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

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16 Literature Review and Background Research In the development of the literature review and in the construction of the research report, the research team considered certain questions and sought to obtain answers: • What are the characteristics and elements that should be included in an effective nonpunitive ESR system? • Which public transit agencies currently have nonpunitive ESR systems? • What does it mean to have a positive safety culture, and how does it affect a transit agency’s ability to implement a nonpunitive ESR system? • Are there initiatives in other industries that public transportation agencies can effectively apply within their own ESR systems? • Do ESR systems lead to improvements in the overall safety of a transit agency? • What are the benefits or importance of ESR systems being nonpunitive? The findings of the literature review address these questions and provide answers that give context to the overall report. It is important to note that a nonpunitive ESR system is only one element of an SMS, but that its role in the overall safety culture within the public transportation industry cannot be overstated. The literature review findings address the following topics and subtopics: • Benefits associated with nonpunitive ESR systems; • Positive impacts of ESR systems on safety culture; • Characteristics and elements of ESR systems, including – The role of stakeholders, – Strategies for collecting and managing data, – The use of third parties, and – Procedural fairness; • Examples of nonpunitive ESR systems from all industries; • ESR system scalability; • ESR system framework; and • Third-party management and report collection. Benefits of a Nonpunitive Employee Safety Reporting System In creating a culture of safety, the American Public Transportation Association (APTA) cites a nonpunitive near miss policy as one of the indicators for an effective SMS.19 Numerous benefits are associated with effective ESR systems, particularly those created through an SMS structure and driven by ESR safety indicators; these benefits are further defined and discussed below. C H A P T E R 2

Literature Review and Background Research 17 Significant research addressing the benefits of ESR systems across the transportation industry has been performed, including on the Federal Aviation Administration’s (FAA’s) well-defined and long-standing Aviation Safety Reporting System (ASRS), and has concluded that nonpunitive ESR systems that identify close calls have benefitted the industries and entities that have adopted them. On the basis of the recognized benefits described in research activities and through improved safety records of those industries, FRA established its C3RS program. In its most recent lessons-learned publication,20 FRA stated: C3RS can be beneficial and sustainable in the railroad industry with both good implementation by individual carriers and continued support from FRA and national labor. FRA has taken steps to support sustainability in the railroad industry. Those steps have included continued funding for the C3RS program’s third party to collect close call reports and the allocation of dedicated staff. Due to its success, FRA’s pilot program had expanded from four original sites to nine sites (two original sites and seven passenger rail agencies) as of August 2019. A 2018 presentation of Volpe’s 2017 study of FRA’s C3RS showed that since the implemen- tation of a C3RS, derailments had been reduced 20% to 40% across three sites, transportation- related injuries had fallen by 18% at one site, and two sites had seen 39% to 90% fewer disciplinary hearings (specific pilot locations were not disclosed).21 The authors attributed the reduction in derailments to the corrective actions that had been taken in response to employee reports and the increase in the level of reporting due to the protection against punitive actions that had been granted to employees. FTA is conducting an SMS Implementation Pilot Program that includes the establishment and implementation of ESR systems. The pilot, which includes the Chicago Transit Authority (CTA) and transit services in Frederick County, Montgomery County, and Charles County, Maryland, serves to provide the public transportation industry with guidance on SMS imple- mentation, including the importance of ESR in both the SMS safety risk management and safety assurance functions. FTA designed the program to demonstrate the benefits of confidential, nonpunitive, near miss reporting in improving transit safety by identifying the risks that exist within an agency and establishing formal approaches, including the development of corrective actions, to mitigate those risks. FTA’s Close Call Reporting System Implementation Plan22 and TRACS Report 11-01, Establishing a Confidential, Non-Punitive, Close Call Safety Reporting System for the Rail Transit Industry,23 were resources used to establish the structure of FTA’s pilot program. Safety Culture Impacts TCRP Report 174 defines safety culture as 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).”24 The importance of safety culture in the discussion of nonpunitive ESR requires an industry shift in the approach to managing public transportation safety. This cultural shift within transit agencies is necessary to ensure that safety is understood as the ultimate goal, with root cause analysis and corrective actions developed and disseminated throughout each transit agency. According to the TRACS report Implementing Safety Management System Principles in Rail Transit Agencies, this shift in safety culture requires a transition from a reactive approach to a proactive approach that includes focused efforts on four cultural aspects: • A reporting culture that encourages the reporting of hazards without fear of retribution, • An informed culture that uses the collection and analysis of leading indicators of safety performance metrics as the basis for all decision-making,

18 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • A learning culture that uses the results of informed decision-making to improve policies or procedures and details all necessary changes through employee training, and • A just culture in which employees are not punished for unintentional errors but are held accountable for deliberate or reckless actions.25 In TRACS Report 16-01, Building Toward a Strong Safety Culture Within the Bus and Rail Transit Industry,26 the working group members recognized that formal data collection systems and nonpunitive ESR systems are necessary elements of a strong safety culture within a transit agency. They stressed that nonpunitive employee reporting does not mean all behavior is accept- able as long as it is reported and added that rules must be followed. However, they characterized safety reporting as an opportunity for transit employees to voice safety concerns without fear of reprisal and to assist in finding solutions to the problems identified, thus strengthening the safety culture.27 A companion study documented in TRACS Report 11-01, Establishing a Confidential, Non- Punitive, Close Call Safety Reporting System for the Rail Transit Industry, found that a nonpuni- tive close call reporting system has the potential to build trust between labor and management, in that employees know the information will be acknowledged and will not be used against the employee who reported it.28,29 ESR systems are central to the maturation of an SMS within a transit agency, but a robust safety culture is at the heart of the effective and successful installation of an ESR system. While safety is often cited as being the Number 1 goal of any transit organization, it is complex and includes all facets of public transportation service delivery, maintenance, and management. Encourag- ing a culture of safety can “determine the commitment to, style, and proficiency of the public transportation agency”30 and, thus, the success of nonpunitive ESR systems. In recognizing the interrelated nature of ESR and safety culture, the literature review does not reflect an examina- tion of ESR in a vacuum, but rather through highly correlated factors such as safety culture. The National Safety Council (NSC) report Near Miss Reporting Systems states that many safety activities are reactive rather than proactive and indicates that close calls or near misses typically occur or are identified before an accident occurs.31 In highly evolved safety cultures, in which the element of trust exists, a nonpunitive, close call ESR system allows hazards or incidents to be reported through a formal ESR system and corrected before an accident or fatality occurs. Statistics detailing how many accidents or fatalities have possibly been prevented as a result of the implementation of a nonpunitive ESR system are limited. However, Hanssen and colleagues’ 2006 report states that close call reporting systems are cost-effective and one of the leading factors in creating a safety culture within an organization. With regard to cost- effectiveness, these systems allows errors to be identified and corrected before they become a cost to the organization. In creating a safety culture, as a nonpunitive ESR system influences the values, attitudes, beliefs, and behaviors within an organization,32 it creates an environment in which “everyone shares and contributes in a responsible manner to their own safety and that of their fellow workers.”33 Safety culture and the benefits of ESR systems were also examined through the evolution of safety culture within the offshore oil and gas industry and the maturation of ESR in that industry. Offshore Oil and Gas Industry The term “safety culture” originated in the investigation of one of the most devastating nuclear power plant accidents in history, Chernobyl.34 This event changed the approach to safety in the nuclear power industry and served as an example for others, such as the offshore oil and gas industry. In 2014, the National Academies of Sciences, Engineering, and Medicine

