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Suggested Citation:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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:"Appendix A - Case Study Narratives." 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.

A-1 Case Study Narratives A-2 Big Blue Bus, Santa Monica, California A-7 Capital Metropolitan Transportation Authority, Austin, Texas A-14 Central Florida Regional Transportation Authority, Orlando, Florida A-16 Chicago Transit Authority, Chicago, Illinois A-18 Greater Cleveland Regional Transit Authority, Cleveland, Ohio A-22 Jacksonville Transportation Authority, Jacksonville, Florida A-26 King County Metro, Seattle, Washington A-29 Lane Transit District, Springfield, Oregon A-31 Lee County Transit, Fort Myers, Florida A-35 Los Angeles County Metropolitan Transportation Authority, Los Angeles, California A-42 Maryland Transit Administration, Baltimore, Maryland A-47 Massachusetts Bay Transportation Authority, Boston, Massachusetts A-53 Metropolitan Atlanta Rapid Transit Authority, Atlanta, Georgia A-58 Miami-Dade Transit, Miami, Florida A-64 Sacramento Regional Transit District, Sacramento, California A-66 Sarasota County Area Transit, Sarasota, Florida A-69 Southeastern Pennsylvania Transportation Authority, Philadelphia, Pennsylvania A-74 Tri-County Metropolitan Transportation District of Oregon, Portland, Oregon A-77 Washington Metropolitan Area Transit Authority, Washington, DC A-82 Participants in Federal Transit Administration Safety Management System Pilot A-86 Endnotes A P P E N D I X A

A-2 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Big Blue Bus Santa Monica, California Employee Safety Reporting System Program Description Big Blue Bus (BBB) implemented a nonpunitive near miss and hazard reporting program in 2015, where employees can report dangerous occurrences, hazards, and near miss events. Employees can report safety issues in three ways: via hard copy forms, in-person reporting, and, as of February 2019, through an online employee portal using Microsoft SharePoint or by e-mail. Employees can report hazards or other safety-related events anonymously using the hard copy forms if they choose to omit their name on the form. In December 2019, BBB approved an updated program, branded as the Employee Safety Hazards and Analysis Reporting Program (SHARP). The updated program formalized many of the previously established characteristics of the original hazard reporting program introduced in 2015. The newly updated SHARP policy was established “to provide staff with a streamlined method of communicating safety hazards, near miss incidents, and other safety concerns that is non- punitive, is flexible and easy to access, provides timely and accessible feedback, and is a vehicle for change.” The SHARP policy explicitly applies to all BBB staff, regardless of location or job description. The policy also defines key terms and the reporting process, as shown in Appendix D. The American Public Transportation Association (APTA) awarded BBB the 2018 Bus Safety and Security Gold Award for its proactive approach to reducing preventable accidents. The approach included the 2017 relaunch of BBB’s Hazard/Near Miss Employee Safety Reporting (ESR) system in addition to other system safety enhancements, such as a comprehensive and interactive accident review and retraining process, a rail safety education campaign, and mandatory quarterly safety meetings for all operators.1 The agency’s approach to reducing preventable accidents resulted in an 18% reduction in preventable accidents and a 78% reduction in passenger injuries between 2015 and 2017. By the end of 2019, BBB rebranded the Hazard/Near Miss ESR system to SHARP and clarified details of the policy, including the purpose of the policy, pertinent definitions, the reporting process, and specific responsibilities. SHARP includes agency-issued bulletins informing operators how to use the program. Infor- mation about the program is also shared at various regular meetings, including the mandatory quarterly safety meetings and safety committee meetings. Additionally, management continuously encourages reporting during all safety meetings, committee meetings, and “tailgate” meetings, which occur at the beginning of maintenance shifts and provide an opportunity for supervisors to reiterate safety reminders and updates to share with frontline mechanics. As a result, the number of employee reports increased 27% between 2015 and 2018, as shown in Figure A-1. 37 13 11 47 0 10 20 30 40 50 2015 2016 2017 2018 Figure A-1. Number of employee safety reports by year at Big Blue Bus.

Case Study Narratives A-3 BBB’s transit safety and security officer reports to the safety and training manager, who is the agency’s designated chief safety officer. The safety and security officer manages SHARP in-house, and all outcomes and resolutions are shared during the quarterly safety meetings without mention of the reporting employee’s name. Related Policies or Procedures The SHARP policy outlines the process that an employee should follow when a hazard is observed or a near miss occurs. The policy defines a near miss as “an incident resulting in neither an injury nor property damage, but is an event that, under slightly different circumstances, could have been an accident. A near miss could also be called a ‘close call’ or a ‘near collision.’” Additionally, a hazard is defined as “any real or potential condition that can cause injury, illness or death; damage to or loss of the facilities, equipment rolling stock, or infrastructure of a public transportation system; damage to the environment; or reduction of ability to perform a prescribed function.” The SHARP Report Form (Figure A-2) provides employees with a convenient method for reporting identified potential hazards or near miss events to their supervisor to allow action to be taken to eliminate or control the hazard. Guidelines in the SHARP Responsibilities section indi- cate that employees should record all hazards and near misses on the SHARP form and submit to either dispatch, the employee’s supervisor, online through MyInfoBlue, or directly to the Safety and Training Division in-person or via e-mail. An employee may submit a report anony- mously through MyInfoBlue by leaving the section for the employee name blank. The information collected on the SHARP Report Form includes the date, time, location, and description of the hazard or near miss event. Additional information collected includes the employee name, number, department, and job title. The form provides employees the opportu- nity to include recommendations for mitigating or eliminating the hazard or near miss event. The back of the form provides space for the agency to document the date on which each resolu- tion process step was taken. The bottom portion of the back of the form allows BBB to identify when a report was sent to another department for correction, who investigated the report, and any final resolution or action that was taken in response. Reporting Practices Once a form is submitted, whether in hard copy or online, it is sent to the safety and secu- rity officer, who reviews the report and notifies other leaders if necessary, and the Safety Focus Group—which is composed of the safety and security officer, a transit planner, an operator supervisor, and other parties as necessary—conducts the investigation. If additional information is required to complete the investigation, the safety and security officer will request additional information from the employee who reported the hazard or near miss event. Once the investiga- tion is completed, the safety and security officer takes the necessary steps to mitigate or eliminate the risk and provide awareness to all staff members. The safety and security officer engages in follow-up activity directly with the individual who made the report. BBB safety personnel share resolutions with all operators at the quarterly safety meetings. Although BBB designed the program to be a hazard and near miss reporting program, agency representatives indicated that the majority of reports are hazard reports and that near miss reporting remains low. The majority of hazards that are reported through the program include low-hanging tree branches, missing equipment, and potholes along the route. Subcontracted employees use their own ESR system, and BBB does not currently receive near miss information from its subcontractors. If nonemployees recognize a hazard, they are encouraged to report it to an operator.

A-4 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-2. BBB SHARP Report Form.

Case Study Narratives A-5 Figure A-2. (Continued). Post-Reporting Follow-Up Activities If an employee provided his or her name on the SHARP Report Form, the safety and security officer will engage in follow-up activity directly with the individual who made the report. The safety and security officer will e-mail the resolution to the employee who reported the hazard. The employee is also provided with a hard copy of the resolution in his or her mailbox. Addi- tionally, the resolution is shared in the campus at quarterly safety meetings and at the “Safety Corner,” an area in each building where employees will find all safety-related bulletins, posters, and announcements. While BBB has established no formal performance metrics to measure the effectiveness of the hazard and near miss reporting program, the agency did witness a decrease in fixed object strikes.

A-6 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Representatives attribute this decrease to the mitigations that were incorporated as a result of the employee reporting program. Additionally, as an improvement to the previous hazard reporting program at BBB, all SHARP report information is entered into the SHARP Master Log to allow for future trend analyses. Tracking all information from the SHARP program will allow for holistic investigations into recurring themes that arise while also providing an opportunity to examine the timeliness and effectiveness of corrective actions and subsequent communication feedback loops. Training BBB provides tailored instructor-led training to its bus operators, supervisors, maintenance, and administrative personnel that describes the hazard and near miss reporting procedures; as mentioned previously, outcomes and resolutions are discussed at quarterly safety meetings. The training content introduces program reporting procedures, defines hazards and near miss events, and provides guidelines on the program. The agency also provides annual refresher training that includes hazard and near miss program updates. Stakeholder Input The International Association of Sheet Metal, Air, Rail, and Transportation Workers (SMART) was involved from the inception of BBB’s reporting program, and union manage- ment works in tandem with BBB safety management to encourage employee reporting. Agency representatives reported that the positive relationship between the Safety Department and union management was pivotal in implementing a strong safety culture, which provided the platform on which the safety reporting program could be constructed and implemented. Employees have the opportunity to provide feedback to improve the ESR system during the quarterly safety meetings and more formally during safety committee meetings. Quarterly safety meetings include presentations from the safety and training manager and operations superintendent to an audience of motor coach operators, motor coach operator supervisors, and training coordinators. In addition to the quarterly safety meetings, there are also monthly safety focus group meetings, campus safety committee meetings, and service delivery safety committee meetings where employees can voice their opinions. While the agency has not devel- oped and issued a formal employee acceptance survey, the safety focus group, which includes the safety and security officer, a planning team member, and an operations supervisor, has reported that the employees view the Hazard/Near Miss Reporting Program favorably and have appreciated the information communicated back through the ESR system. BBB used resources provided by Federal Transit Administration (FTA) in developing its safety management system (SMS) and Hazard/Near Miss Reporting Program, which led to the development of two safety committees, collectively referred to as “Safety Share.” Safety Share includes the Campus Safety Committee and Service Delivery Safety Committee. The Campus Safety Committee consists of a safety and training manager, a safety and security officer, two maintenance technicians, a motor coach cleaner, a maintenance supervisor, a maintenance trainer, a maintenance manager, a city safety officer, and a facilities officer. The Campus Safety Committee is tasked with ensuring that the BBB campus remains safe for all maintenance and facilities personnel. The Service Delivery Safety Committee, composed of the safety and training manager, a safety and security officer, five motor coach operators, a motor coach operator supervisor, a city safety officer, and an operations superintendent, is tasked with ensuring the safety of all motor coach operators. It is during these Service Delivery Safety Committee meetings that operators have a formal opportunity to provide feedback to the management team. The

Case Study Narratives A-7 Accident Review Committee is separate from the BBB safety committees and consists of a safety and security coordinator, a union representative, a motor coach operator, and a third party, the Santa Monica Police Department. Barriers to Implementation The key barrier to implementation reported by BBB personnel was the type of informa- tion that is currently reported on the SHARP Report Form, as near misses are not typically reported. While the procedure was designed to include near miss reporting, the agency is receiving few of these reports. Elements of Success As noted earlier, BBB experienced a decrease in fixed-object strikes that it attributes to the employee hazard and near miss ESR system. In 2017, representatives began analyzing accidents by type. This analysis revealed the most frequent types of collisions were with fixed objects, which included low-hanging branches, electric boxes, and other various fleet fixed objects and agency infrastructure. Further analysis found that multiple accidents were occurring at the same location. Once the agency assessed the information, it distributed it to the team and external agencies to have trees trimmed or removed, as an example. Operators were encouraged by removal of the hazards and the agency’s responsiveness. BBB suggested that this ongoing responsiveness led to an increase in reporting over the following 6 months and a decrease in fixed-object collisions, including those with low-hanging tree branches. While BBB has not specifically calculated the specific cost savings associated with these mitigations, it stated that the reduction in fixed-object collisions led to safer bus operations and fewer vehicle repairs. Capital Metropolitan Transportation Authority Austin, Texas Employee Safety Reporting System Program Description Capital Metropolitan Transportation Authority (Capital Metro) has adopted the SMS approach to safety. Central to this approach is the agency’s ESR, implemented in August 2017. Employees, contractors, or service providers have the option of reporting hazards or safety concerns associated with Capital Metro’s fixed-route bus, demand-response, or commuter rail systems online or through the Safety Reporting Hotline and may submit a report anonymously. Agency personnel manage the collection of submitted reports and all activities required to resolve reported concerns; no third parties are used. The agency also has a close call ESR system that operators can use to immediately report safety and security hazards to Capital Metro’s radio control. This system also allows radio control to communicate directly with the operator to gather additional information related to the event or hazard. While these reports are documented in a separate database, the data are integrated into the ESR to allow an effective dissemination of reported agency hazards and other concerns. Capital Metro does not use hard copy reporting forms and indicated that the reason for this is related to document control, adding that hard copy forms could be misplaced, lost, or incorrectly routed. Related Policies or Procedures Capital Metro is in the process of establishing a formal ESR policy. However, the agency currently has a well-framed, structured reporting process described in the following section.

A-8 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Its bus operators and maintenance technicians are contractor employees and the use of the ESR is a standard requirement written into Capital Metro’s contractor agreements. Reporting Practices Agency employees and its contractor employees may report safety concerns online at https://app.capitalmetro.org/safety or through the Hotline at (512)852-SAFE. If an employee elects to submit a report online, he or she may establish a “safety account” that will provide Capital Metro the opportunity to respond directly to the reporter and allow the reporter to monitor the processing of the report. The agency’s policy is to provide a response to reporters within 30 business days of report submittal. If the reporter does not create a safety account or submit through an existing safety account, the report will be anonymous. An employee who uses the unmanned Safety Reporting Hotline has the option of leaving a message anony- mously or providing contact information. The agency will review messages left on the Hotline within 24 business hours. The online process includes a series of steps reflected in the screen shots below, starting with the initial log-in screen shown in Figure A-3. Figure A-4 shows the second step in the online process. Reporters are instructed to select “No Login” if they wish to remain anonymous. Agency employees and contracted employees will then have the option of selecting the type of report from a drop-down menu. Reporting choices include a safety concern, a security concern, a close call, or other, as shown in Figure A-5. Employees are instructed to provide as much information as possible and be specific about the concern or event. If the employee were reporting an unsafe behavior or close call of a peer employee, that would be documented in the event description section of the online form. The online form has fields that must be completed for the report to be processed (items marked with an asterisk in Figure A-6). Employees are also asked to indicate the method by which they prefer to be contacted. Figure A-3. Initial login screen.

Case Study Narratives A-9 Figure A-4. Creating a log-in and beginning the reporting process. Figure A-5. Selecting the type of report.

A-10 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Post-Reporting Follow-Up Activities Once the safety concern has been submitted, the ESR program manager reviews the report and forwards the content of the report to the department and/or service provider assigned the responsibility of investigating the concern and providing a response to the reporter. At this point, the program manager changes the concern status from “open” to “in progress.” The department assigned to investigate the report must respond with a resolution within 10 days of the assign- ment, and a response to the reporter must be provided within 30 days. During this time, the program manager monitors activities to ensure the disposition of the report by the end of the 30-day period. If the assigned department is unable to provide a resolution to the reported concern, the program manager submits the concern to the agency’s Safety Committee or relevant committee(s) to seek resolution. During each monthly meeting, the Safety Committee discusses the reports submitted, reporting trends and the resolution of those concerns. On a quarterly basis, the project manager submits a report to affected departments and service providers that identifies the number of reports submitted, those that are in process and closed, and the resolution of the reported concerns. Through the tracking and trending of the safety concerns reported, Capital Metro has noticed an increase in the reporting of growth of vegetation around bus stops and tree limbs that interfere with the bus route. Cost of Implementation The cost of developing the custom online application was $13,000. The agency is in the process of developing ESR 2.0 that will include a number of improvements, including the Figure A-6. Required fields in online employee reporting form.

Case Study Narratives A-11 option of allowing reporters to submit photos of the hazard or concern. There may be costs associated with this modification that are presently unknown. Capital Metro did not provide additional cost data, and the agency has not performed a return on investment analysis. Training In preparation for the ESR implementation in 2017, Capital Metro’s contractor provided hands-on training to its frontline employees (operators and maintenance technicians) at kiosks located in employee breakrooms. The contractor created a PowerPoint presentation that provides step-by-step instructions on how to report a safety concern. The contractor also promotes the ESR system through regularly scheduled safety meetings. Agency representatives added that the ESR system was built to be very simple and require little training; therefore, it relies on promo- tional materials posted at agency facilities, such as the example in Figure A-7. It also provide wallets cards that bus operators and maintenance technicians can keep with them at all times. In an effort to increase reporting, Capital Metro worked with its marketing and commu- nication teams, vice presidents, directors, and others to develop a strategy for promoting the Figure A-7. ESR system poster.

A-12 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation program. One of the methods it is using is informing employees about federal public trans- portation and passenger transportation laws and regulations that protect them from harass- ment and aggression from their employers and direct supervisors when they report hazards, close calls, and near misses. The agency stated that it wants employees to be confident that they are protected from being fired, harassed, suspended, or treated differently because of their reporting and that there are mechanisms in place to protect them. Further, it wants employees to understand that their participation in the program is necessary and that manage- ment wants to know when there are concerns or hazards to report. Stakeholder Input The Amalgamated Transit Union (ATU) is the collective bargaining unit at Capital Metro. ATU was consulted during the initial design and implementation of the ESR but was not actively involved in its development. Capital Metro provides opportunities for labor union input and engagement. The local ATU president is a member of the System Safety Committee. The agency discussed the reporting application and the associated procedures and reported that the union was well pleased. A labor union representative is also present at all SMS Committee meetings and other agency safety meetings, where he or she is afforded the opportunity to review and comment on all plans developed in response to reported concerns prior to implementation. The agency also directly reached out to frontline employees, including both bus operators and maintenance technicians, who also voiced their support for the program. Capital Metro has contracted with the Texas Transportation Institute to study its ESR. Part of this process will seek input from agency employees, including those in the bargaining unit. One of the projected outcomes of the study will be the identification of methods to make the ESR system more transparent by sharing concerns across the entire workforce. One example provided by agency representatives was the ability to place report updates on a central site available to all employees and service providers. Capital Metro is examining various options to improve reporting and gathering of employee input. Options the agency is considering are establishing an incentive program that would recognize employees in agency newsletters or other information-sharing platforms and giving the reporters swag or other gifts. The agency has also discussed instituting an employee focus group. Barriers to Implementation Capital Metro representatives did not report specific barriers to implementation but did reference some challenges. In some of the engagement with frontline employees, concerns were expressed that recordings through the Hotline would allow employees to be identified as the reporter. The agency reported this as the most significant concern they encountered in their outreach to frontline employees. The culture of the agency, especially for employees who have been with the agency for some time, has presented challenges. The interviewee stated that, historically, employees felt management was not listening to their concerns, as reports of events and hazards had gone without resolution. The agency added that this perception has been difficult to modify but is an important challenge that should be recognized and addressed. For employees to report, they should be confident that their concerns will be addressed. However, Capital Metro did add that it is important to manage expectations. Some of the hazards reported, such as over- hanging tree branches (a frequently reported hazard), require the involvement of outside agencies, such as municipal or County public works offices, which can add to the amount of time necessary to correct the hazard or reported concern.

Case Study Narratives A-13 The agency shared its concern that its contracted operator may be using its own separate ESR system. Although that is not a barrier per se, Capital Metro has been diligent in working with its contractor to express the need for the agency to be the clearinghouse for safety concerns expressed through employee reporting. Capital Metro stated that it is not receiving the report volume originally envisioned and suggested that this might be due to reports submitted through the contractor’s ESR system. While these challenges could present barriers to effective implementation of the ESR system, understanding them when a transit agency is initially designing and establishing its ESR system can assist it in addressing these challenges prior to implementation. Elements of Success Agency representatives reflected on a recent opportunity to engage all employees, including bus operators, adding that it was able to see success from that engagement. One of the union stewards voluntarily said he was going to take all employee reporting cards and make sure that he handed them out to the operators. Following this meeting, he reported to agency manage- ment that he had distributed all of the pocket cards and was “trying to drum up interest.” He further provided a positive warning that they “would likely be overwhelmed” with the amount of reports submitted. Agency representatives indicated that the online ESR system has been successful and provided options for reporters with the ultimate goal of increasing the number and frequency with which employees submit reports. Through the tracking and trending of the safety concerns reported, Capital Metro has noticed an increase in the reporting of the growth of vegetation around bus stops and of tree limbs that interfere with the bus route. Overgrown vegetation around bus stops has the potential to obstruct visibility, resulting in both safety and security concerns. Additionally, tree limbs that interfere with an operator’s ability to navigate the assigned bus route may increase the risk associated with the necessity of changing lanes to avoid contact with the tree limb, contribute to delays, or even result in costly repairs that must be made to a bus if the operator is unable to avoid the interfering tree limbs. Therefore, the agency considers the increase in this type of hazard reporting and subsequent hazard mitiga- tion an element of success. Capital Metro reflected on a few of the other reported hazards or safety concerns that led to recognized safety improvements. These included a report submitted by one of the agency’s bus checkers of a hole in a walkway that presented an imminent hazard for passengers and transit personnel. The agency corrected this hole to mitigate potential injury. A second example resulted in a change to bus stop placement. In this example, the design of an agency bus rapid transit station included the placement of a bus stop that left boarding or alighting customers vulnerable to collisions with motor vehicles. Passengers had to cross two lanes of traffic to get to the bus stop island, and when the bus was at the stop, motor vehicle operators were prevented from being able to turn right safely. The agency corrected this situation quickly, and the stop is now safer for both passengers and motor vehicle operators. Finally, operators submitted reports of homeless individuals gathering at transit facilities, noting that the presence of these individuals made them feel threatened. In response, Capital Metro’s recently opened park-and-ride lot includes fencing to restrict the access of the homeless population to the facility. As mentioned, the agency has contracted with the Texas Transportation Institute to evaluate the program’s effectiveness, including the benefits associated with the ESR system.

