Improving Safety-Related Rules Compliance in the Public Transportation Industry (2011)

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To address safety-related rule noncompliance by transit operators, the American Public Transportation Association (APTA) adopted a voluntary standard for compliance testing in light and heavy rail transit systems. While this standard is an important step toward achieving safe operating practices in the public transportation industry, more remains to be done. Recent incidents resulting from violations of safety-related rules have called into question the safety of public transportation. Most notable was the September 2008 commuter rail crash in Chatsworth, California, that killed 25 and injured 135 others. The National Transportation Safety Board (NTSB) concluded that “the probable cause . . . was the failure of the Metrolink engineer to observe and appropriately respond to the red signal . . . because he was engaged in prohibited use of a wireless device . . . that distracted him from his duties.” (NTSB 2010). Texting has also been implicated in a subsequent collision on the Massachusetts Bay Transportation Authority (MBTA) Green Line in May 2009. Most recently, NTSB’s report on the June 2009 collision of two Washington Metropolitan Area Transit Authority (WMATA) trains recommended that the Federal Transit Administration (FTA) facilitate the development of a nonpunitive safety report- ing system at all public transit agencies. The purpose of such a system would be to collect reports from all employees regarding near-misses and unsafe conditions. Under TCRP Project A-34, this project had the objective to develop a resource for improving safety-related rule compli- ance in the public transportation industry because of the potentially serious consequences of safety-related rule noncompliance. Intended Report Usage The information, methods, and techniques in this report are designed to be administered by the public transit professional who plays a role in a transit agency’s rules compliance program. This might be the safety director, rules program officials, training director, or supervisors involved in daily oversight of transit operations and maintenance. Not all tools and strategies will work at a particular transit agency because of cultural and operational differences. With few exceptions, the practices described in Chapter 4 are applicable to all public transit modes and are scalable to the size of the transit agency. Transit agencies should view the practices as ideas for consideration when looking for ways to improve an existing rules compliance program or when designing a program for a new operation. Safety-related rules apply to employees involved in the operation and maintenance of the tran- sit system. This includes vehicle operators, dispatchers, and other operations personnel, as well as those who maintain the vehicles and track infrastructure. The scope of this report is primarily on safety-related rules that are designed to prevent high consequence events, especially those where the public is affected or where there may be harm to transit agency employees. 1 C H A P T E R 1 Introduction

Development of TCRP Report 149 The research began with a comprehensive review of safety-related and organizational research that identified proven approaches for improving rules compliance in public transportation and other safety-critical industries. A review of accident reports prepared by NTSB and two state agen- cies identified the errors or rule violations that caused or contributed to public transit accidents. Structured interviews with safety officials in the public transportation industry as well as the rail- road, aviation, trucking, motorcoach, and petrochemical industries were used to gather informa- tion on rule compliance best practices in each industry. The interviews covered approaches for preventing and managing noncompliance stemming from both errors and violations. Using criteria relevant to public transportation, the research team selected best practices for improving safety-related rule compliance. The applicability of each of the best practices to tran- sit agencies of different sizes and different transit modes was assessed. Separately, existing safety reporting systems for aviation, railroading, and firefighting as well as two systems in the public transportation industry were investigated. The focus of this investiga- tion was on understanding how the system was developed, stakeholder concerns during system design, key features and provisions of each, and experiences to date. Best practices for a prototype safety reporting system for public transportation drew on the experiences of the other systems. All these elements—literature review, accident report review, selected best practices, design of a public transportation safety reporting system—plus feedback from the TCRP Project A-34 panel formed the basis for the content of this report. How to Use TCRP Report 149 Achieving safety-related rule compliance requires more than monitoring and responding to noncompliance when it occurs. It requires preventive actions designed to encourage compliant behavior. It begins with the prospective employee screening and hiring process. By hiring employ- ees who are not likely to engage in risky behavior, noncompliance with safety-related rules is less likely to occur. Once hired, the training program must teach proper application of the rules as well as their purpose. The training program must also provide ample opportunity for the employee to practice application of the rules while receiving coaching and positive feedback. Once on the job, effective communication methods will reinforce compliant behavior and provide the means to communicate changes in the rules. Ideally, every public transit agency has a safety management system or a mechanism for employees to report safety risks and concerns without risk of punitive consequences. TCRP Report 149 suggests best practices for all the elements of a comprehensive approach to safety-related rules compliance. The categories of best practices, which correspond to the elements of a safety-related rules compliance program, are the following: • Screening and Selecting Employees • Training and Testing • Communication • Monitoring Rules Compliance • Responding to Noncompliance • Safety Management Recommended Steps The following is the recommended approach for most effectively using this report: 1. First, develop an understanding of the various factors that can lead to rule noncompliance by reading Chapter 2. This is a prerequisite to developing a new safety-related rules compliance pro- 2 Improving Safety-Related Rules Compliance in the Public Transportation Industry