Literature Review and Background Research 19 convened the Committee on Offshore Oil and Gas Industry Safety Culture and commissioned the study “Strengthening the Safety Culture of the Offshore Oil and Gas Industry.” The study examined the history of the industry and described the historical culture as one of “produc- tion over safety.” It reflected on a theme found in many industries—that there are significant inconsistencies in data collection and the reporting of accidents and injuries. Following several disasters and the institution of regulations and practices, improvements were reported in the industry, but with incomplete historical data, improvements were difficult to quantify or confirm. The Committee on Offshore Oil and Gas Industry Safety Culture estab- lished several recommendations to the industry that included methods for strengthening and sustaining safety culture: • Conducting collective and collaborative actions—industry leaders, federal regulators, operators, and contractors; • Establishing an independent entity dedicated solely to offshore safety; • Adopting safety management systems; • Assessing safety culture; • Implementing change; • Using safety management principles to improve safety performance; • Ensuring data collection and the availability of that data; • Seeking safety culture champions from within the industry; • Establishing memoranda of understanding (MOUs) to promote safety culture; and • Assessing and improving safety culture. In April 2010, the Deepwater Horizon explosion and fire occurred, and the subsequent investigation identified numerous deficiencies. In response, the American Petroleum Institute created the Center for Offshore Safety (COS), an industry association focused on improving the safety of the offshore oil and gas industry with responsibilities that include • Developing good practice documents for the offshore industry in the area of Safety and Envi- ronmental Management Systems (SEMS), • Auditing by third-party certification program auditors to ensure that the program’s goals and objectives are being met, • Compiling and analyzing key industry safety performance metrics, • Establishing Coordinating Center–sponsored functions designed to facilitate the sharing and learning process, • Identifying and promoting opportunities for the industry to continuously improve, and • Developing outreach programs to facilitate communication with government and external stakeholders. In addition, the U.S. Department of the Interior’s Bureau of Safety and Environmental Enforcement (BSEE), one of the regulatory and oversight bodies for the offshore oil and gas industry, made compliance with the SEMS rule, which requires the industry to submit near misses and incident reports and share them with the industry, compulsory.35 In 2013, BSEE released a list of characteristics of organizations that have developed strong safety cultures:36 • Leadership commitment to safety values and actions, • Respectful work environment, • Environment for raising concerns (emphasis added by author), • Effective safety and environmental communication, • Personal accountability, • Inquiring attitude,

20 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Hazard identification and risk management, • Safe work processes, and • Continuous improvement. In 2013, BSEE also entered into an interagency agreement with the Bureau of Transporta- tion Statistics (BTS) to implement and operate a voluntary confidential near miss ESR system for the offshore industry, the Safe Outer Continental Shelf (SafeOCS). BSEE established this system to provide an environment in which operators and employees could raise concerns and report equipment and other safety-related events. In November 2016, an MOU between BSEE and BTS expanded the program to include the reporting of safety and pollution prevention equipment (SPPE) failures.37 Characteristics and Elements of a Nonpunitive Employee Safety Reporting System This section presents the specific characteristics and elements of nonpunitive ESR systems found in the background research, including the roles of stakeholders, types of data that should be collected, data collection strategies, and strategies for procedural fairness. A nonpunitive ESR system promotes the reporting of safety issues and incorporates basic structural characteristics that guarantee confidentiality and, sometimes, anonymity for those who report. Additional key characteristics include policies with explicit rules regarding who can report, the types of reports employees can make, guidelines for reporting, guidelines for data usage, identification of eligible reporters, and delineation of ESR system ownership.38 The pur- pose of the nonpunitive element of an ESR system is to “provide protection from disciplinary action for employees who submit qualifying reports”;39 this should be clearly stated in any pro- cess or procedural documents. Persons who believe they will be disciplined for a safety-related issue are less likely to report it. The TRACS report Establishing a Confidential, Non-Punitive, Close Call Safety Reporting System for the Rail Transit Industry goes a little further by also including the need for all reporting to be voluntary, in an attempt to give all reports equal standing no matter who submits the issue. It notes the use of a third party as a viable solution for data collection, de-identification of reporters, and report preparation to help maintain confidentiality and investigate the reports to prevent conflicts of interest. The report stresses that feedback pro- vided by a third-party investigator plays an essential role in identifying the actual problem and safety risk areas for an agency and proposing solutions.40 Depending on the size of the transit agency, this may not be fiscally feasible or otherwise warranted; however, larger transit agencies or those with less mature safety cultures may find the use of a third party a viable or preferred option. The August 2019 FTA Transit Safety and Oversight Spotlight newsletter41 highlighted four elements required in an ESR program that are included in the PTASP regulation (49 C.F.R. Part 673): • A process that allows employees to report safety conditions to senior management; • Protections for employees who report safety conditions to senior management; • A description of employee behaviors that may result in disciplinary action and, therefore, are excluded from protection; and • Communication on actions taken in response to employee reports. The ESR process should be considered a reporting cycle that serves as an iterative source of safety data.