A-14 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Central Florida Regional Transportation Authority Orlando, Florida Employee Safety Reporting System Program Description The Central Florida Regional Transportation Authority (dba LYNX) is the main transporta- tion hub for central Florida and serves Orange, Osceola, and Seminole counties, with limited service to Polk County. LYNX developed and implemented a nonpunitive ESR system called Nip-It-in-the-Bud in 2013. The ESR system is an electronic platform currently accessible only to operators, who can use it to report hazards, safety/security concerns, and route/customer issues, including damage to shelters, low-hanging branches, or unsafe bus stop locations. As part of the new SMS, LYNX is planning to revamp its existing nonpunitive ESR system and make it available to all employees rather than to bus operators only. Additionally, LYNX is projecting the inclusion of near miss reports into the ESR system. The agency also wants to give more visibility to Nip-It-in-the-Bud promoting its use across the organization through marketing. Related Policies or Procedures LYNX has not developed a policy that outlines the Nip-It-in-the-Bud program. However, in the effort to revamp the nonpunitive ESR system, the agency is planning to develop a policy that will be distributed to all employees and will include a distinction between what is report- able through nonpunitive reporting and what are considered negligent or illegal actions requiring discipline. Reporting Practices The LYNX Nip-It-in-the-Bud program is entirely electronic and will soon be open to all employees. Currently, operators can report hazards or safety/security issues encountered along the routes they operate. This ESR system is mainly used to report conditions at bus stops, such as damaged shelters or unsafe bus stop locations. Operators must log in through their portal called INLYNX to complete the Nip-It-in-the-Bud form, shown in Figure A-8. Once the report is submitted, the ESR system generates an e-mail that is received by a customer relations counselor, who assigns it to the appropriate department, and by an IT programmer. LYNX employees can use the same Nip-It-in-the-Bud ESR Form to report unsafe acts of peer employees as well. Those reports are handled in the same manner as any other reported hazard or near miss event. Post-Reporting Follow-Up Activities The appropriate department investigates all the issues once the report is received from the customer relations counselor. Reports containing safety issues are also forwarded to the Safety and Security Department, which will initiate its own investigation. The assigned department is responsible for investigating the reported issue and taking the necessary steps to eliminate or mitigate the hazard and bring it to an acceptable level. Once the reported hazard is resolved, the report is sent back to the customer relations counselor, who will close the case. There is cur- rently no defined appeal process for LYNX employees who do not feel their reported hazard was adequately mitigated. Training LYNX introduces the program to all new employees during their initial training. Currently, no refresher training related to the Nip-It-in-the-Bud Program is provided. Contractors use

Case Study Narratives A-15 their own ESR system, which LYNX monitors. No training is offered. However, LYNX plans to include contractors in its nonpunitive ESR system once it is developed. At that point, LYNX will provide contracted employees with the pertinent training. Stakeholder Input The IT Department developed the nonpunitive ESR system platform currently in use under the guidance of the Safety and Security and Operation Departments. LYNX representatives indicated that ATU views the ESR system favorably and feels comfortable that the agency is concerned about operator issues, noting that many are valid issues—for example, hazards at bus stops and route designs that require bus operators to cross many lanes of heavy traffic to reach bus stops. LYNX representatives noted that follow-up encourages participation. However, the union representatives did not provide input to current ESR system design and implementation. LYNX has not yet conducted a safety culture survey within its agency, but as part of its imple- mentation of the SMS, operator input will be gathered through the Trackit program, which allows the posting of pictures, operator reports, and other documentation of hazards or events. Supervisors can enter accident documentation through a mobile application. LYNX representatives indicated that this ESR system will allow them to track near misses and other events “from cradle to grave.” Figure A-8. LYNX Nip-It-in-the-Bud employee safety reporting form.

A-16 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation LYNX will be tracking preventable accidents, incidents, incidents by route, type of accidents, number of National Transit Database reportable events, and operator assault, all of which are on a dashboard built into the program. The ESR system allows for tracking and reporting safety hazards to management and provides a supplemental method of increasing system safety at LYNX and protecting its employees and riders and the public. Barriers to Implementation LYNX personnel assisting with the study did not identify any barriers encountered during the development and implementation of the Nip-It-in-the-Bud program. Elements of Success LYNX personnel indicated that they do not have elements of success to share regarding the Nip-It-in-the-Bud program because they currently have no data available that highlight the effectiveness of the ESR system. Chicago Transit Authority Chicago, Illinois Employee Safety Reporting System Program Description The Chicago Transit Authority (CTA) is part of a pilot program sponsored by FTA to pilot the implementation of an SMS at CTA and in other small bus transit agencies in Illinois. As part of this project, CTA implemented a nonpunitive ESR system in December 2014. Prior to instituting the program, CTA performed a comprehensive examination of existing ESR systems and recognized two successful programs, the Federal Railroad Administration’s (FRA’s) Confidential Close Call Reporting System (C3RS) and FAA’s Aviation Safety Reporting System managed by the National Aeronautics and Space Administration NASA. Currently, CTA employs an anonymous voicemail ESR system called Safe Line that employees can use to report safety concerns. Every call received is followed up within 24–48 hours. Follow-up activities associated with anonymous calls are published in the employees’ break room, and safety personnel investigate the safety concern. In addition, employees who leave their contact information have the certainty they will receive a report of follow-up activity regarding the issue reported. The ESR system is largely used by employees as one means of communication with the agency. However, CTA observed that this phone line is used more to report issues and safety concerns, such as hazards that were identified, than to report close call events. Therefore, there is room for improvement to transition the anonymous voicemail into a self-reporting ESR system promoted as an SMS component. The Safety Department is the only unit that has access to Safe Line data, and it handles the program in-house, stating the volume of the issues reported does not justify the use of a third party to manage and operate the program at CTA. In addition, the agency also reflected that outsourcing the service to a third party might result in additional concerns for the agency. Related Policies or Procedures CTA has a policy that regulates the use of Safe Line and stipulates the requirements for follow-up activities associated with submitted reports.

Case Study Narratives A-17 Reporting Practices Safety Department personnel—generally, a safety officer and two safety managers—check Safe Line voicemails daily. These individuals are the only ones who have access to the ESR system. Once the Safety Department has investigated the concern reported, an initial report is completed and, depending on the issue, appropriate staff members are engaged to determine the solution. While the Safety Department is the leader of these efforts, it may not be respon- sible for resolving the issue. This responsibility often lies on the subject matter experts assigned within CTA’s operational groups. Once the issue has been resolved, the Safety Department disseminates the report, including solutions, through safety bulletins, safety meetings, and employee notification boards. For those concerns not reported anonymously, the Safety Department directly contacts the reporter. CTA’s contractors report safety concerns using the same ESR system used by CTA employees. Additionally, riders and general citizens can report their concerns through a separate line called 411CTA. This is the line used to report security issues and customer complaints. Post-Reporting Follow-Up Activities As noted earlier, CTA conducts follow-up activities for every report submitted. If the employee provides contact information, CTA shares the activity made on the issue reported and the status of the concern to that individual. If the problem was reported anonymously, all follow-up activities are published in company safety bulletins, which are shared during the recurrent safety meetings and posted on employee boards. Training At CTA, training is a crucial element that influences the performance of new and veteran employees. On the first day of training, during the orientation portion of the instruction, each employee is informed of the existence of the Safe Line. In addition, instructors perform a live demonstration of the Safe Line. Employees of each mode (bus and rail) are encouraged to add the Safe Line number to their contacts, so it is easily and quickly accessible when needed. After initial training, employees are reminded about and retrained in the use of the Safe Line every time they undergo a refresher safety training. Moreover, posters, cards, and each safety bulletin issued by CTA provide instructions on how to use the Safe Line. Stakeholder Input CTA collectively bargained with ATU Locals 241 and 308, which have been involved in the implementation of the Safe Line. These locals are actively participating in the develop- ment of CTA’s SMS program. As part of the framing of its SMS and associated ESR system, CTA management researched existing programs and conducted interviews with a number of agencies and organizations. Research and engagement included numerous transit industry stakeholders, such as the Washington Metropolitan Area Transit Authority (WMATA) and FTA. CTA also investigated ESR systems outside the transit industry, including FRA, the Federal Aviation Administration (FAA), United Airlines, air traffic controllers, and NASA, to understand these ESR systems. It concluded that a nonpunitive ESR system would be at the core of CTA’s SMS program. CTA recognizes the importance of verifying that any safety program is properly imple- mented and of ensuring compliance with the established program goals. Therefore, it periodi- cally surveys employees regarding their perception of safety. However, CTA has not conducted specific surveys seeking employee input on the Safe Line.

A-18 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Barriers to Implementation CTA did indicate that an adversarial relationship between a transit agency and the collective bargaining unit could become a significant barrier to implementation. As reflected in the background research performed for this study and the information obtained from case study sites, involving these units early in the process can help overcome some of these barriers. CTA indicated it would appreciate help from FTA or APTA in leading the effort to create a centralized ESR system that will serve all transit agencies and lead, in their opinion, to better safety outcomes. Elements of Success CTA representatives emphasized that ESR is critical for transit agencies with respect to gathering the information necessary to manage risk, noting that frontline employees have the best information related to existing agency hazards. CTA recognizes that all resource-constrained environments benefit from targeted prioritization of resources to mitigate the hazards of most concern first. CTA is confident that the information collected through the ESR oppor- tunities will be valuable in the SMS framework. CTA’s participation in FTA’s SMS Implementation Pilot program provided unique oppor- tunities for the agency to learn from the Chicago O’Hare International Airport ESR system, the Air Traffic Safety Action Program. FTA, FAA, and the National Air Traffic Control- lers Association presented CTA with examples of effective ESR systems in an effort to assist the development and implementation of its ESR system. Through involvement in the pilot, CTA representatives were able to glean some lessons learned about the entire pilot process. First, CTA recognized that although everyone will own the safety risk management process eventually, it might be necessary for the Safety Department to own and champion the process initially to ensure consistency. CTA representatives understood the importance of focusing on the process, rather than the results, in order to make sure they were establishing a process that was holistic and implementable. They added that transit agencies should consider process refinement and should gather input from all stakeholders to ensure the risk management process is working as intended. Finally, CTA representatives indicated that transit agencies should understand the constraints of their safety risk management process and set explicit expecta- tions up front to obtain management support. Greater Cleveland Regional Transit Authority Cleveland, Ohio Employee Safety Reporting System Program Description In 2011, the Greater Cleveland Regional Transit Authority (GCRTA) implemented a non- punitive safety reporting policy that addresses employee reporting of system hazards and risks. The associated Hazard Reporting and Management Procedure [GCRTA Standing Operating Procedure (SOP) 8.1] allows employees to inform the agency about safety concerns in two ways—via a telephone line called the Safety Hotline and through a hazard reporting form that is routed to the Safety Department. In both cases, employees have the option to report anonymously or leave their contact information. The number of hazard reports submitted has been steady since 2015, and GCRTA is planning to integrate the procedure with the ongoing implementation of its SMS and Public Transportation Agency Safety Plan (PTASP), as mandated

Case Study Narratives A-19 by FTA. Data collected through the ESR system are collected and maintained by GCRTA. The agency does not use a third party for its hazard reporting and management. The Executive Safety Committee (ESC) handles all open hazards and consists of represen- tatives from the GCRTA departments of safety, engineering, operation districts, training, legal, human resources, service quality, IT, and marketing. The ESC processes hazard reports but does not manage or assign disciplinary actions. Therefore, it is neutral and is perceived as a trustful reporting entity within the agency. The ESC is responsible for follow-up activities regarding any open report until the reported issue has been resolved. To promote the ESR system, GCRTA has established the Suggestion-of-the-Year Award that recognizes employees who submitted concerns that led to great changes for the organization or for the community. Related Policies or Procedures SOP 8.1 provides definitions of the purpose and objectives of the Hazard Reporting and Management Procedure, guidance on various mechanisms available for reporting conditions that may be safety critical, and outlines the process adopted to have uninhibited reports of incidents, hazards, occurrences, and risks that may compromise safe operations. The goal of this policy is to provide a process for identifying safety hazards and tracking the actions taken to mitigate them. It provides a standardized method for categorizing, tracking, and resolving hazards and reducing incidents and injuries through the resolution of the identified hazards. To this extent, the procedure provides an ESR system by which employees and management have a reporting process and are able to track each reported hazard until it has been abated or mitigated. The Hazard Reporting and Management Procedure also explicitly defines that the policy does not apply to information provided to GCRTA from a source other than the employee or to illegal acts or deliberate or willful disregard of agency regulations or procedures. Finally, the policy includes a series of attachments, such as the Hazard Report form (Figure A-9), a matrix for classifying hazards, and a flowchart that outlines the proce- dures for resolving the hazards reported. The information collected on the Hazard Report form include the date, time, location, and description of the hazard or near miss event. Additional information collected includes the employee name, number, department, and job title, which are marked as optional information to guarantee the anonymity of the report. Finally, the employee has an opportunity to provide recommendations to mitigate or eliminate the hazard or near miss event. The bottom portion of the form allows GCRTA to identify when a report was sent to another department for correction, who the report was investigated by, and any final resolution or action that was taken in response to the report. Reporting Practices Employees and contractors can report safety concerns anonymously or can leave their contact information. If the report is not anonymous, the Safety Department will follow-up via phone call, e-mail, or in person. If the report has been submitted anonymously, follow-up activity will be reported and discussed in bimonthly meetings with the Local Safety Committee. GCRTA’s contractors have the same options as regular employees to report hazards they may encounter while working on agency property and may also use specific reporting procedures that are included in contract clauses, if provided. The general public can use the agency web page to file a customer complaint, which may include hazards. Employees may complete and deposit Hazard Report forms in a Hazard Report box located in each GCRTA operational district. The hard copy forms are reviewed daily by local district managers and, when possible, are resolved at the lowest management level prior to escalation

A-20 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-9. GCRTA Hazard Report Form. to the Safety Department. All resolved hazards are discussed at local Safety Committee meetings. If the reported hazard entails an expensive mitigation measure or a significant investment of time or resources, it is escalated to the Safety Department. Safety personnel or other personnel the Safety Department deems expert in the topic are responsible for addressing the report and reducing, mitigating, or eliminating the hazard. Once the issue has been resolved, the department or subject matter experts assigned the responsibility of completing the progress must provide the Safety Department a report of the actions taken to address the hazard. The Safety Department then finalizes the report of the steps taken to address and mitigate the

Case Study Narratives A-21 hazard. The Director of Safety discusses all reported hazards with the Safety Committee during bimonthly scheduled meetings. If the identified issue is not resolved, discussions occur until a resolution is provided and the case can be considered closed. Reports of hazards that are received through the Safety Hotline voicemail are checked daily by the Safety Department, which logs and tracks all hazards through completion. GCRTA’s vendor trains accident investigators and supervisors with investigative respon- sibilities to use their product, which provides a root-cause methodology to aid in the inves- tigation of hazards and events. The methodology aid provides a flow chart that may be used to identify the root cause of an accident, incident, or hazard and ultimately assist in the mitigation of the risks associated with the identified hazard. This root-cause analysis is applied to each agency activity, including procedures, training, quality control, communi- cation, management system, human engineering, and work direction. Personnel with hazard resolution responsibilities are provided with a pocket book that investigators may use to note the answers to the questions highlighted in the corresponding causal chart, so that they can develop a report with corrective action plans that prevent a recurrence or mitigate the potential for occurrence of similar incidents. The product vendor offers a 5-day initial training followed by 2 days of refresher training every 2 years. Post-Reporting Follow-Up Activities GCRTA generates and delivers a cumulative report of all outstanding ranked hazards to local districts, where individuals are assigned responsibility for initiating and completing the abatement activities. Local districts provide status updates to the Safety Department at least bimonthly. GCRTA shares open rail hazard reports with the Ohio Department of Transpor- tation (DOT), which serves as the state safety oversight agency (SSOA), and the information is presented at the Executive Safety Committee meetings every other month. The individual responsible for each abatement action reviews the report that was initially submitted, submits evidence of completion of the resolution, and sends associated documenta- tion to the Safety Department for final notation and closure on the Hazard Tracking Reporting Log. Once the Safety Department confirms the resolution, the agency gives a “Closed Residual Hazard” ranking to the hazard, stating the new hazard category. Training GCRTA does not tailor its nonpunitive hazard reporting and management procedure training by position within the company. All employees are informed during new employee orientation of the various methods available to report hazards. GCTRA’s contractors receive the same non- punitive hazard reporting policy training that all new employees receive prior to employment. Stakeholder Input In 2011, GCRTA conducted a survey of executives and supervisors that established a base- line for improving the safety culture within the agency. Survey participants agreed that encouraging hazard reporting was paramount in improving the safety culture of the organiza- tion. This focus toward improved safety culture led to the implementation of GCRTA’s hazard reporting process. GCRTA management implemented the nonpunitive ESR system without direct negotiations with ATU. Employees may use the Safety Hotline and the Hazard Report Form to provide feedback to enhance the ESR system anytime.

A-22 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Barriers to Implementation GCRTA has not encountered significant barriers to the implementation of the program. However, representatives indicated that the majority of reports that are currently received through the ESR system are minimal in nature—primarily related to issues such as needing adhesive bandages in a district first aid kit. Elements of Success GCRTA has been deliberate in the promotion of nonpunitive reporting benefits, especially to district management staff, to ensure that no animosity creeps into the safety culture. GCRTA boasts that one of the most important leading indicators is the encouragement of all employees to identify and report hazards and potentially hazardous conditions without fear of reprisal. Any employee who believes he or she has been retaliated against is encouraged to contact the Occupational Safety and Health Administration (OSHA). Hazard reports from employees have led to improved maintenance procedures, which also resulted in asset management benefits using updated asset trees and condition tabs to ensure optimal maintenance attention. GCRTA is also promoting the reporting of significant hazards and improvement suggestions through its Suggestion-of-the-Year Award, which is given to an employee who the CEO feels has reported a hazard or suggested other agency improvement that ultimately led to significant changes. This award is given annually and is available through reports received through the Safety Hotline, the Hazard Report Form, or verbal reports provided to supervisors or the Safety Department. If a hazard is submitted with a suggested mitigation measure, the person who submitted the hazard is entered as a candidate for the Suggestion-of-the-Year Award. Jacksonville Transportation Authority Jacksonville, Florida Employee Safety Reporting System Program Description The Jacksonville Transportation Authority (JTA) implemented the ELERTS communica- tion system, which they branded as the “JTA See & Say” app, in January 2018. The mobile phone application can be downloaded to any mobile device at no cost to the user. Additionally, the app includes a “text a tip” number for employees and customers who do not have data service on their mobile devices. In addition to the app, JTA has a hazard line that employees can call to report any hazard, and they have the option to do so anonymously. The hazard line has been in place for many years and was instituted prior to the hiring of the JTA representative who the research team interviewed. Therefore, information on the initial design and implementation of the program was limited. JTA’s close call reporting is voluntary and confidential and provides protection from dis- ciplinary action for employees who submit a qualifying report. This protection is in place to encourage employees to report all safety concerns “without fear of potential discipline, reprisal, dismissal, or legal discovery” to ensure that JTA can accurately and thoroughly identify all potential areas of concern and implement subsequent solutions or mitigation measures prior to a collision or injury occurring. Close call reporting allows JTA to know about otherwise

Case Study Narratives A-23 unreported unsafe acts, providing the opportunity for safety assessments and opportunities to strategically improve JTA’s safety performance. Related Policies or Procedures JTA is currently developing a draft nonpunitive ESR system policy. Within that draft policy, a close call is defined as a situation or circumstance that had the potential for safety conse- quences but did not result in an adverse safety event. Knowledge about a close call presents an opportunity to improve safety practices and culture. Within the draft policy, JTA has outlined the concept of operations for a confidential, nonpunitive, close call ESR system, as shown in Figure A-10. JTA’s draft policy provides an appendix with examples of events that could qualify for confidential nonpunitive close call safety reporting in both rail and bus environments. Examples of the types of events that would qualify in a rail transit environment include • Doors opening on the wrong side, • Overshooting or bypassing a station, • Split switch incidents, • Signal run-through incidents, • Doors opening when train is not properly berthed, • Running through any required stop, • Speeding, • Improper flagging, • Failing to blow the horn when required, • Going through a grade crossing with broken gates without stopping, • Operating on the wrong track, • Operating beyond authorized limits, • Failure to protect adjacent track when necessary for safety, • Noncompliance with wayside rail transit worker protection rules, and • Third-rail or overhead catenary system power-related incidents. Examples of the types of events that would qualify for confidential, nonpunitive, close call safety reporting in a bus transit environment include • Overshooting or bypassing a bus stop, • Traffic signal run-through incidents, • Running through any required stop, • Speeding, • Failing to blow the horn when required, and • Going through a grade crossing with broken gates without stopping. Reporting Practices JTA logs all hazards, close calls, and near misses into its hazard logs and the cloud-based data management system where it stores and analyzes its hazard and incident data. Contracted employees have the same hazard reporting options as all JTA employees, and employees may report any hazard they witness, even if it involves another employee. Information reported through the hazard line, through the JTA See & Say mobile app, or any other means of reporting, is logged into Trackit, and hazards that are reported are also entered into the hazard log. JTA uses the data management as documentation of the initial report of a safety event or occurrence. All reports received are monitored by an employee in the Risk Department who is responsible for assigning the reported concern to the appropriate department for investigation and response. Establishment Reporting Acceptance and Processing Review and Information Sharing Corrective Action Feedback Figure A-10. JTA’s concept of operations for a confidential, nonpunitive, close call safety reporting system.

