Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation (2020) / Chapter Skim
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16 Literature Review and Background Research In the development of the literature review and in the construction of the research report, the research team considered certain questions and sought to obtain answers: • What are the characteristics and elements that should be included in an effective nonpunitive ESR system? • Which public transit agencies currently have nonpunitive ESR systems?
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Literature Review and Background Research 17 Significant research addressing the benefits of ESR systems across the transportation industry has been performed, including on the Federal Aviation Administration's (FAA's) well-defined and long-standing Aviation Safety Reporting System (ASRS)
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18 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • A learning culture that uses the results of informed decision-making to improve policies or procedures and details all necessary changes through employee training, and • A just culture in which employees are not punished for unintentional errors but are held accountable for deliberate or reckless actions.25 In TRACS Report 16-01, Building Toward a Strong Safety Culture Within the Bus and Rail Transit Industry,26 the working group members recognized that formal data collection systems and nonpunitive ESR systems are necessary elements of a strong safety culture within a transit agency. They stressed that nonpunitive employee reporting does not mean all behavior is acceptable as long as it is reported and added that rules must be followed.
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Literature Review and Background Research 19 convened the Committee on Offshore Oil and Gas Industry Safety Culture and commissioned the study "Strengthening the Safety Culture of the Offshore Oil and Gas Industry." The study examined the history of the industry and described the historical culture as one of "production over safety." It reflected on a theme found in many industries -- that there are significant inconsistencies in data collection and the reporting of accidents and injuries. Following several disasters and the institution of regulations and practices, improvements were reported in the industry, but with incomplete historical data, improvements were difficult to quantify or confirm.
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20 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Hazard identification and risk management, • Safe work processes, and • Continuous improvement. In 2013, BSEE also entered into an interagency agreement with the Bureau of Transportation Statistics (BTS)
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Literature Review and Background Research 21 In TCRP Report 149: Improving Safety-Related Rules Compliance in the Public Transportation Industry, the authors developed a best practices checklist that transit agencies could use in designing and implementing an ESR system.42 Best practices were established within four categories: • Ensuring stakeholder participation and buy-in, • Establishing processes and protocols for piloting the ESR system, • Disseminating the results to the industry and providing the assistance necessary to ensure its success, and • Disseminating the information obtained through the ESR system. Roles of Stakeholders Key stakeholders in a nonpunitive ESR system may include: • The labor union; • Organizational management; • An independent third party, as further described in subsequent sections; • State or Federal oversight agencies (where applicable)
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22 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Funding for supporting the system and mitigation strategies • Responsible officials Stakeholders may also provide process oversight and monitoring functions to the ESR system. Oversight can include monitoring to ensure that report analyses are conducted effectively and accurately and that all reports remain nonpunitive (unless the safety issue is determined to be the result of intentional noncompliance)
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Literature Review and Background Research 23 Dekker further explains that while it is easy to instruct employees to report everything, the question of how data should be reported still remains. An event or situation that one employee does not see as a hazard potentially could be related to or cause a hazard, leading to a much larger problem in the future.
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24 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation In summary, transit agency policies and procedures should prescribe and define the data elements that should be collected in support of agency-established performance measures. The examples above include common metrics.
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Literature Review and Background Research 25 others should seek to determine whether the event was related to "missteps," employee error, or misleading or ineffective guidance.73 Analyzing Data Action on any report submitted requires the data to be reviewed. Hanssen et al.
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26 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation 59 Gulf of Mexico production operators, representing 35% of active wells and 40% of total oil production in the Gulf of Mexico.83 As summarized in the 2017 annual report, while the majority of these failures were attributed to internal leakages (88%) , which pose less risk, the thoroughness of the reporting provided by the nine operational units reflects conformance with the required reporting and, more importantly, demonstrates the industry's heightened focus on prevention.
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Literature Review and Background Research 27 and observable. A rubric would include standards for reporting and process statements with the goal of ensuring fairness to the reporter.
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28 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Bureau of Safety and Environmental Enforcement As noted, BSEE established SafeOCS as a voluntary program for confidential reporting of near misses in the offshore oil and gas industry occurring on the Outer Continental Shelf (OCS)
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Literature Review and Background Research 29 they found that low reporting rates do not necessarily indicate poor implementation. Areas identified for improvement include communication, analysis, efficiency, and the method and process to track corrective actions.93 Federal Transit Administration The PTASP regulation at 49 C.F.R.
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30 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation An MOU between FAA and NATCA identifies the reporting standards. As with the ASRS, employees may submit reports to the ATSAP website, and program analysts review each submittal and remove any identifiable information.
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Literature Review and Background Research 31 a work environment that discourages workers from raising safety concerns, and other matters related to NRC-regulated activities.99 Reports may be submitted by e-mail to allegation@nrc.gov or on NRC's Safety Hotline at 1-800-695-7403. NRC's Allegation Program protects the identity of reporters.
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32 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation the criteria for what does not meet the reporting criteria.103 Confidentiality should also be a policy with all reporting and "sufficient care should be taken to establish the proper legal basis for the maximum protection of the pilot system's confidential data." Once confidentiality is breached, the trust employees have in the ESR system will be forever lost.104 To ensure confidentiality, it is good practice to employ an impartial third-party reviewer to receive, process, and investigate reports.105 Policies and procedures should address, at a minimum, the following: • Methods for reporting; • Step-by-step process from original receipt of the report through the development and implementation of corrective measures; • Time lines for each process step; • Membership and roles of committees, peer review teams, and investigators involved in the program; • Participation of the collective bargaining unit (CBU) in the process; • Investigation process that demonstrates the involvement of multiple players from across the agency; • Feedback to reporters, from initial receipt of the report through the process and once the hazard has been corrected -- both for those who included contact information and for anonymous reporters; • A written agreement, which could be included as part of the collective bargaining agreement (CBA)
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Literature Review and Background Research 33 Performance Measures TRACS Working Group 16-02, in its report Safety Data and Performance Measures in Transit, established a list of eight characteristics of good safety performance measures.108 Safety performance measures should be 1. Quantifiable; 2.
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34 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • ASRS Directline -- journal published periodically to meet the needs of operators and flight crews of complex aircraft; articles cover topics reported through the ASRS that analysts have categorized as significant; and • Research studies -- focus reports that cover safety topics of interest in cooperation with aviation organizations. Seminal to establishing and tracking performance measures and proactively responding to areas of risk is the collection and maintenance of a granular, robust data set, as discussed previously.
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Literature Review and Background Research 35 Summary As established through the literature review, there are many characteristics that should be taken into account and considerations that should be made in the design, implementation, and management of an ESR system. Stakeholders should be a part of the development and implementation of an ESR system and should trust that the ESR system, as designed, protects their anonymity (when necessary)
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36 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation As summarized in the 2017 annual report, the majority of these failures were attributed to internal leakages (88%)
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