Literature Review and Background Research 21 In TCRP Report 149: Improving Safety-Related Rules Compliance in the Public Transporta- tion Industry, the authors developed a best practices checklist that transit agencies could use in designing and implementing an ESR system.42 Best practices were established within four categories: • Ensuring stakeholder participation and buy-in, • Establishing processes and protocols for piloting the ESR system, • Disseminating the results to the industry and providing the assistance necessary to ensure its success, and • Disseminating the information obtained through the ESR system. Roles of Stakeholders Key stakeholders in a nonpunitive ESR system may include: • The labor union; • Organizational management; • An independent third party, as further described in subsequent sections; • State or Federal oversight agencies (where applicable); • A peer review team; • Regulators, such as FRA; and • Other external parties. In addition, transit agencies should consider any internal or external committees or teams assigned to implement an SMS as stakeholders in this process. In TCRP Report 149: Improving Safety-Related Rules Compliance in the Public Transporta- tion Industry, the authors established that an environment of cooperation between labor and management is foundational in an ESR system.43 Stakeholder participation is not only estab- lished as important during the initial design and implementation of the ESR system, but as an ongoing procedural element. Their roles should include, but not be limited to, providing specific feedback on safety reports submitted, ensuring compliance with established policies, periodic evaluation of the ESR system, and representing an opportunity for obtaining feed- back on the overall program effectiveness or any procedural modifications that may need to be considered. An MOU is one of the most important first steps in defining the roles and responsibilities of all ESR system stakeholders. The development of the MOU is a shared responsibility of stakeholders and should clearly define: • Reporting process; • Eligible reporters; • Reporting process/procedures; • Criteria for report acceptance; • Reporting forms or platforms available; • Time limits for reporting an event; • Confidentiality and anonymity; • Protection from discipline, with criteria; • Use of ESR system data; • Corrective action development, institution, and dissemination; • Stakeholder responsibilities; • ESR system modifications; • ESR system or process duration; and • Record keeping.

22 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Funding for supporting the system and mitigation strategies • Responsible officials Stakeholders may also provide process oversight and monitoring functions to the ESR system. Oversight can include monitoring to ensure that report analyses are conducted effectively and accurately and that all reports remain nonpunitive (unless the safety issue is determined to be the result of intentional noncompliance).44,45 This oversight and monitoring should be prescribed in the MOU. Maintaining the functions of the MOU is the responsibility of all stakeholders, as it creates trust for all persons using the ESR system.46 Strategies for Collecting and Managing Data The research suggests that data collected through an ESR system should remain confidential to maintain reporter confidence. However, other elements are important in the collection and management of the data, including collecting the right information, addressing gaps, conduct- ing interviews with employees and other stakeholders, providing feedback, ensuring ease of reporting, analyzing the data, and using third-party collectors and reviewers when determined necessary or if transit agencies have limited personnel resources. Each of these elements is dis- cussed in more detail. Data Protections In a discussion of data management, data protections should be addressed. For organizations and transit agencies that use BTS, such as BSEE and WMATA, data are protected through the Confidential Information Protection and Statistical Efficiency Act (CIPSEA), Public Law 107- 347, promulgated at 44 U.S.C. § 101. However, transit agencies that collect close call or near miss data—even those that do so under confidential methods—may not have these same protections. TRB’s Special Report 326: Admissibility and Public Availability of Transit Safety Planning Records,47 discusses evidentiary protections for safety planning records, which include ESR data collected and maintained by public transportation agencies through SMS practices performed in accordance with the requirements of 49 U.S.C. § 5329. The objective of the project was to evaluate and provide recommendations on whether it is in the public transportation industry’s interest to withhold from civil litigation all records collected in compliance with these requirements. The committee recommended that evidentiary protections be extended to public transportation agencies. Further, the committee provided a specific recommendation to the U.S. Congress: Congress should prohibit, by establishing an admissibility bar, the introduction of the records generated by public transit agencies in fulfilling the safety planning requirements of MAP-21 into legal proceedings. This bar should apply only to data, analyses, reports, and other similar information prepared in response to or used in support of the MAP-21 mandate and FTA’s corresponding safety program requirements.48 An additional recommendation to Congress established that if this prohibition was approved, an assurance would be included that the bar could not be waived on a record-by-record or lawsuit- by-lawsuit basis. The committee recommended that states be allowed to opt out through the enactment of state law applicable to public transportation agencies. Collecting the Right Information It has been established that the contents of employee safety reports collected remain confi- dential and nonpunitive to maintain trust and develop a just safety culture within an organiza- tion. However, what kind of data should an organization collect? The authors of both Building Toward a Strong Safety Culture Within the Bus and Rail Transit Industry and Just Culture state that, whereas a nonpunitive ESR system focuses mostly on close calls, employees can identify any issue they feel hinders safety.49,50

Literature Review and Background Research 23 Dekker further explains that while it is easy to instruct employees to report everything, the question of how data should be reported still remains. An event or situation that one employee does not see as a hazard potentially could be related to or cause a hazard, leading to a much larger problem in the future. The book goes on to describe that every report is a judgment made by the reporter, based on experience, normalizing safety issues or uncertainty. Ultimately, Dekker concludes that the ethical obligation in what kind of data to report is “If in doubt, report.”51 The question of what information should be collected ultimately depends on the MOU between all parties. WMATA’s C3RS MOU (included in Appendix C) states that the only crite- ria for reporting is that the employee submitting the report provide enough detailed descrip- tion about an event that BTS can investigate and evaluate the situation effectively.52 The level of information collected through an ESR system should be sufficient to correct the safety issue at hand and sustain the improvements made.53 The TRACS 14-02 Letter Report recommends transit agencies begin investigations by col- lecting all objective information possible without the need to contact the reporter and then quickly reaching out for any additional information from the reporter, if self-identified, as necessary after the initial report.54 The information collected needs to lead to the right con- clusion for past event(s) and be used to conduct “health checks” to prevent future events of a similar type.55 When a determination is being made about the right data to collect, it is also important that data elements are well defined and understood by agency personnel to provide accurate baseline and temporal analyses. TRACS Final Report 16-02, Safety and Performance Measures in Transit, lists the following minimum information metrics (data) that transit agen- cies should collect:56 • Date and time, • Weather, • Pavement and light condition, • Geographic location, • Property damage, • Number of injuries/fatalities, • Number vehicles and pedestrians involved, • Type of vehicle(s) involved, and • Preventability. A NASA ESR sample report form includes57 • Name and personal address; • Event type; • Personnel involved; • Event location; • Job function (e.g., engineer, dispatcher, trainee); • Years of experience; • Time of event; • Weather at the time of the event; • Visibility at time of event (or obstruction, if applicable); • Type of operation; • Rules in effect, including operating rules; • Vehicle activity; and • A description of the event or situation. From the reports, statistical analyses, correlation studies, trending, and performance measure- ments can be studied and reviewed.58