A-24 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation The Safety and Security Department can also see the reported concerns. JTA instituted several checks and balances in its reporting program through the assignment of follow-up responsi- bilities across the Dispatch Center, the Risk Department, the Safety and Security Department, and the private security force. When reports of concerns are received through the See & Say app, an automatic response is generated to inform the reporter that his or her concern was received. Additional follow-up information can be provided through the app to inform the reporter when the mitigation measure has been implemented and the concern has been closed. Post-Reporting Follow-Up Activities Once the appropriate department is assigned to respond to a reported concern, that depart- ment is responsible for reviewing and implementing mitigations or solutions to the concern and then reporting back to the Risk Department via e-mail, entering the information in the hazard log, and reporting the solution in the data management software. JTA has a goal of closing out a reported hazard within 7 days of receiving the report. When the volume of reported concerns increases, JTA uses the Military Standard 882 Risk Assessment Matrix to determine the level of risk associated with the hazard and establish the order of the priority in which each concern will be addressed. Follow-up is subsequently conducted at 30, 60, and 90 days after the mitigation measure was instituted to ensure that the mitigation has worked as intended and not contributed to or caused separate issues. This follow-up practice is in place to ensure that the implementation of a solution does not lead to the introduction of any unintended additional hazards. JTA reports that this incremental follow-up has improved employee morale and buy-in to the hazard reporting process, as it has shown frontline employees that management is working with them to reduce hazards. Through the tracking and trending of the hazards that have been reported to JTA, the agency has witnessed an increase in hazards related to unruly customers and homeless camps at bus shelters. Costs of Implementation JTA pays a fee of $24,000 annually, which is one of the many levels of services available from ELERTS. This cost includes the ability to see all reports, communicate back to the reporter, and forward reports via e-mail to responsible departments within the transit agency. The See & Say app also serves as a mass communication system for employees and the public. Training The JTA See & Say mobile app for reporting hazards, near miss events, and close calls is introduced during new-hire training and at quarterly safety meetings and is also provided to contracted service employees such as paratransit operators. Training is tailored by employment position at JTA, as employees responsible for implementing mitigation measures are provided more training than employees who are only responsible for reporting concerns. Stakeholder Input JTA employees, safety and security personnel, and dispatch and operations personnel were actively involved in the design and implementation of the hazard reporting line when it was first implemented. JTA implemented the See & Say app to improve the simultaneous dissemi- nation of agency hazards or safety occurrences to multiple representatives within the agency to aid in the review of hazards, incidents, accidents, and occurrences. Prior to the implementation

Case Study Narratives A-25 of the app, dispatch was required to call several people to notify them individually of an incident that was taking place. With the implementation of the app, dispatch can contact several different people simultaneously with the same message, thus improving the overall performance and response time of the agency. The app also provided the ability to submit nonpunitive employee reporting on the same application that the riding public was using. JTA surveyed its employees to gain an understanding on the rate of acceptance and found that employees appreciate the ability to report concerns through the mobile phone app. Barriers to Implementation Through an employee survey, JTA found that specific technological barriers were preventing older operators and the riding public from downloading and using the app. To combat this issue, JTA developed an index card (Figure A-11) that describes the necessary steps to download and use the app. This index card is used in new-hire training, and additional hands-on assis- tance is provided as needed. One lesson learned from JTA, which was not necessarily a barrier because it was recognized early, was the necessity to brand the ELERTS See & Say app with its own name to ensure it can be found in app stores and that it is identifiable to JTA. Elements of Success JTA representatives expressed that to be effective, all parties should work together to improve safety, and the ESR system should make all participants feel comfortable reporting their concerns without fear of potential discipline, reprisal, dismissal, or legal discovery. A close call ESR system, at its best, is an opportunity for employees and management to collaborate in achieving a higher goal—safety. An accident or an injury affects everyone, so it is essential that employees and management work together toward building a nonpunitive close call ESR system. The launch of the See & Say app was, in essence, a rebranding of the ability to report hazards to the agency, which expanded the reporting capabilities from only employees to all stakeholders, including the riding public. Additionally, encouraging hazard reporting through the See & Say app improves the autonomy of updating hazard logs. A report submitted through the See & Say app led to lighting improvements at one particular shelter located on a community college campus. The employee who reported the hazardous condition was able to report the lack of lighting through the app and submit the report with a Figure A-11. JTA See & Say index card.

A-26 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation photo and short video that showed how dark the conditions were. After the report was received, the lighting configuration at the shelter was improved and the hazard was eliminated. The See & Say app has also been beneficial when the entity required to respond to the hazard is not the transit agency. One reposted hazard that was reported through the See & Say app was an exposed broken drainpipe located near a bus shelter. The broken drainpipe was in the City of Jacksonville’s jurisdiction; therefore, JTA reported the hazard to the city, along with accompanying photos that were submitted with the hazard report made through the See & Say app. The city was able to assess the hazard and respond within a week of the report. Additional issues that have been reported through the See & Say app are associated with home- less persons who have either permanently encroached on or vandalized bus stops or shelters, which the city has been addressing. One additional advantage of the See & Say app is the transit agency’s ability to send out alert messages to specific employees and to the riding public who have downloaded it. JTA uses the app to send simultaneous alert messages to specific employees—for instance, those who should respond to an incident that resulted in transport from the scene—all at one time rather than requiring dispatch to call and repeat the same message to each employee who needs to be notified. JTA has also used this app feature to send safety campaign messages to the riding public. One campaign message was sent at the start of the hurricane season to inform the public that the season was starting and encourage proper storm season preparation activities. Another campaign was Airbag Recall Repair Month, which provided a link to CheckToProtect.org for owners to verify whether their model vehicle had a defective airbag. King County Metro Seattle, Washington Employee Safety Reporting System Program Description A few decades ago, King County Metro implemented a nonpunitive reporting program called the Safety Information Report (SIR) Reporting System. The SIR, internally referred as “Green Cards” for the bus mode and “Yellow Cards” for rail, was tailored to frontline employees but is used by everyone to report both safety and management hazards across the transit agency. Additionally, Green Cards serve as a platform for providing safety sugges- tions. The agency encourages employees to use this reporting method and ensures no threat of discipline or retaliation for submitting the form. The implementation of King County Metro’s SMS forced the agency to revamp the Green Card ESR system, which included efforts to move it to an online ESR system. Currently, employees have multiple means for reporting safety hazards, near misses, and safety suggestions. The SIR and e-mail options allow for anonymous reporting, as they are sent directly to designated administrative staff in the Safety Department for review and processing. Employees can send an e-mail to a specific address accessible by the Safety Department that manages the program, or they can complete a paper form available in all operation locations, maintenance shops, other facilities, and break rooms. The agency is implementing a cloud-based data management system called Origami that will satisfy the agency’s SMS program requirements, and all safety reporting, including Green/Yellow Cards will be part of this new ESR system. Origami’s platform can receive, record, and analyze data regarding collisions, near misses, security events, and safety hazards. Supported by the implementation of this ESR system, the agency established a long- term goal of reducing collisions and employee injuries by 10% per year for 5 years. During the past 2 to 3 years, as the agency was introducing the SMS into functional areas of the organization, it promoted the SIR and observed an increase in the level of quantitative and qualitative reporting.

Case Study Narratives A-27 Presently, King County Metro manages the SIR Reporting System in-house, and all out- comes are shared during monthly Safety Committee meetings without mention of the reporting employee’s name. The agency will continue to manage this program directly after digitaliza- tion of the program has occurred. Currently, King County Metro is engaged in internal discus- sions about the use of a third party to scrub the personal information from safety reports if the reporting party requests anonymity. Related Policies or Procedures King County Metro outlines its safety information reporting processes and procedures in two company policies, the Safety Management Policy and the Accident Prevention Program. In both, accidents, incidents, and near misses are defined according to the National Safety Council guidelines in use at the agency since 1982. Agency policies do not distinguish between what is reportable through nonpunitive reporting and what are considered negligent or illegal actions requiring discipline. This distinction is currently limited only to the Drug and Alcohol Program. However, it will be expanded as the SMS becomes fully integrated in the agency procedures and as the agency trains and educates employees on their roles related to safety responsibilities and hazard reporting. Reporting Practices Once an employee submits the report via e-mail or by using the paper form, it is routed to the Safety Department, where the safety officer on duty reviews the report and directs it to the appropriate department, depending on the affected worksite. SIRs in hard copy can also be submitted through frontline supervisors, who forward the submission to the Safety Depart- ment through the previously described procedure. Once the affected department receives the form, it examines it and takes the appropriate steps to correct the issue or to mitigate it. At this point, the affected department closes the report and notifies the Safety Department, which will communicate the resolution to the submitter of the report if contact information was provided. For reports submitted anonymously, the agency will post remediation or mitiga- tion activities in the employee break room and other locations where employees can see it. During monthly safety meetings, issues reported and those resolved are discussed. King County Metro has not established a review team to review the data collected in these safety reports. However, the new Safety Data Management System is designed to do so, and, once implemented, it will capture all this information. Contractors do not follow the agency’s procedure because they use their own ESR system, which is monitored by the agency. However, unification of the ESR system is planned as SMS implementation advances. Investigation and Follow-Up Activities King County Metro is dynamic in correcting the issues reported and communicating the actions taken to mitigate or eliminate hazards. Anonymous report resolutions are published in safety bulletins and posted in employee break rooms at each facility. All employees who generate hazard reports are contacted and informed of the status and resolution of the issue reported. The agency is in the process of designing and implementing Origami to comply with its SMS requirements. This improved ESR system will have a revised and enhanced ability for employee reporting functions. The examination and implementation of this new ESR system received inputs from test teams consisting of frontline staff, frontline supervisors, other agency stakeholders, and safety staff, which helped in the design of tools and processes.

A-28 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Training King County Metro has tailored its current training program by employment position. However, once Origami has become fully implemented, the agency is expecting to modify its training program to provide the same type of instruction to all employees. Presently, the agency provides information regarding SIRs and their use during initial training, in the employee orientation session, and during refresher onboarding training. Additionally, monthly safety meetings serve as opportunity to discuss the correct use of the ESR system. Stakeholder Input Agency personnel interviewed for this research did not know whether local unions were involved in the implementation of the SIR Reporting System from its inception. However, there is active labor participation in the current redesign of the program. Additionally, ATU plays an important role in encouraging employees to use the program to report hazards and to provide safety suggestions. Union management is described as supportive of SMS implementa- tion and the positive changes an SMS will bring to the agency. The positive relationship estab- lished between the organization and the local union has been and continues to be pivotal to the successful maturation of the agency’s safety culture. Metro officials offer that their example could serve as a model for other transit agencies interested in understanding how safety culture should work. The development and implementation of Origami also involved frontline staff, frontline supervisors, other agency stakeholders, and safety staff through the creation of test teams tasked with revising and enhancing the ESR system. These stakeholders also helped with the design of tools and processes for ESR system execution. The agency does not use employee surveys to improve the effectiveness of the ESR system; however, employees can use the Green Cards to provide comments about the program. Currently, King County Metro does not have performance measures in place to track the efficacy of the ESR system; however, once Origami is fully operational, it will be used to track the effectiveness of the ESR system. The agency is not planning to contract out the data management that will be generated, because it wants to have full authority and interaction with the data it will gather. Barriers to Implementation The key barrier reported by King County Metro personnel was the cost of implementation, with specific reference to the ability to demonstrate a return on investment. The agency is employing cost analysis studies to track the actual cost of the ESR system, including its utiliza- tion and management and the effective benefits it can bring to the agency in terms of accident reduction and liability cost abatement. Union representatives and senior management have been very supportive and cooperative, which has made the transition from the old ESR system to the new one very smooth. Elements of Success While King County Metro currently does not track the effectiveness specifically attributed to the SIR or Origami (not yet fully implemented), it will be establishing, tracking, and trending performance measures once Origami is fully implemented. However, the agency has noticed a change in its safety culture, in which employees are more aware of their surroundings and more likely to report issues; the volume of reports has increased since the inception of the hazard

Case Study Narratives A-29 reporting program. Other than its annual Safe Driver Award, King County Metro does not have specific awards linked to the ESR system. Lane Transit District Springfield, Oregon Employee Safety Reporting System Program Description Lane Transit District (LTD) has two nonpunitive ESR systems: the Blue Card system and the Hazard Card system. The Blue Card system, implemented approximately 20 years ago, is exclusively for bus operators to use to report anything they consider unsafe along the route, at bus stops, in the bus, or at bus terminals. The Hazard Card System, implemented 15 years ago, is for other staff members, maintenance personnel, yard workers, and contractors. In addition, the public also can report hazards and safety concerns directly to operators or road supervisors. The public can use the form available on the agency’s social media or can report safety concerns through the telephone line connected directly to LTD’s Customer Service Department. LTD is currently revising the existing nonpunitive ESR system as part of SMS implementation. During this effort, it is planning to develop a more effective and sophisticated nonpunitive ESR system with which it can effectively track the reports received by volume and by severity, identify main areas of concerns, and proactively address accident prevention, as SMS principles mandate. Related Policies or Procedures LTD’s nonpunitive reporting activities, including reporting methods, follow-up activities, data collection, and development and tracking of corrective actions to eliminate or mitigate issues reported, are outlined in two policies and in LTD’s collective bargaining agreement (CBA) with the ATU Local 757. The policies, the LTD Operator Policy and Procedure Manual and the Administrative Employee Handbook, are made available to drivers online and in hard copy form. These documents highlight the distinction between the issues that can be reported through the nonpunitive ESR system (Blue Cards and Hazard Cards) and actions considered negligent or illegal that require disciplinary actions. The role of the Safety Committee, which comprises 11 members from different departments and two director-level senior management members, is also provided in the policies. Reporting Practices Bus operators use the Blue Cards, and other LTD employees use the Hazard Cards. They follow two separate processing paths once submitted. Bus operators use the Blue Cards to submit safety concerns and hazards. Operations Department administrative staff analyze the report and route the responsibility for resolution to the appropriate department. Blue Card reports may be directed to the Safety Department, where mitigation prioritization may be increased on the basis of assigned levels of risk of the reported hazard. Issues that are deemed urgent are resolved immediately, while the others are discussed during monthly Safety Committee meetings. The Safety Committee is tasked with determining the pertinent action(s) to take in response to each report. Safety Committee meeting minutes are public and posted throughout the organization when available. Hazard Cards are submitted to the Human Resources Department, where they are initially analyzed by a supervisor or by the Risk Manager, who redirects the complaint to the appropriate department, which will take the pertinent actions to correct the issue. Once the concern is corrected, it is sent back to Human Resources for follow-up activities. Human Resources can

A-30 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation also request the assistance of the Safety Department to prioritize the report received. Corrective actions are taken depending on the severity or level of risk assigned to the reports. Reported issues that are deemed urgent require immediate action, while others are discussed during LTD’s Safety Committee meetings following the same process as Blue Card reports. The Customer Service Department handles reports submitted by the public, routing them to the appropriate department, where the investigation and corrective action process follow the same procedure used for the Blue Cards and Hazard Cards. Post-Reporting Follow-Up Activities LTD representatives indicated that they do not consider the reports received to be confi- dential, since they can affect the safety of the entire agency. However, LTD does allow anony- mous reporting. Once the designated person or department solves the issue, the report is closed and goes back to the Operations Department if submitted via a Blue Card or to Human Resources if submitted via a Hazard Card. In both cases, if the originator provided contact information, he or she is provided detailed information about the solution of the case. If the originator of the report is unknown, the report is closed, and no further action is required. However, Safety Committee meeting minutes note the reports that have been resolved and the actions taken. Training LTD provides training on the nonpunitive ESR system to all employees during the first day of orientation. In addition, operators are provided with 8 hours of mandatory refresher training annually, during which several topics are presented, including the nonpunitive ESR system. LTD also offers tailored training according to employee roles and positions. Contractors are informed of the need to meet federal and state safety regulations in their contracts. They are also trained on the LTD nonpunitive ESR system. Contractors are required to compile Hazard Cards in the same way as company employees. Stakeholder Input The nonpunitive ESR system was implemented 20 years ago, and the initial input provided during program implementation is not available. However, employees are offered the opportunity to provide input on the safety reporting system at any time using the same cards they use to report hazards and safety issues. In addition, LTD recently conducted an employee opinion survey on the ESR system, and the agency received positive feedback. Barriers to Implementation Because the nonpunitive ESR system was implemented 20 years ago, LTD personnel were unable to provide information regarding barriers encountered during its implementation. Elements of Success Many safety improvements have resulted from the successful implementation of the Blue Card operator hazard reporting opportunity. When a bus operator reported that a tree limb presented a hazardous situation, the agency was able to contact the city and get the tree trimmed to remove the hazard. Another successful improvement involved the relocation of a bus stop to accommodate the safety of a regular customer in a mobility device after an operator used a

Case Study Narratives A-31 Blue Card to report the unsafe condition. Additional improvements that were instituted as a result of Blue Card reports include replacement of lighting at bus stops, reprogramming of erroneous route information on a bus head sign, and repair of leaks at the transit agency restroom facilities. With the many successful mitigations instituted as a response of Blue Card reports, LTD bus operators confirm that management is listening to their reported concerns and is committed to systemic safety improvements. Lee County Transit Fort Myers, Florida Employee Safety Reporting System Program Description Lee County Transit (LeeTran) implemented an ESR Policy in January 2019 as part of its SMS program established to comply with the National Public Transportation Safety Plan and associated FTA safety regulations. Employees can report hazards encountered and near misses through the reporting procedure. Reports can be submitted online—the preferred method found directly on the agency’s web page—and in hard copy by using a reporting form that can be deposited in mailboxes provided exclusively for this purpose. Reporters may include contact information or may submit anonymously. Reports are processed in the same manner, no matter whether they were received online or through the hard copy form. LeeTran’s ESR system is included as a safety risk management element under the SMS umbrella. Accela Automation, a cloud-based platform for government software solutions, powers LeeTran’s online ESR system. LeeTran’s ESR system is managed by the Safety Department, established as the main hub for all safety concerns. Related Policies or Procedures LeeTran is a department of Lee County and regulated by county policies and procedures. In addition, the agency is required to comply with relevant FTA and Florida DOT regulations. Lee County’s Risk Management Department oversees the nonpunitive ESR system. LeeTran established a Policy and Procedure Committee that is responsible for rewriting all the guide- lines that address safety reporting, follow-up procedures, data collection, punitive policies, and defining areas of immediate safety risks. However, the agency does not expect any major change in the ESR system, which started in January 2019; changes will include a distinction between what is reportable through the ESR system and what is a negligent or illegal action, which would not be covered by the ESR system. Reporting Practices As noted, LeeTran uses two methods to report hazards and near misses: online or in hard copy. Employees can use the hard copy form shown in Figure A-12 to submit their concerns, either by placing the form in a labeled mailbox that is visited daily or by hand-delivering the form to a Safety Specialist. Once the form is received, the Safety Specialist processes and analyzes the request following SMS safety risk management principles and assigns it a priority category on the basis of Military Standard (MIL-STD) 882E. Concerns are then forwarded to the appropriate department for resolution according to the priority category assigned. LeeTran’s Operations Manager is notified once the report is entered into the ESR system and receives updates during the process. LeeTran follows the “circle back” methodology, so once the safety concern has been resolved, it is returned to the Safety Specialist, who will communicate

A-32 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation the result to the originator of the report, if known. If the originator is unknown, the Safety Specialist will post the resolution to the safety boards in several locations in LeeTran’s Operating Facility and in the agency’s safety bulletins. Reports submitted online are processed according to the same procedure; the only difference is in the origination method. Employees who choose to use the web page to communicate safety concerns must log into the employee portal and complete and submit the form. Once the report is submitted, a number is assigned to it, and LeeTran follows the same process used for reports submitted on the hard copy form. Contractors and subcontractors at LeeTran have their own ESR system and follow their own procedures, which currently are not monitored. However, LeeTran is planning to implement a unified ESR system that will include contractors and subcontractors so that, in the future, the agency will have some control over external providers. Post-Reporting Follow-Up Activities LeeTran follows up on every report received. Employees who provide their name and contact information on the report form are notified by the Safety Specialist of the steps taken to resolve the concern reported. This follow-up also provides an opportunity to obtain feedback from the employee if he or she is not satisfied with the efforts made to correct the hazard. If the employee completed and submitted the form anonymously, the resolution of the issue is posted Figure A-12. LeeTran Employee Safety Reporting Form.

