Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access (2020)

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6 Introduction Employers in all industries provide restroom access. They often, but not invariably, attempt to comply with the sanitation standard requirements of the Occupational Safety and Health Administration (OSHA). They do this out of respect for the health, dignity, and morale of the workforce as well as to ensure their productivity or attention to the job. Multiple infrastructure limitations and service demands on a mobile workforce make adequate and timely restroom access harder to achieve—for public transit operators in particular. TCRP Project F-25, “Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access” demonstrates that many transit agencies (TAs) are trying to achieve health and timely restroom access, but that there is still some distance to go. The safety, health, and responsiveness of TA operating staff are keystones of transit system safety, operations, and economic viability. An enhanced industry focus on comprehensive integration of vehicle, passenger, and public safety, including the safety management system approach, highlights the important influence of transit operator health, wellness, and morale on system safety, operations, and costs. Bus operators around the United States and Canada have identified access to safe and clean restrooms as a major concern that affects their health, stress levels, and job satisfaction (Kessler C H A P T E R 1 Transit Operator Restroom Access: Issues and Good Practice Organizational environment and practices Infrastruc- ture and capital planning Route planning SchedulingService delivery Cost assess- ment and evaluation

Transit Operator Restroom Access: Issues and Good Practice 7 and Gonzales 2014). As a mobile workforce providing scheduled service, many transit employees encounter barriers to using toilet facilities when they need them. Schedule demands and route design can impede restroom access even between runs, and facilities are not always adequate at terminal locations. Access on the road can be an even bigger challenge: Transit vehicle operators have reported distress, anger, fear, and humiliation when unable to get to clean, safe facilities in a timely way (Kessler and Gonzales 2014). Similar problems have been described for taxi drivers, where the possible health effects have included significant urological disorders (Burgel et al. 2012, Mass et al. 2014, Perez and Dang 2008). Around the United States and Canada, both TAs and the unions representing operators have recognized the serious impact of limited restroom access and begun to negotiate ways to address this problem. As early as 2009, TCRP Report 135: Controlling System Costs: Basic and Advanced Scheduling Manuals and Contemporary Issues in Transit Scheduling (Boyle et al. 2009) emphasized the importance of restroom access to planners and schedulers. The 2015 Fixing America’s Surface Transportation Act (FAST) called for the secretary of transportation to review industry standards related to scheduling fixed-route rail and bus service with adequate time and access for operators to use restroom facilities (Staes 2017). TCRP F-25 follows up on those initiatives and recommendations by investigating the range of approaches being taken by TAs and identifying effective practices to help TAs of all types, sizes, and locations assess their own needs and tailor effective solutions. The results described here show a wide variation in the extent of the problems related to restroom access and the impact and the appropriate responses specific to each TA. At the same time, concerns about restroom access illustrated in campaigns and initiatives around the world are remarkably similar to those raised in the United States and Canada (Asian News International 2014, Leedham 2019, Paas and Hanley 2019, Unite the Union 2019). Practical, simple approaches have been adopted but are not in use at all TAs. Addressing this issue and the corresponding implications for economic, operational, and employee well-being is essential for a safe and successful transit system. As the public transit industry faces ongoing retention problems and a potential shortage in the transit workforce, initiatives that strengthen an organization’s safety culture may help by attracting employees and keeping operations personnel in the workplace longer (Cronin et al. 2013, p. I-17). TAs have paid the most concerted attention to the experience of bus operators in scheduled service, and less to fixed rail operators or paratransit. This is in part because of how unscheduled restroom needs can affect service delivery, but it may also be in part because bus operators are known to be at increased risk for metabolic syndrome and related diseases, to which stress and the physical demands of work are likely to contribute. However, train operators, conductors, and paratransit drivers are also affected, and most of the project’s recommendations and tools can be applied to all vehicle operators. Some of the specific differences for rail and paratransit are discussed throughout this report. Respondents reported that other people working alone or far from restroom facilities were also faced with limited restroom access. In particular, employees who are in the field as part of their job duties often have difficulty finding adequate restroom facilities during early- and late-hour shifts. In addition to vehicle operators, the transit employees affected included bus and station cleaners, controllers and dispatchers, field supervisors, on-board evaluators, and station agents. Assuring restroom access is likely to limit the risk of accidents, stress, and possible health effects and, in turn, improve TA safety records and operator turnover. This project also sets the stage for further research on health outcomes and programmatic interventions that can improve operations policy and efficiency, promote health and prevent illness, and inform medical diag- nosis and treatment for vehicle operators.

8 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Terminology and Other Conventions Restrooms can be referred to in a variety of ways. In the United States “bathroom” is common, despite the lack of a bath. At some TAs they are “comfort stations.” Canadians typically refer to the “washroom.” In other countries, they may use the simple “toilet” or variations on the archaic “water closet” (WC). For simplicity, this project uses the term “restroom,” except in direct quotations. Restroom access is carefully distinguished from breaks in this report. Breaks can be scheduled or planned for, and are often based on state regulations or collective bargaining agreements. Restroom access includes unscheduled, as-needed use and focuses on the infrastructure as well as the schedule. This distinction was inadvertently blurred in the survey phase of the project but has been maintained whenever possible. Sources’ conflation of breaks with restroom use is presented as spoken. Restroom teams can take a variety of forms: small groups of people addressing issues as needed, designated representatives from relevant departments, and formal labor–management committees jointly constituted are just a few. The term “restroom team” is used here, except when such a group is called something specific by the TA responding. To avoid wordy repetition, “transit agency” and “local union” are referred to by the acronyms TA and LU, respectively. TCRP F-25: Process and Products How Information Was Collected and Used The project was designed to identify how operator restroom access affects vehicle operator health, service delivery, and costs in public TAs. The project team consisted of a transit work- place health and safety researcher, the director and staff of a transit transportation manage ment and operations firm, a work environment researcher, a transit operations researcher, and a urologist. The project team explored current practices, policies, and limitations at more than a hundred TAs across the United States and Canada. The investigation was conducted in three main phases: • Setting the scene, • Developing the case for good practice, and • Designing effective tools to support good practice. Setting the Scene To set the scene, the project team explored the health research literature for evidence of how restrictions to restroom access might affect transit operators and what health considerations have an impact on restroom needs. The results are presented later in this chapter. The team also searched industry and media sources for information on the impact of transit operators’ rest- room use on operations and safety. Next, the project team interviewed 20 industry experts from North America, Europe, Africa, and Asia with many years’ experience in transit management, route planning and scheduling, county-wide transit planning and management, contracted transit management, regional transit coordination, software development, driving buses and rail vehicles, researching transit operations and health economics, labor concerns, and work- place safety enforcement. Developing the Case for Good Practice To develop the case for good practice, the project team invited TA heads from across the United States and Canada and LU leaders representing four international unions to complete an extensive online survey. Complete survey data were collected from 85 TA respondents and

