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

Chapter: Chapter 3 - Classifying Noncompliance

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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
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Suggested Citation:"Chapter 3 - Classifying Noncompliance." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

This taxonomy is intended to aid public transit agencies in identifying the reason(s) or root cause(s) for any given instance of safety-related rule noncompliance. The taxonomy is based on several human error/violation taxonomies that exist in other human performance domains. Combining the results of a review of transit accidents with some of the classic taxonomies, the authors present the following information, which is tailored for public transit agencies to use to investigate the cause of safety-related rule noncompliance. Because this taxonomy is tailored to the needs of public transit agencies to investigate noncompliance, the user is discouraged from comparing other taxonomies to this one as there may be subtle but meaningful differences. The examples provided are based on actual transit incidents and accidents but have been altered to enhance their illustrative properties. The taxonomy is influenced by the work of James Reason (1990), who identified that accidents are the result of a long chain of events. While the employee’s act is the last link in the chain of events leading to an accident, there are many other contextual factors that most likely contributed to the event. Reason suggested that creating barriers to these contextual factors may thwart the opportu- nity for future accidents by breaking the intermediate links in the chain. Akin to the metaphor of a chain, Reason proposed the Swiss cheese model of accident causation (Figure 3). In this model, contextual factors are the latent failures or preconditions that allow unsafe acts, such as rule noncompliance, to occur. Ultimately, “an accident is one incident too many” (Reinhart 1996). Consider the head-on collision of a bus with a car. The accident report indicated that the bus operator fell asleep at the wheel and veered into the lane of oncoming traffic. By examining the chain of events leading to this accident, the creation of a robust explanation for the accident is possible. The operator unintentionally fell asleep at the wheel (Level I factor). The employee did not have adequate rest prior to his or her shift (Level II factor). The employee’s supervisor sched- uled the employee to return to duty without an adequate opportunity for rest (Level III factor). The public transit agency recently had budget cuts which reduced the number of bus drivers (Level IV). This made it difficult for supervisors to have an adequate number of personnel for the service routes. If one or more of these events did not occur, the accident may have been avoided. By addressing these factors after an incident occurs, future accidents may be prevented. The following guidelines are recommended practices for using the taxonomy. Chapter 2 explains much of the terminology in the taxonomy. It is important to review this entire chapter before attempting to use the taxonomy. The first step is to determine the employee’s intent. Determining whether noncompliance was intentional or due to human error is key to under- standing why an employee failed to comply. Understanding the employee’s intent will also allow identification of the appropriate response or remedial action. The taxonomy consists of four levels that are based on Reason’s accident causation model. The levels are designated by the Roman numerals I through IV and the subfactors for each level are 21 C H A P T E R 3 Classifying Noncompliance

numbered as well. The numbering system corresponds to the levels in Figure 3 and Figure 4 as well as the numbers for the root cause questions in the Investigating the Causal and Contributing Factors of Safety-Related Rules Noncompliance section of this chapter. If a close call, incident, or accident involved multiple instances of noncompliance, use the taxonomy to “drill down” the underlying factors for each noncompliant act. Figure 4 presents a diagram of the taxonomy and illustrates its hierarchy. While the categories of Level I are mutually exclusive for a single non- compliant act, subsequent levels are not. It is important to capture as many contributing factors for Levels II through IV as possible so that corrective actions (i.e., barriers) can be implemented to prevent reoccurrence of noncompliance. A table summarizing the elements of each level of the taxonomy follows the description of that level. Level I: Employee Noncompliance Employee actions are the last event in a chain of events that are closest in time and physical prox- imity to an incident that has resulted from rules noncompliance. While these actions most recently contributed to an incident’s occurrence, they are only one of several contributing factors. Based on the intention of the employee, an action can be classified as an error (unintentional noncompli- ance) or a violation (intentional noncompliance). Errors and violations can be further classified based on the underlying reasons for the noncompliance. In-depth classifications will provide a better understanding of why the noncompliance occurred as well as aid the identification of the appropriate corrective measures. 1. Intentionality Determining intentionality is key to understanding the reasons behind noncompliance. Inten- tional noncompliance is referred to as a violation, whereas unintentional noncompliance is con- sidered human error. The challenge to distinguishing violations from errors is the willingness of the employee to share this information. In an environment where the employee fears disciplinary action, he or she may not be forthcoming about intentionally violating a rule. Some employees 22 Improving Safety-Related Rules Compliance in the Public Transportation Industry Figure 3. Reason’s Swiss cheese model of accident causation (Reason 1990).

may claim they were unaware of their noncompliance to avoid disciplinary action. As a result, the noncompliant act may be inappropriately categorized as an error. Because errors and violations have distinct factors contributing to them as well as different strategies to mitigate them, wrongly categorizing actions at this level of the taxonomy will not allow the user to identify the actual rea- sons behind the noncompliant act. Nor will the user identify the appropriate corrective measures to prevent similar instances of noncompliance from reoccurring in the future. One transit agency investigated signal noncompliance and found that the event recorder data, specifically speed, was useful for identifying the underlying reasons for these events. The agency Classifying Noncompliance 23 Figure 4. Levels of the taxonomy.