gram as well as improving an existing one. Chapter 2 explains the nature of rule noncompliance and the reasons it occurs. Without understanding the underlying reason(s) for the noncompli- ance, efforts to correct it and prevent future occurrences may be ineffective. Chapter 2 also provides background information and research on issues related to encouraging compliance. 2. Next, read Chapter 3 which lays out a structure for classifying noncompliance. The non- compliance structure defined here provides a methodology for examining an instance of rule noncompliance to determine its root or underlying cause(s). 3. Review the checklist in Table 1. This checklist uses the six program elements listed above. For each “yes” item, read the description of the related best practice(s) to see if improvements in Introduction 3 Checklist Questions Practices Screening and Selecting Employees Do you screen for risk-taking behavior when you evaluate candidates for employment? Screening and selecting employees Training and Testing Does your rules training program follow effective preparatory practices? Effective training preparation Does your rules training explain the purpose of the rule? Information transfer methods Does your rules training demonstrate the application of the rule? Information transfer methods Action-based rules training Do you provide opportunity for trainee to practice or apply the rule? Action-based rules training Do you give feedback to the trainee during and after practice? Action-based rules training Do you incorporate teambuilding in your training? Crew resource management Do you measure the effectiveness of rules training? Metrics highlighted in Chapter 4 Training and Testing Communication Do you have communication strategies that reinforce the importance of adhering to rules? Proactive rules communication Do you provide a forum for your employees to raise questions or concerns regarding rules? Opportunities to ask questions Does your rules communication process ensure that the employees receive information about changes to rules? Communicating changes to rules Do you use positive safety language in your communications with employees? Positive safety language Do you have a mechanism for your customers to communicate about operator behavior? Customer feedback Monitoring Rules Compliance Do you have an operational testing program? Operational testing Do you have a method to observe employee behavior (interior or exterior to the vehicle)? Observational methods Do you have an automated means to collect data from the vehicle or signal system that allows you to detect noncompliant vehicle operation? Automated methods Do you review your accidents and/or incidents for rules noncompliance? Chapter 3 Classifying Noncompliance Do you have the ability to monitor radio communications? Review radio transmissions Table 1. Safety-related rules compliance program checklist. (continued on next page)

your transit agency’s current program are possible. For each “no,” consider whether or not the best practice is suitable for the agency. Chapter 4 describes each of the best practices listed in Table 1. Again, the best practices are grouped by the six program elements listed. The unique characteristics of a transit agency, such as size and modes, its existing rules compli- ance activities, and budgetary constraints will determine the combination of activities that are feasible for the organization. The best practice descriptions include potential metrics for measuring the impact of the practices. 4. If your transit agency is interested in implementing a safety reporting system, read Chapter 5. A safety reporting system is one of the best practices in the Safety Management group of best practices. Because the implementation of this type of system involves significant effort, a sep- arate chapter addresses it. TCRP Report 149 includes several appendices that complement the information in the vari- ous chapters. The best practices of Chapter 4 were developed based on the experiences of other industries as well as public transit agencies. Appendix A describes the practices and experiences of other industries and Appendix B provides similar information for the various public transit modes. Before formulating an approach to a safety reporting system for transit, the research team explored the experiences of other transportation modes as well as existing practices in the pub- lic transportation industry. Appendix C describes these safety reporting systems. Appendix D offers some Rules Compliance Program Success Stories as examples of successful approaches to achieving compliance. Finally, the table in Appendix E summarizes the effectiveness metrics that appear with the best practices in Chapter 4. Initiating a Safety-Related Rules Compliance Program For transit agencies that are initiating a safety-related rules compliance program for either an existing or new public transit service, consider the following approach: 4 Improving Safety-Related Rules Compliance in the Public Transportation Industry Checklist Questions Practices Responding to Noncompliance Do you assign personnel to investigate each instance of noncompliance? Chapter 3 Classifying Noncompliance Do you identify the underlying cause(s) of noncompliant events? Chapter 3 Classifying Noncompliance Do you have a noncompliance classification system (levels that define severity of violation) that allows you to determine which corrective measures (training/coaching and/or discipline) apply? Responding to noncompliance Safety Management Does your process for evaluating your rules compliance program incorporate both leading and lagging indicators? Assessing the rules compliance program Do you have a rules review process that incorporates the views of both management and labor? Encouraging employee involvement Do you have a confidential, nonpunitive and voluntary means for employees to report near misses or unsafe conditions? Reporting near-misses and other safety risks Do you have a safety incentive program that rewards rules compliance and encourages desired behavior? Incentivizing rules compliance Table 1. (Continued).

1. Contact other public transit agencies offering similar services to learn from their experiences. The Success Stories in Appendix D as well as the callout boxes in Chapter 4 should help. 2. Begin by establishing a program for monitoring rules compliance, including metrics for measuring effectiveness. The Monitoring Rules Compliance section in Chapter 4 describes methods for doing this. 3. Develop policies that clearly define your transit agency’s response to different types of noncompliance. 4. Next consider the screening and selection of employees, followed by new hire training. 5. Keep employees informed of the new rules compliance program as it is developed and implemented. 6. Consider a safety reporting system only after the other elements of your program are success- fully operating. If a contract operator provides your transit service, there are two key factors to ensure that the contract operator follows practices for safety-related rules compliance. They are the following: • Include specific language in the contract as to what exactly is expected. • Closely oversee the contractor operation to ensure that contract provisions are followed. Introduction 5