Transit Operator Restroom Access: Issues and Good Practice 9 29 LU respondents from 100 different TAs in 31 U.S. states and six Canadian provinces. On the basis of the practices described, the project team carried out 21 detailed interviews with personnel in 15 TAs, including management, vehicle operators, and, where possible, the union leaders representing them. The project team drew from data to propose good practices for restroom access that were reviewed by industry stakeholders; these practices included restroom access policy, needs assessment, infrastructure inventory, route and schedule planning applications, service delivery support, and evaluation. Designing Effective Tools to Support Good Practice To design effective tools to support good practice, the project team collected examples of policies and tools used by TAs, described in industry literature, or available on the Internet. The toolbox materials, which are described in the annex at the end of this report, were developed by combining the approaches of multiple TAs with experience spanning decades and often new perspectives as well. Many of the TAs’ tools are presented as good examples in each section of this report, and some were adapted to create the project toolbox. The contents of the toolbox are discussed in the next section of this chapter. At each stage, the project team asked industry subject matter experts to review the work products described below. This was done at industry events, at union meetings, by e-mail exchanges with target groups, and by group and individual phone calls. Report, Tools, and Resources Report This report describes the state of restroom access in the public transit industry and provides suggestions for good practices to address specific TA and vehicle operator concerns. Each chapter covers a significant area identified by the project sources. The associated tools contents are also explained. The graphic at the beginning of each chapter highlights the information to be covered in the chapter in the context of the other organizational, planning, and operational considerations. The remaining sections of the report cover the following material: • Chapter 2 discusses aspects of work organization related to restroom access, needs that may vary by TA size, modes and organizational characteristics, and resources that can be leveraged in different situations. • Chapter 3 defines the infrastructure considerations, including geography, the built environ- ment, transit service interfaces, and capital planning. • Chapter 4 walks through the connections between restroom access and route planning and scheduling. Ideas from a range of TAs are provided about how and when stakeholders can communicate about their needs and interests, and the regulatory requirements for restroom access are reviewed. • Chapter 5 follows up with a review of service delivery impacts and the concrete steps to ensure that restroom access policy and practices support both on-time service and operator health and safety. • Chapter 6 finishes by considering approaches to evaluation and cost assessment. • Annex: Supporting Materials. Part 1 of the annex presents eight case studies of TAs chosen from the survey respondents for follow-up interviews. Part 2 summarizes the contents of the toolbox. Part 3 gathers the lists of good practices suggested throughout the report into a “Compendium of Good Practices.” Toolbox The toolbox consists of spreadsheets for information collection and analysis, policy boilerplate, and written materials that may be freely adapted and used by transit stakeholders. There are

10 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access four tools. Three are Microsoft Excel files that are available on the TRB website (trb.org) on the summary web page for this report: • Transit Operator Restroom Inventory Tools, a set of data-collection tools for inventorying existing restrooms, assessing restroom accessibility and compliance, and calculating distances to restrooms; • Transit Operator Restroom Access Planning Tools, a set of data-tracking tools for identi- fying restroom needs, finding new locations, and planning for working with stakeholder groups; and • Transit Operator Restroom Access Cost Estimation Tools, a set of linked spreadsheets that allows TAs to estimate, track, and evaluate their own costs. The fourth tool, Templates for Restroom Access Policies and Boilerplate Contract Language, is a set of templates for restroom access policies and boilerplate contract language. These templates are provided at the end of this volume as well as in modifiable Microsoft Word format on the summary web page for this report on the TRB website (trb.org). Technical Appendixes The report also includes the following technical appendices: Appendix A: Technical Report on Data Collection and Survey Results, Appendix B: Summary of Health Literature, Appendix C: Summary of the Literature on Restroom Access and Transit Operations, Appendix D: Laws and Regulations About Restroom Access for Transit Vehicle Operators, and Appendix E: Collective Bargaining Agreement Restroom Language. Current Transit Agency Practice, Issues, and Concerns Management typically says that people are the transit agency’s greatest resource, but how is that opera- tionalized? We make a restroom, not even a question in an office. People have the same bodily needs, but it never or seldom becomes a question. Because NOW people have raised hell to get management to recognize that this was not ancillary. Most of what happened is that systems looked at it begrudgingly. Employees and their unions brought it to the table. If we say that people are our greatest resources, that should have been on management’s radar. —Past Chief Executive Officer The industry experts interviewed for this project all reported that restroom access is a problem that is pervasive and not well addressed around the world. This opinion was expressed most strongly by those with the longest transit management experience. They also affirmed that rest- room access is an issue of human dignity and a basic right. In general, the industry experts felt that restroom access is at most rolled in to layover, recovery, or break time considerations during planning and scheduling. They focused on three areas that are most affected by restroom access needs: route planning and scheduling (done manually or with software), operations (service delivery and recovery and break times), and work organization (policies, discipline). Industry experts had not encountered much concern about restroom access as a health issue, with the exception of the labor experts. For union representatives and their members, health was one of the most important aspects. The biggest barrier to improving restroom access was the cost to the TAs, whether measured or guessed at. One industry expert warned that concern about the potential financial impli- cations could be a major block to the adoption of otherwise sensible practices. Given this, a customized approach to applying recommendations and using tools is essential, and insisting on a single best solution would be unrealistic. Clearly, there is no one-size-fits-all approach to improving restroom access.