found that the noncompliant events fell into two speed categories, those occurring at high speed and those at lower speeds. Those that occurred at high speeds were generally attributable to human error (unintentional) often the result of distraction. The reasons for noncompliance at the lower speeds were variable. The transit agency identified that train handling, a skill-based technique error, was sometimes the culprit. At a different transit agency, a root-cause investigation of signal non- compliance showed that the majority of light rail vehicle operators who had violated the stop sig- nal reported that they presumed that the signal would be permissive by the time they reached it. The latter is an example of a violation where the operator engaged in risky behavior due to over- confidence in his or her ability to predict the signal. 2. Errors Human error arises because our brains are organized in a way that allows us to solve prob- lems by processing information automatically (i.e., often without conscious thought) and making educated guesses (i.e., heuristics). While automaticity and shortcuts make us fast and efficient, inevitably we will succumb to error. Much of noncompliance is due to errors we are unaware of until it is too late. Identifying the type of error that occurred will inform an effec- tive mitigation strategy. 2.1 Perceptual Errors Perception is the psychological construct used to describe how people experience their environ- ment with their senses (seeing, hearing, touching, etc.). These errors occur when one experiences something in the environment that is different from reality. Sometimes people hear or see what they expect to experience. Blind spots resulting from the manner in which mirrors are laid out in an oper- ator’s workspace can give the illusion that no person or object is near the vehicle. However, another object, vehicle, or person could be in the blind spot and not be detected by the operator. Sometimes, people incorrectly “fill in” missing or degraded information (e.g., signage) or experience illusions that result in the wrong action. 2.2 Skill-Based Errors Skill-based errors often occur during the execution of highly practiced routines in which there is little or no conscious thought required. These errors commonly happen to everyone in everyday life. As such, they should not be considered an anomaly when they happen during work-related activities. Someone who experiences this type of error is not necessarily incom- petent. Rather, the person is so skilled at what he or she does, the work becomes automatic. Some common, everyday examples include intending to drive to the grocery store after work, but then driving home instead because the route home is similar and more frequently trav- eled. Also included are leaving out a step in a task or walking into a room and not remem- bering the purpose for going there. Skill-based errors can be further categorized into slips, lapses, and technique errors. 2.2.1 Slips. Slips refer to the execution of the wrong action during activities when the employee is not consciously aware of his or her action because he or she is so highly skilled. Slips include habit capture errors (the grocery store example above), misordering, repeating or insert- ing erroneous steps in a task sequence; they tend to be errors of commission. For example, a bus maintainer without awareness of his mistake installed an air line that was longer than the origi- nal hose. As a result, the brakes failed while the bus was in service causing the bus to strike the rear of an automobile that was stopped at a red traffic signal. 2.2.2 Lapses. Lapses, often failures of short-term memory, refer to the omission of some part or all of a task. As such, lapses tend to be omission errors. An employee may become dis- tracted by, or sometimes hyperfocused on, a second task or an extraneous situation to the detri- 24 Improving Safety-Related Rules Compliance in the Public Transportation Industry

ment of the primary task. As a result, the employee either forgets where he or she was in the first task sequence, omitting a critical step, or the employee forgets to resume the first task completely. This can occur, for example, when a bus driver becomes so engrossed in passenger relations, he or she may forget to make a scheduled stop. A lapse occurred when an experienced engineer for- got to make sure that the position of the forward/reverse switch on the master control panel was in the correct position before operating the train. 2.2.3 Technique errors. As employees develop their skill set, they acquire their own personal techniques that may differ from employee to employee. These techniques become engrained into how the employee performs his or her job. Technique errors occur when an employee has developed a maladaptive way of performing his or her job. While the techniques may not violate any specific rule, per se, they set employees up for rule noncompliance. Failure to exer- cise defensive driving skills is a good example of this. Employees develop personal driving techniques over the course of many years before they become professional drivers (e.g., bus drivers). While some companies may require defensive driving courses, it is difficult for employees to abandon how they have driven for years with limited time spent in defensive driving training courses. 2.3 Decision-Based Errors Decision-based errors are also unintentional and can be divided into two subcategories: strategy-based and knowledge-based errors. These errors can be thought of as ineffective deci- sions or honest mistakes involving the application of rules. 2.3.1 Strategy-based decision errors. As employees develop experience, they acquire a repertoire of strategies to accomplish different aspects of their jobs. Sometimes an individual chooses the wrong strategy for a situation or misapplies an effective strategy to the wrong situation; this is known as a strategy-based decision error. An example of a strategy-based error occurred when the procedure of a bus maintenance department did not sufficiently describe the actions required to properly construct, route, and secure a steel braided surge tank vent hose. The mechanic followed the procedure to the best of his or her ability, but used a less than ideal method to secure the hose (the method for that part of the procedure was not specifically defined). The result was a bus engine compartment fire. 2.3.2 Knowledge-based decision errors. Other times employees are inexperienced or are unfamiliar with some aspect of their jobs. They may have a limited set of pre-formed plans they can use when performing their job. These employees may have to identify novel solutions to a problem or find themselves in a situation where they have to interpret and execute rarely used or difficult to understand rules. When an employee fails to comply because of a lack of under- standing of a rule or how to execute it, a knowledge-based decision error has occurred. A knowledge-based error occurred when a novice dispatcher was called by a light rail operator faced with a fire in a tunnel. This is a rare occurrence and one for which the rules and proce- dures are somewhat complex depending on which tunnel is involved. The dispatcher had to respond quickly and neglected to activate the fans in the tunnel. The transit agency deter- mined that the dispatcher did not understand the rule because she had inadequate training on emergency procedures. 3. Violations Within the context of this taxonomy, violations, are always intentional, that is, the employee understands the rule and knows how to apply it, but voluntarily chooses not to comply. Many times supervisors and management think that the only reason people violate rules is because of some per- sonal attribute (e.g., risk taker, no respect for rules). While this is sometimes true, particularly in the Classifying Noncompliance 25

