safety cultures? • What factors set these organizations apart from their peers? • How are safety culture improvements made? What are the methods for monitoring and achieving continuous improvement? • How can these insights be applied to the public transportation industry? This project has recently become more important to public transportation because of the passage of MAP-21. MAP-21 stands for “Moving Ahead for Progress in the 21st Century.” This legislation grants the Federal Transportation Administration (FTA) license to establish and enforce a new comprehensive framework to oversee the safety of public transportation in the United States. MAP-21 requires that the FTA develop safety performance criteria for all transportation modes, vehicle safety performance standards, and a public transporta- tion safety certification program for safety auditors and safety oversight officers. It requires all transit agencies receiving federal funds to develop and have certified a safety plan and all states to establish safety oversight programs. MAP-21 also gives the FTA comprehensive Improving Safety Culture in Public Transportation

2authority to issue directives and conduct safety inspections, audits, and investigations. MAP-21 gives the FTA enforcement authority as well, including the option of requiring that formula grant funds be spent to correct safety deficiencies before they are spent on other projects (U.S. Department of Transportation, Federal Transit Administration, 2012). Finally, the sub- sequent formal adoption of the safety management system (SMS) approach as the FTA’s legislatively required comprehensive safety framework ushers in “the promise of a stronger (safety) culture for employees and managers to work together to solve safety problems” (U.S. Department of Transportation, Federal Transit Administration, 2013). Literature Review Highlights Since little has been written about the role of safety culture in public transportation, the research team relied heavily on the literature of the theory of safety culture and its applica- tion to aviation, nuclear power operations, natural resource extraction, and related fields. Early accident investigations and discussions of safety science mostly focused on techni- cal failures and human error. There were a few studies that focused on organizational and social factors. For example, Turner (1978) used accident case studies to produce a theory of socio-technical accidents that examined such causes. Theoretical Foundations The literature presents two research streams that form the theoretical foundation for safety culture. These are the fields of safety climate research and safety culture research. • Safety climate research flows from the concept of organizational climate, which is grounded in psychology. • Safety culture research, on the other hand, is based on organizational culture, with orga- nizational culture’s roots being found in anthropology and sociology. The effective application of safety climate research really began when Zohar (1980) took the organizational/social factors derived from the theory of organizational climate and devised a safety climate questionnaire to examine how the workforce perceived these factors. When collecting safety data from various Israeli manufacturing organizations, he found that scores developed from safety climate data significantly correlated with company accident rates and ratings by safety inspectors. Additional safety climate studies involving a formal quantitative approach (“quantitative” defined as measures of attitudes and empiri- cal relationships to other variables, versus qualitative measures characterized by conclu- sions derived from case studies) followed in different industries and cultural contexts. These quantitative studies generally supported a relationship between safety climate scores and safety performance. Safety culture research got a boost from a series of serious accidents—Three Mile Island (1979), Bhopal (1984), Chernobyl (1986), Zeebrugge Ferry (1987), King’s Cross Under- ground (1988), Clapham Junction (1989), and Piper Alpha (1990). These accidents high- lighted the significant role played by organizational and social factors (Zhang et al., 2002). The International Nuclear Safety Advisory Group (INSAG) first introduced the term “safety culture” in the aftermath of the nuclear disaster at Chernobyl. It was used in a number of subsequent accident inquiries as an umbrella term for a combination of managerial, organi- zational, and social factors that were seen as causally contributing to accidents. In this way, the concept of safety culture—unlike that of safety climate—initially sprang into public consciousness without benefit of an equivalent degree of theoretical derivation.