24 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation In summary, transit agency policies and procedures should prescribe and define the data elements that should be collected in support of agency-established performance measures. The examples above include common metrics. Addressing Data Gaps Lack of time, writing ability, and motivation are some of the factors that contribute to limited reporting or none or that may be involved when employees submit reports that do not suffi- ciently articulate the observed or experienced hazard or event. Developing an Effective Corrective Action Process: Lessons Learned from Operating a Confidential Close Call Reporting System intro- duces five strategies designed to help address gaps in reports and give better insight, explanation, and context for decisions and actions by employees:59 • Working with a third party to improve the quality of the reports, • Developing standardized questions on particular topics for the third party to ask, • Having a method for the reporter to submit supplemental information, • Reaching out to everyone involved in a close call event to report, and • Requiring report submission by the individual in order to receive nonpunitive protection. Multer et al. suggest using a third party as a strategy to improve the quality of reports and recog- nize that not all transit agencies use one, nor are they required to do so. Dekker states that any review process should include staff who are impartial to the situation.60 Using a third party is one way to ensure every report is reviewed in an impartial manner.61 Conducting Interviews Interviews are a method used to close gaps during analysis efforts.62 Whereas maintaining confidentiality is key, interviews may be necessary to gather more information to determine the validity of a report.63 Interviews allow for clarity outside the structure of a written form and also offer another form of standardization, in which responses can be coded and analyzed to identify trends within the overall culture of the organization.64 Interviews open the opportunity for supplemental materials to be submitted, such as maps, photographs or other images, and written documentation.65 Providing Feedback Whether gathered in-house or through a third party, feedback has the ability to encourage employees to continue the reporting process.66 Sharing the analysis results and the implemented corrective action(s) fosters the ability to maintain trust in the nonpunitive ESR system and may provide incentive to maintain the implemented corrective action(s). Publicizing feedback also provides opportunity for peer transit agencies to learn about identified safety issues and how they are addressed.67 It is important to note, however, that feedback is only one necessary ele- ment of a successful nonpunitive ESR system; providing feedback alone likely will not lead to improving conditions.68 There should be active, demonstrable engagement with the data col- lected and feedback given to explain why safety actions were taken and why safety procedures have changed.69,70 Ensuring Ease of Reporting Managing the Risks of Organizational Accidents identifies the characteristics of the reporting mechanism, which include the format, length, and content of the reporting form, as one of the most important factors in collecting and managing data.71 NASA’s C3RS features both an electronic report submission and a mail-in paper form, thus providing options for what the reporter is most comfortable with while also maintaining confidentiality.72 The author states that there should be only a limited number of questions directed to the incident that occurred;

Literature Review and Background Research 25 others should seek to determine whether the event was related to “missteps,” employee error, or misleading or ineffective guidance.73 Analyzing Data Action on any report submitted requires the data to be reviewed. Hanssen et al. present two methods of data analysis in Confidential Close Call Reporting in the Railroad Industry: A Litera- ture Review to Inform Evaluation.74 The first method is qualitative, focusing on the cause, sever- ity, consequences, and how it was avoided. The second focuses on trends over time; however, the authors note that this type of analysis is dependent on the first to create a case record. The second method, through expanded analysis, focuses on a specific period of time, which allows reports to be coded to find trends and allows reviewers to take a more quantitative approach to analysis by creating statistics and identifying frequencies of issues. Use of Third Parties A strategy employed in confidential ESR systems is the use of a third party to collect data, perform an impartial analysis of all hazard reports, and ensure confidentiality.75 BTS served as FRA’s initial third-party reviewer for its C3RS program, a role now performed by NASA. FRA’s original pilot implementation sites included Union Pacific’s North Platte Service Area, Canadian Pacific’s Chicago service area, and New Jersey Transit (NJT) and Amtrak. FRA has extended the program and, as of 2019, nine passenger rail carriers are participating in the program: Amtrak, Long Island Railroad, MBTA/Keolis, Metra, Metro-North, NJT, North County Transit District (NCTD), SEPTA, and Denton County (Texas) Transportation. An MOU was negotiated by labor, management, and FRA for each C3RS location, defining those close call events included within the program scope, requirements for confidentiality, and the obligations and commitments of all parties. The MOU established the roles, responsibilities, and reporting parameters for the program to “identify why close calls may occur, recommend corrective action, and evaluate the effectiveness of any such action that was implemented.”76 (Appendix C includes FRA’s C3RS MOUs with SEPTA, MBTA, and NJT.) Through the ESR system, close calls can be reported confidentially, and reported events are addressed by peer review teams consisting of representatives from labor, management, and FRA.77 For any reports made, the third-party reviewer determines whether the report meets minimum qualifications (estab- lished in the MOU). Figure 1 illustrates FRA’s current C3RS program reporting and follow-up processes.78 NASA redacts all identifying information before it is distributed to the employer.79 In 2010, FRA and NASA signed an interagency agreement assigning NASA as the third- party administrator for Amtrak; since that time, FRA has transitioned the administration of all C3RS locations to NASA. NASA uses a process similar to that established through BTS but also modified the process on the basis of its administration of the ASRS, the system that collects aviation safety incident and situational reports submitted by pilots, controllers, and others.80 As noted previously, BTS and BSEE signed an MOU establishing a near miss ESR system for the offshore industry. SafeOCS is a voluntary and confidential reporting system that pro- vides industry operators and employers a method for sharing information related to equipment failure and safety data. BTS shares aggregated data with the public through its website. Data are also used to identify safety trends and increase the understanding of offshore risk.81 BTS began collecting data on equipment component failures reported through the ESR system in December 2016. Although too early to determine the success of the program in reducing safety risks in the industry, Oil and Gas Production Safety System Events, BTS’s 2017 annual report for SafeOCS,82 summarized the first full year of reporting, which included 112 SPPE failures from nine of