case of egregious violations or criminal acts, many times there are other reasons an employee may violate a rule. These factors include issues with employee supervision and management, environ- ment and ergonomics, as well as problems with organizational culture. The purpose of calling out the factors associated with violations is not to shift blame from the employee to management or other external factors, but to identify all factors that contribute to a violation so that problems at all levels can be addressed to minimize the probability of reoccurrence. 3.1 Egregious and Criminal Acts As a general rule, transit agencies should have a no tolerance policy for criminal acts such as illegal drug use and working while under the influence of drugs and alcohol. Some transit agen- cies now consider cell phone use while on duty to be an egregious act. Each agency must define what qualifies as an egregious act. Caution should be taken not to make this category too broad because the response to these types of noncompliance is zero-tolerance generally resulting in removal from employment. For example, including violations such as speeding in this category is not useful. Speeding may occur because an employee feels pressure from a supervisor to be on time. By categorizing these types of violations in this category, there is no opportunity to identify the supervisory factor. Because of an organization’s response (typically termination) to egregious and criminal acts, determining the root cause of such violations is nearly impossible because there is no incentive for the employee to share information. Therefore, in the case of truly criminal acts, foregoing root cause analysis is warranted. Transit agencies can enhance compliance with zero-tolerance policies by educating the employees regarding the risk associated with noncompliance. 3.2 Routine Violations These occur when a shortcut or quicker way to the end goal presents itself and is taken on a reg- ular basis. While the act may be against the rules, employees reason that their skill offsets the pos- sible consequences of or risk associated with the noncompliance. A routine violation occurred when track maintainers were found to regularly forego the application of a redundant shunting device to protect a crew working on the tracks because they believed that protection from the train dispatcher was adequate. 3.3 Exceptional Violations These often occur when employees are faced with unusual circumstances that call for an unusual response (e.g., emergency situations). Often times, the rules or procedures may be inadequate to accommodate the situation. The distinguishing feature between decision-based errors, as they previously are described, and exceptional violations is the employee’s intention. With respect to decision-based errors, the employee is unaware that he or she misunderstood the rule or failed to apply it correctly. With exceptional violations, the employee understands the rule, but either does not trust the rule’s effectiveness (or appropriateness) or thinks that the alter- nate response he or she conceived is more appropriate. When exceptional violations occur, the applicability of the rule that is broken should always be revisited in the context of the situation in which it was violated. The following example describes an exceptional violation: a public transit agency has a rule that forbids bus operators from letting off passengers between stops. Due to bad weather and a passenger’s request, a bus operator let off an elderly passenger between stops. The passenger felt it was too icy to walk from the stop to her home. 3.4 Situational Violations These occur because an employee is conflicted regarding the balance between adherence to the rules (e.g., procedures designed to ensure safety) and meeting performance goals (e.g., on- 26 Improving Safety-Related Rules Compliance in the Public Transportation Industry

time performance). Due to the employees’ work conditions or demands, they often find it diffi- cult or impossible to remain within the boundaries of safe working practices defined by the rules. When performance targets are met, these violations are overlooked. However, employees com- mitting these types of violations are often disciplined when accidents ensue. The inconsistent disciplinary approach to enforcement is not an effective way to reduce these violations. The fol- lowing example illustrates a situational violation: a bus mechanic has many routine maintenance checks to do on buses that must go out today. Pressured by his supervisor to stay on schedule at all cost, he chooses not to complete the final checklist to save time and prevent delays in the bus schedule. As a result, he fails to catch a loose bolt on one of the wheels that had been removed for brake work. An accident resulted later that day. Table 2 summarizes the factors of Level I. Level II: Preconditions for Employee Noncompliance Preconditions for employee acts are those work-related, contextual, environmental and per- sonal factors that exist prior to the incident but indirectly contribute to an incident’s occurrence, often by setting up or fostering a situation in which one or more operator acts occurs. Pre- conditions are organized into three major categories: environmental factors, employee condition, and personnel factors. Classifying Noncompliance 27 Category Subcategory Description Potential Causes Error Perceptual Error Employee’s perception of work conditions is different from reality Degraded signage, radio communications and the employee’s expectations Skill-Based Slip Habit capture, misordering, repeating or inserting erroneous steps in a task sequence Distraction, fatigue, loss of situation awareness Skill-Based Lapse Failures of short-term memory resulting in the omission of some part or all of a task Distraction, multi- tasking, high workload Skill-Based Technique Error Personal technique places an operator at risk for rule noncompliance Personality, maladaptive operating practices Strategy-Based Decision Error Applied the wrong rule or misapplied the correct rule to a work situation Vague rules, lack of or inadequate rule training Knowledge-Based Decision Error Employee did not understand or was unaware of a rule Lack of experience or inadequate rule training Violation Egregious/Criminal Act Acts for which a transit agency has zero-tolerance such as drug or alcohol abuse Personality and psychopathology Routine Violation Occurs when a shortcut or quicker way to the end goal presents itself and is taken on a regular basis Inadequate supervision, overconfidence in skill, pressure to adhere to performance goals Exceptional Violation Occurs when employee is required to handle an unexpected circumstance Lack of or inadequate training, vague rules Situational Violation Occurs when there are competing performance goals (e.g., safety v. on-time performance) Inconsistent supervision and/or disciplinary action Table 2. Employee noncompliance (Level I).