Transit Operator Restroom Access: Issues and Good Practice 11 As none of the industry experts was able to identify a location where they thought the issue was being handled as well as it should be, they recommended approaches that were derived from their professional experience and insight rather than from observed practice. In par- ticular, they all stated strongly that TAs had to start with a commitment to the dignity and the health of the operators; however, they felt that this was not common. More specifically, the industry experts recommended that, in scheduling, flexible time for restroom access should be systematically integrated instead of relying on scheduled recov- ery times. Existing software and other technology, which have enabled transit schedulers to tighten the control of recovery time, could be better used than they currently are to achieve systematic integration of flexible time for restroom access. On a larger scale, and earlier in the service process, route planning should incorporate restroom availability considerations. This raised the question of how different stakeholders collaborate, and for what purposes. For example, as departments work to control costs and do more with less—both reasonable goals—opportunities to resolve restroom access issues may be reduced. The project team talked with TAs that were, in fact, carrying out many of these recommended planning and scheduling approaches. Despite the industry experts’ sense that TAs were not taking a comprehensive approach, examples of good practices were indeed found throughout the industry. Where these occur, they are often developed with or endorsed by labor represen- tatives and operators. Restroom Access in the Project Sample TA surveys were sent to the chief executive officer or person with an equivalent title, who either completed the survey or sent it to someone on his or her staff to complete. American Public Transport Association (APTA) committee chairs and other transit industry organizations also reached out to their memberships. General managers and chief executive officers completed 26% of the completed surveys, and operations staff members completed 63%, along with a few respondents from other areas, as shown in Figure 1-1. Operations Executive Planning and Scheduling Safety Human Resources Labor Relations Figure 1-1. Survey results: TA respondents’ divisions.

12 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access TAs and LUs cared about restroom access. The survey results in Figure 1-2 show that restroom access was a serious issue or one of the most important at 75% of the respondents’ locations. Restroom access was particularly a problem on specific routes (74%), at specific times (65%) and for specific operators (35%), rather than for all operators. TA practices usually supported bus operators in making unscheduled stops and using rest- rooms before and after runs and at hubs at the great majority of TAs, as shown in Figure 1-3. But practices did not always match policies. Issues were experienced in two main areas: rest- room facilities at regularly scheduled locations were often not adequate or even available, and unscheduled restroom use was limited by schedule pressure and other factors. Overall, transit operators had the most trouble finding restroom facilities at ends of lines that were not associ- ated with a transit property or with a large commercial location such as a mall. Smaller transit hubs and transfer points also posed problems, as did systems where the main transit facilities closed before the end of bus service. Access to restrooms was, overall, better for fixed guideway operators, because their vehicles typically ended in full-service terminals. It was harder to make unscheduled stops. Paratransit operators had more access than other modes at layovers and less when they had passengers in the vehicle. Not at all 2% Not very 7% Medium 16% Serious 46% One of the most important 29% Figure 1-2. Survey results: How important is restroom access at your TA? 0 10 20 30 40 50 60 70 Bus (N=112) Fixed Guideway (N=29) Paratransit (N=81) Along Designated Routes Layovers With Passengers End of Runs At Hubs Unscheduled Stops Before Runs Without Passengers Figure 1-3. Survey results: Percentage of participants reporting that restrooms are never, rarely, or sometimes available, by situation and mode.

Transit Operator Restroom Access: Issues and Good Practice 13 Bus division planners and managers reported providing between 10% and 20% recovery time, although some acknowledged that this time had not yet been provided in all routes. Most respon- dents agreed that time pressure is a consideration for operators and for service delivery. Our agency keeps track of the nearest available restrooms for operators at every layover, and we calcu- late the distance and time involved to reach them. We strive to locate layovers as close as possible to rest- rooms, because fast restroom access helps reduce service delays. We recognize that providing adequate layover time is in the interest of everyone—operators, customers, and the agency—because doing so is essential to ensure strong on-time performance. —Senior Transit Operations Planner LU leaders frequently stated that operations pressures took precedence over vehicle operators’ needs. According to one, “Operators may be questioned why they did not leave on time or why they stopped when already running late. I am not aware of anyone who has been disciplined in regards to restroom break, but it is frowned upon during rush times.” Respondents reported that restrooms were almost always in compliance with sanitation stan- dards (toilet paper, soap, running water for washing hands, towels or dryers, light and heat when needed). However, the location of the restrooms often did not comply with OSHA’s rule that workers must be able to use a restroom within 10 minutes of needing one (see Chapter 2.) The facilities were usually safe; it was more frequent for them not to be clean or sanitary. Privacy was not always guaranteed, in particular when the facilities were shared with the public. Portable toilets are commonly seen as a temporary solution and as part of a broader restroom access plan; about 5% of TAs reported these were their only restrooms. Restroom access is not always limited, and vehicle operators could usually or always get to a restroom within 15 minutes, according to half of the TA respondents in the project sample. Bus operators are a little less likely than rail or paratransit operators to be able to access rest- rooms within 15 minutes of needing one. This was true for all modes, according to both TA and LU respondents. But longer delays were still common, as shown in Figure 1-4. At more than a quarter of all TAs, operators had to wait 15–30 minutes, according to their LU leaders— 7 of 29 in bus, 3 of 6 in rail, and 6 of 20 in paratransit. TA respondents did not report that operators waited for more than 60 minutes to use the restroom, but LUs did. How Did Restroom Access Affect Operator Health in the Project Sample? On the whole, survey respondents felt that limitations to restroom access did not cause or aggravate health issues, as shown in Figure 1-5. However, one-third responded that they simply 0% 10% 20% 30% 40% 50% 60% Bus Rail Paratransit LU 15-30 TA 15-30 LU 30-60 TA 30-60 LU >60 TA >60 Figure 1-4. Survey results: How long (minutes) operators always or usually have to wait for restroom access, by mode and source of information.