Case Study Narratives A-33 on safety boards placed in strategic locations within the facility and highlighted in monthly safety bulletins. In both cases, the resolution of the issue is presented by the Safety Specialist and discussed during quarterly safety meetings. Training LeeTran has a comprehensive training program for its bus operators that includes ESR as a key SMS principle. During these sessions, operators are instructed on the different options for reporting hazards and near misses using either the hard copy or online report form. The content of LeeTran’s ESR system training does not vary by the personnel attending the training; how- ever, operators do receive some specific training with regard to the nature of their duties. The agency has not developed an explicit training for supervisors. The agency is planning to implement yearly safety campaigns that will be held prior to the onset of the hurricane season starting in 2020. During these campaigns, one topic will be the nonpunitive ESR system and its utilization. LeeTran also plans to allot extra time to training and working with operators to ensure they commit to safety, using the ESR system as a tool. With the implementation of the nonpunitive ESR system, LeeTran has reformatted the way to report issues “from the driver’s seat” perspec- tive, as its marketing campaign states. The “From the Driver’s Seat” Near Miss Employee Safety Reporting form is shown in Figure A-13. This form is available to all operators to use in reporting issues that occurred throughout their shift. The campaign is focused on identifying hazards such as hanging branches or shelter conditions that plague operators on their daily routes. Stakeholder Input LeeTran surveyed its employees during the design stage of the ESR system to receive and consider their input. The agency is nonunionized; therefore, the nonpunitive ESR system was created internally, and only agency management were involved in the proposal, approval, design, and development of the program. To continue to foster a collaborative environment, LeeTran plans to conduct periodic employee surveys to garner employee input on the ESR system, including suggested opportunities for improvements. Following the mandates of federal public transportation law, including the adoption of the SMS framework codified in 49 U.S.C. § 5329, LeeTran created a Safety Specialist position with the specific task of implementing and organizing a safety department and ensuring the adoption and maturation of an SMS. The nonpunitive ESR system is part of this effort. LeeTran partici- pated in an FTA Voluntary Bus Safety Review and SMS Gap Analysis to assist the agency with an overall understanding of the new regulatory requirements and the areas that must be addressed to ensure an effective SMS. This partnership and analysis allowed LeeTran key staff members to become knowledgeable with SMS fundamentals. The first step in this process was an onsite visit for the FTA consultant team to become familiar with LeeTran staff, roles, and responsibilities and to conduct a gap analysis. The purpose of the gap analysis was to identify areas within the agency that needed to be improved or modified to allow a functional SMS to work at the agency. LeeTran acknowledged the areas presented for improvement and began to develop its SMS, ESR system, and data acquisition and analysis process. LeeTran developed several drafts of the employee reporting policy and sent it to Lee County’s General Counsel and Risk Department to ensure that the new policy was not at odds with existing policies. LeeTran staff worked with the FTA consultant group after the initial visit to provide progress updates and work through technical questions related to the development of the SMS. The agency reported that the findings from the gap analysis and overall partnership with the FTA consultant team proved to be an invaluable resource, as it provided a perspective

A-34 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation from an independent expert. It was paramount to have this consultant team assist the agency, as it provided LeeTran staff members with unbiased recommendations relating to employee reporting as well as other key SMS fundamentals. The agency subsequently developed a working SMS sized to fit its needs while including all attributes from the hazard analysis, so as to create a process that will better predict unsafe events across all departments. The ESR system is a key and productive element of the agency’s new approach to safety. Barriers to Implementation LeeTran personnel assisting with the study did not identify barriers encountered during implementation of the ESR system. Management and employees have been supportive of the ESR system, and its implementation has been well received. Elements of Success The ESR system was launched in January 2019; therefore, LeeTran does not yet have enough data to document the success of the ESR system. In addition, LeeTran has not formally established performance measures to track the effectiveness of the ESR system. The agency will create a Figure A-13. “From the Driver’s Seat” Near Miss Employee Safety Reporting Form.

Case Study Narratives A-35 formal performance metric system to gather and analyze all the information collected from the ESR system once it has sufficient data. Currently, the volume of the reports received is still too small to define a successful trend in any specific hazards addressed. With recent changes in top management, and with the goal of encouraging employees to use the newly established ESR system, LeeTran is in the process of developing a campaign to reintroduce the near miss reporting options and advantages. The campaign will include • A digital message board that plays videos of operators and staff demonstrating the ease of filling out a form; • A poster that details what types of events should be reported and why, which will be displayed in the operator break room; • A trifold poster that displays the near miss form; • A time clock advisory placed above both time clocks in the operator break room; and • An information table at events where a Safety Specialist explains the near miss policy and hands out raffle tickets for a prize drawing that takes place at the end of the weeklong campaign. A previous information table that was focused on the benefits of stretching is shown in Figure A-11. LeeTran’s Safety Specialist expressed excitement about the reintroduction of the near miss reporting opportunities at LeeTran and the potential safety benefits that accompany this type of reporting. Los Angeles County Metropolitan Transportation Authority Los Angeles, California Employee Safety Reporting System Program Description The Los Angeles County Metropolitan Transportation Authority (LA Metro) implemented a nonpunitive ESR system called SAFE-7 more than 20 years ago. The SAFE-7 system is a hazard/ near miss ESR system that encompasses the processes and resources employees use to report Figure A-14. LeeTran’s information table.

A-36 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation safety concerns and hazards while also providing a method for management to identify, evaluate, and correct or avoid hazards holistically through corrective actions. In January 2019, the agency created an online version of SAFE-7. Employees can use the online version to report hazards and near misses they encounter agencywide. LA Metro installed desktop computers at each division and provides access to every employee. In this way, all employees may readily access the ESR system to complete the SAFE-7 form informing the agency of any unsafe condition or near miss incident. Employees may make SAFE-7 reports anonymously and with impunity. However, there are some rule violations at LA Metro that automatically result in discipline, in accordance with the terms of the respective CBAs. LA Metro manages the ESR system completely in-house and does not use any third-party vendor or consultant to analyze the data the ESR system generates. The Safety Department was involved in the design of SAFE-7 and manages all aspects of the ESR system in its entirety, including the identification of changes in the program or process and implementation of any modifications that may be needed. Related Policies or Procedures LA Metro’s System Safety Program Plan includes a safety policy that regulates the reporting process. This policy obligates every employee to report unsafe conditions encountered on the agency premises, including any type of near miss. The same policy also mandates management to investigate any event reported through SAFE-7 and inform the originator of the report of the status of the claim. LA Metro’s SAFE-7 procedure defines “near miss” as an unplanned event that did not result in injury, illness, or damage but that had the potential to do so. “Hazard” is defined as any source of potential damage, harm, or adverse health effects on something or someone. LA Metro’s safety policy does not include a distinction between items reportable through the nonpunitive ESR system and infractions considered negligent or illegal that require disci- pline, such as drug and alcohol violations. However, there are specific major infractions governed by the SMART CBA that can lead to suspension or discharge, such as insubordination, drug and alcohol violations, violations of the Americans with Disabilities Act (ADA), falsifica- tion of reports, and infringements on the wireless communication policy. Reporting Practices When a near miss or incident has occurred or a hazard is identified, employees are required to immediately alert the responsible supervisor/manager through the SAFE-7 system online. Employees may enter their contact information or submit the report anonymously (Figure A-15). Figure A-15. SAFE-7 System initial entry page.

Case Study Narratives A-37 Employees may report hazards or near miss events that occur on or off LA Metro property, as illustrated in Figure A-16. The SAFE-7 system prompts employees to identify the category of the hazard or indicate that they are reporting a near miss event (Figure A-17). Employees are asked to include a narrative description of the hazard (or the condition or act contributing to a hazard) and provide a possible solution. An employee reporting an unsafe behavior of a peer employee would give that information in the narrative description box. Reports of peer employee behavior are handled in the same manner as any other hazard or unsafe behavior. When the employee submits the report, the SAFE-7 system will automatically generate a notice to him or her that the report has been received, with a confirmation identification number that can be used by the employee to check the status of the report and any associated actions (Figure A-18). The confirmation identification code travels with the report through closure. All entries associated with the investigation, mitigation, other corrective actions, and close-out are tracked through the identification code. Once an employee submits a SAFE-7 report, his or her department head receives a notification via e-mail with the compiled form. This department is ultimately responsible for the inves- tigation and for informing the employee regarding the status of the safety report if it has been submitted with the employee’s contact information. In the case of anonymous reporting, the findings and corrective actions taken are posted on the safety bulletin board. As soon as the report has been examined, the manager or supervisor in charge of the inves- tigation enters the findings in the SAFE-7 system, along with supporting documents such as photos, reports, and short videos. The department head reviews the case and, in the event the results are satisfactory, the investigation is concluded and a notification is sent back to the employee who originated the report, if known. Otherwise, it is sent back to the departmental manager or supervisor, who is the person in charge of the investigation, for additional infor- mation that may be needed. Reports must be closed within 30 days of its origination (unless the mitigation is classified as a long-term resolution item), and the results must be published 217357115_c9b0d11cec_o Figure A-16. Location reporting screen.

A-38 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-17. Hazard reporting categories. Figure A-18. Report confirmation.

Case Study Narratives A-39 or the originator notified of the report and related actions within this time frame. If the reporting employee is not contacted but has provided contact information, he or she can contact the safety department for assistance. While there is no preestablished team tasked with reviewing the SAFE-7 forms submitted, there is an executive-level team called the Operations Safety Steering Committee that reviews the overall implementation of the SAFE-7 program at quarterly meetings. Post-Reporting Follow-Up Activities Follow-up activities occur in two ways. If the employee who reports an issue provides contact information, LA Metro will contact the employee and provide status information and its final resolution, including actions taken to mitigate or eliminate the issue. If the report has been submitted anonymously, the resolution is posted on the safety bulletin board accessible to all employees. In both cases, the employee can enter the SAFE-7 system any time to learn about the status of the report. To ensure timely responses, any SAFE-7 report that has not been resolved (or is not under investigation) within 7 days is highlighted in yellow in the SAFE-7 system; a SAFE-7 report that is not closed with a satisfactory resolution within 30 days is highlighted red in the SAFE-7 system. Training LA Metro provides employee training on how to complete the SAFE-7 form during new-hire orientation. A PowerPoint presentation, “SAFE-7 Hazard/Near Miss Reporting System Guide- lines,” addresses the following: • Purpose; • Differences between a near miss and a hazard; • Procedure; • Step-by-step guidance on entering a report; • Notice given to employees once SAFE-7 is submitted, which includes a confirmation identification number; • Procedure management for investigating supervisor/manager and division/cost center heads; • Tracking through the Management Dashboard; • File management; and • Process close-out activities. Additionally, the agency prepared and currently disseminates training materials to all employees. The materials produced, which include a memo, program flyers, pocket cards, FAQs, and brochures describing the ESR system, serve as a form of refresher training and have been effective in preparing employees for the transition to the online form. LA Metro’s SAFE-7 pamphlet, shown in Figure A-19, is an explanatory tool that guides employees through the online ESR system. Additionally, it contains a section of questions and answers to resolve the most typical doubts an employee may have regarding the completion of the form, as shown in Figure A-20. LA Metro provides additional training to supervisors who have investigative responsibilities. This training focuses on report analysis, how to address reported issues, and how to communi- cate the resolution of the issues addressed. Stakeholder Input The five collective bargaining units at LA Metro (SMART, ATU, the Transportation Commu- nications Union, the American Federation of State, County and Municipal Employees, and the

A-40 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Teamsters Union) were involved during the inception and implementation of the SAFE-7 system 25 years ago. In January 2019, with the migration of SAFE-7 to the online ESR system, the unions were informed, but they did not actively participate in the development of the online ESR system. LA Metro emphasizes its open-door policy as new employees enter the agency. This means that employees can submit their feedback at any time to management or supervisory personnel. In addition, recognizing the importance of employee feedback, LA Metro conducted two employee surveys to assist in evaluating the agency’s safety culture. In both, a consultant was used to interpret the survey responses related to safety culture and the SAFE-7 Program. On the basis of the results of these surveys, LA Metro determined that the current ESR system works well and that no changes were necessary. Figure A-19. Reporting guidelines provided in LA Metro’s SAFE-7 pamphlet.

Case Study Narratives A-41 The California Occupational Safety and Health Administration (CalOSHA) and the California Public Utilities Commission (CPUC) mandate the implementation of a nonpunitive reporting system. CalOSHA enforces California Labor Code §6401.7 and Title 8, California Code of Regu- lations, §3203, which requires the documented establishment and implementation of an Injury and Illness Prevention (IIP) Program. The IIP Program requires the inclusion of hazard assess- ment procedures that result in a comprehensive evaluation of hazards present in the workplace.2 CalOSHA and CPUC have not established any data protection law to regulate the nonpunitive reporting system and the release of information submitted through the system. While LA Metro has not established specific measures to track the effectiveness of the hazard and near miss ESR system, the Safety Department evaluates the substantive quality of the issue Figure A-20. Frequently asked questions in LA Metro’s SAFE-7 pamphlet.

A-42 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation reported and the implementation of corrective actions to mitigate unsafe conditions reported. LA Metro can track and trend the most prominent concerns, now that it has fully transitioned to the online ESR system. However, as previously noted, the online ESR system has been in place only since January 2019; therefore, it is too early to perform a longitudinal analysis of its effectiveness. To constantly evaluate ways to improve its ESR system, LA Metro is also studying potential future improvements to the ESR system design that will be able to capture additional information. Barriers to Implementation LA Metro personnel who participated in the interview did not report barriers to ESR system implementation. The online version has been implemented completely in-house and is reported to be well received by employees. Elements of Success LA Metro’s accident data collection system was the impetus for two very important and impactful agencywide changes: • Installation of a pilot program that involved the installation of gates that control left-turn movements along new light-rail corridors to reduce collisions with motor vehicles and • Pedestrian warning barriers implemented on the Blue Line. The left-turn gates along the light-rail corridors close the left-turn lane for motor vehicles when the traffic light for the left-turn movement is red and the train is approaching. Because of the success of these gates, they are LA Metro’s design standard for its Crenshaw Line scheduled to open in 2021. LA Metro has invested $34 million in pedestrian warning strategies at the grade crossings. This includes the use of small gates that close simultaneously with the vehicular gates described above. With these gates, the intersection is completely sealed when a train is approaching, as it crosses the intersection, and as it clears the intersection. This investment has led to a considerable reduction in pedestrian versus train events. Maryland Transit Administration Baltimore, Maryland Employee Safety Reporting System Program Description The Maryland Transit Administration (MTA) instituted an ESR hotline about 10 years ago and an ESR e-mail address about 5 years ago. In 2018, MTA also made hard copy and postcard-like reporting forms available to its employees for submitting safety concerns. The forms are located throughout various MTA facilities for ease of access and convenience. The data from the ESR system are collected, managed, analyzed, and trended internally by the Office of Safety and the Safety Management Systems team. All data are collected anonymously, although employees may include their contact information if they so choose. MTA has proactively implemented the ESR system to provide employees with an oppor- tunity to share information about potentially hazardous environments or events that would otherwise remain unknown by the agency. MTA instituted this approach with the understanding

Case Study Narratives A-43 that ESR would be required as it transitions from a system safety program, plan-driven approach to safety to the SMS approach, which will drive its new PTASP. Related Policies or Procedures MTA has not officially established formal policies or procedures related to its ESR system and currently relies on promotional materials posted in its facilities. Additionally, along the same lines, MTA’s discipline policies do not address safety reporting. However, MTA is in the process of formalizing and documenting the definitions and processes that will be used in the establishment of a formal ESR system policy. MTA representatives are aware of and have reviewed the processes used in the C3RS programs currently in use at several Class 1 and commuter railroads and are also familiar with WMATA’s program, which includes a partnership with the Bureau of Transportation Statistics (BTS). Reporting Practices When an employee submits a report through the ESR system, it is logged in with all relevant information, the reported hazard is assessed against the risk matrix (a calculation of the hazard’s initial severity in relation to its probability), and it is assigned an initial level of risk. Employees can report unsafe acts of peer employees in the same manner as they would report any other observed hazard. Once logged and categorized, the hazard report is submitted to respective departments or modes, where it is added to the departmental hazard log for tracking, classification, mitigation, and closure. Relevant key personnel throughout the agency, including the Executive Safety Committee and the Risk Review Committee, with membership that includes a representative from MTA administration, the chief safety officer, and the department heads of planning, operations, and the general counsel’s office, have access to submitted reports. Agency leaders are notified of safety reports that have been received through a summary of hazard and incident reports provided at monthly modal department meetings. On a quarterly basis, the Risk Review Committee reviews reported Category 1 and Category 2 hazards, and each respective modal department reviews all reported hazards on a monthly basis. ESR system hotline personnel follow a decision tree to determine the category of the hazard that is reported and enter it into the log. Upon receiving a call, hotline personnel are directed to ask first whether the call is related to an emergency, as emergency calls should be directed to the Operations Control Center or MTA police. Once it is determined that the call is not related to an immediate emergency, consideration is given to whether the hazard could immediately result in an injury to an individual, includes property damage, or is already under consideration by an active work order. From there, a determination of the type of hazard is made, classifying the report as a close call, an event, or hazard. Hotline personnel then prompt the reporter with additional questions to determine whether the report is an employee-versus- management issue, what the mode associated with the report is, and whether the caller wishes to remain anonymous. On the basis of the specifics of the report, hotline personnel then determine the category of the report and enter the information into a log. Post-Reporting Follow-Up Activities Once a report has been logged, information gathered for that report is provided to each modal department affiliated with the report. Each MTA modal department is tasked with mitigating all hazards possible within its department. Agencywide hazards or issues are brought to the Risk Review Committee for implementation of mitigation. Follow-up confirmation communication with the reporting employee occurs within 24 hours if contact information has been provided. However, if the report is provided anonymously, the mitigation measures implemented as a result of the report are shared at monthly modal department meetings.