1. Environmental Factors Environmental factors refer to the conditions in the employee’s immediate working environ- ment that encouraged noncompliance. The factors are subdivided into three categories. 1.1 Natural Environment This factor refers to conditions such as weather and time of day that are completely beyond the control of the employee. This factor was evident when blowing snow and ice build-up contributed to the failure of a train operator when she overran the platform and struck the bumper block. 1.2 Physical Environment This factor refers specifically to the employees’ assigned workspace, which could be behind the wheel of a bus or outdoors maintaining track. A less than ideal workspace existed when an engineer’s view of a signal was obstructed by the cab car’s configuration and control stand leav- ing the engineer to rely solely on the conductor to inform of the signal aspect. If the conductor is mistaken, the engineer does not have the opportunity to correct the situation. 1.3 Human–Work System Interface This factor refers to a mismatch between what the employee requires in the workspace to ade- quately perform his or her job and what is actually provided in the form of technology, equip- ment, and the functional design of the workspace. This factor contributed to a perceptual error resulting in an accident. Poor color markings of the horn and emergency stop cords caused the conductor to activate the horn rather than the emergency stop. This factor is also known to con- tribute to situational violations as well. Wheel chair tie downs are reported as difficult to secure by operators. Sometimes schedule pressure causes an operator not to secure them properly plac- ing the passenger at risk of injury. 2. Employee Condition The condition of the employee refers to the state of the employee’s mental and physical well- being at the time of the noncompliant event. This category is divided into five subcategories. 2.1 Employee Readiness This factor refers to the extent to which an employee is mentally and physically able to perform his or her job. This category may include the following factors: insufficient rest or overexertion due to non work-related activities, use of performance impairing substances (e.g., over-the-counter, prescription, or illicit), untreated medical issue, or failure to adhere to medical treatment. An event involving lack of employee readiness occurred when a vehicle operator used an over-the-counter cough medicine that had a sedating effect. As a result, the operator’s attention was impaired and she failed to notice a red signal and passed it. 2.2 Mental State The employee’s mental state refers to any temporary cognitive limitations he or she may expe- rience as a result of events that happened prior to reporting for duty (e.g., emotional upset) or the person’s task/job demands. Sometimes high workload can lead an employee to become overly focused when he or she is unfamiliar with certain aspects of his or her job. Other times, an employee can become distracted under high workload conditions. An example of distraction occurred when flashing lights in a field next to the rail right-of-way distracted the engineer and caused him to run a red signal. Another result of high workload is mental fatigue. Mental fatigue can occur when a person is well-rested but may be required to be vigilant for long periods dur- ing his or her job; vigilance is known to produce mental fatigue. 28 Improving Safety-Related Rules Compliance in the Public Transportation Industry

Low workload, as well as overconfidence in one’s ability, can result in employee complacence. Complacence occurred when a bus driver failed to exercise defensive driving skills and collided with another vehicle. 2.3 Attitude and Personality An employee’s attitude and personality can contribute to noncompliance. An employee’s attitude regarding a rule may play a role in noncompliance as do job dissatisfaction and overconfidence in one’s skills. These factors can further lead an employee to have a history of noncompliant behav- ior as well as a pattern of underestimating the risk associated with noncompliance. The lat- ter occurred when an experienced track worker believed he did not have to wear personal protective equipment because he thought he would always hear an approaching train. This was a contributing factor to the track worker being struck by an oncoming light rail vehicle. 2.4 Adverse Physiological State An adverse physiological state, such as medical illness or even physiological incapacitation, may contribute to noncompliance. For example, a diabetic bus driver failed to eat. The driver’s blood sugar dropped, impairing his judgment and causing the driver to stop where there was no bus stop. The chain of events led to a collision with another vehicle. In a different incident, a driver choked on a piece of candy and lost consciousness. The bus she was driving struck another bus from the rear as a result of her incapacitation. 2.5 Mental or Physical Limitations There may be aspects of an employee’s inherent mental or physical limitations that con- tributed to noncompliance. These may include visual limitations, incompatible intelligence or aptitude, incompatible physical capability, poor inference/reasoning skills, or slow reaction time. In one incident an engineer’s undiagnosed color blindness caused him to pass a red signal and strike another train. 3. Employee Communication and Rapport This factor refers to how peer members of the operational staff communicate and coordinate work efforts with one another. This can involve the simple discourse between a commuter rail engineer and dispatcher or the more complex interactions among track maintenance crew mem- bers. This factor may contribute to noncompliance when there is a failure in communication or coordination among peer staff members, when employees fail to use all available resources, or when there is a failure of leadership in the workgroup. A breakdown in communication within a track engineering department resulted when staff members did not properly interpret the results of a track geometry car inspection and issue their findings in a timely manner. As a result, a train derailed because of the condition of the track. In a different incident involving a failure of leadership, a foreman failed to follow regulations that ensured a safe working environment on a job site. The foreman allowed the signalman to raise the crossing gate before checking for trains in the area, resulting in a train striking a car at the crossing. Table 3 presents the factors associated with Level II of the taxonomy. Level III: Supervisory Factors Supervisory factors sometimes play a role in noncompliance. These factors typically fall into one of five categories: supervisor provided inadequate oversight, supervisor/management planned inadequate work schedule, supervisor provided inadequate information and/or resources, supervisor failed to correct a known problem, and supervisor noncompliance. Classifying Noncompliance 29