14 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access did not know how often these might happen. Restroom limitations interacted with health conditions such as diabetes, pregnancy, or age-related changes. Transit employee union rep- resentatives reported serious concerns about the potential impact of limited restroom access on health. They question whether delaying voiding can lead to urinary tract infections, kidney stones, gastrointestinal problems, and even fertility issues or cancer. However, management hears about health problems as well: We have had operators report that they have had kidney infections and bladder infections and different things along those lines. And then, just purely for the human side of it, knowing that just being in the seat for that long a period of time without having the ability to use a restroom facility . . . and it’s something that we’ve just heard about for years now. —Service Operations Manager Surprisingly, few TAs (5%) reported a formal policy for addressing restroom access accom- modation for health issues such as irritable bowel syndrome, and TAs deferred to their human resources department. At times, accommodation assignments created conflicts with seniority- based pick rules. Some concerns are not health problems as such. A clean restroom with running water and light can be especially pressing for menstruating women, because of the mechanics of changing menstrual products. Pregnancy increases not only urinary urgency, but often resource needs, as one TA reported: “A new issue that has recently come up is providing a room for lactation purposes. There are specific requirements which create accommodation problems, costs, and delays in relieving operator from route.” TA participants and LU participants reported different frequencies of public hygiene events— operators urinating or defecating in places other than restrooms, whether accidently or inten- tionally, as shown in Figure 1-6. In interviews, some TA participants described bus operators urinating outside even when restrooms were made available. At the same time, LU participants reported bus operators soiling seats because they simply could not stop driving. This is certainly the restroom access issue that engenders the most press, video clips, and outrage. Medical qualification issues for transit operators, health care costs, and retention are ongoing concerns for TAs. However, neither TAs nor LUs who responded to the survey or agreed to be interviewed felt that restroom access was implicated in workforce availability or retention. Interview participants felt that operators with health issues might pick differently, if they had enough seniority. –10% 0% 10% 20% 30% 40% 50% 60% Safety Health Stress Operations Never Rarely Sometimes Often Figure 1-5. Survey results: Percentage of participants reporting adverse restroom-related events.

Transit Operator Restroom Access: Issues and Good Practice 15 On the whole, project participants felt that recruitment and retention were so dependent on wages and unemployment overall that this would be a minor issue. [Do you think there’s any chance that restroom access could affect retention or recruitment?] Not so much from a health perspective. What we hear, I think more than anything, are just overall the health of our bus drivers may not be as good as other positions in transit because it’s such a sedentary position where they’re not as active—they’re behind the wheel for long hours. And we know that their insurance premiums are driven by their financial performance. And we know that that seems to be somewhat high for bus drivers just in general. But not specifically related to this issue that I’m aware of. And in terms of retention, I think that what we find more often [is that] the newer drivers have the worst shifts and the worst hours. And it does take a lot to get seniority to be able to pick and choose what you’re able to do every day. —Vice President of Operations How Did Restroom Access Affect Safety and Operations in the Project Sample? The project sample did not report that restroom access typically was a factor in vehicle safety events. Restroom-related operator stress and job dissatisfaction and operations issues were more common. Service delays can result when there are not enough open restrooms for drivers on a turnaround. Restrooms shared with passengers caused transit operators to wait and sometimes led them to forgo using the restroom so as not to delay their bus departure. A common con- cern was not being able to use facilities owned by other transit organizations at transfer points. However, the impact of restroom access needs and problems on operations was not typically evaluated in TA data collection. Access to restrooms is rarely an issue for employees with titles other than “vehicle operator.” Some respondents did describe problems that occur for people who work in the field or alone. The affected job titles included cleaners, fuelers, controllers, dispatchers, field supervisors, on-board evaluators, schedule checkers, station agents, and fare enforcement officers. Even for maintainers, there are places without enough restroom facilities or with facilities that are not kept serviceable. TA Policies on Restroom Access As shown in Figure 1-7, less than half of respondents reported having any written policy on restroom access. The most common policy was the procedure for contacting the control center 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% TA LU Never Rarely Sometimes Often Figure 1-6. Survey results: How often hygiene events occur due to lack of access.

16 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access when an unscheduled break was needed. Forty percent of respondents had a written policy on unscheduled stops, and another 46% addressed it informally. Everyone interviewed stated that these policies allowed operators to use the restroom whenever they needed it and could stop the vehicle safely. In some cases, this issue was covered in the collective bargaining agreement. At the same time, several TA participants said that they encouraged operators to wait until scheduled layover locations and times, especially during rush hours. Some TAs allowed opera- tors to diverge from a route if needed, but others explicitly did not allow this. Virtually all project participants agreed that operators were not to be disciplined for using restrooms or for related delays. Some mentioned that they would investigate situations where operators seemed to be taking advantage of the opportunity. Operators are allowed to make unscheduled stops if needed to access restrooms, but they are required to notify dispatch in these cases. Failure to do so, which sometimes happens, can result in discipline. Unknown whether this is a written or informal policy. Operators can be counseled or disciplined for excessive or unreasonable dwell time, especially after an investigation, but identifying these violations is not systematic. —Senior Planner Restroom access information is being used by more than a third of TAs to set break or layover parameters in runcut or scheduling software. However, routes and schedules are not specifically adjusted for restroom access in almost half the TAs. Written planning policies are not common, as shown in Figure 1-8, although informal practice does allow for break or layover adjustments. 0 10 20 30 40 50 60 70 None Informal Written Call in to dispatchers Unscheduled stops Route deviations Disciplined for breaks Disciplined for delays Figure 1-7. Survey results: Percentage of respondents with policies related to restroom access. 31% 45% 24% 51% 41% 46% 61% 0% 10% 20% 30% 40% 50% 60% Restroom access policy guides planners Restroom data used to set parameters in software Written policy set breaks or layovers Informal practice for break or layover Routes and schedules not specifically adjusted for restroom access Operators contribute to route planning and scheduling decisions Accommodations for operators with needs Figure 1-8. Survey results: How does planning address restroom access?

