Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation (2020)

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11 Introduction Moving Ahead for Progress in the 21st Century (MAP-21) and its successor, the Fixing America’s Surface Transportation (FAST) Act, prompted the Federal Transit Administration (FTA) to establish the safety management system (SMS) framework as the basis for its National Public Transportation Safety Program [49 United States Code (U.S.C.) Section 5329]. The establishment of a proactive employee safety reporting (ESR) system is a key aspect of the SMS safety assurance function and is elemental in the implementation of an effective SMS. A nonpunitive ESR system is defined in the report Establishing a Confidential, Non-Punitive, Close Call Safety Reporting System for the Rail Transit Industry as follows: a voluntary system encouraging all employees to report events that otherwise would not have been dis- covered by transit agency management, yet nonetheless could be symptoms of problems that could lead to more serious future events.5 Nonpunitive ESR not only will allow public transportation agencies to identify safety hazards that may otherwise go unrecognized but will also help ensure the support of transit workers so that potential risks can be identified and abated before any accident or incident occurs. Effective nonpunitive ESR systems are reflective of a robust safety culture in which all stakeholders work together to continuously improve safety.6 TCRP Research Report 218: Characteristics and Elements of Nonpunitive Employee Reporting Systems for Public Transportation identifies the basis of nonpunitive ESR systems to assist public transportation agencies in advancing SMSs in their transit agencies. This examination focuses on policy and procedural aspects as well as cultural elements that are reflected in transit agencies at which this reporting has been, and continues to be, successful. The challenges faced through the implementation phases of ESR system deployment are also included. The literature review and other background research were the first steps in the development of the project report and helped frame subsequent narrative and findings from interviews with public transportation agency personnel in the case studies. This study draws from lessons learned by other transportation modes, including, but not limited to, the airline and railroad industries and from nontransportation industries such as the petroleum and nuclear power industries. Additionally, it builds on related research conducted by or for the transportation industry by Federal agencies and organizations including, but not limited to, FTA, the National Transportation Safety Board (NTSB), TCRP, TRB, and the U.S. Department of Transportation (U.S. DOT) Volpe National Transportation Systems Center. This report addresses the following critical, relevant aspects regarding the development and implementation of a nonpunitive ESR system: • Experience of transit agencies that have implemented an ESR system; • Specific characteristics and elements implemented; C H A P T E R 1

12 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Organizational strategies for promoting procedural fairness for employees; • Impact of nonpunitive ESR systems on the safety culture of an organization; • Roles of stakeholders in the development, implementation, and ongoing operation of a nonpunitive ESR system; • Types of data that should be collected, tracked, and trended; • Strategies for collecting and managing the data; • Scalability of the ESR system for transit agencies of different sizes and data-processing capabilities; and • Use of third parties. Objective The objective of this research was to produce a compilation of the best practices used in nonpunitive employee reporting programs at transit agencies. The best practices would include examples of how nonpunitive employee reporting programs benefit transit agen- cies and their employees and could be used to assist transit agencies with developing their programs. In accordance with this objective, this report presents the characteristics and elements of a nonpunitive ESR system to facilitate improved safety performance for rail and bus transit agencies. The literature review provided the framework upon which to base the review of each agency’s ESR system. Nonpunitive ESR system successes, for the purposes of this study, were determined by the transit agency; the research team did not use a statistical modeling or evaluation method to determine success. Research Methodology The research team used the following methods to determine the characteristics and elements that lead to an effective and mature ESR system: • Literature review and background research and • Case studies of 19 public transportation agencies. The literature review and background research document the benefits of nonpunitive ESR systems, including the role of safety culture in the efficacy of an ESR system and relevant aspects of a program. The research included case studies of 19 public transportation agencies that have implemented an ESR system. The transit agencies are geographically dispersed and vary in size, operating characteristics, and the complexity of the ESR system instituted. A summary of the case study research is presented in Chapter 3, complete case study narratives are included in Appendix A, and the initial survey instrument developed and disseminated to case study participants is included in Appendix B. The background and case study research provided context and presented common non- punitive ESR system elements. These common elements, as well as leading practices and other findings from the research, are discussed in Chapter 4. Conclusions and recommendations for additional research are presented in Chapter 5. Study Limitations Limitations of the study center on the challenges of program cost and associated benefit valuation based on case study examinations.