Factor 1. Inadequate Oversight This factor is evident when a supervisor fails to provide guidance, particularly to less experienced and confident staff. This category also includes failure of supervisors and/or management to pro- vide and encourage training opportunities. Poor leadership and failure to verify employee qualifi- cations and monitor job performance are included in this category. An example of a lack of supervisory oversight occurred when the supervisor did not oversee a car inspector’s work and the inspector failed to properly secure the locking nut on a brake shoe assembly later resulting in a derailment. Another incident occurred when a supervisor failed to monitor employee qualifi- cations. All employees at this public transit agency are required to have training before operat- ing a new type of vehicle. Because the supervisor failed to make sure that all employees received the training, an untrained employee operated the new vehicle improperly causing an accident. Factor 2. Inadequate Work Schedule A supervisor or the scheduling department may plan work schedules that do not allow for ade- quate rest. The result may influence an employee’s noncompliance because of fatigue. Fatigue pro- motes human error and can tempt an employee to take shortcuts (i.e., rule violation) to get the job done. An example of this happened when, in spite of an operator’s complaint of work-schedule- related fatigue, the supervisor insisted that the employee operate the train. The employee fell asleep on duty and rear-ended another train. Another example involving inadequate rest occurred when a work schedule only allowed 8 hours between consecutive work periods that involved an 30 Improving Safety-Related Rules Compliance in the Public Transportation Industry Category Examples Environmental Factors Natural environment Climate, weather, time of day, glare, etc. Physical environment Workspace Human–work system interface Human–machine interaction Employee Condition Personal readiness Over-exertion Self-medicating Lack of sleep/physical fatigue Mental state Overfocused Distracted Complacent Mental fatigue Emotional upset Workload Attitude/personality Attitude toward the system Job dissatisfaction History of noncompliant behavior Misperceiving risk of hazard Low self-esteem Adverse physiological state Medical illness Physiological incapacitation Mental/physical limitation Insufficient reaction time Visual limitation Incompatible intelligence/aptitude Incompatible physical capability Poor inference/reasoning Employee Coordination and Rapport N/A Failure of leadership Failure to communicate/coordinate Failure to conduct adequate job briefing Table 3. Preconditions for employee noncompliance (Level II).

overnight split assignment. Due to fatigue, an engineer failed to stop at the stop marker before entering a station. Factor 3. Inadequate Information and Resources A supervisor may also fail to provide the operational information that an employee needs to perform the job (e.g., fail to provide job brief). A supervisor may also fail to provide adequate staffing, thereby stretching the resources of the operational staff. A maintenance supervisor had an inadequate number of personnel assigned to perform the periodic preventive maintenance inspection for a light rail fleet. Trying to adhere to the maintenance schedule and prevent delay in operations, the inspection personnel skipped steps in the inspection checklist. One of the light rail cars had a loose bolt which caused a derailment. Factor 4. Failure to Correct a Known Problem Failing to correct a known problem is a supervisor inaction that may contribute to noncompli- ance. This occurs when a supervisor does not identify and address at-risk employees with remedial or corrective action. An example of this occurred when a bus driver was reported by peers to take risks while operating the bus (e.g., speeding, closing doors before looking to see if a passenger was still in the doorway). While aware of these behaviors, the supervisor did not coach the employee on the risks of these behaviors. The driver was subsequently involved in an intersection accident caused by the driver’s failure to properly judge the speed of oncoming vehicles. In a different incident, many operators reported that a signal was difficult to see in bright sunlight but management did not take action to correct the problem until an accident occurred. Factor 5. Supervisor Rule Noncompliance Supervisors may themselves commit errors and violations associated with noncompliance that contribute to their subordinates’ lack of compliance. This may include authorizing employees to break the rules and failing to enforce rules or regulations. An incident occurred when a supervisor authorized an employee to break the rules. A bus supervisor emphasized schedule adherence as the most important goal, even at the expense of maintaining a safe operating speed. The bus driver was later involved in an accident where speeding by the bus operator was cited as the probable cause. In another incident, a track maintenance supervisor failed to ensure that the rail was prop- erly secured prior to authorizing a train to travel through the work area. The train passed over the loose rail and derailed. Table 4 lists the factors associated with Level III of the taxonomy. Level IV: Organizational and Regulatory Factors The decisions and policies of upper management and regulatory agencies directly influence public transit supervisor practices. As such, they can directly contribute to incidents or accidents stemming from rules noncompliance. Contributing to these factors are economic challenges that wax and wane over time. During times of economic prosperity, public transit agencies may be able to satisfactorily bal- ance the requirements associated with safe operating practices with the performance goals of the agency (e.g., customer satisfaction and on-time performance). Historically, when economic con- straints come into play, commitment to safety often takes a back seat to performance goals. This has a trickle-down effect to first-line supervisors as well as front-line employees. During times of economic hardship, cutbacks in staffing, training, incentives, and maintenance often lead to Classifying Noncompliance 31