Transit Operator Restroom Access: Issues and Good Practice 17 Notably, vehicle operators contributed to the planning and scheduling decisions in almost one- half of TAs. Practices diverged from policies at a given TA in two main areas: operators might fail to call in as required, and transit supervisors did not always prioritize operator comfort over service delivery. LU participants described cases in which restroom access and the no-discipline poli- cies were contravened by supervisors who wanted the operator to continue driving. Some TAs deferred to the managing companies, as described here: In terms of discipline, contract operations managers may choose to maintain the same level of disci- pline actions for counseling of operators for causing trip delays when using the restroom. Currently [TA] is working on developing policies that will provide relief at terminals to allow operators ample time to use the restroom at metrorail stations and transit centers. —Service Development Planner How Did Transit Agencies Address Cost? TAs are willing to pay for restroom access. Many of the agencies clearly spend a significant amount in staff time to address restroom issues. One TA stated that its restroom-related capi- tal budget was $500,000 a year. Another reported a per capita payment to businesses allowing operators to use their restrooms. The overall position taken by TA participants is that, while restroom considerations should be addressed in planning (route and capital), scheduling, and operations, the impact and costs are often not assessed separately from contractual or mandated breaks, schedule recovery time, and capital planning. However, some TAs identified cost areas they pay attention to, including • Delays related to unscheduled use; • Cost related to adapting schedules, including increased layover time; • Capital costs for building restroom facilities; • Contracts with businesses; and • Health impact (costs encountered by LU benefits fund). Restroom Access and Health: Literature Summary In contrast to the industry experts, transit vehicle operators, along with their labor organi- zations, have shown significant and consistent concerns about the health impact of access to restrooms. Transit vehicle operators have long felt that limited restroom access has a negative effect on their recognized health problems and on workplace safety. The transit industry is aware that employees generally, and bus operators in particular, have higher rates of diabetes, high blood pressure, cardiovascular disease, and gastrointestinal problems. This also included health concerns that make restroom access more important or pressing, including commercial driver’s license issues such as hypertension and diabetes and groups with increased restroom needs, such as pregnant women and aging workers. Figure 1-9 and the rest of this section summarize those findings, which are addressed in greater detail in Appendix B. Medical information and common experience suggest that restricted restroom access at work could affect health. The available literature supports the idea that UTIs, constipation, fertility problems, and stress-related illnesses such as hypertension, among others, could all be caused or made worse by restricted restroom access. There is also no consensus about how often a person must be allowed to use the restroom to avoid health problems. Some research suggests that the average person uses the restroom about five to eight times a day, but the intervals vary among individuals (Fitzgerald et al. 2002). The industry experts and physicians contributing to the project concurred that a specific time

18 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access limit cannot be established. While this is clearly an important question for TAs and for vehicle operators, the individual’s needs are the determining factor. OSHA defines “reasonable access” as less than 10 minutes from needing it, but explains: Individuals vary significantly in the frequency with which they need to urinate and defecate, with preg- nant women, women with stress incontinence, and men with prostatic hypertrophy needing to urinate more frequently. Increased frequency of voiding may also be caused by various medications, by environ- mental factors such as cold, and by high fluid intake, which may be necessary for individuals working in a hot environment. Diet, medication use, and medical condition are among the factors that can affect the frequency of defecation. Medical studies show the importance of regular urination, with women generally needing to void more frequently than men. Adverse health effects that may result from voluntary urinary retention include increased frequency of urinary tract infections (UTIs), which can lead to more serious infections and, in rare situations, renal damage. (OSHA 1998) Literature Related to Potential Health Impact of Restroom Access at Work This section summarizes the potential impact of restricted restroom access on the health and safety of transit employees and describes the body systems involved. The health research litera- ture that constitutes the basis of this summary is discussed in detail in Appendix B, “Summary of Health Literature.” Cardiovascular System Hypertension, cardiovascular disease (CVD), and stroke occur at higher rates in bus operators and other transit workers than in the workforce at large. This is attributed in part What increases urination needs? • Drinking • Eating • Pregnancy • Age • Illness • Job stress • Colder temperatures • Whole body vibration What are the job stress & strain concerns? • Harassment • Anxiety • Scheduling issues • Vigilance • Increased runtime • Lost productivity • Dignity • Humiliation • Distraction • Long working hours What results are possible? • Urological problems • UTIs • Kidney stones • Gastrointestinal problems • Constipation, impaction • Cognitive impairment • Reduced attention, awareness • Motor vehicle accidents • Cardiovascular disease • Hypertension • Atherosclerosis • Heart attack • Stroke • Reproductive health • Male fertility • Low birth weight • Cancer • Bladder • Colorectal • Toxic shock syndrome • Multiple organs affected Many likely mediated by dehydration Restricted restroom access can affect operator health • Urological • Central nervous system • Gastrointestinal • Cardiovascular • Reproductive • Multi-organ involvement What is the public health impact? • Passenger safety • Reduced hand washing • Use of containers • Voiding in vehicles or public areas Image developed by D. Wigmore Figure 1-9. Connections between restroom access and operator health and safety.

Transit Operator Restroom Access: Issues and Good Practice 19 to the physical hazards of the job, which include traffic congestion, safety hazards, noise, and ergonomic problems. Limited restroom access can lead to feelings of distress and sometimes to risky behaviors, such as speeding. Transit bus operators have described experiencing significant stress related to lack of restroom access, with feelings of anxiety about where they can go, hyper- vigilance because of the distraction, and even shame. Stress is known to increase CVD. It can take an uncommon form in the face of limited restroom access: diuretic medications are commonly prescribed to control hypertension. Taking a diuretic during the workday can be especially challenging for operators, and some have reported adjusting or eliminating doses when they know they will not be able to access a restroom when needed. Gastrointestinal System Constipation may result from ignoring the urge to have a bowel movement, and people who get less than about 2 quarts of water per day from eating and drinking are more likely to be constipated. Chronic constipation can lead to impaction and severe health outcomes. Physical activity, including standing, promotes colon movement. Colorectal cancer is the third most common cancer diagnosed in the United States. Low water intake might contribute, as low fluid content of feces could cause constipation. Animal studies have shown that reduced fecal output may be linked to a higher incidence of colorectal tumors. There is some evidence that rectal cancer could be increased following sustained exposure to high diesel emissions. Decreased fluid consumption could play a role by increasing colorectal tissue contact time with carcinogenic substances in diesel exhaust fumes. Urinary Tract Work environments are required to provide adequate access, cleanliness and safety for toilet facilities; lack thereof can cause decreases in liquid intake or infrequent voiding by workers that can lead to compro- mised bladder function or urinary tract infection. (Lukacz et al. 2011) Bladder problems include incontinence and restricted voiding. Working long hours without restroom access can restrain the desire to void for extended times, leading to the over-distension of the bladder muscle and damage to bladder sensation and muscular function. Drivers with diabetes may develop diabetic bladder dysfunction, which can lead to urinary urgency, especially when there is reduced access to clean and safe restrooms. A demanding work schedule, combined with restricted restroom access, is related to infrequent voiding among drivers. Urinary incontinence is a problem when paired with the lack of access to adequate rest- room facilities. It is a bigger problem for women: Urinary incontinence was reported by 45% of U.S. women in a large survey A recent Korean study exploring urinary incontinence in women in relationship to occupation found that urinary incontinence was associated with having an unclean and uncomfortable workplace and feeling pressed for time. Urinary tract infections are an issue of significant concern among female transit vehicle operators, who feel that their work contributes to the development of infections. A Dan- ish study found that women who voided three times or less per day had more UTIs than women who voided four or more times per day. Female teachers who voluntarily restricted fluids by drinking less because they could not leave their classrooms had more than twice the risk of UTIs than women with adequate hydration. Other studies confirm that access as needed to a restroom is important in preventing UTIs for women. Kidney stones may be caused or aggravated by not drinking enough water. Among profes- sional drivers, dehydration can be intentional, as drivers may restrict fluid intake in an effort to reduce the need to urinate. Lack of restroom access or the pressure to provide on-time transit service can interfere with drivers’ hydration at work. Increased daily fluid intake could decrease the risk of kidney stone formation and, especially, recurrence.