3 Definitions of Safety Culture In “Safety Culture: A Concept in Chaos?” Zhang et al. (2002) review a number of studies conducted in high-risk industries and conclude that there is “considerable disagreement among researchers as to how to define safety culture.” Guldenmund (2000) cited 16 dispa- rate studies that appeared from 1980 through 1997 alone. The research team, based on its experience in public transportation, found the following two definitions from the literature to be the most compelling and relevant to public transportation: The first is the Uttal definition: “Shared values (‘what is important’) and beliefs (‘how things work’) that interact with an organization’s people, structures, and control systems to produce behavioral norms (‘the way we do things around here’)” (Uttal, 1983). The second is the UK Health and Safety Commission definition: “The product of indi- vidual and group values, attitudes, competencies, and patterns of behaviour that determine the commitment to, and the style and efficiency of, an organization’s health and safety pro- grams. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confi- dence in the efficacy measures” (Health and Safety Commission, 1993). The Uttal definition has been echoed in a number of definitions adopted by different federal government organizations. • The Energy Facilities Contractor Group of the Department of Energy (EFCOG/DOE) says a safety culture is “an organization’s values and behaviors, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment” (EFCOG/DOE, 2009). • The Transit Rail Advisory Committee for Safety (TRACS) defines safety culture as “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that can determine the commitment to and the style and proficiency of an orga- nization’s safety management system” (Transit Rail Advisory Committee for Safety, 2011). • The Federal Railroad Administration defines organizational culture as “shared values, norms, and perceptions that are expressed as common expectations, assumptions, and views of rationality within an organization and play a critical role in safety.” It notes that organizations with a positive safety culture are characterized by “communications founded on mutual trust, shared perceptions of the importance of safety, and confidence in the efficacy of preventive measures” (U.S. Federal Register, 2012). Safety Culture Theories and Models Safety culture is complex and multidimensional, and there are numerous theoretical models of safety culture. In the literature review (Appendix A), the research team details the Westrum, Reason, Hudson, Guldenmund, and Cooper models. Also described are the Fleming safety culture maturity model, the DuPont Bradley curve model, the systems view model, and the high-reliability organization model. Of these models, two are of particular interest to the public transportation industry. • Reason’s safety culture model: The most elaborate and sophisticated of these models is the Reason model, which is grounded in Reason’s practical experience. It is this model that the research team believes has the most general application to the public transportation industry. • High-reliability organization (HRO) model: The research team believes that larger transit authorities operating heavy rail should consider adoption of the HRO model normally

4employed in high-risk industries such as aviation, nuclear operations, and offshore petro- leum operations. Two subway trains operating under communications-based train con- trol (CBTC) at rush hour in the tunnels of New York carry up to 5,000 passengers. The results of a head-on collision due to a CBTC failure and a subsequent fire at rush hour would lead to a total number of casualties that would exceed most high-risk industry accidents and could cripple all transportation within New York City for weeks. Components of Safety Culture in the Literature The research team found that no single set of components of safety culture exist in the literature. The number of components in a set and the identity of those components vary significantly from one source to another. The sets found in the literature also differ signifi- cantly in terms of which components are included and which are excluded. The lack of a common set of components in the literature might be best interpreted to indicate that (a) safety culture is a multifaceted phenomenon consisting of scores of contrib- uting components, (b) the prominence of any given component in a specific safety culture is dictated by the dominant circumstances of the environment in which that culture exists, and (c) the safety culture phenomenon accordingly presents many different faces, thereby making promulgation of a universal definition and description difficult. The most common components of safety culture identified in the literature review, in descending order of frequency, are: 1. Maintaining safety as a core value; 2. Requiring strong leadership and management commitment; 3. Enforcing high performance standards; 4. Providing adequate resources for safety; 5. Empowering individuals at each organizational level to be responsible for safety; 6. Involving unions continuously in the safety process (where employees are unionized); 7. Emphasizing learning, education, and training; 8. Ensuring open, honest, and effective communication within the organization and encouraging a questioning environment; 9. Maintaining an effective reporting system, with visible action taken on issues reported, and ensuring timely responses to concerns and issues; 10. Using leading and lagging safety indicators to gauge the effectiveness of safety programs on employee behavior; 11. Demonstrating leadership behaviors that encourage mutual trust between management and employees; 12. Monitoring performance continuously; and 13. Treating employees fairly. Safety Culture Within Public Transportation The research team’s approach to collecting data from the public transportation industry was designed to learn how transit stakeholders understand safety culture and its components and the strategies they use to make improvements within transit organizations. The research methodology included: 1. A research-team–developed transit stakeholder survey to identify the key components of transit safety culture and those transit agencies that are perceived as having a positive safety culture;