26 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation 59 Gulf of Mexico production operators, representing 35% of active wells and 40% of total oil production in the Gulf of Mexico.83 As summarized in the 2017 annual report, while the majority of these failures were attributed to internal leakages (88%), which pose less risk, the thoroughness of the reporting provided by the nine operational units reflects conformance with the required reporting and, more importantly, demonstrates the industry’s heightened focus on prevention. Implementing a nonpunitive ESR system through an independent third party could be a valuable option for transit agencies whose safety culture is in its infancy. The independent third party can ensure confidentiality, provide an impartial analysis of the reported hazard or event, and protect the reporter from punitive measures or retaliation by the agency, directors, supervi- sors, or other employees. The use of a third party may remove any real or perceived barriers to procedural fairness and increase employees’ willingness to report. Procedural Fairness for Employees Human resources, public policy, political reform, and justice-related research examine the topic of procedural fairness and are consistent in the underlying platform on which their defini- tions are based. For this report, procedural fairness is described as the systematic development of processes and procedures, employees’ understanding of the process, and management’s compli- ance with and execution of those processes and procedures without prejudice to the individual or the process, ensuring effective and fair outcomes. Procedural fairness is one of the main factors in successful nonpunitive ESR systems and may lead to a greater level of trust among employees. Procedural fairness will be reflected in the transparency of the process, the ability for all employees to participate (regardless of position) and be notified of the outcome of safety events or conditions reported, and the protection from punitive actions, retaliation, or discrimination granted through the program. To maintain a level of fairness, several sources cite strategies to maintain trust in the ESR system. One strategy is the development of a rubric that contains values and definitions to ensure implementation can occur consistently across all sites or units, allowing results that are objective Figure 1. Confidential close call reporting system. Note: PRT = peer review team; MCIA = multiple cause incident analysis. Source: J. M. Ranney, M. Davey, J. Morell, M. Zuschlag, and S. Kidda, Confidential Close Call Reporting System (C3RS) Lessons Learned Evaluation—Final Report, DOT/FRA/ORD-19/01, Federal Railroad Administration, U.S. Department of Transportation, 2018.

Literature Review and Background Research 27 and observable. A rubric would include standards for reporting and process statements with the goal of ensuring fairness to the reporter. A rating system for the hazards or events reported, with corresponding actions, could be developed that would assist an established review team or other investigative unit in reviewing and rating each hazard, comparing ratings, and prioritizing actions.84 Even though an ESR system is nonpunitive, it may not establish that all reported behavior is acceptable.85 Every nonpunitive ESR system should have an established formal policy and corresponding implementation procedure that clearly defines the types of protections that are being afforded by reporting and how identifiable information will be used.86 Fair treatment of employees also requires fairness and consistency in dealing with rule violations. When rule violations occur, there should be a fair appeals system in place to dispute them in case of a disagreement.87 Employees should be made aware of what is punishable when there appears to be blatant dis- regard for rules or when an issue is determined to be intentional or due to negligence.88 Examples of Nonpunitive Employee Safety Reporting Systems Examples of functioning nonpunitive ESR systems or associated pilots illustrate their use in a real-world setting and the application of what has been presented in this literature review. In general, formal nonpunitive ESR systems within U.S. public transit agencies are still in their infancy; thus, additional examples are provided from other transportation modes and non- transportation industries. Resources discussing the scalability of a nonpunitive ESR system are then presented. The ESR systems of public transportation agencies selected as case studies for this report are summarized in Chapter 3, and comprehensive case study discussion is given in Appendix A. Aviation Safety Reporting System FAA implemented the Aviation Safety Program in 1975 in response to high-profile aviation accidents. In 1976, the ASRS was established through an MOU between FAA and NASA, the third-party administrator of the safety reporting system. The ASRS is a voluntary reporting system in the aviation industry available to pilots, air traffic controllers, dispatchers, cabin crews, maintenance technicians, and others. Initially, approximately 400 safety reports were submitted per month; as of July 2019, reports have increased to more than 8,251 per month.89 Reports can be submitted electronically or can be mailed to NASA’s Moffett Airfield Post Office in Mountain View, California. Once received, reports are dated and time-stamped, and ASRS analysts screen each report submitted within three working days to categorize and deter- mine the next steps in the process. If a hazardous situation is reported, the analyst may issue an alert message and provide information, scrubbed of reporter detail, to the subject organization for further evaluation and corrective action. If clarification or further detail are needed, an ana- lyst will contact the reporter by telephone to clarify. Reports go through a number of steps, including a final check to ensure accuracy. NASA includes initial and subsequent documentation in the final event record after all personally iden- tifiable information has been removed from the report. ASRS uses this information as the source for Alert Messages (alert bulletins or information notices) and for information included in its monthly safety newsletter CALLBACK, its ASRS Directline journal, aviation safety research, and elsewhere. A category of review called “quick response” initiates a rapid data analysis process for reports of immediate operational importance.

28 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Bureau of Safety and Environmental Enforcement As noted, BSEE established SafeOCS as a voluntary program for confidential reporting of near misses in the offshore oil and gas industry occurring on the Outer Continental Shelf (OCS). In 2013, BSEE conducted outreach events with the industry and offshore workers, followed by public workshops on the reporting system. Volunteers were used to test the online reporting forms and associated interview procedures before the system was institutionalized. In 2016, BSEE, working with BTS, expanded the program to collect event data on equipment failure and blowout prevention system safety. BTS’s responsibilities include90 • Collecting, owning, and protecting submitted confidential near miss reports; • Aggregating and statistically analyzing submitted information with BTS subject matter experts; • Identifying trends, emerging safety and environmental concerns, and potential causal factors of near miss incidents; and • Developing aggregated statistical reports and making them available to the public, in accor- dance with Office of Management and Budget statistical policy directives. Employees or other industry representatives can create an account and register through the reporting system. Those with accounts can report near misses through the program website at www.safeocs.gov. Once BTS receives the reports, it evaluates and analyzes information submit- ted through the reporting system and presents aggregated results to stakeholders. SafeOCS has been actively collecting data only since early 2017; thus, there is little information to provide to quantify the benefits of the program. However, as noted, the reporting system has been effective in providing a platform for the industry and its employees to report near misses and equipment failures. The 2018 Annual Report documented the successes of both equip- ment failures and the blowout prevention components of the program, as reflected in increased reporting and utilization of data collected through the reporting that the industry can use to correct existing safety concerns. Federal Railroad Administration FRA’s C3RS program is discussed earlier in this report, and the opportunities for public trans- portation agencies to consider when framing their programs have been noted. Several passenger rail agencies are participating in the program, including NJT, MBTA, and SEPTA, which have been included as case study sites in this study. New Jersey Transit In 2009, NJT piloted an FRA-sponsored nonpunitive close call ESR system for its rail opera- tions on which it owned tracks. The ESR system enabled 1,700 employees to report close call or safety issues. In the Ranney et al. Lessons Learned evaluation of FRA’s C3RS program,91 the research team conducted a study of the FRA program, including the NJT ESR system. The authors report that from the beginning of the research period in October 2009 and throughout the 18 months that followed, NJT labor and management returned 812 responses to submitted reports, which were analyzed with ATLAS.ti software. While the report does not single out NJT in its conclusions, which also include Amtrak, Union Pacific North Platte Service, and the Canadian Pacific Chicago Service Area Road Territory, the authors found that both labor and management were committed to using the ESR system and were willing to commit the time needed for the system to be a success.92 Conclusions identified the necessity of ESR agencywide support and cooperation from all stakeholders. Additionally,