20 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Bladder cancer could be related to transit work. Transit work may be a risk factor for bladder cancer, even after smoking, gender, and age are taken into consideration. The studies do not strongly connect the two. One mechanism could be exposure to diesel exhaust. Another study found that more daily fluid intake was related to a lower risk of bladder cancer. Reproductive System Prostate symptoms were more frequent and severe in a group of taxi drivers than in a group of office workers and a group of barbers who stand and are assumed to use restrooms when they want to. Transit operators, like taxi drivers, have limited access to restrooms and may be at risk of related health problems. Pregnancy and birth outcomes are a frequent concern among female transit operators, who raise concerns about the effects of restricted restrooms during pregnancy. These concerns, which include pregnant women’s need to use restrooms more frequently and pregnancy risks such as miscarriage and premature labor, have not been evaluated in any published studies. However, urinary frequency and urgency are commonly reported by pregnant women. Pregnant women also have up to four times the risk of developing UTIs, and UTIs are implicated in premature labor and other adverse outcomes. Male infertility might be affected by occupational exposures. Driving vehicles, sedentary employment, and habitual sitting are thought to contribute to chronic prostatitis. Other research indicates that industrial drivers have higher rates of prostatitis, urinary complaints, perineal pain, and the enlargement and congestion of the urological and reproductive systems. The produc- tion of abnormal sperm and lowered fertility were more common among occupational drivers than other patients being treated for male health issues in one study. Impaired fertility might be associated with prolonged occupational sitting and related increases in scrotum temperature. Toxic Shock Syndrome Toxic shock syndrome (TSS) is an acute-onset illness associated with fever, rash, and hypo- tension, which can lead to systemwide organ failure. Menstrual-associated TSS is found in otherwise healthy young women who use high-absorbency tampons. Although TSS is extremely rare, the risk could be increased if limited restroom access discourages women from changing their tampons often enough. Fluid Intake Many of the possible effects that are of concern to vehicle operators might be the result of not drinking enough water. In this project, some transit vehicle operators reported that they did not drink much because they knew they would not be able to stop and use a restroom. Dehydration can occur when it is hot, in the context of physical activity and insufficient replacement of water loss. In a laboratory study, healthy young women who were dehydrated by exercise or exercise plus a diuretic had increased fatigue and anger as compared with those who were not dehydrated; they also experienced increases in task difficulty, difficulty concentrating, and headache. Men in a related study also demonstrated increased fatigue and tension/anxiety as well as changes in visual vigilance and working memory. Does adequate hydration prevent problems such as UTIs? Although many conditions have been studied, only kidney stones have consistently been associated with chronic low daily water intake in a range of studies up to 2011. However, a more recent, carefully designed study found that women with cystitis who increased their water intake above 1.5 liters per day had fewer episodes at 1 year than women who did not. There is also evidence that not drinking enough is associated with the release of a hormone that can contribute to hypertension, diabetes, and a variety of other disorders.

Transit Operator Restroom Access: Issues and Good Practice 21 Public Health Impact How often transit operators relieve themselves in public areas, use containers, or even soil the seat as they work is not known. These events do receive extensive attention in news and informal report sources. Many news articles refer to health concerns of transit workers, such as long bathroom waiting periods that may last up to 5 hours, pregnancy and menstruation risks, UTIs, and digestive diseases. They underscore the enormous stress experienced by transit operators who cannot reach a restroom in the time available, or feel they cannot take the time to do so. The related public health impacts affect not only operators but also transit vehicle cleaners, sanitation workers and the public, who are all potentially exposed to human waste. In some instances, limited access to restroom facilities has resulted in critical injuries and death. In 2004, Diane Boothe, a transit bus driver in the Portland area, was fatally run over by her bus as she rushed to a terminal restroom. Eleven years later, Laquito Alvin of Miami–Dade County died while trying to stop her bus, which she had apparently left running because she had “just a few minutes to go to the bathroom before starting the circuit all over again.” Mechanical problems with the rear door had delayed her getting off, and the system designed to set off an alarm in this situation was not functioning. Recently, a New York City bus driver was hospitalized when trying to stop his bus from rolling into a Queens cemetery after he had left it to use a restroom. An additional stress for transit operators—one that can lead employers to crack down on inappropriate behavior—are the thousands of videos and images posted to YouTube and Insta gram showing bus drivers who have to relieve themselves at inconvenient times or inappro- priate places, or the signs of their doing so, such as containers filled with urine. Some of the coverage is empathetic to the plight of transit workers, but most of the posts function to shame the drivers. Video footage or photographic evidence depicting transit operators peeing on the job not only perpetuates what a LU leader refers to as “an invasion of privacy,” but it can also jeopardize transit employees’ employment. Health Issues and Changes That May Affect Restroom Access and Related Risk In addition to the direct impact of restricted restroom access on the health of transit opera- tors, there are many health issues and individual concerns that affect how often operators will need to use a restroom and how urgently. These include demographics such as age and gender; chronic conditions such as cardiovascular disease, diabetes, and irritable bowel syndrome; and temporary conditions such as pregnancy, diarrhea caused by medication or stress, or even brief gastrointestinal illness that come on during work. Some examples: • An aging workforce is likely to need more frequent restroom access. Incontinence increases over time for women and men. Although the common belief is that women urinate more than men, this seems to be truer in their thirties, when women’s frequency is highest and men’s is lowest. Men and women get closer in frequency over time. • In surveys, focus groups, and informally, drivers report taking prescribed diuretics only when being tested for hypertension, or only off-shift, so they will not be caught out on the road. Both these decisions can cause problems, in the form of under-controlled hypertension or excessive fatigue from waking to urinate more frequently. • Uncontrolled diabetes can lead to increased voiding. Transit operators are required to establish adequate control in order to work, so this should not be a problem for them. However, over time, even controlled diabetes can lead to nerve damage that affects urinary urgency, both increasing bladder reactivity and limiting the bladder sensation of fullness. Some diabetics will also want access to a clean and private location to test blood sugar at times that may not correspond to their scheduled breaks.