A-44 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation If an employee does not feel the hazard they reported was resolved adequately, the employee may notify the safety officer of his or her concern during the required debrief that occurs if the hazard is not reported anonymously. If the employee reported the hazard anonymously and is not satisfied with the corrective action, he or she may file another report. Training MTA finalized its new ESR system directive in August 2019, as explained in detail in MTA’s Introduction to SMS and Hazard Reporting training. The ESR system is included in new-hire training. Additionally, the agency has produced a litany of promotional media about the various methods available in the ESR system to report hazards that is displayed throughout all modal facilities. Figure A-21 and Figure A-22 are examples of materials MTA has posted to promote the use of the program. Contractor employees, such as those who provide paratransit services, do not currently receive ESR training or a briefing on the program, but MTA representatives envision that contractors will qualify to report through the ESR system when the agency imple- ments its official policies. To proactively identify and address potential hazards, MTA provides employees with an SMS card that outlines the frontline employee’s role: to work safely and wear proper personal protection equipment; remain compliant with procedures and regulations; and report hazards, safety concerns, or safety suggestions (Figure A-23). The card also identifies what employees can report, including hazards and potential hazards, issues and mistakes, safety concerns, accidents and incidents, and possible solutions and safety improvements. The ESR system hotline number is displayed prominently on the card, and the back of the card lists the ways in which an employee can submit a safety report, including notifying a lead supervisor or local safety representative, formally submitting a confidential report through the SMS, calling the safety hotline, or sending an e-mail. The card also establishes that employees are accountable for • Their own safety and the safety of those around them, • Following agency procedures, • Wearing proper protective equipment, • Reporting any unsafe conditions promptly, • Reporting injuries and damages, and • Striving to be safe at work and at home. Finally, the card highlights unacceptable workplace behaviors, such as willful safety violations, reckless and neglectful acts, at-risk behavior, criminal activities, and alcohol or drug use. Stakeholder Input The ESR system is underpinned and largely driven by the various reporting methods at MTA and is not explicitly defined or detailed in policies or procedures at this time. There- fore, labor partner involvement in the development and implementation of the ESR program was limited. To date, MTA has not solicited employee feedback regarding the acceptance or effectiveness of the program; however, a forthcoming agencywide safety culture employee survey will contain several questions to garner advice on suggested improvements in the program. Barriers to Implementation Improving the safety culture of an organization is the biggest barrier to the implementation of an ESR system. Currently MTA receives about 10 ESR system reports per month, the majority of which do not involve near miss events but rather identify some other type of hazard.

Case Study Narratives A-45 Figure A-21. MTA Commitment to Safety with ESR system references.

A-46 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-22. MTA hazard reporting program poster. Figure A-23. Maryland DOT Safety Management System card.

Case Study Narratives A-47 Elements of Success MTA currently tracks several performance measures to gauge the efficacy of its program, including the number of open and closed reports; the hazard classification of each report; average days to closure; reports per month; reports by mode; and reports by area, such as facilities, equipment, systems, and security. In addition, MTA recently formalized its program into a directive approved by the accountable executive (the MTA Administrator), and has rebranded and expanded promotional materials throughout the agency to promote the reporting of hazards. Hazard reporting is also a main element of the Introduction to SMS and Hazard Reporting training module. MTA also has streamlined the process of reporting hazards through the Safety Hotline. Instead of a hazard reporter getting a voicemail after business hours that would prompt him or her to call another number, there is now one easy-to-remember number (844-MTA-SAFE), and a safety officer is available to answer the phone at all times. Massachusetts Bay Transportation Authority Boston, Massachusetts Employee Safety Reporting System Program Description The Massachusetts Bay Transportation Authority (MBTA) currently has three methods by which employees can report hazards and near miss events in a nonpunitive manner—MBTA Form B, Notification to MBTA Safety (Figure A-24); the Safety Hotline at (617) 222-5135 (Figure A-25), and via e-mail at safetynotification@mbta.com. MBTA established each of these hazard and near miss event reporting methods at different times. MBTA Form B is the oldest hazard and near miss reporting method in place at MBTA; it was instituted in the early 2000s and is seldom used. The Safety Hotline was introduced in 2010 as a new way to report hazards and near miss events. Initially, many reports were submitted through the hotline, but reporting volumes have decreased to two to five calls per month, on average. The newest and most-used reporting method at MBTA is the safety notification e-mail, which was instituted in 2014 and is consistently used for reporting accidents and injuries and occasionally to report hazards and near miss events. MBTA representatives indicated that the volume of safety notification e-mails increased in the first half of 2019. There are additional reporting methods that are available to the riding public that could potentially be used by MBTA employees. ELERTS produced the MBTA See Say mobile phone app that allows anyone to make an anonymous report at any time. MBTA has also received reports of various hazards through unconventional reporting methods such as the customer service hotline and the Text-A-Tip line that is managed by the MBTA Police Department. MBTA has entered into a C3RS implementing memorandum of understanding (MOU) with primary stakeholders, FRA, Keolis, and four labor unions—SMART-United Transpor- tation Union, the Brotherhood of Locomotive Engineers and Trainmen (BLET), the American Train Dispatchers Association, and the Transportation Communications Union—for their commuter rail services. This implementing MOU is in place only for employees of Keolis, the company through which MBTA contracts all commuter rail services. Related Policies or Procedures MBTA operational rule books describe the procedures for reporting. While MBTA has not yet established a stand-alone reporting policy, related policies were under development as of August 2019. The stand-alone policy will include a distinction between a reportable event or hazard

A-48 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-24. MBTA Form B: Notification to MBTA Safety.

Case Study Narratives A-49 and acts that are considered negligent or willful violation of MBTA rules. While all reported near miss events would be nonpunitive, the policy currently under development will clearly define what prohibited acts will result in disciplinary actions. The C3RS implementing MOU in place for commuter rail personnel outlines the specific reporting procedures, including the criteria for close call report acceptance, and all confiden- tiality details. It details that when an employee of Keolis observes a safety problem or experiences a close call event, he or she should use the online form to report the problem or event in detail to NASA. NASA subsequently de-identifies the information and provides the details to the Figure A-25. MBTA Safety Hotline poster.

A-50 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Peer Review Team (PRT) for analysis and development of implementations for consideration. The PRT includes individuals from each of the primary stakeholders mentioned previously. Reporting Practices MBTA Form B can be found throughout various locations at MBTA and, once filled out, can be placed in an envelope and sent to the MBTA Safety Department via interoffice mail. Alternatively, the form can be sent via fax or scanned and e-mailed. As noted, MBTA’s Form B is not heavily used by employees. The Safety Hotline is a voicemail box that is checked by MBTA Safety Department staff regularly. The Safety Hotline does not currently provide for instant response, since it is a voicemail box that needs to be retrieved. For this reason, its use tends to be minimal, as other methods allow for quicker response and resolution. The safety notification e-mail is an e-mail address that simultaneously sends the same infor- mation to all managers and several office personnel. While this e-mail comes directly from the employee’s agency-provided e-mail address, employees can request to remain anonymous, and their personal information will not be included in any reports. If an employee uses the ESR system to report unsafe behaviors of another employee, the Safety Department will inves- tigate the reported concern, maintain confidentiality, and, if necessary, contact the employee involved in the reported concern to offer an opportunity to submit a report of his or her own. Once a hazard or near miss report has been received, MBTA’s Safety Department determines the level of involvement or plan of action that will be required from other departments and initiates communication with those departments. The MBTA Safety Department holds all responsibility for review and follow-up communication. Post-Reporting Follow-Up Activities Once a hazard report has been received and the Safety Department has reviewed the report, it sends an e-mail to the reporter indicating that the report has been received. If the report was submitted anonymously, this notification of receipt e-mail is bypassed. Simultaneously, the MBTA Safety Department assigns an appropriate staff member to investigate the reported hazard. Staff assigned to each hazard report typically are the personnel most familiar with the area of concern. After a hazard is reported and staff are assigned, the hazard is confirmed through an inves- tigation, which involves the collection and logging of supplemental photos and documentation that will detail what the hazardous environment entails. The safety concern is logged, recom- mendations for mitigation measures are developed, and follow-up ensues until hazard mitiga- tion is complete. The duration of the investigation process varies, depending on the nature of the reported hazard. If employees do not feel the safety hazard was adequately mitigated, they can use the ESR system again for further clarity on the risk control implemented and if it is effective. Additionally, if an employee does not feel that a safety issue has been addressed and considers him- or herself in harm’s way, the employee may issue a Good Faith Safety Challenge. Training MBTA employees are trained to report hazards and near miss events in new-hire, OSHA, and right-of-way training. Additionally, MBTA emphasizes hazard reporting via written Safety Flashes and management blitzes. MBTA’s new-hire orientation course, “Safety Awareness at the MBTA,” defines system safety, provides the “Take 5 for Safety” training, and discusses the

Case Study Narratives A-51 MBTA policies and procedures that support workplace safety. Module A, “What is System Safety?” presents how to identify hazards, determine levels of risk, and develop an action plan. Module B, “Take 5 for Safety!” includes the following: • Be Aware: Identify and Eliminate Hazards. • Plan Ahead. • Stay Alert—Don’t Get Hurt. • Speak Up: Report Hazards and Near Misses, All Injuries, and Communicate Concerns with Fellow Workers. • Use Proper Personal Protective Equipment (PPE). Module C, “Work Place Safety,” presents MBTA’s safety goals and asks employees what they can do to help the agency attain its goals. Areas of workplace safety discussed during new-hire training include housekeeping; electrical safety; walking, walkways, and stairs; and specialized training that may be required, depending on the employee’s job duties and respon- sibilities. The curriculum includes a segment on employees’ responsibility to report all hazards to their supervisor—both unsafe conditions and acts; to report all accidents, injuries, and near misses to the supervisor or management; and to obey all warning and caution signs. The curriculum also establishes that “horseplay” is forbidden. This transitions into the reporting methods, as referenced above. All employees receive the same general training on the methods by which they can report hazards and near miss events. There is a limited curriculum that has been structured specifically for certain positions, which includes topics such as lockout/tagout for right-of-way employees, fall protection, machine/equipment operation, PPE, and electrical safety. Currently, MBTA does not provide hazard reporting training to contracted personnel such as paratransit operators. Contracted employees have the option of reporting hazards through MBTA’s Safety Hotline. Additionally, as SMS is implemented at MBTA, all future contracts will have language requiring contracted employers to have an SMS, including an ESR system. The Safe Travels newsletter is produced by MBTA’s Safety Department to help keep internal customers and industry partners better informed about issues that affect personal and professional safety. It includes an “Employee Question of the Month” (Figure A-26), pro- vides notification of career opportunities at MBTA, recognizes employees for making MBTA’s system safer, and highlights the teamwork and respect between MBTA and its collective bargaining units. Stakeholder Input MBTA did not initially include any of its approximately 28 labor unions in the develop- ment and implementation of its hazard and near miss reporting method alternatives. How- ever, as the agency develops its PTASP and updates its nonpunitive reporting alternatives to be governed by policy and standard operating procedures, it plans to include labor representatives in future policy development. Barriers to Implementation MBTA management historically relied on disciplinary actions, which strained the relation- ship between management and represented employees. This continues to influence MBTA’s safety culture; thus, implementing a nonpunitive reporting program has been challenging. Additionally, gathering the volume of reports necessary to perform trend analyses has been challenging.

A-52 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Elements of Success MBTA representatives indicated their understanding of the significant importance of estab- lishing and encouraging a mature safety culture that will support a well-developed and fully utilized ESR system. They also connect mature safety culture to the ability to gain a better understanding of the overall risk of operations from frontline workers and subsequently focus limited resources on areas that present the greatest risk to the agency. MBTA repre- sentatives stressed that when all hazards are reported, trends and analyses can be performed to gain a better understanding of the overall risk of operations and can subsequently focus limited resources on areas that present the greatest risk to the agency. MBTA’s Safety Office received a Safety Hotline notification regarding an unsafe platform observed at Green Street Station by an employee—a set of stairs leading to the right-of-way without any return. The MBTA Safety Office investigated the location and evaluated other stations to determine whether a similar layout was being used that could create hazards. The hazard was identified only at MBTA’s Green Street Station, and a work order was placed for the installation of a railing (Figure A-27). Another example of a successfully reported hazard was related to a tripping hazard. Once the safety concern was reported and the hazard was confirmed, a mitigation was instituted to Figure A-26. MBTA’s Safe Travels newsletter and example employee question of the month.

Case Study Narratives A-53 keep the tripping hazard off the ground. Another hazard reported was related to nighttime track worker concerns about animals on the track and limited lighting. Once the concern was reported through the hazard reporting program, MBTA Safety Department representatives evaluated the nighttime environment, looking for animals and considering the lighting confi- guration. While the reported animals were not substantiated, the reported lighting concerns were confirmed, and the lighting configuration was improved with additional trackside head- lamps to allow better views for the nighttime track workers. MBTA also purchased upgraded flashlights for their track workers that provided better illumination. Another successful mitigation measure that was implemented in response to a hazard report was a safety concern an operator expressed related to the way a specific bus was handling in inclement weather. The operator explained that the back end of the bus was pulling to one side, which was confirmed through follow-up investigation. The bus was sent for testing, and it was determined that the bus manufacturer had unintentionally forgotten to activate some installed software. The software was activated, and the issue was resolved. Through the internal promotion of the successes of the hazard ESR system, MBTA repre- sentatives are hopeful that their hazard and near miss ESR system will benefit the organization while also promoting the future use of the ESR system. Metropolitan Atlanta Rapid Transit Authority Atlanta, Georgia Employee Safety Reporting System Program Description The Metropolitan Atlanta Rapid Transit Authority (MARTA) Safety 1st safety reporting system has been in place for approximately 6 years. Employees, contractors, and riders may submit safety concerns using one of three reporting options—through the Safety Hotline, by submit- ting a hard copy report, or by submitting the report online, which MARTA added as an option 3 years ago. Employees may submit concerns anonymously. MARTA ensures that reprisal will not be taken against any employee who submits a Safety 1st report. Employees who observe a condition in which danger is imminent are instructed to notify a supervisor or manager imme- diately. Employees who discover an unsafe condition that does not pose immediate danger are expected to eliminate the situation if it is safe to do so within their authorization to act. Figure A-27. Safety Hotline hazard identification and mitigation implementation.

A-54 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation MARTA’s security and maintenance departments each have their own reporting mechanism that maintains logs and corrective actions of reported hazards and concerns. Related Policies and Procedures MARTA’s Safety Hazard Notification and Escalation Process establishes the steps that must be taken to gather, investigate, and correct the reported hazard. It also delineates an appeals process in the event the reporter is dissatisfied with action taken or the response. MARTA’s Safety Hotline Procedure (SQA-SOP-1020) provides the scope and purpose of the hotline, the definitions used, various responsibilities of MARTA personnel involved in the process, and the details of the Safety Hotline notification and investigation process. Reporting Practices MARTA employees or contractors may enter their safety concerns into the Safety 1st online database or provide a hard copy to their supervisor (Figure A-28). Supervisors in receipt of Safety 1st reports must enter the report into the online database before the end of their shift. MARTA will make alternative arrangements for “discreet delivery” of Safety 1st if neces- sary, such as notifying the System Safety Officer or an ATU Local 732 representative. Once the report is entered, the Safety 1st ESR system automatically distributes it to the employee’s supervisor, unit director, ATU officers, Joint Health and Safety Committee (JHSC) members, and Department of Safety and Quality Assurance personnel. Any Safety 1st report that requires resources from other departments is referred within 24 hours to the appropriate department manager for processing and response. Employees and contractors may also submit reports through the Safety Hotline, which provides for anonymous safety concern reporting. MARTA’s Office of Safety monitors the hotline and ensures that the reporting standard is followed. The hotline program task leader operates the Safety Hotline and is responsible for checking hotline messages daily, vetting/ validating notifications, assigning a ticket ID number for notifications, notifying the assigned lead investigator, updating the status of each notification, and preparing weekly status reports of all open and closed tickets. The lead investigator is responsible for verifying and investigating reported incidents or safety risks and for developing corrective action plans and forwarding findings to the hotline program task leader. Lead investigators are assigned on a rolling basis, with each rotation beginning on Monday and ending on Sunday. Post-Reporting Follow-Up Activities Once online or hard copy reports are submitted and distributed in accordance with MARTA policies, the reporter’s supervisor (or other recipient) reviews the Safety 1st report and must provide a verbal response to the employee within 3 days of report submittal to acknowledge receipt and review the details of the reported hazard. The supervisor must promptly investigate the reported hazard and take appropriate actions (presented in MARTA’s priority order): • Assess the seriousness of the situation (life threatening, could cause injury, could cause a mishap, nonhazardous). • Remove persons at risk of death or injury. • Eliminate the hazard, if possible, if within their level of authority, and if safe to do so. • Isolate, guard, or place warnings (lockout/tagout). • Notify the affected employees and management chain of the Safety 1st report and actions taken for resolution. • If, upon investigation, it is determined that a hazard does not exist, this is communicated to the reporter.

Case Study Narratives A-55 • If the employee is not satisfied with the response, the employee has 3 calendar days to request initiation of the appeal process. Once the investigation process has concluded, the reporting database is updated to reflect the report status as “denied,” “closed,” or “pending approval.” If, after corrective actions have been taken, the hazard has not been resolved 5 days following entry, the Safety 1st report will automatically escalate to the unit director with copies provided to the ATU officer, the JHSC, and the assistant general manager (AGM) of safety and quality Figure A-28. MARTA Safety 1st report form.

A-56 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation assurance. The director has 5 days to address the submitted Safety 1st report by an action plan and/or a specific timeline for resolving the issue. The director will notify the director of safety, department general manager (DGM), Office of Safety, JHSC cochairs, and all full- time ATU officers of the plan and corrective action status. If the director cannot resolve the Safety 1st report within 5 days and it remains in open or in-progress status, it will automatically be escalated to the JHSC. Within 5 calendar days of notification to the JHSC, the cochairs of the JHSC will assign, if needed, members of the committee (including one ATU representative) to evaluate the plan and submit a correc- tive action status to the JHSC cochairs. If JHSC determines that the proposed corrective action and schedule for implementation are inadequate, the report will be referred to the AGM/DGM and ATU officers for review. All items referred to the AGM/DGM and ATU officers are reported at the general manager/chief executive officer safety committee meeting to review the hazard, the corrective action proposed, and the schedule and status. Final hazard resolution results are provided to the employee reporter, ATU officers, and JHSC as part of the monthly meetings and are recorded in the minutes of the meeting. Once a reported hazard or concern has been addressed, MARTA has an electronic Safety 1st Closure Form that includes the following information with corresponding drop-down selection options: • Report identification number; • Title of the reported hazard or concern; • Employee name (if provided); • Job title; • Department; • Vehicle, equipment, or location of the hazard; • Brief description; • Employee-recommended changes; • Description of the unsafe condition or hazardous work practice; • Supervisor recommended change/action; • Supervisor’s name; • Date the report was created; and • Resolution status. The hotline program task leader assigns concerns submitted through the Safety Hotline to the lead investigator, who verifies and investigates the reported incident or safety risk. They are also responsible for developing corrective action plans and forwarding findings to the hotline program task leader to ensure the hotline log is up to date. Summary reports of all hotline submittals, the status of the report, and the summary of the action(s) taken are included in weekly status reports and presented in a biweekly report submitted to MARTA’s AGM. MARTA’s Safety Hotline process is shown in Figure A-29. During the telephone interview with MARTA personnel, they shared that they are reviewing the current process, which will likely result in a reduction of the number of report investigation and resolution steps and in the number of days to process, from 30 days to 14 days. Cost of Implementation Implementation and management-related costs of the ESR system are difficult to valuate. The program depends almost exclusively on agency man-hours. Training During the initial implementation of the program, MARTA provided training to manage- ment staff and then provided a “rolling show” for all employees. It is now a part of new-hire

Case Study Narratives A-57 training, and MARTA developed an e-learning presentation on the program that is available to all employees. Stakeholder Input MARTA’s JHSC, which includes an ATU representative, was involved in the development of the program and is responsible for any review or updates to the process. In addition, this body is actively involved in the progression and resolution of Safety 1st reports. MARTA also conducted an in-person soft survey with the ATU management and union stewards before the rollout of the program to gain input on how to report and how members could use the ESR system. At that time, ATU viewed the ESR system favorably. However, ATU members established that when reports are submitted, they want to see action taken. Note: HPTL = hotline program task leader; LI = lead investigator. Figure A-29. MARTA’s draft safety hotline notification and investigation process, August 2019.