5 2. Selection of transit agencies for mini–case studies based on stakeholder recommendations, leading and lagging performance indicators, and other measures; and 3. Mini–case studies of nine transit agencies considered to be on the road to a positive safety culture, involving interviews with employees at all levels and analysis of relevant documentation. Transit Stakeholder Survey From the results of the transit stakeholder survey, the 15 factors listed in the following were ranked in order of importance as components of safety culture: 1. Safety is recognized as the highest organizational priority, and both management and employees are committed to it. 2. Adequate training is provided so that employees have an understanding of how to per- form their jobs in a safe manner. 3. There is open, frequent, and effective communication on safety. 4. Adequate financial and human resources are dedicated to ensure the safety and health of employees. 5. Management and employees are willing to interrupt schedules and service for safety reasons. 6. There is competence within the organization to draw appropriate conclusions from safety information. 7. The organization takes action visible to employees on all reported safety issues. 8. The organization collects and analyzes relevant data and actively disseminates safety information. 9. There is significant employee involvement in the continuous improvement of safety policies and rules. 10. The culture of safety is deeply ingrained within the organization, and no leadership transition within either management or union will likely change that commitment. 11. Accidents are reviewed from the perspective of future prevention rather than focusing exclusively on finding someone to blame. 12. There is a high level of trust between management and frontline staff. 13. Employees are encouraged to report near misses and other safety events without fear of blame or retribution. 14. Where there is union representation, the union is continually involved in the safety processes as a full partner, including in joint safety data collection, analysis, and prob- lem solving. Where there is not, the same result is sought—shared ownership with and responsibility by employees. 15. Employees are rewarded for reinforcing safety at work. Note that the results were an overall aggregation of data from different groups who ordered the components differently and that the overall aggregation’s results could have been influ- enced by the different proportion of respondents from each group. Transit Agency Mini–Case Studies The research involved mini–case studies of those transit agencies identified by industry stake- holders in the survey as possessing a positive safety culture. Stakeholders were asked to identify up to three large, three medium, and three small public transit agencies that have positive safety cultures. Based on stakeholder recommendations, nine transit agencies were selected.

6A list of top-level management and union contacts was compiled, and the research team e-mailed or phoned the individuals from these selected agencies, and—in some cases—visited them in person, seeking their participation in the case study research. Inter- views were sought at all levels of the organization—with chief executive officers (CEOs), safety directors and officers, mid-level managers from operations and maintenance, local union presidents and safety representatives, and frontline employees. Most of the contacts responded positively. Where possible, the first interviews at each location were scheduled with the CEOs/general managers (GMs) and the local union presidents; they, in turn, provided a list of additional candidates. Interviews were recorded when consent was granted. To allow candid opinions to be expressed, participants were assured of confidentiality. Based on the literature review and the survey results, the research team developed a ques- tionnaire to guide and provide a common structure for the interviews. The results of the nine mini–case studies on safety culture are summarized in Table S-1. Safety Culture Outside Public Transportation The research team conducted structured interviews on safety culture with nine companies outside the public transportation industry. The interviews were held with top safety manag- ers and senior executives within these companies. The interviews reinforced findings from previous research in the literature and within public transportation in identifying the key components of safety culture, as presented in Table S-2. The following themes appeared again and again in the interviews: • The CEO is clearly the leader of the organization for safety culture. While methods vary from company to company, each interviewee expressed the importance of the CEO’s role in shaping and leading safety culture. A CEO’s emphasis on safety and repetition of key values when interacting with employees, boards of directors, and stakeholders sends a clear message that safety is front and center and is a principle that drives the other perfor- mance factors of the organization. • This group of companies empowers employees to communicate freely and to champion safety values. Methods differ—one company encourages employees to contribute to and receive safety culture information through their real-time reporting system; another sends out daily safety e-mails to keep all employees abreast of safety incidents and activities. In all of these organizations, employees are the core of the culture; they are recruited, trained, retained, and empowered to play an essential role in safety. Since they are regarded as the most valuable asset in these profit-driven companies, maintaining a safe work environ- ment is not only the right thing to do, it also is the best way to keep productivity and profits high. • The practice of reporting and investigating in an environment that is free from fear is common to all, the importance of near-miss reporting is unanimously supported, and employees are willing to waive anonymity to place their names on a report or safety docu- ment, which indicates a high degree of trust. Definition and Key Components The research team prepared a definition of safety culture for public transportation draw- ing on the literature review, the stakeholder survey, the case studies, and the interviews from outside the transit industry described previously. While many options and concepts