Literature Review and Background Research 29 they found that low reporting rates do not necessarily indicate poor implementation. Areas identified for improvement include communication, analysis, efficiency, and the method and process to track corrective actions.93 Federal Transit Administration The PTASP regulation at 49 C.F.R. Part 673 includes a requirement for public transit agencies to develop an ESR program in support of the PTASP. In the safety management policy require- ments included in §673.23(b), transit agencies must • Establish and implement a process that allows all employees, including contractors, to report safety conditions to senior management; • Specify protections for employees who report safety conditions; and • Describe employee behaviors that may result in disciplinary actions and, therefore, would not be covered by protections. ESR program requirements are also included within safety assurance [§673.27(b)] and safety promotion [§673.29(b)], which require transit agencies to monitor information reported through any internal ESR program and inform employees of safety actions taken in response to reports submitted through the program. FTA-developed guidance to the industry provides the characteristics of both a “good employee safety reporting program” and “good safety culture”:94 • Good employee safety reporting program: – Management’s commitment, – Safety is everyone’s responsibility, – Clear safety roles for each individual, – Empowered employees, – Staff involved in ESRP planning process, and – Culture of learning from past mistakes. • Good safety culture: – Culture of learning, – Flexible and adaptable, – Flexible organizational structure, – Both managers and operators should be informed, – Organizational factors, and – Trust is essential. As noted, FTA is conducting an SMS Implementation Pilot Program with four public transit agencies that includes the establishment and implementation of an ESR system at each of these transit agencies. The pilot includes CTA and the transit services of Frederick County, Montgomery County, and Charles County, Maryland, and serves to provide guidance on imple- menting an SMS to the public transportation industry, including the importance of ESR in the SMS safety risk management and safety assurance functions. CTA is included as a case study in the present report. The three Maryland pilot locations, which are in their infancy, are also discussed in Appendix A. National Air Traffic Controllers Association The National Air Traffic Controllers Association’s (NATCA’s) Air Traffic Safety Action Program (ATSAP) is modeled after FAA’s Aviation Safety Action Program and includes a voluntary nonpunitive safety reporting system for air traffic controllers and other employees.

30 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation An MOU between FAA and NATCA identifies the reporting standards. As with the ASRS, employees may submit reports to the ATSAP website, and program analysts review each submittal and remove any identifiable information. An ATSAP Event Review Committee (ERC) comprising a member of FAA’s Air Traffic Organization Management, a NATCA representative, and a member of FAA’s Air Traffic Safety Oversight Service evaluates each report submitted and determines whether it meets the requirements established through the MOU. If the report meets the standards prescribed, the ERC accepts the report and logs it into ATSAP. During the review process, the ERC also reviews each report to identify actual or potential problems and causal factors. It also uses the Safety Risk Management Risk Assessment Matrix of FAA’s Air Traffic Organization to determine the severity of the event and the appropriate response.95 The ERC may prescribe training or may refer an individual to a union profes- sional standards program. Either the ERC or the ATSAP analysts may also request additional information from a facility, service unit, or office to supplement report contents. The ERC may also make a formal corrective action request to resolve a reported safety concern, and recipients should provide a corrective action plan in accordance with the time line established in the request. The program provides employee protections from punitive or disciplinary action for those personally involved in the safety events. Safety areas reported are tracked to iden- tifying any systemic industry trends.96 The program provides a feedback loop to the reporter. NATCA considers the safety reporting system a success and feels reporters are comfortable submitting information because they know all information submitted is confidential and nonpunitive.97 Occupational Safety and Health Administration The Occupational Safety and Health Act of 1970 (29 U.S.C. § 651 and 29 C.F.R. Parts 1900 to 2400) grants employees and their representatives the right to file a complaint and request the Occupational Safety and Health Administration (OSHA) to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHA standards. The act also establishes the employee’s or other complainant’s right to request that his or her name not be revealed to the employer. Employees may submit a confidential complaint form through an online portal (https://www.osha.gov/pls/osha7/eComplaintForm.html) or an OSHA com- plaint form via fax or by mail, or they may call the local OSHA regional or area office. Training videos that cover how to file a complaint and the rights of workers to report are provided in Spanish and English at https://www.osha.gov/workers/file_complaint.html. Employees who feel their employer has retaliated or taken punitive action against them may file a whistleblower complaint; OSHA provides instructions for how to do so at https://www. whistleblowers.gov/complaint_page. Procedures for OSHA’s investigation of these complaints are provided in OSHA’s Whistleblower Investigations Manual.98 U.S. Nuclear Regulatory Commission The U.S. Nuclear Regulatory Commission (NRC) established the Allegation Program through which employees or the public can report safety concerns. Safety concerns may be potential or actual safety issues associated with the NRC’s jurisdiction, including, but not limited to, the areas of design, construction, operation, maintenance, radiation protection, safeguards, security, emergency preparedness, harassment, intimidation, retaliation, discrimination, wrongdoing,

