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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/25852.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

2020 T R A N S I T C O O P E R A T I V E R E S E A R C H P R O G R A M TCRP RESEARCH REPORT 218 Research sponsored by the Federal Transit Administration in cooperation with the Transit Development Corporation Subject Areas Public Transportation • Safety and Human Factors Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Lisa Staes Jodi Godfrey Center for Urban transportation researCh University of soUth florida Tampa, FL

TCRP RESEARCH REPORT 218 Project F-27 ISSN 2572-3782 ISBN 978-0-309-67365-5 © 2020 National Academy of Sciences. All rights reserved. COPYRIGHT INFORMATION Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously published or copyrighted material used herein. Cooperative Research Programs (CRP) grants permission to reproduce material in this publication for classroom and not-for-profit purposes. Permission is given with the understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, FTA, GHSA, NHTSA, or TDC endorsement of a particular product, method, or practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment of the source of any reprinted or reproduced material. For other uses of the material, request permission from CRP. Cover photo credits: Left to right and top to bottom: New York Metropolitan Transportation Authority; Mitch Spicer, Center for Urban Transportation Research (CUTR), University of South Florida, Tampa; Jacksonville Transit Authority; iStock.com/David Tran; iStock.com/mtcurado; and Lisa Staes, CUTR. NOTICE The research report was reviewed by the technical panel and accepted for publication according to procedures established and overseen by the Transportation Research Board and approved by the National Academies of Sciences, Engineering, and Medicine. The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessarily those of the Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; or the program sponsors. The Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; and the sponsors of the Transit Cooperative Research Program do not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the object of the report. TRANSIT COOPERATIVE RESEARCH PROGRAM The nation’s growth and the need to meet mobility, environmental, and energy objectives place demands on public transit systems. Cur- rent systems, some of which are old and in need of upgrading, must expand service area, increase service frequency, and improve efficiency to serve these demands. Research is necessary to solve operating prob- lems, adapt appropriate new technologies from other industries, and introduce innovations into the transit industry. The Transit Coopera- tive Research Program (TCRP) serves as one of the principal means by which the transit industry can develop innovative near-term solutions to meet demands placed on it. The need for TCRP was originally identified in TRB Special Report 213—Research for Public Transit: New Directions, published in 1987 and based on a study sponsored by the Urban Mass Transportation Administration—now the Federal Transit Administration (FTA). A report by the American Public Transportation Association (APTA), Transportation 2000, also recognized the need for local, problem- solving research. TCRP, modeled after the successful National Coop- erative Highway Research Program (NCHRP), undertakes research and other technical activities in response to the needs of transit ser- vice providers. The scope of TCRP includes various transit research fields including planning, service configuration, equipment, facilities, operations, human resources, maintenance, policy, and administrative practices. TCRP was established under FTA sponsorship in July 1992. Proposed by the U.S. Department of Transportation, TCRP was authorized as part of the Intermodal Surface Transportation Efficiency Act of 1991 (ISTEA). On May 13, 1992, a memorandum agreement outlining TCRP operating procedures was executed by the three cooperating organi- zations: FTA; the National Academies of Sciences, Engineering, and Medicine, acting through the Transportation Research Board (TRB); and the Transit Development Corporation, Inc. (TDC), a nonprofit educational and research organization established by APTA. TDC is responsible for forming the independent governing board, designated as the TCRP Oversight and Project Selection (TOPS) Commission. Research problem statements for TCRP are solicited periodically but may be submitted to TRB by anyone at any time. It is the responsibility of the TOPS Commission to formulate the research program by identi- fying the highest priority projects. As part of the evaluation, the TOPS Commission defines funding levels and expected products. Once selected, each project is assigned to an expert panel appointed by TRB. The panels prepare project statements (requests for propos- als), select contractors, and provide technical guidance and counsel throughout the life of the project. The process for developing research problem statements and selecting research agencies has been used by TRB in managing cooperative research programs since 1962. As in other TRB activities, TCRP project panels serve voluntarily without compensation. Because research cannot have the desired effect if products fail to reach the intended audience, special emphasis is placed on disseminat- ing TCRP results to the intended users of the research: transit agen- cies, service providers, and suppliers. TRB provides a series of research reports, syntheses of transit practice, and other supporting material developed by TCRP research. APTA will arrange for workshops, train- ing aids, field visits, and other activities to ensure that results are imple- mented by urban and rural transit industry practitioners. TCRP provides a forum where transit agencies can cooperatively address common operational problems. TCRP results support and complement other ongoing transit research and training programs. Published research reports of the TRANSIT COOPERATIVE RESEARCH PROGRAM are available from Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet by going to https://www.nationalacademies.org and then searching for TRB Printed in the United States of America

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, non- governmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to provide leadership in transportation improvements and innovation through trusted, timely, impartial, and evidence-based information exchange, research, and advice regarding all modes of transportation. The Board’s varied activities annually engage about 8,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. Learn more about the Transportation Research Board at www.TRB.org.