Introduction 13 Estimation of Costs In the areas of program development, implementation, and ESR system management costs, case study transit agencies established ESR systems as part of their SMS program and, therefore, were unable to segment the personnel efforts for ESR system activities. More specifically, • Case study transit agencies are not documenting personnel participation and management of the report review, processing, follow-up, and ongoing tracking of reported safety concerns. • For many case study transit agencies, these processes, while not as robust or far-reaching as those that now exist as a part of their SMSs, have been in place as hazard reporting systems. • Establishing the additional costs associated with this expanded focus and post-reporting practices has not been consistently performed. • While there were transit agencies that could identify a cost associated with the development of tools and online ESR systems, many developed these tools and ESR systems “in house” by employees who were also responsible for other agency support activities. Estimation of Benefits Estimation of the benefits of a transit agency’s ESR system should include quantitative measures supported by performance data; this presents additional challenges. Each transit agency must establish minimum safety performance targets in its Public Transportation Agency Safety Plan (PTASP), consistent with FTA’s National Public Transportation Safety Plan, for the following: • Fatalities, • Injuries, • Safety events, and • ESR system reliability. Longitudinal analysis and presentation of benefits is hindered by the relative immatu- rity of the ESR systems examined or the transition from existing hazard ESR systems to the more comprehensive ESR systems encapsulated in SMS processes. In addition, the variability of these occurrences—specifically, injuries, fatalities, and safety events—would present challenges to transit agencies that were evaluating the improvements in their systems through time. In their implementation of SMSs, transit agencies have redefined and restructured their approach to organizational safety. The development and implementation of an ESR system may be one of many safety solutions and mitigation strategies adopted by public transit agen- cies. Strategies could—and, in the case study examples, do—include focused and more fre- quent training, infrastructure modifications, and institution of various technologies, such as collision warning and other systems. In this environment, public transit agencies and other program evaluators would not be able to attribute agency improvements reported within any of the performance targets specifically to the ESR system and, therefore, would not be able to delineate the benefits of the ESR system on the basis of these targets. Findings from the literature review reflect demonstrated data-supported benefits identified as “leading practices.” These are examined in the following section. General Background and History NTSB investigated catastrophic collisions that resulted in loss of life, injuries, and costly damage and deduced that many of these events could have been avoided had an effective ESR system been in place. One of these collisions, the 2009 Washington Metropolitan Area Transit Authority (WMATA) train-on-train collision near the Fort Totten Station, resulted in