an overworked, less motivated, and less qualified staff operating suboptimal equipment. This scenario, when combined with an organization that values performance goals over safety, may lead supervisors and their employees to break safety-related rules, resulting in an accident. The factors in this category include those of resource and acquisition management, organiza- tional climate, an organization’s operations, and regulatory influences. Factor 1. Resource and Acquisition Management This factor includes the acquisition and management of public transit employees, equipment, and facilities. Resource management may involve human resources, monetary or budget resources, and equipment and facility resources including maintenance. With respect to the latter two contrib- utors, budget restrictions may prevent a public transit agency from replacing old equipment that require extra maintenance and repairs. As a result, there is more opportunity during the main- tenance process for errors that may lead to equipment failure. Factor 2. Organizational Climate Organizational climate can generally be regarded as the working atmosphere within an organiza- tion. Safety climate is the collective values of management, supervisory staff, and employees as they relate to work safety at a given point in time. Alignment of an organization’s formal safety policies, procedures, and rules with the informal values, beliefs, and attitudes of an organization’s management and staff is a predictor of a positive safety climate. However, when upper level man- agement claims to embrace an organization’s safety policies (i.e., talk the talk) only to overlook those same policies behind the scenes (i.e., failing to walk the walk), erosion of the organization’s safety climate occurs. Organizational structure in a public transit agency may contribute to climate erosion when the agency’s safety management personnel are not represented at every level of the organization. An agency’s safety policies as well as their safety culture may also contribute to noncompliance. In organizations entrenched in a culture of blame, there is often no attempt to identify risks before an incident occurs. Instead of being proactive and preventive, the managers in this type of environ- ment are reactive, looking to blame an employee when there is noncompliance or an accident. 32 Improving Safety-Related Rules Compliance in the Public Transportation Industry Category Examples Inadequate oversight Failed to provide guidance Failed to provide training opportunities Poor leadership Lack of oversight Failed to monitor employee qualifications Failed to track performance Inadequate work schedule Provided inadequate opportunity for employee rest Inadequate information/resources Failed to properly brief employee Failed to give the employee necessary information Provided inadequate staffing Failure to correct known problem Did not call out at-risk employee Did not report unsafe tendencies Did not initiate remedial or corrective action Supervisor rule noncompliance Authorized employee to break the rules Failed to enforce rules or regulations Allowed unqualified employees to perform job Table 4. Supervisory factors (Level III).

Factor 3. Organizational Processes This factor includes work tempo, incentives, operating practices and procedures (or lack of), and public transit agency specific oversight activities that help to ensure a safe work environment (e.g., risk management programs). A problem with an organizational process occurred when a failure in procedures led maintenance staff to use the wrong sized bolts during the repair of a work train causing it to derail. There was a lack of quality control procedures to ensure the cor- rect hardware was used during the maintenance process. Factor 4. Regulatory Factors Regulatory factors, including legislative ones, are beyond the control of a public transit agency. Yet, they affect operations because of the adherence requirement. Some regulations may strain tran- sit agencies’ already tenuous budgets and resources. Lack of regulations or regulatory oversight may contribute to incidents stemming from noncompliance to an agency’s safety-related rules. For example, prior to the FTA requirement that all rail systems have system safety plans with state over- sight, public transit agencies did not necessarily have formal rules compliance programs. Table 5 presents the factors associated with Level IV of the taxonomy. Investigating the Causal and Contributing Factors of Safety-Related Rules Noncompliance Based on the previous descriptions and explanations of the taxonomy, the following tables pres- ent questions designed to help a public transit agency investigate the underlying factors of safety- related rules noncompliance. If an incident involves more than one instance of noncompliance, use the taxonomy to investigate each instance. Keep in mind that the categories of Level I of the taxonomy are mutually exclusive; whereas subsequent levels are not. Therefore, consider the appli- cability of all categories for Levels II through IV. If it is not possible to determine the Level I factors, you should continue to identify any con- tributing factors in Levels II through IV as well as review the rule that was broken. A rule review should be conducted for all instances of rule noncompliance and, at a minimum, include the following questions: • Is the safety-related rule’s noncompliance rate high? • Is the safety-related rule easily comprehended? • Have safety-related rules been explained well both verbally and in written form? • Has the safety-related rule been demonstrated to the employee in classroom, computer-based, and/or on-the-job training? Classifying Noncompliance 33 Category Examples Resource/Acquisition Management Human Resources Monetary Budget Resources Equipment/Facility Resources Organizational Climate Organizational Structure Policies Safety Culture Organizational Operations Process Procedures Oversight Regulatory Factors Lack of regulatory oversight Lack of regulations Table 5. Organizational and regulatory factors (Level IV).