22 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access • Pregnancy, not a health problem in itself, frequently increases the urge to urinate and makes adequate hydration with frequent voiding even more important, as discussed earlier in this review. • Menstruating women may also require unscheduled restroom access. Health Literature Summary The patterns of evidence spanning more than 50 years suggest that restricted restroom access can negatively affect the physical and cognitive health of transit vehicle operators. This could have an impact on performance and productivity. The technical literature review in Appendix B outlines some potential biological mechanisms and causal pathways between restricted rest- room access and health effects, but none of these have been studied in the specific context of transit operators’ work. In research pertaining to taxi drivers, the impact of extended seated work is not clearly separated from the impact of restricted restroom access and hydration. Some of the original literature is dated and many studies were not well designed or carried out. In some cases, the research shows a statistical link but does not explain why this would occur. The health model in Figure 1-9 suggests potential links between restricted restroom access and health effects. The evidence is probably strongest for urinary tract infections, stress, and distractions. The model does not establish direct cause–effect relationships or show the extent to which the health of transit vehicle operators might be affected. Some simple approaches to collecting information on the health impact are discussed in Chapter 6. Operator and Vehicle Safety: Literature Summary One, the driver has to stop the bus and park it out in the street. Let’s say they’re mid route: The bus is left unattended. There are usually people on the bus. They risk the theft of the bus or the fare boxes. It allows the bus to be susceptible to an accident, somebody driving into the rear end, and that happens a lot. Rear-end collisions with buses [are] probably one of the highest-ranking accidents the buses have. —Service Scheduler Safety concerns about accidents for drivers were not a priority in the project sample. Only 10% of the surveys reported that restroom-related safety problems had occurred. In interviews, respondents did discuss the safety of operators when using portable toilets, including risk of assaults and icy access paths; safely parking buses for unscheduled restroom stops; and distraction related to driving when under pressure to use the restroom. Reduced focus on driving can increase the likelihood of an accident. Delaying urinating following fluid consumption led to a decline in attention and working memory in a laboratory study of healthy young volunteers. The effect, likely due to distraction and discomfort, was as strong as 24 hours with no sleep or a blood alcohol level of 0.05% (Lewis et al. 2011). Restroom Access and Transit Operations: Literature Summary Transportation research has long referred to the impact of restroom access on retention and on operations demands. As early as 1999, TCRP Synthesis of Transit Practice 33: Practices in Assuring Employee Availability noted restroom access as a cause of operator absenteeism related to schedule pressures, substandard facilities, and management communication and support (Volinski 1999, pp. 10–12). TCRP Report 77: Managing Transit’s Workforce in the New Millen­ nium described the Utah Transit Authority’s Bus Operator Restroom Task Team (McGlothlin Davis, Inc., and Corporate Strategies, Inc. 2002, p. 34). TCRP Report 81: Toolbox for Transit Operator Fatigue mentions restrooms in the context of rest breaks that can counter the effects of fatigue (Gertler et al. 2002, p. 118).

Transit Operator Restroom Access: Issues and Good Practice 23 These sources and many others in the intervening years provide suggestions for reducing the financial impact of unscheduled breaks while, at the same time, acknowledging contradictions that may be involved in providing timely and efficient service that is also safe and responsive to health needs. More importantly, the TAs and other sources participating in this project described concrete practical approaches to those contradictions. A detailed summary of the literature on operational issues surrounding restroom access is included as Appendix C. It is based on a review of transit-funded technical reports from govern- ment, nongovernment, and industry organizations; journal articles; newspaper and magazine articles; and labor and trade industry web-based documents. Four main areas of action were highlighted in the literature for the operations areas related to operator restroom access: infra- structure and capital planning, route planning, scheduling, and service delivery, as laid out with examples in Figure 1-10. This section addresses some of the literature covering each domain. Following the data collection period, the domains were expanded to address organizational structure and evaluation of impact and costs, as reflected in the following chapters. Summary of the Literature on Infrastructure The three important factors that affect on-time service delivery—restroom location, rest- room type, and travel time—are largely determined by the available infrastructure (Boyle et al. 2009). Infrastructure encompasses restroom resources on TA property, in business, and in the public sector. The built environment—existing business, residential zoning, bridges, tunnels, highways—plays a role in what is available. Finally, the local geography (e.g., hills, rivers, flood zones) may have an impact. Infrastructure development can be coordinated with transit capital planning, or linked to transit-oriented development. • Geography and built environment Business, residential Bridges, tunnels, highways Hills, rivers • Restroom resources: transit facility, commercial sector, public sector • Capital planning: coordinated with transit planning, linked to transit-oriented development ROUTE PLANNING • Match routes to existing restroom facilities • Link planning to restroom availability: new routes as demand changes or as facilities change • Explore connections with restrooms: park-and-ride, transit hubs • Explore potential for temporary or shared facilities SCHEDUL- ING • Schedule flexibility and tolerances Adding time to schedule for unplanned restroom access Dwell time Adjusting for adequate regular breaks • Restroom locations: distance to stopping points • Timed transfer locations are a pressure point for operators SERVICE DELIVERY • Service demand, traffic impact on recovery time available • Delays from unscheduled breaks • Operator availability • Relief staff availability and locations • Passenger satisfaction, complaints • Variable operator needs • Operations controls actions to maintain scheduled service • Use of intelligent transportation systems data to identify and correct problems INFRA- STRUCTURE Figure 1-10. Restroom impact areas.