A-58 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Barriers to Implementation MARTA representatives did not identify barriers to implementation. However, they recognize that periodic program and process evaluation is necessary. At the time of the interview, they were updating associated program policies and procedures. Elements of Success An example of success relates to multiple reports of “significant potholes.” MARTA conducted a site visit of the location and determined that it was likely that the potholes were causing damage to bus suspensions, wheels, and structural elements. The issue was assigned to MARTA’s Maintenance Department, which made the repair within 4 days of receiving the assignment. This was described as a proactive step that helped the agency mitigate damages to its transit buses. In another example, because of the layout of an apartment complex parking area, buses were required to perform backing maneuvers, which presented collision risk for bus operators. MARTA personnel visited the location and developed a mitigation strategy that allowed bus operators to maneuver on the property with less risk. Miami-Dade Transit Miami, Florida Employee Safety Reporting System Program Description Miami-Dade Transit (MDT) employees can report safety concerns through a number of avenues, including an online application at https://www.miamidade.gov/transit/safety-concern.asp or on the agency-created proprietary smartphone app, the MDT Tracker (Figure A-30), both instituted more than 5 years ago. Employees may also submit a Report of Safety Concern using a hard copy form (Figure A-31), which MDT has used for more than 15 years. Reporters submitting safety concerns either by the online form or through the mobile app can remain anonymous. MDT representatives stated that frontline employees are more likely to report concerns directly to their supervisors than to submit a report via the hard copy, online, or app options. They indicated that many of these reported concerns are resolved without being elevated to the Office of Safety and Security. The Transport Workers Union of America (TWU) is the collective bargaining unit at MDT. TWU shop steward or officers can bring forward concerns reported by frontline employees to the Union–Management Safety Committee (UMSC) meetings, which are logged into the safety reporting system. MDT has a group that monitors social media posts and reports any posted safety or security- related items to the Office of Safety and Security. For security-related concerns, MDT uses the location-aware Transit Watch app. Any report of suspicious or dangerous activity on MDT buses or trains submitted through this ESR system is sent directly to a security dispatcher who can immediately deploy a security guard or local police. This also gives riders the option of sending text messages related to ride quality. Miami-Dade County has a 311 third-party customer service app and ESR system, but MDT representatives indicated that few reports are made through this ESR system.

Case Study Narratives A-59 Related Policies or Procedures MDT employee rule books require the reporting of safety violations, including observed viola- tions. In addition, the agency has instituted the Rail Service On-Track Good Faith Challenge Policy (SOP PR-RS-032), which grants employees the right to challenge, in good faith, the effectiveness of the roadway worker protection applied at the job location. Employees making the challenge are directed to remain clear of the roadway until the issue is resolved and/or the procedures are shown to be in compliance with MDT’s policy. Additionally, a roadway worker has the right to challenge any directive that would violate an MDT procedure, rule, or practice that could cause a potentially unsafe condition. MDT’s Metrorail Roadway Worker Protection Plan also highlights the Good Faith Safety Challenge. The Good Faith Challenge Form includes blocks for the reporting the employee’s name and identification number; the date, time, location (including segment of track), and specific track; and the employee’s statement, and signature. The responding authority(ies) use the form to document follow-up activities, corrective actions, and other activities performed in the investigation and resolution of the report. The challenge is based on the FRA program established at 49 C.F.R. §218.97, which provides opportunities for employees to report any good faith determination that they have been directed to either take actions that would violate existing regulations or those that would violate a railroad’s operating rules. MDT’s Administrative Policy POL-SS-008 ensures TWU participation in the UMSC, which formalizes stakeholder input to safety and security practices. Reporting Practices The Report of Safety Concern Form is for employees to use to report a safety concern (Figure A-31). The employee must complete Section I and provide a copy to his or her supervisor and one to the Office of Transit Safety. The employee’s supervisor completes Section 2 and, Figure A-30. MDT Tracker app.

A-60 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Figure A-31. MDT Report of Safety Concern.

Case Study Narratives A-61 if resolution requires action by someone other than the supervisor, a copy of the form is submitted to the appropriate MDT division and the Office of Safety and Security. A copy of the form that includes the narrative providing the outcome of the supervisor’s evaluation and resolution, the action assigned, and the required completion date is provided to the employee. If the employee is not satisfied with the evaluation and associated resolution, he or she may request a transit safety review. The final approval of either the initially prescribed resolution or other corrective action is provided to MDT’s chief of transit safety and security. MDT’s online Report of Safety Concern or MDT Tracker app may be used by employees and the general public, although MDT representatives indicated that it is used primarily by members of the general public. Employees submitting reports through these mechanisms can do so anonymously. The online form prompts reporters to identify the type of complaint— Metrobus, Metrorail, Metromover, Special Transportation Service, transit employee, or other. They are then asked to provide the date and time of the incident, including the hour and minute. Reporters can add narrative details, which they are encouraged to provide, in a text box. Subsequent screens ask route information and direction of travel, boarding location, destina- tion, and vehicle number (if available). A final page requests the reporter’s contact information, first and last name, street address, zip code, daytime/evening telephone number, and e-mail address. Reporters are notified that the report provided is a public record and are given the option of submitting anonymously. Employees who report through this ESR system receive confirmation within approximately 24 hours that the report has been received. MDT’s Construction Safety Manual and associated contracting agreements require contractors to have their own safety plan and a safety representative on every project. Contractor safety representatives and the assigned MDT safety representative speak and meet regularly to address safety concerns of contracted employees. Any report submitted, whether in hard copy, online, or through the MDT Tracker, is subject to a public records request, and MDT has received requests for this information. A separate MDT section handles all activities regarding public record requests. MDT does not use a third party to collect data and manage its program. However, agency repre- sentatives indicated that this is something they may consider with the PTASP requirements. Post-Reporting Follow-Up Activities MDT uses an Excel spreadsheet to track all safety concern reports. For concerns submitted via the hard copy form, the employee’s supervisor begins the investigation and the Office of Safety and Security is provide a copy of the initial report. If the supervisor is unable to inves- tigate and establish a remediation, the concern is forwarded to an appropriate MDT section to take action. As noted, if the employee is not satisfied with the evaluation and associated resolution, he or she may request a transit safety review. MDT’s chief of transit safety and secu- rity makes the final determination and either approves the initially prescribed resolution or alternate corrective action. The Office of Safety and Security receive all reports submitted through the online reporting portal or through MDT Tracker. Reports are logged, and the Office of Safety and Security acts on the report or refers it to another MDT section management lead. Priorities are established using MIL-STD 888 guidelines or escalated if deemed “safety critical.” MDT representatives indicated that they work closely with their transit operations group to develop mitigation measures or take corrective actions. Once an investigation is completed, mitigation measures or remediation elements are identified, and the corrective action process is completed, the employee who reported by the hard copy form, the online portal, or the MDT Tracker application will receive notice of

A-62 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation the investigation outcome and associated resolutions. If the report was submitted anonymously, the reporter will learn of the outcome through the Safety Committee or through his or her division manager. All reports are closed out by the Office of Safety and Security. The data captured through the online and hard copy forms allow MDT to track events by location, identify locational hazards, and address those hazards in an effort to reduce safety risks. Cost of Implementation MDT representatives did not have cost information to share. The online form and MDT Tracker were both developed in-house, so there were limited costs associated with the initial development and updates. Training When the new reporting ESR system options were implemented, MDT encouraged super- visors and unit managers to discuss these options with their employees. In addition, report- ing requirements and options for submitting employee safety concerns are discussed during new-hire training and as needed. Curriculum is consistent across positions, including front- line employees and supervisors. It is also consistently an agenda item during monthly safety committee meetings. MDT does not provide contractor training. Stakeholder Input While TWU was not involved in the initial design of the ESR options, it is integrated into the decision-making process through its membership and participation in the monthly UMSC. In addition, the committee developed the Report of Safety Concern form (Figure A-31). As noted, MDT’s Administrative Policy POL-SS-008 ensures TWU participation in the committee, as defined in the CBA. The committee’s membership includes one management representative each from Metrobus Operations, Metrobus Maintenance, Metrorail Opera- tions, Metrorail Maintenance, Metromover Maintenance, Track Maintenance, Power, Labor Relations, and Safety and Security. Seven representatives appointed by TWU also serve on the committee. MDT surveys employees about the ESR system. Participation is approximately 5%–10% of MDT employees each year (Figure A-32). MDT’s audit and compliance section interacts with employees on a regular basis and asks about the methods available to them to report hazards. Employees are also asked about reluctance they may have about repercussions or punitive actions in response to their reporting. MDT representatives indicated that there have been no reports from this effort that reflect concerns about the ESR system. Barriers to Implementation MDT representatives stated that there were not many challenges to the implementation of the ESR system. MDT representatives indicated that “prescriptive” ESR system guidance, such as that for FRA’s C3RS program, from FTA would be helpful, although they did not describe the lack of such as a barrier. Elements of Success MDT representatives provided two examples of employee reporting that led to improved safety. In the first, an MDT station was under construction, restricting normal access to the

Case Study Narratives A-63 Figure A-32. MDT Office of Safety and Security, Audit and Compliance Section, Employee Survey.

A-64 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation typical disembarking station. An older female passenger was taken to a bus bay some distance from the Metrorail station. Lighting at the location was poor and was reported as presenting a safety and security issue. Within 24–48 hours of her initial report, MDT modified its practices during the construction period, disembarking passengers at the kiosk at the Metrorail station and in an area with better lighting. In another example, an existing bus route com- ing into downtown Miami from Brickell had a very tight right turn, and personal vehicles were striking the buses while in that turn (including a number of reportable events). Videos captur- ing these events, including close calls, were used to document the challenges at that location. MDT rerouted to avoid that specific corner. It benefited MDT in reducing transit agency losses from vehicle damages and claims and employees by reducing collisions deemed preventable. Sacramento Regional Transit District Sacramento, California Employee Safety Reporting System Program Description The Sacramento Regional Transit District (SacRT) implemented an anonymous near miss employee reporting program through the use of a hard copy form in 2010. The implementation of the form was the result of SacRT receiving several complaints of close calls with wayside workers who were on the right-of-way and not following proper procedures and exhibiting other risky behavior. Realizing that discipline was counterintuitive to producing desired system safety improvement results, SacRT focused on encouraging employees to report the events anonymously and nonpunitively. SacRT safety representatives wanted to have the ability to be made aware of these events and to track them to ensure there were no agencywide contributing factors to close call events. In addition to ESR opportunities, there are campaigns such as “See it, Hear It, Report It” and mobile phone apps such as Alert SacRT that are targeted toward the traveling public to report nonemergency crimes or suspicious activity. While employees have used these alternative reporting methods on rare occasions, most reports are made by the public and are related to station cleanliness or overall station appearance. Related Policies or Procedures SacRT has an SOP in place to govern the use of the anonymous near miss employee reporting program. The SOP defines that willful negligence and acts of sabotage are not included in the nonpunitive aspect of the near miss reporting program. Reporting Practices SacRT agency leaders within the operations, maintenance, safety, human resources, and management departments are notified via e-mail that a near miss report was submitted, and a confirmation of the receipt of the submission is sent to the reporting employee within 24 hours. The director of light rail; representatives from operations, maintenance, and risk; the chief of safety; and CPUC meet monthly to discuss safety issues, including reported near miss events or hazards that were reported by employees. Once a near miss report is submitted, operations management and safety and risk manage- ment have access to it, and the Hazard Fire Life Safety Resolution Committee (HFLSRC) is responsible for reviewing it and taking action based on the information provided. The Safety Department performs internal tracking by means of an Excel spreadsheet. However, the agency

Case Study Narratives A-65 is currently in the process of transitioning the tracking aspect of the near miss reports to SacRT’s SharePoint site to allow for seamless communication between departments. The majority of near miss reports that are submitted are anonymous. Prior to anonymity being an option, SacRT was not receiving near miss reports. Once the anonymous option was incorporated, the average number of near miss reports increased to 3–4 per month; sub- sequently, it decreased to about 1 report every few months; however, between May and July 2019, there were no near miss reports. SacRT credits the reduced volume of near miss reports to an improved reiteration of the processes in place. In addition to near miss reporting options in place at SacRT, there are occurrence reports, which are used to report issues such as facilities that need to be repaired, branches that come in contact with the catenary or vehicle, shopping carts, potholes, and the like. Occurrence reports are transferred to facilities or wayside departments for repair or mitigation. Post-Reporting Follow-Up Activities When a near miss event or hazard is reported via the near miss reporting form, the first step after acknowledging receipt of the report is to investigate the report details. The HFLSRC will pull video from the light rail vehicle and review footage from onboard or station cameras that may help to clarify what occurred. Once the review committee can successfully identify what occurred, if training is deemed necessary, it is formulated to ensure that the event does not occur again, and coaching ensues. Follow-up is also performed after training and coaching have been completed to ensure that the employee(s) successfully learned/improved as a result of the provided training. Training Training is provided to all SacRT personnel during new-hire and refresher training to inform employees of the definition of a near miss and how to report a near miss, including how to use the forms and where to submit them. The training related to the anonymous near miss employee reporting program does not vary by employment position, as all employees receive the same training. Additionally, non-SacRT personnel who work on the right-of-way are provided with the same near miss reporting training that SacRT employees receive. Remedial training may be required depending on the outcome of HFLSRC investigations. Stakeholder Input SacRT collaborated closely with its two labor unions to develop and implement the non- punitive anonymous employee near miss reporting program. ATU represents SacRT’s transit operators, and the International Brotherhood of Electrical Workers represents its mechanics. Union representatives provided input to the design of the forms and were instrumental in spreading the news of the near miss reporting opportunity and encouraging all employees to report all identified near miss events and hazards. Barriers to Implementation The main reported barrier present in the development stages of the nonpunitive near miss reporting program was described as union pushback. Once the union was aware and convinced that the program would be used in a nonpunitive manner and that reports could be submitted anonymously, it was supportive and involved in the iterative development of the program. As noted, prior allowing submission of anonymous near miss reports, SacRT had a difficult time encouraging employees to report hazards or near miss events.

A-66 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Elements of Success SacRT was awarded the Transportation Security Administration’s (TSA’s) Gold Standard Award in 2018 for its improvements in safety and security along its light rail line. A significant element of those safety improvements was the development and implementation of the employee safety reporting system and the procedures established for follow-up activities. In addition, TSA recognized the success of the Alert SacRT mobile phone app. These aspects of SacRT’s safety program contributed to its selection as a TSA Gold Standard Award recipient. Sarasota County Area Transit Sarasota, Florida Employee Safety Reporting System Program Description Sarasota County Area Transit (SCAT) has used a Hazard Report Form for many years. This is a hard copy form that is available in various locations throughout the organization. Within the past year, a new reporting mechanism was made available that allows SCAT employees to nonpunitively and anonymously report hazards online through a link on SCAT work computers, through personal computers or smart phones, or via a safety hotline. Since the inception of the new reporting mechanisms, the level of reporting has increased, so SCAT representatives feel their hazard ESR system is improving. Employees are assured of nonpunitive responses when they report unsafe acts, close call events, or accidental risky behavior, as long as the reported event did not result in a loss. SCAT defines a loss as any required repair that results in a cost to the agency that requires an insurance report. Employee announcements and all labor–management meeting minutes explicitly state that It shall be the policy of Sarasota County Area Transit that any unsafe act, close call, or accidental risky behavior will not be penalized as long as the issue is self-reported prior to a loss. We want to hear about it and prevent future risk! Related Policies or Procedures While the process of reporting a hazard has been available for many years at SCAT, SOP-610, Hazard Self-Reporting, was put into effect on July 1, 2019. The SOP has a defined purpose of establishing “a process for encouraging employees of SCAT to self-report dangerous situations” to allow the agency to develop a full understanding of the risks the agency faces. According to SOP-610, “any unsafe act, close call, or accidental risky behavior will not be penalized as long as the issue is self-reported prior to a loss.” The SOP also includes specific valid examples of self-reporting issues, including • Hazardous intersections, • Running a malfunctioning red traffic signal, • Dangerous service stops, • Road hazards, • Potentially confrontational passengers, and • Any other circumstance that places bus operators, passengers, or the general public at risk. Employees are instructed to self-report via a hazard form, Smartsheet link, e-mail, or a call to the safety manager or the SCAT Safety Hotline. Employees are encouraged to report anonymously and report every hazard in the spirit of increasing communication and elimi- nating hazards.

Case Study Narratives A-67 Reporting Practices Anonymous safety reporting can be completed online, and the reports are sent directly to ATU Local 1701 and senior management. SCAT uses Smartsheet as a third-party data collection tool for all safety data that are reported electronically. While all reports can be made anonymously if preferred, reporting employees also have the option to include their personal contact information if they would like follow-up information regarding the hazard or incident that they reported. When employees witness a hazard, they are encouraged to report it using a SCAT computer or their personal electronic device via https://app.smartsheet.com/ b/form/a052079d4dc24b38bd877aebb1f46958. The link leads to the Smartsheet form used to report any dangerous situation or act. It is intended as a self-reporting tool for near miss events, even if they were the fault of the operator. While the form is anonymous, employees may add a code to their report so that they can claim the reported issue in the future if they choose. Additionally, desired additional pictures or supporting documents must be e-mailed to the safety manager. Employees who wish to remain anonymous but have supporting documentation have the opportunity to present their supporting documen- tation to their union representative without the requirement of sending a direct e-mail to the safety manager. The only required fields on the online form are the location of the hazard, the situation, and the date. All other fields are optional; these include the following: • How can we fix this? • Other information, • Name (if you would like a follow-up), and • Phone number (if you would like a follow-up call). While the hard copy forms remain available at SCAT, employees are encouraged to use the new reporting methods to improve follow-up and ease of tracking. Post-Reporting Follow-Up Activities Once the report is submitted, key management, union, and Safety Committee members (comprising operators and maintenance, safety, and operations representatives) all have access to the data reported to ensure widespread knowledge of the issues occurring at the agency. In addition, dissemination of the reports reinforces that responsible parties review everything submitted for risk management purposes. SCAT’s process of sharing the reports ensures that all employees know they are being heard and that their opinions matter to management. SCAT also takes every opportunity to notify frontline employees when actions have been taken in response to an employee-submitted area of safety concern or recommendation. The safety manager is responsible for reviewing the report and initiating follow-up action based on the information provided. Reports that require immediate attention are distributed to various departments throughout SCAT as needed, and nonurgent reports are reviewed at monthly Safety Committee meetings. Training SCAT introduces the agency’s anonymous ESR process during new-hire training, and the reporting alternatives are refreshed on the “safety television” located in the employee lounge, which displays different safety messages throughout the day. SCAT employees are trained to “blow their own horn” by reporting everything, as shown in an excerpt from SCAT’s training materials in Figure A-33. SCAT encourages employees to report hazards and near misses through the safety reporting process and when they witness another bus operator doing something great. They are encouraged to report customer compliments and other celebratory daily wins so they can be shared organization-wide.

A-68 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Stakeholder Input Union representation assisted SCAT management in the development and implementation of the reporting formats used. SCAT’s safety manager, members of the Safety Committee, and ATU worked collaboratively to define what was needed to develop a nonpunitive hazard reporting program. ATU is also included in the hazard report review process to ensure anonymity when desired. Barriers to Implementation One challenge that SCAT has reduced with the introduction of the electronic submission alternatives was the possibility that hard copy forms would be misplaced or go through several managers prior to reaching the best person within the agency to mitigate the hazard. The electronic reporting alternatives streamline the tracking and trending of hazard reports within the agency. The key barriers that SCAT has experienced are encouraging employees to report hazards and ensuring them that their input is valued and that they will be protected from punitive consequences. SCAT recognizes that these reflect the maturity of the safety culture and under- stands that advancing safety culture, and the associated level of trust, takes time to improve. Elements of Success SCAT is an example of a transit agency with a successful informal hazard reporting process. Although the program is not mature in its policy development, the process has matured and improved overtime. SCAT has found success through this ESR system, illustrated in the examples provided. The agency was able to successfully close a minimally used bus stop after a report was received detailing the garbage and loitering issues at the stop. Overgrown trees that were blocking operator views and those of waiting passengers were trimmed due to a hazard report that was received. Other hazard reports have led to route change improvements, the implementation of de-escalation training into the refresher and new-hire training materials, and route scheduling improvements. Each of these improvements, defined as successful by SCAT, and subsequent action taken as a result of hazard reporting are highlighted throughout SCAT to promote the use of the ESR system. SCAT uses these success stories as opportunities to boost the importance of receiving hazard reports and emphasize the pride that reporting employees feel when they witness changes occurring in response to their input. SCAT Figure A-33. Excerpt from SCAT Hazard Report Form training.