Literature Review and Background Research 31 a work environment that discourages workers from raising safety concerns, and other matters related to NRC-regulated activities.99 Reports may be submitted by e-mail to allegation@nrc.gov or on NRC’s Safety Hotline at 1-800-695-7403. NRC’s Allegation Program protects the identity of reporters. Once a report has been received, it is assigned to an allegation coordinator, who is responsible for communicat- ing with the reporter and arranging for the investigation and evaluation of the concern by NRC employees and managers who serve on the Allegation Review Board (ARB). The ARB reviews the reported concern and issues a preliminary determination. It also determines whether feed- back from other agencies is needed to complete the investigation. The allegation coordinator documents all actions taken in response to a report and provides updates and the final investiga- tion report to the reporter once the process concludes. Although NRC makes all “reasonable efforts” to protect the identity of a reporter, it does not provide employees the same protections as those found in the programs managed through NASA or BTS. An employee who feels he or she has been discriminated against because of the submission of an allegation can have the case investigated by NRC’s Office of Investigations or may seek personal remedies from the U.S. Department of Labor. Scalability The scalability of a nonpunitive ESR system is explored in several of the materials exam- ined in the background research for this study. FTA’s monthly newsletter, Transit Safety and Oversight Spotlight, stated that FAA selected NATCA to present its day-to-day operation and implementation of the ESR system to CTA because the membership of NATCA is of similar size to CTA’s union membership.100 However, NATCA and CTA are still very large organizations as compared with many transit agencies throughout the United States. For smaller urban and rural public transportation agencies, the National Rural Transit Assistance Program (National RTAP) has a one-page policy template that includes objectives, nonpenal statements, and commitment to safety.101 There are also examples in the case studies of smaller transit agencies that have successfully implemented nonpunitive ESR systems that are not procedural heavy or supported by advanced reporting methods (see Appendix A). There are opportunities to implement ESR systems scaled to the local agency’s profile and operating environment. The framework established by each agency should reflect scaled agency-appropriate and specific needs. Framework of a Nonpunitive Employee Safety Reporting System For a nonpunitive ESR system to be effective, governance, strategies, and reviews are necessary in written form and agreed upon throughout the organization by those who will be affected by it. This section presents policies, procedures, mitigation and response strategies, performance measures, and lessons learned found in the literature. Policies and Procedures TRACS Working Group 16-01, in its report Building Toward a Strong Safety Culture Within the Bus and Rail Transit Industry, makes clear that a nonpunitive ESR system does not mean all behavior is acceptable.102 Policy should clarify that any blatant disregard for safety pre- cautions will still result in disciplinary action. WMATA’s C3RS MOU, as an example, includes

32 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation the criteria for what does not meet the reporting criteria.103 Confidentiality should also be a policy with all reporting and “sufficient care should be taken to establish the proper legal basis for the maximum protection of the pilot system’s confidential data.” Once confidential- ity is breached, the trust employees have in the ESR system will be forever lost.104 To ensure confidentiality, it is good practice to employ an impartial third-party reviewer to receive, process, and investigate reports.105 Policies and procedures should address, at a minimum, the following: • Methods for reporting; • Step-by-step process from original receipt of the report through the development and implementation of corrective measures; • Time lines for each process step; • Membership and roles of committees, peer review teams, and investigators involved in the program; • Participation of the collective bargaining unit (CBU) in the process; • Investigation process that demonstrates the involvement of multiple players from across the agency; • Feedback to reporters, from initial receipt of the report through the process and once the hazard has been corrected—both for those who included contact information and for anonymous reporters; • A written agreement, which could be included as part of the collective bargaining agree- ment (CBA) or the agency policy, that reporters can remain anonymous and that, if contact information is provided, no punitive action or any form of intimidation or harass- ment will be taken; • Precise statement of what is and is not considered nonpunitive; • Method to allow a reporter to challenge or appeal the outcome of the investigation or the corrective action taken; • Process for disseminating hazards reported and corrective actions; • Performance measurement; and • Periodic process and program evaluation, including obtaining employee input. Response and Mitigation Strategies As reflected above, it is important to clearly identify what should be reported and have a process for responding to and mitigating reported concerns. Just Culture: Balancing Safety and Accountability states that one of the best strategies for response and mitigation of any safety issue is to report everything.106 WMATA’s MOU with BTS states, “Any condition or event that is perceived as potentially endangering employees, the public, equipment, or the environment” should be reported.107 Once a report has been made, response and mitigation efforts should follow a well-defined framework. As indicated previously, this starts with the acceptance of a report submitted in accordance with the agency’s policy, which should contain reporting criteria, including the level of detail and thoroughness required. The framework follows the procedural aspects of the ESR system: • A thorough examination of the report contents; • A formal investigation through the process established in the policy or procedural document; • An SMS process that examines the reported hazard, develops mitigation strategies in response to a report, and provides effective evaluation of the strategy employed to ensure unintended consequences are not present; and • A communication strategy to inform employees of the steps taken to correct the hazard.

Literature Review and Background Research 33 Performance Measures TRACS Working Group 16-02, in its report Safety Data and Performance Measures in Transit, established a list of eight characteristics of good safety performance measures.108 Safety perfor- mance measures should be 1. Quantifiable; 2. Representative of what is being measured; 3. Consistent throughout; 4. Detectable despite changes in behavior or environment; 5. Efficient; 6. Easily understood in analysis; 7. Capable of quality control; and 8. Have a manageable set of measures, metrics, and indicators. The final report of TRACS Working Group 16-01, Building Toward a Strong Safety Culture Within the Bus and Rail Transit Industry, lists three leading indicators to assess in monitoring and managing performance and safety culture in an organization: actions, behaviors, and pro- cess. The report suggests that promotion of positive changes in an organization’s safety culture should focus less on being reactive to safety issues and more on being proactive in informing and creating a safety culture.109 TRACS Working Group 11-01 created a list of 13 substantive outcomes for nonpunitive ESR systems that should be included in a program’s evaluation criteria and supported by corresponding metrics:110 • Safety improvement (i.e., the reduction of hazards and risks); • Identification of hazards that otherwise may not have been reported; • Extent of change in the completeness of close call and safety issue reports; • Extent of change in the number of close call reports; • Extent of change in the number of follow-up reports to close call reports; • Extent of change in the reporting of other safety issues; • Ability to determine the degree of hazard pervasiveness (i.e., unique, pervasive, increasing); • Collection of hazard information useful for remedial action for either a single instance or an emerging trend; • Expansion of the safety information pool (i.e., those who engage in safety improvement and development); • Future actions to be taken to reduce identified hazards; • Participation of all members of the organization in hazard identification and reduction; • Empowerment of members who otherwise might think that reporting hazards is futile or personally harmful; and • Overall safety performance in terms of injuries and events. FAA’s ASRS collects and reports the following “significant items” (the quantities given reflect the total number of events, reports, and activities that have occurred from the inception of the program in January 1981 through December 2018):111 • Number of incident reports received (n = 1,625,738); • Safety alert messages issued to organizations in “positions of authority” for evaluation and possible corrective actions (n = 6,515); • Quick responses—rapid data analysis by ASRS staff that is of immediate operational importance; generally limited to governmental agencies (n =144); • CALLBACK—monthly newsletter that provides lessons learned to the industry (467 issues);