• Have you queried employees or labor representatives regarding the relevance of the safety- related rule? • Do employees report that it is difficult to comply with a safety-related rule and if so, why? Tables 6 through 9 contain the root cause questions for Levels I through IV of the taxonomy, respectively. If the answer to a question is yes, the number associated with the question corresponds to the description of the factor(s) described in the previous taxonomy. The user is encouraged to review the taxonomic information associated with the factors identified in the root-cause process. This information will aid in identifying strategies to mitigate the contributing factors. 34 Improving Safety-Related Rules Compliance in the Public Transportation Industry Questions Does it apply? 1. Determine employee intent. 1.1 Was the noncompliance unintentional? Was the employee unaware that he, or she, failed to comply with a rule until an unexpected occurrence happened? If yes, then noncompliance is the result of an error; go to 2. 1.2 Was the noncompliance intentional? Was the employee aware that he, or she, broke a rule? If yes, then noncompliance is the result of a violation; go to 3. 1.3 If intention cannot be determined, conduct a rule review and proceed to Level II. Cannot determine 2. What type of error occurred? 2.1 Perceptual Error 2.1.1 Did the employee indicate that they experienced (e.g., saw or heard) something in a way that was different from reality? Was information in the employee’s environment obscured or degraded in any way when noncompliance occurred? Did the employee indicate that they experienced what they expected rather than what was actually present? If yes, then a perceptual error occurred; proceed to Level II. 2.2 Skill-Based Error 2.2.1 Did the employee perform the wrong action (e.g., habit capture, misordering, repeating or inserting the wrong steps while performing their job) and did the employee report being surprised that their action did not produce the intended result? If yes, then a skill-based slip occurred; proceed to Level II. 2.2.2 Did the employee report “forgetting” to do something and not realize they forgot until the incident occurred? If yes, then a skill-based lapse occurred; proceed to Level II. 2.2.3 Did the employee’s personal style of performing his or her job lead him or her to not comply with a rule? If yes, then a skill-based technique error occurred; proceed to Level II. 2.3 Decision-Based Error 2.3.1 Did the employee incorrectly apply a strategy to the situation, or did the employee use a proven strategy, but applied it to the wrong situation? If yes, then a strategy-based decision error occurred; proceed to Level II. 2.3.2 Did the employee express difficulty understanding the rule? Is the employee relatively inexperienced? If yes, then a knowledge-based decision error occurred; proceed to Level II. Table 6. Root cause questions for employee noncompliance (Level I). (continued on next page)

Classifying Noncompliance 35 Questions Does it apply? 3. What type of violation occurred? 3.1 Egregious/Criminal Acts 3.1.1 Was the noncompliance the result of the employee intending harm? Did the employee engage in criminal behavior? If yes, then an egregious/criminal act occurred; stop here, root cause cannot be determined. 3.2 Routine Violations 3.2.1 Does the employee have a history of this type of noncompliance? Do other workers in the employee’s peer group have the same pattern of noncompliant behavior? Does the employee’s supervisor(s) fail to take action for this type of noncompliance? If yes, then a routine violation occurred; proceed to Level II. 3.3 Exceptional Violations 3.3.1 Was the situation where the rule was broken a rare event? Was the employee’s action perceived as more effective for the situation than following the required rule, or procedure? If yes, then an exceptional violation occurred; proceed to Level II. 3.4 Situational Violations 3.4.1 Did the employee feel compelled to break the rule or not follow a procedure in order to meet performance goals? Do supervisors provide inconsistent disciplinary action for this type of noncompliance, i.e., overlook it when it supports performance goals and punish when it results in incident? If yes, then a situational violation occurred; proceed to Level II. Table 6. (Continued).

Questions Does it apply? 1. Was the environment a factor? 1.1 Did factors such as the weather, time of day, temperature, or glare contribute to the operator’s noncompliance? If yes, then the natural environment was a factor in the noncompliance; proceed to next question. 1.2 Was the workspace or work environment inadequate? Was there a lack of or inadequate equipment available to perform the job? Was there an operational problem with the transit vehicle? N If yes, then the physical environment was a factor; proceed to next question. 1.3 Was there a mismatch between the employee and some aspect of the work system? Was there a functional design issue with the workspace or an interface such that perception was obscured or situational awareness was impaired? Did the work system or procedures not match the needs or requirements of the employee? If yes, then the human-work system interface was a factor; proceed to next question. 2. Was the employee’s condition a factor? 2.1 Did the employee get insufficient rest, or overexert him/herself while off duty? Did the employee use over-the-counter, prescription or illicit drugs (including alcohol) that may have affected his or her ability to perform optimally while on- duty? Did the employee, in any way, fail to prepare for duty, mentally or physically? If yes, employee readiness was a factor; proceed to next question. 2.2 Were there any mental factors, perceptions, attitudes, moods, conditions, or states that momentarily and negatively affected the operator’s performance? Was the employee generally distracted or focused on non-work factors? Was the employee anxious, stressed, worried, excited, or otherwise in an unusual mental state? Was the employee fixated on a particular task or did he or she lose situation awareness? If yes, the employee’s mental state was a factor; proceed to next question. 2.3 Did the employee have a poor attitude regarding the safety rules or the public transit agency, in general? Does the employee have a history of risk-taking behavior? Was the employee complacent, overconfident, or under-confident? If yes, the employee’s attitude and/or personality was a factor; proceed to next question. 2.4 Were there any medical or physiological conditions that momentarily and negatively affected the employee? Was the employee in poor health resulting from an acute or chronic medical condition? Was the employee negatively affected by the medical condition? If yes, the employee experienced an adverse physiological state; proceed to next question. 2.5 Did the job demands exceed the ability of the employee? Was the employee able to see or hear everything he or she needed to complete the job assignment? Was the employee not adequately trained, inexperienced or lack the necessary knowledge to perform the job? Was the employee not able to keep up with the pace of operations? Was the employee’s aptitude, ability, strength or proficiency an influencing factor? If yes, the employee had mental and/or physical limitations that contributed to the noncompliance; proceed to next question. 3. Employee Communication and Rapport 3.1 Was there poor communication or poor coordination among those involved? If applicable, was a job briefing omitted or abridged? Was there any type of personnel conflict that contributed to the noncompliance? If yes, then employee communication and/or rapport was a factor; proceed to next question. Table 7. Root cause questions for preconditions for employee noncompliance (Level II). 36 Improving Safety-Related Rules Compliance in the Public Transportation Industry