7 were considered, the research team believes that a modified Uttal definition is the best alternative: Safety culture is shared values (what is important to all public transportation system members who are responsible for safe, efficient revenue service) and shared beliefs and attitudes (how the transportation system works and what individual roles should be) that interact with all system members, safety policies, procedures, and rules to produce behavioral norms (the way we do our jobs, whether observed or not). The definition was reviewed by an expert safety culture panel, formed to vet key findings and recommendations from this research. The safety culture panel, which was composed of Table S-1. Key elements of safety culture observed in nine mini–case studies. Key Elements Agency Code A (S) B (M) C (S) D (L) E (L) F (M) G (S) H (L) I (M) Agencies Total*** 1. Safety as a core value that management and employees are committed to (updated using stakeholder survey comments) 9 2. Adequate safety training provided 9 3. Open and effective safety communication + 8 4. Adequate resources dedicated to safety 8 5. Management and employees willing to interrupt service for safety 9 6. Organizational safety competence 9 7. Visible action on all reported safety issues + + + 5 8. Significant employee involvement + 8 9. Using safety metrics and leading and lagging indicators to gauge safety performance 9 10. Safety culture stable through leadership transitions + 7 11. Accident focus is preventing recurrence + + 5 12. High level of trust between management and workers √ + + * + 6 13. Near-miss accident reporting in place (and data collected) ** ** ** ** ** 4 14. Union involvement in safety process n/a + + 6 15. Employee safety performance rewards 9 Total Count *** 13 13 7 12 15 10 13 13 15 Legend: = key element implemented; = key element emphasized; + = missing element linked to trust; = missing elements not linked to trust; S = small; M = medium; L = large. * High trust only in transit rail division. ** These agencies do not directly operate commuter rail and are thus not regulated by the Federal Railroad Administration (FRA) to have a near-miss reporting system. *** Double checks are counted as one, and row 13 (near-miss accident reporting in place) is not counted because this is implemented mostly in rail divisions that are regulated by the FRA.

8individuals recognized for promoting positive safety culture within public transportation and other industries, generally concurred with this definition. Assessing the State of Safety Culture Various methods can be used to assess an organization’s safety culture. Among the most common and frequently employed are direct observation, interviews, focus groups, surveys, and performance indicator tracking. Direct Observation Direct observations of workplace behavior may provide objective information regarding safety culture pertaining to the effectiveness of training, management, accountability, and behavior expectations. Direct observation of employees at work can also provide valuable information on involvement, attitude, and willingness to confront perceived unsafe behav- ior. However, observations cannot be quantified and used for statistical purposes, and there is always the risk of overgeneralization from too few observations (EFCOG/DOE, 2009). Conducting sufficient observations to produce an accurate assessment of the state of safety culture will be time-consuming and expensive. Interviews Interviews can play a significant role in the assessment of culture. They can be used to develop information directly on the state of safety culture in an organization, or they can be used as a means of providing input to survey design or to explore issues in greater depth that have emerged from a survey. An advantage of interviews is that the respondents are not limited by the wording or structure of a written survey. The greater flexibility in an interview allows the interviewer to drill down until an opportunity or problem is fully clarified and ambiguities are addressed. However, generalization of findings from interviews to an entire organization is risky if the interviews are limited in number. As with direct observation, interviews to assess an organization’s safety culture can be time-consuming and expensive. Strong leadership, management, and organizational commitment to safety Employee/union shared ownership and participation Effective safety communication Proactive use of safety data, key indicators, and benchmarking Organizational learning Consistent safety reporting and investigation for prevention Employee recognition and rewards High level of organizational trust Table S-2. Key components of safety culture.

9 Focus Groups Focus groups are more efficient but less flexible than individual interviews to assess an organization’s safety culture. One interviewer can elicit the views of multiple employees in a single session. Valid focus groups are conducted by skilled, experienced facilitators who bring all participants into the discussion. Well-designed focus groups can provide great sources of insight beyond surveys. Flexibility is somewhat reduced because the interviewer generally uses a set of prepared questions to bring basic organization and direction to the discussion. Surveys Surveys have been useful and effective tools to assess safety culture. They have an advan- tage over other assessment methods with respect to efficiency. The views of large numbers of employees can be obtained with a fraction of the resources required to obtain the same amount of information using observation, interviews, and focus groups. Individuals may also feel more comfortable addressing an organization’s safety culture in a survey in that their responses are provided anonymously and held in confidence. The most significant lim- itations are that surveys are somewhat inflexible and may not necessarily yield high response rates (introducing potential bias). The only information that can be obtained is that in the direct responses to each specific question posed. The elicitation of subtle distinctions is generally difficult to obtain from a survey. Performance Indicator Tracking Performance indicators can be used to monitor safety culture performance over time within an organization and to make peer comparisons among similar organizations. In either case, it is important that the performance measures be consistently defined so that meaningful time-series analyses and peer comparisons can be made. The public transit industry would benefit from having a common set of publicly published safety performance and safety culture indicators. The lack of such indicators precludes meaningful comparisons and benchmarking of safety performance and safety culture across the transit industry. There are two types of indicators used to monitor and manage safety performance and safety culture in public transportation and other industries. • Lagging indicators measure past performance. Examples are customer injuries per 100,000 customers or customer injuries per 100,000 passenger miles traveled. The pri- mary utility of lagging indicators to safety culture is that a positive safety culture, ceteris paribus, should produce positive safety performance. Therefore, superior safety culture ultimately results in superior safety performance, as measured by lagging indicators. • Leading indicators have the distinctive and defining property of predicting future per- formance. Currently, the U.S. transit industry falls short of the aviation industry in terms of the number of leading indicators tracked and the use of those indicators to flag devel- oping safety problems and vulnerabilities. Consequently, important opportunities for improvement exist in the use of leading indicators by U.S. transit agencies. Blair and O’Toole (2010) quote Part 6.1 of ANSI Z10-2005: Organizations should develop predictive or “leading” performance measures or indicators. The organiza- tion can use these measures to identify and correct problems and identify opportunities for risk reduction before injuries or illnesses occur. The leading indicators can be used in combination with carefully collected