C O O P E R A T I V E R E S E A R C H P R O G R A M S CRP STAFF FOR TCRP RESEARCH REPORT 218 Christopher J. Hedges, Director, Cooperative Research Programs Lori L. Sundstrom, Deputy Director, Cooperative Research Programs Gwen Chisholm Smith, Manager, Transit Cooperative Research Program Dianne S. Schwager, Senior Program Officer Jarrel McAfee, Senior Program Assistant Eileen P. Delaney, Director of Publications Natalie Barnes, Associate Director of Publications Janet M. McNaughton, Senior Editor TCRP PROJECT F-27 PANEL Field of Human Resources Harry Saporta, Tri-County Metropolitan Transportation District, Portland, OR (Chair) Melvin Clark, LTK Engineering Services, MBTA PTC Office, Newton Center, MA Judith B. Gertler, Wellesley, MA David A. Lee, First Transit, West Hartford, CT James E. Moore, University of Southern California, Los Angeles, CA Timothy Sanderson, Des Moines Area Regional Transit Authority, Des Moines, IA Gardner Tabon, Union, NJ Roger Toussaint, Petit Valley, Trinidad and Tobago Edward F. Watt, Rockaway Park, NY Christopher R. LaMacchia, FTA Liaison Nazy Sobhi, FTA Liaison MacPherson Hughes-Cromwick, APTA Liaison Jordan Multer, Office of the Assistant Secretary for Research and Technology (OST-R) Liaison Katherine A. Kortum, TRB Liaison

TCRP Research Report 218: Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation facilitates improved safety performance and furthers the understanding of methods by which rail and bus public transit agencies can effectively establish these reporting systems in accordance with federal transit law. This report will support the public transit industry’s efforts to institute nonpunitive employee safety reporting as a critical element in the implementation of safety management systems. This report addresses the development and implementation of nonpunitive employee safety reporting and discusses the importance of safety culture and procedural fairness for the successful operation of these reporting systems. The research included a literature review and stakeholder interviews that were the basis for case studies on 19 public transit agencies that have implemented employee safety reporting systems. The report presents data-supported leading practices from the literature review, common practices reported as successful by the public transit agencies that participated in the case studies, and barriers to implementation. The report recommends that nonpunitive employee safety reporting systems for public transit agencies should (1) have clear, concise definitions, including what is a reportable event; (2) delineate a structured process that specifies procedures for reporting and confirmation to the reporter; and (3) thoroughly describe the follow-up investigation and resolution process and timeline. Common elements of nonpunitive employee safety reporting systems include • Access or ease of reporting, • Appeal process, • Data utilization and performance measurement, • Documented/prescribed reporting and investigative processes, • Feedback loops, • Periodic process and program evaluation, • Third-party utilization (when appropriate), • Training and program promotion, and • Union participation. This research anticipates future opportunities for a central repository of reported safety hazards, close calls, and near misses with which to produce aggregated national reports beneficial to the public transit industry. It suggests examining opportunities to establish a national employee safety reporting system for the industry and the steps that would need to be made to institute such a system. It also discusses the importance of providing evidentiary protections for reporters and public transit agencies to protect employee-submitted data or accident/incident data, as examples. The authors suggest these protections will likely ensure greater reporting and, in turn, safer public transit agencies. F O R E W O R D By Dianne S. Schwager Staff Officer Transportation Research Board

1 Summary 11 Chapter 1 Introduction 12 Objective 12 Research Methodology 12 Study Limitations 13 General Background and History 14 Federal Transit Administration and Close Call Reporting 16 Chapter 2 Literature Review and Background Research 16 Benefits of a Nonpunitive Employee Safety Reporting System 17 Safety Culture Impacts 18 Offshore Oil and Gas Industry 20 Characteristics and Elements of a Nonpunitive Employee Safety Reporting System 21 Roles of Stakeholders 22 Strategies for Collecting and Managing Data 26 Procedural Fairness for Employees 27 Examples of Nonpunitive Employee Safety Reporting Systems 27 Aviation Safety Reporting System 28 Bureau of Safety and Environmental Enforcement 28 Federal Railroad Administration 28 New Jersey Transit 29 Federal Transit Administration 29 National Air Traffic Controllers Association 30 Occupational Safety and Health Administration 30 U.S. Nuclear Regulatory Commission 31 Scalability 31 Framework of a Nonpunitive Employee Safety Reporting System 31 Policies and Procedures 32 Response and Mitigation Strategies 33 Performance Measures 34 Third-Party Management and Report Collection 35 Summary 37 Chapter 3 Public Transportation Agency Case Studies 37 Process 37 General Observations and Findings 40 Policies and Reporting Practices 40 Training 41 Stakeholder Input 42 Performance Measures C O N T E N T S

44 Chapter 4 Characteristics and Elements of an Effective Employee Safety Reporting System 45 Program Design Framework 47 Definitions of Close Call, Near Miss, and Other Terms of Relevance 48 Delineation of Reportable Events 48 Reporting Process 48 Confirmation 52 Common Characteristics and Elements of Effective Employee Safety Reporting Systems 52 Access—Ease of Reporting 53 Appeal Process 54 Data Utilization and Performance Measurement 55 Documented and Prescribed Reporting and Investigative Processes 57 Feedback Loops 58 Periodic Process and Program Evaluation 58 Third-Party Utilization 59 Training and Program Promotion 62 Union Participation 64 Chapter 5 Conclusions and Recommendations for Additional Research 64 Conclusions 64 Employee Safety Reporting System Program Description 65 Policies 65 Training 66 Stakeholder Input 67 Barriers to Implementation 68 Elements of Success 71 Recommendations for Additional Research 73 Endnotes A-1 Appendix A Case Study Narratives B-1 Appendix B Interview Script C-1 Appendix C Example Confidential Close Call Reporting System and Bureau of Transportation Statistics Safety Reporting Memorandums of Understanding D-1 Appendix D Example Policies and Procedures E-1 Appendix E Acronyms

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The importance of safety cannot be overstated and requires continued shifts in the approach to safety management within the public transportation industry.

The TRB Transit Cooperative Research Program's TCRP Research Report 218: Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation compiles the best practices used in nonpunitive employee safety reporting systems at transit agencies.

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