34 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • ASRS Directline—journal published periodically to meet the needs of operators and flight crews of complex aircraft; articles cover topics reported through the ASRS that analysts have categorized as significant; and • Research studies—focus reports that cover safety topics of interest in cooperation with avia- tion organizations. Seminal to establishing and tracking performance measures and proactively responding to areas of risk is the collection and maintenance of a granular, robust data set, as dis- cussed previously. This can present challenges to maintaining reporter confidentiality or anonymity. Third-Party Management and Report Collection One of the strategies employed in confidential ESR systems is the utilization of a third party to collect data. Third-party data collection and management allow for an impar- tial analysis of all hazard reports and ensure confidentiality.112 Although third parties do not administer all nonpunitive ESR systems or structures, the research team did examine this topic through the literature review and case studies. Third parties are administering several long-standing ESR systems, including one that provides data disclosure protections through federal law. Reporters who submit through the U.S. DOT’s BTS, including BSEE and WMATA, are covered under CIPSEA, Public Law 107-347, promulgated at 44 U.S.C. § 101. CIPSEA protections include the following: • No government agency may require, for any reason, a copy of a respondent’s report; • A court cannot require a copy of any respondent’s report; • Reports are immune from the legal process and cannot be admitted as evidence; • Reports are exempt from Freedom of Information Act (FOIA) requests; and • Information may not be disclosed in identifiable form for any nonstatistical purpose without the informed consent of a respondent. The literature review conducted for this study included an examination of well-established and formally structured nonpunitive ESR systems that use third parties. As discussed previously, since 1976, NASA has operated FAA’s ASRS. According to NASA’s program brief- ing documents, the ASRS program “receives, processes, and analyzes voluntarily submitted incident reports from pilots, air traffic controllers, dispatchers, cabin crew, maintenance technicians and others.”113 Reporters may describe both unsafe occurrences and hazardous situations. The ASRS program is voluntary, confidential, and nonpunitive. In 2010, FRA and NASA signed an interagency agreement assigning NASA as the third- party administrator for Amtrak; since that time, FRA has transitioned the administration of all C3RS locations, which now include nine passenger rail carriers, to NASA. FRA and representatives of labor and management negotiated an MOU for the C3RS locations, as described earlier, defining those close call events included within the program scope, requirements for confidentiality, and the obligations and commitments of all parties. NASA determines whether the report meets the review qualifications and, if so, follows up with the reporter and informs him or her of the outcome of any corrective actions or miti- gation measures. All identifying information is redacted before the report is provided to the agency. Two of the case study transit agencies summarized in the next chapter, MBTA and SEPTA, participate in FRA’s C3RS program for their commuter rail systems.

Literature Review and Background Research 35 Summary As established through the literature review, there are many characteristics that should be taken into account and considerations that should be made in the design, implementation, and management of an ESR system. Stakeholders should be a part of the development and imple- mentation of an ESR system and should trust that the ESR system, as designed, protects their anonymity (when necessary) and ensures that hazard reporting can be made with impunity and without fear of retribution. The benefits to the implementation of a nonpunitive ESR system include improved system safety, safety risk abatement, and the resultant decreases in injuries and fatalities. Implementing a nonpunitive ESR system through an independent third party could be a valuable option for transit agencies whose safety culture is in its infancy. A third party can ensure confidentiality, provide an impartial analysis of the reported hazard or event, and prevent the reporter from being subject to punitive measures or retaliation by the agency, directors, super- visors, or other employees. The use of a third party may remove any real or perceived barriers to procedural fairness and increase employee willingness to report. The literature review and background research established the following data-supported leading practices that are central to the ASRS, C3RS, SafeOCS, OSHA, NATCA, and NRC ESR systems: • Investigation and corrective actions—structured and comprehensive examination of reported hazards or near misses based on defined reporting parameters; • Notification of hazard and dissemination—a formal approach to dissemination of reported hazards, close call events, and mitigation strategies; • Online reporting system—online reporting systems provide greater access to affected employees as well as both perceived and, in some cases, real anonymity; and • Protection from punitive action—the literature documents the success achieved when employees are protected from punitive action. This success is reflected in significant growth in employee reporting in several national ESR systems. For example, a 2018 presentation of Volpe’s 2017 study of FRA’s C3RS showed that since the implementation of a C3RS, derailments decreased by 20% to 40% across three sites, trans- portation-related injuries fell by 18% at one site, and two sites saw 39% to 90% fewer disci- plinary hearings (the specific pilot locations were not disclosed).114 The authors attributed the reduction in derailments to the corrective actions taken in response to employee reports and the level of reporting that now exists as a result of the protection against punitive actions that has been granted to employees. Since FAA implemented the ASRS, the number of safety reports submitted per month has grown from 400 in 1976 to more than 8,200 in 2019.115 Similar increases have been reported by other systems such as C3RS and NRC. Research suggests this growth can be attributed to online reporting, protections granted to employees, and the notifications and safety improvements made in response to those notifications. Organizations that have established MOUs with BTS have seen successes through both the confidentiality of the ESR system and industry-wide information-sharing. As an example, BTS first began collecting data on equipment component failures in the offshore oil and gas industry in December 2016. The 2017 annual report Oil and Gas Production Safety System Events,116 summarized the first full year of reporting shared with the industry. These reports included 112 SPPE failures from nine of 59 Gulf of Mexico production operators. These nine opera- tors represented 35% of active wells and 40% of total oil production in the Gulf of Mexico.117

36 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation As summarized in the 2017 annual report, the majority of these failures were attributed to inter- nal leakages (88%). However, although these pose less risk, the findings speak to the effectiveness of the information dissemination and the utility of the ESR system. The 19 public transportation agencies that served as case studies for this study illustrate the common practices those agencies reported as successful. The findings from these case studies further illustrate and validate the findings from the literature review. Chapter 3 provides a summary of these case studies; the complete narratives are presented in Appendix A.