10 injury and illness rates to measure performance. Some examples of indicators of potential problem areas are human factors risks, near-miss incidents, and non-conformances found during inspections. A significant finding of the research team, however, is that U.S. transit agencies generally fall short of the aviation industry in terms of the number of leading indicators tracked and the use of those indicators to flag developing problems and vulnerabilities in the area of safety culture. There are exceptions to this rule. For example, one transit agency uses statistics such as the number of signal violations by train operators and red light violations by bus operators as leading or predictive indicators. A significant increase in signal violations, for example, could be interpreted as indicating deterioration in the observance of critical rules or the existence of technical problems, which could be a harbinger or predictor of serious accidents. Scandinavian Airlines System (SAS), however, reports having more than 50 indicators based on flight abnormalities for which a significant increase also could predict a serious accident about to happen. The SAS leading indicators, therefore, might be seen as precursors to near misses. Such flagging by leading indicators allows the taking of appropriate corrective action on a timely basis and prior to the occurrence of a serious incident/accident. Developing a Plan for an Assessment of Safety Culture Assessments of safety culture can be initiated in various ways, ranging from a full-scale review to periodic performance indicator checks. Full-scale assessments require a significant investment of resources for the review itself and, possibly, a far greater investment to rem- edy problems found. Such full assessments, therefore, are most often launched by a transit agency board or a CEO committed to the development/improvement of a positive safety culture. After making the decision to proceed, an important step is to engage management and union leadership teams to explain the purpose and mechanics of the assessment. Super- visors and hourly workers need to be similarly engaged and involved. An abbreviated and less time-consuming approach involves the combination of a stan- dard survey to provide general information followed by a series of interviews and focus groups to develop specific and in-depth information on issues emerging from the survey. This combination has the advantage of using the survey to identify the issues as perceived by employees at all levels of the organization in the most economical manner possible and then concentrating the interviews and focus groups on obtaining detailed information on those issues. A plan of action could be drawn up based on the results. This is a more efficient process. The research team believes that the development and full validation of a safety culture survey and associated confidential database for the public transit industry would contrib- ute to the industry’s pursuit of improved safety culture. In the meantime, transit agencies wanting to conduct a safety culture assessment survey may use the Reason survey or a com- mercially available, copyrighted safety culture assessment survey. Best Practices for Improving Safety Culture The research team identified 34 best practices that will likely result in improvements in safety culture. The expert safety culture panel rated the practices in terms of their value to a transit agency using a five-point Likert scale, with 5 being extremely valuable and 1 being not very valuable. The ranked list of best practices is discussed in greater detail in Chapter 7. These 34 practices fall into the safety culture categories in Table S-3.