Case Study Narratives A-69 representatives suggested that this method of safety promotion—positive reinforcement— is one way to improve system safety. Between 2016 and 2019, bus operator exposure to potentially violent situations decreased by 44% on buses and by 71% at transit stations and stops. These improvements are at least partially attributed to SCAT’s ESR system. SCAT defines violent situations as those that involve verbal abuse, threats, assault, vandalism, passenger eviction, or refusal of service to any passenger. Additionally, through a strategized focus on the promotion of self-reporting and the subsequent safety successes, the volume of self-reports increased 300% between 2018 and 2019. SCAT credits the success of its hazard reporting program to the successful involvement of labor and management in the initial planning and implementation of the program. It also characterizes the process of including the labor union in the distribution of hazard reports as a successful practice. This allows labor representatives to ensure the anonymity of reporters and authenticate the safety issues reported. Finally, SCAT credits its success to thorough follow-up with anyone who reports and to the engagement of the Safety Committee and the entire agency through newsletters and videos. SCAT representatives touted the importance of accountability in the follow-up process, which ensures that all intentions are clearly defined, reports are thoroughly investigated, outcomes are effectively communicated, and mitigations are executed. Southeastern Pennsylvania Transportation Authority Philadelphia, Pennsylvania Employee Safety Reporting System Program Description The Southeastern Pennsylvania Transportation Authority (SEPTA) has many different methods by which employees can report hazards in a nonpunitive manner—they can notify their managers verbally, fill out a Hazard Report Form, or notify their Location Safety Committee representative, options that were instituted more than 20 years ago. Electronic options for ESR include completing an online form found on SEPTANow, the employee internal intranet, or sending an e-mail to systemsafety@septa.org. Employees also have the option to report hazards through a nonemergency safety hotline. The online and hotline reporting options have been in place at SEPTA since October 2017. Some employees have also used SEPTA’s Veritas customer service tracking system to report hazards. The SEPTA commuter rail system is a part of FRA’s C3RS program, a reporting partnership with the unions and FRA, with NASA as the third-party data administrator. The reporting of close call events and safety hazards at SEPTA is intended to be an additional tool for improving safety, not a replacement or circumvention of any other safety programs or procedures in place. Related Policies or Procedures SEPTA has an MOU in place with FRA, BLET, and the transportation division of SMART that details the C3RS program. The C3RS program was developed with the purpose of improving railroad operations by providing all SEPTA employees performing activities in support of SEPTA railroad operations with the opportunity to report all close call events and safety hazards without the fear of punishment or retribution. SEPTA’s C3RS MOU defines a close call as an opportunity to improve the safety of activities in support of SEPTA railroad operations in a situation or incident that has the potential for more serious adverse consequences to railroad safety. The reported close call represents a situation in which an ongoing consequence of events was stopped from developing

A-70 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation further, preventing the occurrence of potentially serious safety-related consequences. Fatalities and personal injuries do not fall into the category of a close call and will continue to be reported and handled under the current SEPTA and FRA regulations, or any subsequent revisions to SEPTA rules and/or FRA regulations. For non-commuter-rail modes, SEPTA has a Hazard Management Program defined and outlined in its Multi-Modal System Safety Program Plan, which will be transitioning into an Agency Safety Plan. Within the Hazard Management Program, General Section 9.1, midlevel managers and line supervisors are explicitly responsible for ensuring that the safety and envi- ronmental programs, procedures, and protocols applicable to their mode are implemented at every level. Therefore, hazard resolution by field personnel is preferred, when appropriate. Hazards that are not routine or readily correctable at the grassroots level go through a formal process to adequately identify their risk level and develop appropriate mitigation strategies. Unusual conditions identified that cannot be readily assessed and corrected are typically referred to the System Safety Department by location management, where hazards are classified with the Military Standard 882 (MIL 882) as the guiding principal default analysis method. Reporting Practices SEPTA’s C3RS reporting procedures indicate that SEPTA employees who observe a safety problem or experience a close call event should report the problem or event and describe it in detail to NASA. NASA developed a close call report form that collects information related to the date, time, location, contributing factors actions taken, and potential consequences of an event, along with any other information necessary to fully describe the event or problem. Employees have the option of submitting either an online form or a paper form that is available at work locations. For paper reports, NASA mails a receipt to the employee. If insufficient data are included in the initial report, NASA reaches out to the reporting employee to gather the additional necessary information. Once a report is accepted, NASA evaluates and de-identifies all information and provides it to the PRT for evaluation. The PRT consists of local FRA, SEPTA, BLET, and SMART representatives who meet regularly to solve problems. The System Safety Department reviews all safety reports received electronically (but not associated with the C3RS program) and assigns them to the work group responsible for addressing the concern. These reports and assignments are logged on an internal Hazard Tracking Log spreadsheet to keep track of the status of subsequent follow-up actions. The Hazard Tracking Log includes the following information: • Alphanumeric hazard identifier, • Mode, • Date discovered, • Location, • Method of discovery, • Description, • MIL 882 hazard classification, and • Reference to a corrective action plan. When a report is made directly to a manager or through the Hazard Report Form, if the concern cannot be handled immediately, the manager will put in a maintenance request form to address infrastructure concerns. The responsible party is then notified of the concern and is responsible for addressing the concern according to the priority order deter- mined in the System Safety Department MIL-STD 882 hazard classification. After the request is completed and verified, the request is closed out by the System Safety Department in the Hazard Tracking Log.

Case Study Narratives A-71 Every issue that is e-mailed or called in through the safety hotline goes directly to the System Safety Department for review, and that department ensures that corrective actions have been assigned to the appropriate department. If a safety concern is reported through the Veritas customer service system, each reported issue is assigned to the Safety Department and is tracked in Veritas until it is closed out. If an issue has not been resolved within 20 days, a reminder notification is sent to the System Safety Department to ensure follow-up actions are occurring. Most issues are closed within 30 days. Post-Reporting Follow-Up Activities If an e-mail address or other contact information was provided, the employee who made the safety report will be notified of the outcome, once the report has been closed. If a safety report is received through one of SEPTA’s 30 Location Safety Committees (LSCs), then all follow-up activity related to that particular topic is reflected in monthly meeting minutes. Ultimately, regardless of how the hazard was reported, the employee will be informed of the hazard mitigation measures implemented; if not satisfied with the solution, the employee can either re-report the issue or elevate the issue to the union or through the Senior Leadership JHSC, which is over all the LSCs. To measure and track the efficacy of its hazard ESR system, SEPTA collects and maintains safety data and documents and tracks many performance measures. This information is reviewed, and the trends are used to define the effectiveness of the reporting process. Perfor- mance measures SEPTA tracks to monitor the efficacy of their ESR system include • Lost-time and non-lost-time injury rates per 200,000 work hours, • Customer complaints, • Issues reported, • Length of time taken to address issues, and • Vehicle accident rates per 100,000 miles. SEPTA representatives indicated that there are challenges associated with maintaining several different tracking systems for each type of necessary reporting. For example, data required to be collected and reported for SEPTA’s SMS in accordance with the requirements of the Federal Public Transportation Law (49 U.S.C. § 5329 and 49 U.S.C. Part 673) are captured differently than data received through the LSCs, and accident investigations are captured in the same system as the process audits. Additionally, if the state indicates that it would like to see something addressed, that is logged into yet another data system. To reduce this data challenge, SEPTA is investigating the ability to create a master data SharePoint that will enable anyone in the organization to enter and access hazard information. Another challenge to this process is that SEPTA has both FTA state safety oversight and FRA oversight. The regulatory responsibilities under both 49 C.F.R. 673 and the future 49 C.F.R. 270 do not lend themselves to one master tracking list, since the SSOA does not want to see FRA railroad-related items and FRA does not want to see items related to FTA/state safety oversight. Any master log that would be developed would need to have the capability of producing separate lists for FTA/SSOA and FRA. Training During new-hire training, SEPTA addresses the importance of identifying and reporting workplace hazards. In addition, 30 minutes of new-hire orientation is devoted to informing employees about how to identify and report safety concerns. SEPTA employees are trained to report all concerns, because “hazards cannot be addressed if they are not reported.” The hazard

A-72 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation reporting training emphasizes that employees are never too busy for safety and that reporting hazards is faster and easier than ever before with the new reporting options using e-mail, the hotline, or the online SEPTANow portal. SEPTA teaches employees that the benefits of the new reporting mechanisms available make it easier to report, allow them to check on the status of the follow-up measures that are instituted, and afford System Safety the opportunity to provide feedback and track and trend the hazard reports. Additionally, the agency stresses that the reporting can be anonymous. During semiannual internal employee safety days, generally held in the fall and spring of each year, managers review various safety topics, dis- cuss trends and issues at SEPTA and within the industry, and remind employees of the options available for reporting hazards. In addition to the new-hire training focused on hazard reporting and the semiannual refresher training provided at SEPTA internal safety awareness days, SEPTA also displays posters that detail the various ways an employee can report a hazard at all locations within the agency. An example of the poster is shown in Figure A-34. Stakeholder Input SEPTA’s System Safety Department led the development of the safety reporting form, e-mail, and hotline options. However, SEPTA works closely with its labor representatives to ensure continuous improvement in the processes in place. There are more than 30 LSCs at Figure A-34. SEPTA hazard reporting poster.

Case Study Narratives A-73 SEPTA, each of which is a union management working group of employees that meets monthly to discuss safety concerns and review accident/injury trends. A System Safety representa- tive who participates in the monthly LSC meetings is assigned to each LSC. Employees who are actively involved in the LSCs are encouraged to offer ideas for improvements to the safety reporting processes. The C3RS program in place for the commuter rail operations at SEPTA includes stake- holders from FRA’s Office of Railroad Safety, NASA, SEPTA, BLET, SMART, the PRT, and the PRT Support Team. The C3RS MOU details the roles of each stakeholder and the necessary actions for modification or cancellation of participation in the program. The MOU explicitly states that confidentiality provided under the C3RS MOU survives its cancellation. Barriers to Implementation Improving the safety culture of SEPTA to ensure that all hazards are reported without fear of retaliation or retribution is something that SEPTA representatives are working to improve. Safety surveys are conducted every 3 years, and the most recent survey, which was conducted before the implementation of the online hazard reporting program, asked three questions related to hazard reporting: • Do you know how to report a hazard? • Would you use the LSC or go through your manager? • Are you comfortable reporting hazards? While the majority of employees responded that they knew how to report a hazard, SEPTA realized there was room for improvement in terms of ensuring that managers were addressing reported issues and improving confidence in the process to help employees feel more comfort- able reporting. Elements of Success SEPTA is in the process of successfully leveraging the benefits of its involvement with the FRA C3RS program to provide guidance and minimize the challenges associated with estab- lishing an authority-wide hazard reporting program across both rail and nonrail modes. When concerns are reported that have the potential to affect more than one location, the concern is escalated to SEPTA’s JHSC for an evaluation of possible mitigation measures. The committee includes both union and management representation, who work together to produce practical applicable solutions to global issues that impact the entire organization. An example of this type of concern was a report related to the operator’s seat, specifically, the repeated whole-body vibrations and inability to properly adjust the seat position to accommodate all operator body types. This report led to an evaluation of the operator seat and the installation of new bus seats. Similarly, a concern was reported related to mirror placement on the buses, which led to changes in the placement of all bus mirrors on SEPTA’s fleet. SEPTA noted that the success of the hazard reporting program can at least be partially attributed to the results of seeing changes implemented within the organization. SEPTA rep- resentatives remarked that as soon as operators realize that his or her concern was heard and sees their personal ability to effect change, they feel empowered. That empowerment encourages operators to share their feelings with co-workers, which, in turn, increases the acceptance and utilization of the program.

A-74 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Tri-County Metropolitan Transportation District of Oregon Portland, Oregon Employee Safety Reporting System Program Description The Tri-County Metropolitan Transportation District of Oregon (TriMet) ESR system is referred to as a “request for safety assessment” (RSA), which is intended to provide an outlet for employees to report safety and security concerns that involve potential harm to persons or property related to TriMet. This ESR system and associated processes were put in place to support the safety risk assessment function of an SMS program. The program has been in place since 2012 and was established to allow employees to report safety concerns through an internal intranet, immediate supervisors, or the RSA Hotline. Employees have the option to remain anonymous when they submit their RSA, in which case the employee is routed to NAVEX Global, a third-party administrator that collects and evaluates the data, routes issues to relevant TriMet departments for notification and action, and responds to the employee who initiated the report with the resulting outcome. All nonanonymous RSAs are managed internally within TriMet. Related Policies or Procedures TriMet’s RSA system and associated processes were put in place to support the safety risk assessment function of the agency’s SMS. The agency-implemented Operating Procedure SSE-053, “Request for Safety Assessment (RSA),” last revised in August 2016, defines the purpose, specific responsibilities by role, and definitions related to TriMet’s RSA. The purpose of the RSA program and the associated procedure is to provide a means for any TriMet employee to communicate safety concerns and to standardize the submission and review of the informa- tion that is communicated. RSAs typically include issues or hazards that cannot be resolved by the employee’s immediate supervisor or manager. TriMet has instructed employees that all collisions or issues that require immediate emergency response be reported to the employee’s supervisor or dispatch/control in accordance with agency procedures rather than through the RSA process. All non-safety-related issues are reported through the online operator gateway portal or through the maintenance defect card process. Reporting Practices TriMet employees can submit an RSA by going to the TriMet website home page (an internal intranet site for employees), by accessing the Safety and Security home page link (also within the intranet site), by contacting an immediate manager or supervisor, or by calling the RSA Hotline. If a TriMet employee calls the RSA Hotline, a safety staff member will follow up with the caller to gather details, and the caller may be asked for additional details. Regardless of how an RSA is received, it is recorded in the database under the name of the employee who reported the issue. Once an issue is recorded, the database sends an automated e-mail receipt to the employee who initiated the RSA to indicate successful submission. The RSA administrator is responsible for assigning key personnel from one or more departments to request input or action related to each RSA received. The administrator is also responsible for correspondence between safety committees and continuous improvement teams to garner input and recommendations on RSAs. The RSA administrator also presents monthly reports to TriMet’s Transit Change and Review Committee, whose membership includes middle managers, directors, and executive directors. Post-Reporting Follow-Up Activities Upon receipt of each RSA submission, the RSA administrator conducts an initial review to ensure the submission is complete and that there are no identical open RSAs. The administrator

Case Study Narratives A-75 then assigns the RSA to applicable departments for review and input. Occasionally, this step includes coordination with external parties as well, such as city engineers, who should be contacted to request a signal timing change. The reviewing department is responsible for reviewing the reported issue, conferring with internal departments and external parties that may be affected by the issue, conducting site visits and interviews, reviewing other technical reports and information, and issuing associated remedies. The manager of each responsible reviewing department, or designee, is responsible for ensuring that the Transit Change and Review Committee reviews and approves all matters related to configuration management, changes in operating procedure, and modifications to equipment, facilities, or infrastructure. The manager is also responsible for prioritizing responses upon receiving notification of an RSA, because timely response is necessary to ensure that safety concerns are properly addressed. Reviewing departments must commu- nicate actions taken by providing documentation in the database within 14 business days of notification of an RSA action item. Assigned reviewing department staff are required to keep their action items in open status until their actions and all communication are complete. Finally, the reviewing department is responsible for closing out the action items in the RSA database once the item has been completed. The RSA administrator is then responsible for reviewing the actions taken to ensure completeness. If a reviewing department fails to respond to its action item assignment within the 14-day time limit, the RSA administrator sends a reminder e-mail to the department and the reviewer’s manager to ensure compliance. When an RSA has led to a final resolution, the RSA administrator composes and documents the final resolution in the database and provides a written response to the requestor, including contact information in case the requestor has additional questions. The RSA administrator then closes out the RSA in the database but maintains the RSA status report. The RSA administrator provides monthly status reports to the executive director and the safety, security, and environmental services divisions and to the director of safety management systems and environmental services. The last duty of the RSA administrator defined in the policy is to assist RSA requestors, as needed, including responding to calls received on the RSA Hotline. Employees can follow up on the status of their RSA through the online intranet site. They can search information by specific keywords, or they can view the Status Summary Report, which details the status of each RSA. The Status Summary Report includes the RSA tracking number, date reported, safety concern, location/route (if applicable), assessment status, follow-up status for tracking, completion date when review was closed, name(s) of assigned review(s), and the dates of assignment. Employees can also call the RSA hotline to check on the status of an RSA, and hotline representatives will provide the same detailed information. Status Summary reports do not include detailed action notes for the specific purpose of limiting the size of the status report. Surveys are sent to employee initiators with each letter of resulting outcome to solicit feedback on ways in which TriMet could improve the RSA process. This survey further emphasizes the value TriMet places on feedback from its frontline operators, which will inevitably make employees understand that they are heard, thus encouraging more employees to use the process to report hazards. Accountability through oversight and follow-up is possible through TriMet’s RSA Team. The RSA Team is assembled in accordance with the parameters of the RSA and typically includes a senior safety specialist, the director of safety, managers in the affected department, and subject matter experts (if known and on staff). The RSA Team meets periodically to review and provide oversight on specific RSAs as needed to ensure that all appropriate evalua- tions have occurred and that reasonable recommendations have been provided. The RSA Team

A-76 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation is also responsible for rendering assistance as necessary to bring open RSAs to closed status using detailed explanations and effective resolutions. The RSA administrator is a designated member of the RSA Team. Training The RSA program was designed to be extremely user-friendly and not require much more than an introduction and program promotion. TriMet promotes the program through communication articles and a module that was added to recertification training and highlights the successes of the process through ExpressLine articles. Supervisors and frontline employees all receive the same training, regardless of employment position. Stakeholder Input TriMet representatives interviewed for this report were not aware of the specific details of the initial implementation of the RSA process due to their tenure and turnover of employees who were involved in the development of the program. However, they reported that there was a concerted effort from district management to frontline employees to support inwardly focused activities, including analyzing the safety culture and developing and implementing programs to advance risk ownership and safety efforts and instill safety as the core value at TriMet. These efforts and their associated outcomes were a part of the design and imple- mentation of the RSA process. Barriers to Implementation An important challenge to the implementation of the RSA process reported by TriMet representatives was establishing the trust necessary for employees to feel that their voices are heard, their opinions matter, and they can be part of the solution. Once TriMet employees felt that management was listening and changes occurred as a result of RSAs, employee hazard reporting increased and peer encouragement to report hazards improved as well. Elements of Success One way that TriMet successfully promoted the involvement of frontline employees was through the development of the Bus Operator’s Continuous Improvement Team (BOCIT), which is instrumental in producing solution alternatives for the various reported RSAs and provides a unique opportunity to foster employee buy-in from the reporting to the mitigation phase of the RSA process. Since its development, BOCIT has been so successful that it was awarded the Oregon Governor’s OSHA award in 2015 for its “extraordinary contri- butions to the field of workplace safety and health.” Through the RSA process, TriMet bus operators reported that dashboard switches and con- trols that are necessary to reach repeatedly in a shift were difficult to reach and could lead to repetitive strain after long shifts. This RSA report led to an ergonomic study of all 3000-series buses, which ultimately led to a reduction in the width of the steering wheels from 20 inches to 18 inches for easier use, relocation of the kneel/ramp switch off the dash, and upgrading of the control handle to reduce repetitive strain. Additionally, key indicator lights were brought down to the dash from the overhead light board for ease of view, and turn-signal light buttons were widened so the left foot could fit between them. Other associated changes included the following: • Fare boxes were lowered, and pedestals were removed to increase visibility. • Mobile data terminals were moved closer to the operator for easier reach.

Case Study Narratives A-77 • The glare from interior lights was reduced by the use of red diffusers and changes in configuration. • Bus mirror configuration was adjusted to improve operator line-of-sight. Another RSA led to the successful resolution of loud buzzer sounds that were occurring on new 3600-series buses when the turn signal or hazard lights were applied. The initial RSA indicated that a “turn signal alarm nightmare” occurred when the turn signals were used and also noted that the alert signal was too loud when the hazard light was engaged. This RSA led to communication with the manufacturer, which was able to remedy the situation so the alarm would sound only when the hazard lights were applied while the bus was in motion and not at all when the turn signals are used. Another noise-related RSA was submitted, a complaint of the noise level of the ADA ramp signal. A campaign was initiated, and BOCIT found a comfortable solution by simply relocating the beeper underneath the bus to lower the volume. Another RSA indicated concern about the lack of exterior lighting at the rear door. This RSA ultimately led to improved exterior lighting, which, TriMet representatives stated, improves passenger safety. Washington Metropolitan Area Transit Authority Washington, DC Employee Safety Reporting System Program Description The Washington Metropolitan Area Transit Authority (WMATA) was the first rail transit agency in the nation to implement a C3RS, in 2013. This program was developed in response to National Transportation Safety Board (NTSB) Recommendation R-10-017 to WMATA to develop and implement a nonpunitive safety reporting program to collect reports from employees, regularly review the reports, and share the results of those reviews organization- wide. This recommendation stemmed from a train-on-train collision at Fort Totten Station in Washington, DC, in June 2009. NTSB found that WMATA’s “lack of a safety culture” contributed to the collision, and the establishment of a nonpunitive safety-reporting program would lead to an improved, informed just culture.3 With the goal of improving transit safety, WMATA’s C3RS program gathers data related to safety issues that might otherwise not be reported to allow for the implementation of proactive and preventive safety actions across all operational modes. In 2016, the C3RS was expanded to include bus operations, which also made WMATA one of the first transit agencies in the nation to have this type of ESR system for transit buses. To support these safety initiatives, WMATA contracts with BTS to confidentially collect and manage employee safety reports and report trend analyses to the agency. This partnership between WMATA, BTS, and the labor unions is governed by the Close Call MOU, which defines close calls as “a situation or circumstance that had the potential for safety consequences but did not result in an adverse safety event.” WMATA’s C3RS program provides the reporting employee protection from discipline but does not eliminate employee accountability for serious rule violations, which are not eligible for protection. Events that are excluded from close call reporting protection include events that resulted in any injury, intent to damage operations or equipment, purposely endangering others, acts of sabotage, criminal offenses, substance abuse or the inappropriate use of controlled substances, the identifiable release of hazardous material, and rail- and bus-specific violations.