14 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation nine fatalities, 52 injuries, and an estimated $12 million in damages. This event led to NTSB recommendation R-10-004 to FTA: Facilitate the development of non-punitive safety reporting programs at all transit agencies to col- lect reports from employees in all divisions within their agencies and to have their safety departments; representatives of their operations, maintenance and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of their agencies.7 NTSB Recommendation R-10-017 to WMATA regarding the Fort Totten collision was as follows: Develop and implement a non-punitive safety reporting program to collect reports from employees in all divisions within your organization, and ensure that the safety department; representatives of the operations, maintenance, and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of your organization.8 NTSB findings from the December 1, 2013, derailment on the Metro-North Railroad Hudson Line in New York City indicated that there was not an effective program in place that encouraged all employees to report safety issues and observations.9 According to the NTSB Special Investi- gative Report Organizational Factors in Metro-North Railroad Accidents, although Metro-North had a safety hotline in place, employees were reluctant to report safety concerns out of fear of both discipline and retaliation resulting from the experiences of previous reporters. One specific unintentional mistake—the inadvertent removal of blocking devices, which resulted in a fatal event—led to an employee’s removal from service for 30 days as a disciplinary measure, 10 days of which were for re-instruction.10 NTSB concluded, the basis of this event, the single report made to the Metro-North safety hotline in the 12 months following the event, and the fear of retaliation expressed by some employees, that Metro-North did not have an effective program.11 Disciplinary action for unintentional mistakes and lack of reporting are both key indicators of an unjust safety culture.12 On September 30, 2010, two Canadian National Railway (CNR) freight trains collided near Two Harbors, Minnesota. In 2013, NTSB released Rail Accident Report RAR-13/01 with associ- ated recommendations for both CNR and the Federal Railroad Administration (FRA). Recom- mendation R-13-13 directed CNR to work with the Brotherhood of Locomotive Engineers and Trainmen and the United Transportation Union to develop and implement a nonpunitive peer audit program focused on rule compliance and operational safety.13 In 2013, the National Safety Council (NSC) found that hazard warnings and near miss inci- dents preceded most loss-producing events and established that recognizing and reporting near misses has the potential to significantly improve worker safety and enhance an organization’s safety culture. Many reports and presentations emphasize the importance of proactive employee hazard reporting with impunity to encourage reporting and improve the overall safety culture.14 Federal Transit Administration and Close Call Reporting In response to the NTSB recommendations and other report findings and to improve data collection and analysis related to close call and near miss safety events in the transit industry, FTA initiated two efforts to further examine ESR systems. In 2009, the U.S. DOT secretary authorized the establishment of the Transit Advisory Committee for Safety (TRACS) to provide advice and recommendations to the FTA administrator regarding transit safety issues. In 2011, the FTA administrator tasked TRACS to develop guidelines for the industry that resulted in the TRACS 11-01 Letter Report Establishing a Confidential, Non-Punitive, Close Call Safety Reporting System for the Rail Transit Industry.15

Introduction 15 FTA’s Close Call Reporting System Program Implementation Plan, published in June 2012, was to help guide an FTA-sponsored pilot for a Confidential Close Call Reporting System (C3RS).16 This pilot, had it been implemented, would have provided an opportunity to develop and iteratively improve a close call ESR system to allow transit agencies the opportunity to identify and subsequently mitigate hazards proactively. FTA envisioned that the ESR systems established through the pilot would foster just safety cultures in which safety concerns would be voluntarily and cooperatively communicated in a nonpunitive environment.17 While FTA did not initiate a C3RS pilot, they did institute an SMS pilot program that included the implementation of an ESR component as part of the pilot transit agencies’ SMS frameworks. During the 2017 TRB Annual Meeting, FTA presented “Safety Management System (SMS) Approach and FTA’s Research Initiatives,” indicating that the PTASP Final Rule would include a requirement that an ESR program be developed as part of the SMS safety assurance func- tion.18 On July 19, 2018, FTA published the PTASP final rule [49 Code of Federal Regulations (C.F.R.) Part 673], with an effective date of July 19, 2019, which established the requirement for transit agencies to develop and institute a nonpunitive ESR system in support of the SMS safety risk management and safety assurance functions. Several transit agencies included in the case studies performed as a part of this research pro- actively implemented ESR systems prior to the release of the PTASP final rule. These agencies included Capital Metropolitan Transportation Authority (Capital Metro), Austin, Texas; Lane Transit District (LTD), Springfield, Oregon; Los Angeles County Metropolitan Trans- portation Authority (LA Metro); Metropolitan Atlanta Rapid Transit Authority (MARTA); Massachusetts Bay Transportation Authority (MBTA), Boston, Massachusetts; Miami-Dade Transit (MDT); Maryland Transportation Authority (MTA), Baltimore, Maryland; and Southeastern Pennsylvania Transportation Authority (SEPTA), Philadelphia, Pennsylvania. The transit agencies that had already established successful ESR systems have been able to provide the industry with valuable insight and advice to assist them in the development of their own programs. Critical elements surfaced through the examples provided by transit agencies that had implemented ESR systems and programs developed in other transportation modes. To ensure successful implementation of a nonpunitive ESR system, there should be an understanding among all employees that the public transportation agency has designed and deployed the ESR system within the SMS framework, that hazard elimination (or mitigation) is a priority for the agency, that the implementation of the ESR system represents the transit agency’s commitment to the safety of all employees and passengers, and that a commitment motivated its development and implementation.