11 It is essential to understand that all 34 best practices will not be appropriate for every transit agency. For example, a practice will not work in a given agency unless the necessary foundation already exists to support that particular practice. Therefore, transit agencies should consider the list of best practices as a menu from which to choose a few practices that appear to be appropriate for their agency and that potentially would remedy a deficiency in current safety culture. Before implementation, the practices being considered should be discussed with all stakeholders and implemented on a trial basis. After a suitable period, the efficacy of each practice should be evaluated and a decision made as to whether the practice is to be retained in its present form, revised, or discarded. Improving Safety Culture—Four Case Studies The research team conducted case studies of four transit agencies that have made signifi- cant improvements in their safety cultures. The case studies considered transit agencies whose efforts to improve safety culture were a reaction to a major accident or incident and transit agencies that improved safety culture without the spur of such an incident or accident. The components of safety culture revealed in the research and first specified in Table S-2 appear in each of the four case studies. An analysis of these four case studies produced important cross-cutting themes that might be considered by transit agencies undertaking a program to improve their safety culture: • Strong Leadership, Management, and Organizational Commitment to Safety. With- out truly committed leadership, there is no hope of improving safety culture. In transit agencies with representation by union employees, truly committed union leadership is as essential as truly committed management leadership. If only with respect to the issue of safety, management and unions must establish an effective working partnership. Coop- eration is essential. A “my way or the highway” approach does not work. • Employee/Union Shared Ownership and Participation. Even the most committed leader- ship will not succeed in improving safety culture without significant employee involvement and buy-in. • Effective Safety Communication. Without effective safety communication, employees will not understand the hazards inherent in their jobs and will not appreciate any progress being made. • Proactive Use of Safety Data, Key Indicators, and Benchmarking. All transit agencies must aggressively collect and use the best data that they can collect to guide their actions. Safety Culture Category Number Recommended Employee involvement 5 Organization 5 Reporting 5 Safety rules and procedures 4 Safety training 3 Key safety performance indicators 2 Management commitment 2 Recruitment 2 Safety communications 2 Safety culture survey 2 Planning 1 Recognition and rewards 1 Total 34 Table S-3. Categories of safety culture practices recommended.

12 • Organizational Learning. Organizational learning is very important to improved safety culture. Employees will not have confidence in organizations that do not learn from their mistakes. • Consistent Safety Reporting and Investigation for Prevention. Employees must have full confidence in the integrity of the reporting and investigating systems. If something is reported, it will be investigated, and appropriate action will be taken. Also, a willingness by management to grant disciplinary immunity to employees who voluntarily report near misses will result in significantly more near misses being reported. • Employee Recognition and Rewards. Employees must be recognized for their contribu- tions to safety culture. At the same time, the disciplinary system must be widely recog- nized as just and effective. • High Level of Organizational Trust. This cannot be established overnight. It must be earned by all members of the organization (managers, supervisors, and hourly employees) through consistent performance. Beginning a safety culture improvement process requires a determination as to where the transit agency stands with respect to the various components of safety culture. Steps on the Path to Improved Safety Culture While the specific steps for implementing a safety culture improvement plan will vary by transit agency, the steps listed in the following will benefit most transit agencies: 1. Secure preliminary commitment from management and union leadership at the highest level. 2. Identify, consult with, and secure the preliminary commitment of all other key stake- holders. 3. Jointly determine the problems to be addressed, subject to regular revision as more information is continuously received. 4. Identify any outside professional help needed to navigate the process. 5. Identify the assessment tools to be used to determine the existing state of safety culture. 6. Secure commitment of the necessary resources to solve identified problems and make required changes. 7. Jointly create a road map for rollout and implementation of the plan. 8. Meet with employee leaders (supervision and hourly) at all levels and secure buy-in. 9. Jointly determine the mechanisms for engaging the target population. 10. Jointly implement outreach to the target population to explain the program, obtain input in return, and act on that input in a highly visible manner. 11. Ensure that senior leaders are noticeably involved and leading by example. 12. Jointly implement changes. 13. Strive for cooperation, avoid imposition, and discipline only as a last resort. 14. Jointly exert constant oversight, anticipate problems, and give special attention to prob- lem areas. 15. Jointly establish litmus tests for success, including ensuring that employees are remain- ing engaged, key safety problems are being tracked, progress is being made, and leaders are constantly recalibrating the program. 16. Report back to employees on a regular basis and obtain additional feedback. To better illuminate these steps, Chapter 9 uses a hypothetical general manager in a hypo- thetical transit agency following these steps to illustrate and provide context for this path.

13 Using This Report The research team suggests that transit agencies take the following approach in using this research report to develop a plan for improving safety culture: • Use this Summary to understand the overall direction of the project and its major conclusions. • Use Chapter 5 to develop an approach for assessing the current state of safety culture in the transit agency. • Ensure that the transit agency’s key performance indicators are adequate for measuring ongoing progress. • Compare the transit agency’s current employee communications plan to the scale of the SAS plan outlined in Chapter 7 and determine if sufficient resources are currently being devoted to safety communication. • Consider adopting some of the best practices identified in Chapter 7 to pursue specific safety culture improvements that the assessment indicated are needed. • Develop a set of guidelines for improving the state of safety culture in the transit agency based on the results of the assessment and the experiences of the four transit agencies outlined in Chapter 8. • Repeat the assessment of the current state of safety culture every 2 or 3 years in order to measure progress made in improving safety culture.