24 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Understanding the overall impact on operations and making smart decisions that support service reliability and operator health and comfort require an assessment of the available resources. Where are the restrooms? What shape are they in? Where are facilities being planned, or where might they be added to development? Where are changing demographics or other factors going to have an impact, and when? On the basis of that evaluation, development steps may include renovating facilities owned by the TA, building new facilities, coordinating with community partners, and upgrading portable restrooms. Several TAs have addressed restroom access in the context of infrastructure in a broad and systematic manner and provided online reports covering their activities. For example, the San Francisco Municipal Transportation Agency (SFMTA) implemented a planning project to increase restroom access for SFMTA operators (Rodriguez 2016). In response to its investigation showing 59 problems pertaining to restroom availability, with some routes requiring driving 85 minutes, SFMTA created a three-phase planning process that included adjusting routes, constructing prefabricated restrooms throughout the city in locations close to areas with problems with restroom access, and the subsidiary use of businesses’ leases or public restrooms. In 2018, the Washington Metropolitan Area Transit Authority (WMATA) assessed restroom access and restroom conditions across its system and defined the benefits and drawbacks of types of restrooms (WMATA 2017, 2018). These approaches and findings are discussed in Chapter 3. Summary of the Literature on Planning and Scheduling Little formal information that addresses route planning in relation to restroom access is available. Rather, the literature more generally mentions the health benefits of having scheduled breaks or the use of extra-board drivers to ensure continuous service while allowing breaks. TCRP Report 135 stresses the impact of scheduled breaks in the context of system costs, scheduling, and labor agreements (Boyle et al. 2009). More effective routes may be established if planners drive and understand the routes before finalizing them. Knowledge of the available facilities is a necessary precursor. Scheduling efficient routes, a perennial transit challenge, is compounded by the unscheduled restroom access that is required for the health and comfort of vehicle operators. Sched- ules have tightened with the use of scheduling software and vehicle location data, leaving less flexibility for unplanned restroom access. Even with dedicated dwell or layover time, buses or trains are often late for reasons beyond the operator’s control. As driving conditions change (e.g., reductions in urban speed limits) operators may be expected to maintain the same schedule and running times until schedules catch up (Volinski 1999). Average recovery or layover times reported in the literature are typically about 10% of running time. However, one study described how planned layovers did not provide access: operators reported that in some places, there were no restroom facilities; in other situations, restrooms were too far away for the operator to travel there and back and leave on time. Predict- ably, operators who had to stop the bus in the middle of a route to use the restroom suffered passenger criticisms and complaints (Volinski 1999). The important roles of schedulers in supporting the health and comfort of operators are described in scheduler training manuals (Lehman Center for Transportation Research 2015; Danaher et al. 2019; Pine et al. 1998). These manuals explain ways to think about fitting rest time into schedules without wasting unneeded minutes, for example (Boyle et al. 2009): • Understanding where the balance of dwell and layover times is affected by the time of day, • Factoring in the time requirement associated with vehicle positioning at relief locations and transfer centers, and

Transit Operator Restroom Access: Issues and Good Practice 25 • Using measured times rather than average times, as average times may overestimate the time required for some runs, which results in inefficiency, or underestimate it, which cuts down on scheduled recovery periods that operators need. Summary of the Literature on Service Delivery There were no simple solutions in the literature to the problem of the unscheduled breaks that have the biggest impact on service delivery. Service reliability depends on having enough time to make the scheduled runs, enough vehicles to send out, and enough operators to drive them. It is affected by the time of day, traffic conditions, weather, changing passenger load, and individual driver needs. A schedule that avoids excessive or insufficient running times can also reduce safety risks. Excessive running times are a cost sink, while with insufficient running times, on-time performance deteriorates. This may increase scheduling pressures among operators and promote risky behaviors, such as increased operating speeds (Diab et al. 2015). Technology can also affect TA service delivery and reliability. In a study on automatic vehicle location data provided to transit operators, drivers improved real-time reliability by speeding up or slowing down, within reason, to arrive at the next stop at the right time or adjusted their dwell time (Ji et al. 2014). The timing information helps when the timing issue is resolvable. The operators in this study were either neutral or positive about using transmitted data in this way; however, Dutch bus drivers reported feeling increased pressure not to use a restroom as needed when they knew exactly how late they were (Paas and Hanley 2019). Factors that may be caused or aggravated by restroom access problems can affect availability. For example, in one study, on-time performance was related to attendance, with operators who were consistently late in departures from given time points more likely than others to have unplanned absences. Other stress or delay factors that affect the likelihood of absence are higher volumes of passenger movements and lift operations and customer complaints about the timeliness or availability of service (Strathman et al. 2009). As discussed in the previous section, health conditions that are not accommodated could also affect attendance. Whether concerns about restroom access push potential recruits away or force some vehicle operators to leave the industry has not been established. The TA project participants did not feel that this was the case, because they provided accommodations. Some of the LU participants agreed, whereas others felt that restroom access combined with other workplace stressors made the job less attractive or tenable. The use of exit interviews could help provide answers to this question. Focused questions for new recruits about their concerns, as a sort of “entry interview” could also make a difference in retention (Cronin et al. 2013). Good Practices: Providing Adequate and Timely Restroom Access Numerous examples of TA restroom access practices provided by project participants illustrate each chapter of this report. These and the extensive discussions held with TA and LU representatives and other industry experts were mined to develop the set of suggested good practices summarized in Box 1-1. Detailed steps and options for these good practices are discussed in the following chapters and listed in full in Part 3 of the annex of supporting materials at the end of the report.

26 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Box 1-1. Suggestions for Good Practice Organizational policies and practices: • Acknowledge and involve stakeholders. • Encourage operators to use restrooms as needed. • Manage and fund staff resources. • Assess restroom-related needs and issues. Infrastructure policies and practices: • Assess restroom resources. • Install or renovate facilities where needed. Planning and scheduling policies and practices: • Planning and scheduling policies support restroom access. • Route planners and schedulers communicate with other stakeholders. • Route and schedule decisions make good use of software and data. Service delivery policies and practices: • Rules for restroom access reduce service impact. • Adequate restroom access is available along routes and at layovers. • Restroom quality is maintained. Evaluation and costs policies and practices: • Establish continuous evaluation and improvement, including stakeholder review of conditions. • Assess and contain costs.