A-78 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Related Policies or Procedures WMATA updated its MOU with BTS on July 23, 2018. The purpose of the MOU is to document the mutual interest between WMATA and its employees in improving system safety; establish the process used to capture trends and analyze data; identify safety systemic, organizational, or procedural issues; and establish the process used to define corrective actions and associated preventive measures. The MOU outlines steps in the reporting process, eligibility criteria, generalized reporting procedures, criteria for close call acceptance, time limits for initiating and finishing reporting to receive protection from discipline, confiden- tiality, nonpunitive information, the use of the data, preventative safety actions, and stakeholder responsibilities. Reporting Practices WMATA employees who see or experience unsafe conditions are encouraged to submit a report to BTS via an online form or phone number. Employees are encouraged to complete their report online within 24 hours of the close call event. Each employee must submit his or her own report to be eligible for protection from discipline. BTS collects the information, performs a confidential interview with the employee, and removes all identifiable informa- tion from the report prior to presenting information to the joint WMATA/Labor Peer Review Team. All information collected by BTS is classified as Confidential Information Protection and Statistical Efficiency Act (CIPSEA) data, which not only protects the employee’s iden- tity but also protects the employee from Freedom of Information Act or subpoena requests. Any violation of CIPSEA, which includes willful disclosure of information, carries fines and possible imprisonment. Post-Reporting Follow-Up Activities Information regarding the follow-up actions that occurred as a result of a Close Call Report is shared via quarterly newsletters distributed by management and the unions and posted on WMATA’s intranet at http://metroweb/departments/DGMO/Pages/Close-Call-Reporting- (Quarterly)-Reports.aspx and on a BTS managed website at https://closecall.bts.gov/c3rs_ publications.htm. As shown in Table A-1, once a close call report is submitted and BTS has accepted the close call event or unsafe condition, a summary of the report, excluding any identifying information, is submitted to the PRT for analysis. The PRT is a joint Metro/Labor committee that meets regularly to establish root causes of reported events and recommend actions that WMATA should take to prevent these reported events from recurring. The PRT includes local representatives from WMATA rail and bus transit infrastructure management, union officers and members, WMATA safety management, and BTS. PRT members are trained to perform root-cause analysis and to perform these duties under a strict confidentiality agree- ment required by BTS. WMATA’s chief operating officer reviews and accepts the decisions on the preventive safety actions, provides oversight and directs the implementation of approved preventative safety actions, and tracks the approved preventive safety actions through imple- mentation. WMATA provides feedback on implemented preventive measures to employees, and the information is shared organization-wide through quarterly newsletters. BTS also contacts the reporting employee directly to provide an update on his or her report and produces an annual report describing the status and activities that have occurred as a result of the close call reporting program. BTS also follows up by producing special reports on single topic issues, as needed.

Case Study Narratives A-79 Step Responsible Party 1 Identify an unsafe event or condition; initiate and then complete a close call report. Employee(s) Employees can use an 800-telephone number to initiate a close call and fill out a report online within the 24-hour deadline to complete the process. Employees also have the option of completing their reports entirely using an 800-telephone number within the required time frames. 2 Enter close call report in tracking system. BTS a. Confirm eligibility (see section 7.1, criteria for close call report acceptance). b. Provide confirmation receipt to employee. c. Provide feedback to reporting employee(s) if report is rejected. 3 BTS will interview all reporting employees to collect additional details about the reported close call event or unsafe condition. If it meets acceptance criteria, the report receives final acceptance. BTS 4 Analyze individual close call report for preliminary root causes and BTS multiple reports for emerging trends and new sources of risk. BTS Produce summary of report based on the collected data and forward to the PRT for analysis. 5 Meet at regular intervals to: a. Review BTS recommendation on preliminary root causes of reported close call incidents. Analyze summarized data from multiple reports. b. Identify new sources of emerging trends and new types of safety-critical risks. c. Assess the association between emerging patterns or trends in close calls, relate those to preventive safety actions to be taken by WMATA, and approve implementation strategies. Management representatives on the PRT are empowered to approve preventive safety actions. If the PRT reaches an impasse or recommends actions that require significant additional resources or executive level actions, the PRT will refer those actions to the chief operating officer (COO) or chief safety officer (CSO), as appropriate for approval. Actions approved by the PRT do not supersede corrective actions already established to address FTA, NTSB, or other external party requirements. d. Review and discuss a summary report comprising the individual close call reports generated from the Close Call Safety Reporting System, emerging trends, identified root causes, and approved (or recommended on the basis of the criteria in Step 5c) preventive safety actions. e. Review and discuss all reports prior to their distribution. PRT or WMATA COO and/or CSO as appropriate 6 Review and accept individual WMATA decisions on preventive safety actions as needed on the basis of Step 5c. WMATA COO and/or CSO 7 Provide oversight and direct the implementation of approved preventive safety actions. WMATA COO and CSO 8 Track preventive safety actions taken in response to close call events. WMATA COO and CSO 9 Make feedback available to employees on preventive safety actions and safety outcomes resulting from their close call reports, including a quarterly status report (WMATA/L689/L922) and individual outreach to reporters (BTS). WMATA/L689 /L922 BTS 10 Write an annual report describing the status of the project, any modifications made, and lessons learned to date; report on reporting activity; describe emerging trends and recommended solutions; distribute and post on a Confidential Close Call Transit Safety Reporting System website. BTS 11 Write special reports on single topic issues, as needed. Distribute to all participants and post on the BTS Close Call website. BTS 12 Develop and continue to improve reporting, tracking, and preventive safety action monitoring systems. WMATA, BTS Table A-1. Steps in WMATA’s C3RS reporting process.

A-80 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Currently, only L689, L922, and their frontline supervisors are eligible to report through C3RS for protection from discipline. The agency is in the process of expanding the program to all WMATA employees. There are also rail- and bus-specific conditions in which a reporting employee is not protected from discipline; these conditions are defined in the MOU. The conditions related to rail include station overruns of more than one door leaf, exceeding the limits of an absolute or permissive block, red signal violations, wrong side door opening, and observed violations. Other exceptions related to bus include an operator’s failure to follow proper vehicle secure- ment procedures that results in a rollaway bus. Training WMATA promotes its C3RS program through ongoing training, brochures, worksite banners, videos, and quarterly newsletters. New employees are first introduced to the C3RS program in new-hire training, which includes a discussion on what a close call is and why it is important to report such incidents. WMATA has developed training that is tailored speci- fically to shop stewards to encourage safety reporting and remove the negative snitching connotation associated with identifying a safety issue. WMATA also has a Quick Guide for Rail and Bus Transit Operations that outlines the necessary information a WMATA employee needs to understand and report a close call event, as shown in Figure A-35. C3RS program training involves educating employees about the program, how to use the program, and an overview of reported concerns and corrective actions taken in response to those items. These trainings occur regularly in new bus operator and bus refresher classes, new rail operator and rail operator refresher classes, new station manager and station manager refresher classes, and regular safety meetings that occur throughout WMATA. Each safety meeting is used as an opportunity to promote the C3RS program and encourage employees to report. Close call actions are reported at the monthly Executive Safety Committee meet- ings, which are attended by the general manager, CSO, COO, and departmental members of the Executive Safety Committee. Stakeholder Input The C3RS program was established as a partnership between WMATA management, ATU Local 689, the International Brotherhood of Teamsters Local 922, and BTS to provide a platform for employees to voluntarily and confidentially report close call events without fear of discipline. In the development of its program, WMATA reviewed existing programs, processes, and MOUs used by airlines (using NASA as a third party) and by New Jersey Transit, a partner in the early C3RS pilot program involving BTS. WMATA cited the confidentiality protection of BTS as a contributing factor in the decision to use BTS as a third-party administrator of its program. BTS is authorized by law [49 U.S.C. 111(c)(2)], to collect transportation information for its programs, including the Close Call Data Program. The BTS confidentiality statute, 49 U.S.C. 111(i), and CIPSEA protect the information BTS collects. These laws make sure that any identifying, sensitive, or proprietary information that BTS collects is not released to unauthorized persons or organizations (https://ccdp.bts.gov/#confidentiality). WMATA tracks the number of reports submitted via BTS monthly reports. While WMATA has not set specific targets for volumes of reports, it has established a general goal of increasing reporting over time. With the understanding that feedback is imperative and will encourage

Case Study Narratives A-81 future reporting, WMATA deliberately and regularly emphasizes the successes of the reporting program through quarterly newsletters and at regular safety meetings. With the confidential aspect of the reporting program at WMATA, it is important that the safety improvements and policy or procedural changes are emphasized organization-wide to ensure that the person who reported the hazard or safety issue is aware that a mitigation measure was put in place. WMATA representatives indicated that this feedback makes its employees feel valued and empowered and thus promotes future reports. Figure A-35. Confidential Close Call Reporting Quick Guide for Rail and Bus Transit Operations, WMATA.

A-82 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation High-level managers have been assigned to participate on PRTs, as described above, and are empowered to implement new safety actions without waiting for executive-level approval. This has led to a reduction in the time it takes to make necessary safety improvements, which, in turn, demonstrates the importance of the ESR system to reporters and the value of their reporting in improving system safety. Monthly Executive Safety Committee meetings provide an additional avenue of program oversight and information dissemination through the presentation of actions that have been taken in response to close call reporting. Barriers to Implementation Despite promotion of the program by all partners, employee reporting remains relatively low—an indication of room for continued improvement. Spreading information about the Close Call Program, including the nonpunitive nature of the program, is a challenge identified by WMATA representatives. Even with various trainings, banners, newsletters, and conversa- tions, WMATA representatives indicated they still come across employees who are unaware of the program. Therefore, barriers to implementation are mostly related to spreading word that the program exists and how to use it properly. Elements of Success Since the C3RS program was implemented at WMATA, many documented preventive safety actions that resulted from employee safety reports have been implemented to improve system safety, including the following: • Improved communication methods for new-hire training; • Switch-movement communication improvements between the rail operations control center and the roadway worker in charge; • Increased awareness of train operator procedures for entering the shop; • Establishment of a logbook for all company vehicles, including maintenance records, to reduce the likelihood of operating defective vehicles; • Improvement of bulkhead door seals on the 2000 and 3000 series rail car models to reduce water infiltration; • Updating of the Controller Handbook to include a malfunctioning decision-making matrix; • Trimming of a median and installation of “No Parking” signs by a local jurisdiction to create more turn space for bus operators; • Revision of the Roadway Access Guide in the Right-of-Way Worker Protection Manual to reflect accurate descriptions of risk throughout the system; • Institution of training on proper disposal of wastewater to deter plant maintenance employees from dumping onto track beds; • Adjustment of Stinger System (power supply for rail vehicles located in maintenance and repair areas) decibel levels from a piercing sound to a comfortable level for shop workers; and • Replacement of older bus shuttles with newer buses to reduce obstruction issues for operators. Participants in Federal Transit Administration Safety Management System Pilot FTA is conducting an SMS Implementation Pilot Program that includes the establishment and implementation of ESR systems. The pilot includes CTA (discussed above) and three transit agencies in Maryland: Transit Services of Frederick County, Montgomery County Transit, and

Case Study Narratives A-83 Charles County Transit. FTA established these pilots in an effort to provide guidance on SMS implementation, including the importance of ESR in both the SMS safety risk management and safety assurance functions, to the public transportation industry. 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. Transit Services of Frederick County Transit Services of Frederick County (TSFC) provides local and commuter bus service and demand-response paratransit services in Frederick County. The concept of SMS was intro- duced to all TSFC staff in September 2018. In November 2019, TSFC released the first version of its PTASP, in which its safety management policy statement delineates TSFC’s commitment to • Establish and operate hazard identification and analysis and safety risk evaluation activities, including an ESR system as a fundamental source for safety concerns and hazard identi- fication, in order to mitigate or eliminate the safety risks of the consequences of hazards resulting from our operations or activities to a point that is consistent with our acceptable level of safety performance, and • Ensure that no punitive or retaliatory action will be taken against any employee who discloses a safety concern through the ESR system, unless disclosure indicates, beyond any reasonable doubt, an illegal act, gross negligence, or a deliberate or willful disregard of regulations or procedures. All reported hazards evaluated by the Safety Committee, which consists of the chief safety officer/SMS manager, the assistant director of operations, an operations manager, a representa- tive from dispatch, a representative from fixed-route, a representative from paratransit, and a representative of county risk management. From the inception of the PTASP, hazard reports and mitigations are shared as a permanent agenda item in all monthly driver meetings and biannual all-staff meetings. The safety management policy included in the agency’s PTASP is dedicated to the ESR system. In the policy, employees are strongly encouraged to report all safety hazards inside and outside facilities and vehicles and on the road. All hazard reports are to be tracked electronically on the hazard log spreadsheet and reviewed daily by the CSO. Reports can be submitted in person to a dispatcher, supervisor, manager, or director. Safety hazard reports can also be submitted anonymously via a locked comment box in the driver area or via e-mail to TransitSafety@FrederickCountyMD.gov. TSFC’s CSO is responsible for investigating the hazards and their potential consequence(s), assessing safety risk, and determining how to mitigate the risk(s) in the future. Safety hazard reports are addressed at bimonthly Safety Committee meetings, and findings are published immediately following mitigation actions. If employees who reported the hazard identify themselves, direct feedback regarding the mitigation is provided. To encourage all hazard reporting, employees who self-report hazards and/or close calls due to their own errors in good faith are protected from disciplinary action. TSFC defines that disciplinary action could result if the hazard report investigation reveals that the employee willfully participated in or conducted a/an illegal act, gross negligence or deliberate or willful disregard of regulations or procedures, including reporting to work under the influence of controlled substances, physical assault of a coworker or passenger, theft of County property, unreported safety events, unreported collisions, and unreported passenger injuries or fatalities.

A-84 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation No specific training is dedicated to the ESR system at TSFC, but the program is mentioned at onboarding and periodically at all-staff meetings. No costs related to the program have been identified by TSFC. Montgomery County Transit Montgomery County Transit provides fixed-route, limited stop, and demand-response bus services to Montgomery County. Through its involvement in the FTA SMS Pilot Program, it recently developed a PTASP, which is currently in the approval process with the account- able executive and the Montgomery County Council. The plan details the ESR system, which includes hazard identification and analysis, risk assessment, and mitigation. The agency ensures that the ESR system is nonpunitive and that no retaliatory action will be taken against employees who disclose safety concerns. Punitive action may be taken if the hazard investiga- tion reveals an illegal act, gross negligence, a deliberate act, or a willful disregard for regulations or procedures. FTA representatives introduced the idea of an SMS to union representatives in 2016 as part of the FTA SMS Pilot Program. The local union is supporting the PTASP and the ESR system, although there is no specific language in the current CBA. Montgomery County Transit employees can report safety hazards in several ways, including: • Radio transmission to central communications when employees are on the road, followed by formal documentation and submission of the concern on an ESR form by the end of the business day; • Directly to any supervisor, manager, or desk coordinator by using the ESR form; and • Anonymously by placing the ESR form in a locked comment box in the driver area. The agency has established processes to identify hazards and associated consequences that will include the use of data collected and reported to management through the following means: • ESR form; • Pre- and post-trip vehicle condition reports; • Routine management observations, such as regular ride checks; • Monthly safety committee and fleet maintenance meetings; • Accident and incident reports; • Maintenance reports; and • System inspections. Hazards are also identified through outside sources, including passenger feedback, the County 311 program,4 public forums, and the Transit Advisory Group, which consists of riders, organization members, and community leaders. Although the ESR system is not yet in place, once it is established, risk will be established through a defined procedure using a risk assessment matrix for decision-making that accounts for probability and severity of identified hazards. Mitigation measures will subsequently be implemented until risk is reduced to an acceptable level. All reported hazards and mitigation measures will be detailed and tracked with Trapeze software. Montgomery County Transit will also track fatalities, injuries, safety events, and system reliability as performance metrics in terms of both nominal and rate per mile traveled. The agency is also dedicated to providing direct feedback to the reporting employee when the hazard has been mitigated. Mitigation measures will also be announced at monthly Safety Committee meetings and reported to depot employees using the safety board. Additionally,

Case Study Narratives A-85 the agency requires that implemented mitigation measures are monitored for effectiveness and unexpected consequences to ensure that the mitigation does not create a hazard. Charles County VanGO Charles County VanGO provides public bus and specialized ADA demand-response services throughout Charles County through contracted services with MV Transportation. The first version of Charles County’s PTASP was issued in July 2018 and includes the agency’s safety management policy, which details its commitment to • Provide appropriate management involvement and necessary resources to establish an effective ESR system that encourages employees to report unsafe work conditions, hazards, or at-risk behavior to management; • Identify hazardous working conditions and analyze data from the ESR system to develop subsequent processes and procedures to mitigate safety risks to appropriate levels of acceptance; and • Ensure that no punitive action will be taken against employees who disclose safety concerns, unless that disclosure indicates an illegal act, gross negligence, or deliberate disregard for regulations or procedures. VanGO employees are encouraged to express safety concerns during safety meetings, indi- vidually to supervisors, or in writing without threat of disciplinary action. However, disciplinary action could result if the condition reported reveals the employee’s willful violation of motor vehicle laws or safety policies adopted by the contractor. Internal communication consists of ad hoc and regularly established activities designed to communicate and reinforce SMS policy, including reported hazards and near miss incidents. When an employee becomes aware of a hazard, he or she must submit a report within 8 business hours of the end of his or her shift, either by submitting an incident form or by direct notification to a supervisor/manager. Supervision/management is required to file a report using the incident report form or other means as deemed appropriate. In the event VanGO’s contractor is unable to mitigate the risk alone, ESR reports may be forwarded to the county for follow-up. Safety/security information is reviewed to determine whether additional methods are necessary to identify threats and vulnerabilities. This review includes a formal three-phase approach that includes a review of equipment preparedness, employee proficiency, and agency effectiveness. A risk assessment matrix is used to determine resolutions, and corrective actions are subsequently taken. VanGO’s Safety Assurance process establishes the activities required to conduct investiga- tions of safety events, including the identification of causal factors, and to monitor informa- tion reported through the ESR system. In a causal factor investigation, evidence and additional information are recorded and analyzed to determine root causes and preventive strategies. Contractor management will assist vehicle operations and maintenance departments with monitoring safety objectives and targets, ESR, and reporting details at weekly staff meetings and monthly safety meetings. Once data from all safety-related activities—including ESR-reported activities—are reviewed, management and/or supervisors will communicate the appropriate information to all employees in the organization. No training has been developed specifically for the ESR system. Additionally, no costs have been identified for the establishment and management of the ESR system. As the program matures, Charles County VanGO will track the hazards reported to determine effectiveness of the program.

A-86 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Endnotes 1. https://www.bigbluebus.com/Newsroom/Press/Big-Blue-Bus-Honored-with-the-Gold-Award-for-Bus- Safety—from-the-American-Public-Transportation-Association.aspx. 2. Division of Occupational Safety and Health Policy and Procedures Manual. California Labor Code §6401.7 and Title 8, California Code of Regulations, §3203. Accessed: https://www.dir.ca.gov/DOSHPol/P&PC-45A.htm. 3. https://www.ntsb.gov/safety/safety-recs/recletters/R-10-008-022.pdf. 4. www3.montgomerycountymd.gov/311/.

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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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