Classifying Noncompliance 37 Questions Does it apply? 1. Was there inadequate oversight of the employee? 1.1 Did front-line supervisors or other managers provide insufficient guidance, leadership, oversight, tracking of operator qualifications/performance, or incentives? Was the supervisor over-tasked, over-worked or under- trained/qualified to such an extent that he or she lost awareness of his or her assigned responsibilities? If yes, then inadequate oversight was a factor in the noncompliance; proceed to next question. 2. Was the employee assigned an inadequate work schedule? 2.1 Did the assigned work schedule prevent the employee from getting adequate rest? Was there no quiet room for the employee to get rest between shifts? Did the work schedule prevent the employee from obtaining at least 8 hours of undisturbed sleep? If yes, then an inadequate work schedule was a factor; proceed to next question. 3. Did the supervisor fail to provide adequate information and/or resources for the employee? 3.1 Did the supervisor fail to provide the employee with a job briefing, documents and materials (e.g., up-to-date bulletins, rule books, special instructions, etc.) or training that prevented the employee from performing optimally? Did the supervisor fail to provide an adequate number of staff to perform operations, i.e. did a lack of peer personnel stretch the limits of the noncompliant employee? If yes, then inadequate information/resources was a factor; proceed to next question. 4. Did the supervisor fail to correct a known problem? 4.1 Have there been recent situations in which inadequacies or shortcomings in materials, equipment, work schedules, personnel or training were known to one or more supervisors, but were allowed to continue uncorrected? Did the supervisor know that unsafe behaviors were occurring regularly but failed to correct the problem? If yes, then the supervisor failed to correct a known problem and it contributed to the employee’s noncompliance; proceed to next question. 5. Did the supervisor fail to comply with a safety rule(s)? 5.1 Did the employee’s supervisor knowingly disregard an organization’s rule policy or regulation, such as allowing employees to perform their jobs without proper licensing or qualifications? Did the supervisor actively encourage the employee to bend or ignore safety rules or punish the employee for following the rules? If yes, then supervisor rule noncompliance was a factor; proceed to next question. Table 8. Root cause questions for supervisory factors (Level III).

38 Improving Safety-Related Rules Compliance in the Public Transportation Industry Questions Does it apply? 1. Did the organization’s resource management play a role in the noncompliance? 1.1 Did the acquisition, allocation, management or maintenance of business assets contribute to the incident’s occurrence? Business assets include human resources, equipment, facilities and financial resources. Is staffing inadequate to a point where workload is excessive? Did the employee lack the equipment or resources needed to work safely? Did excessive cost-cutting or budgetary restrictions contribute to the incident? If yes, then resource management was a factor in the noncompliance; proceed to next question. 2. Was the organizational climate a factor? 2.1 Did the non-operating work environment (organizational climate) appear to contribute to the incident’s occurrence? The organizational climate includes the formal and informal organizational structure, policies and culture. Was there poor communication regarding safety policy and rules between upper and middle management? Does upper management have an inconsistent message regarding safety policies and rules? Do they proclaim the importance of these policies and rules, yet send the message to their employees that on-time performance is more important? Do fellow employees have a low regard for the agencies safety policies, rules and procedures? If yes, then organizational climate was a factor; proceed to next question. 3. Were the organization’s processes a factor in the noncompliant event? 3.1 Was the work pace (operational tempo) too fast? Were there any unsafe or inadequate operating practices, procedures, rules or administrative controls that contributed to the noncompliance? Were corporate safety programs and risk management programs inadequate? Was there a lack of, or an inadequate, safety reporting system that would have helped to identify patterns of noncompliance that could have prevented the incident being investigated? Did upper-level management or an agency executive bend or violate either internal or external procedures, processes or regulations? If yes, then organizational processes was a factor; proceed to next question. 4. Did non-agency regulatory factors play a role in the noncompliance? 4.1 Could a government regulation, law, action or order, if one had been in place, prevented or reduced the likelihood of noncompliance? Was there relevant government regulation, law, action or order in place at the time of the incident, but it was inadequate or ambiguous in terms of specifying requirements or performance standards for an operation, practice or equipment? Did an existing government regulation, law, action or order appear to contribute to the noncompliance? If yes, then regulatory factors contributed to the noncompliance; stop root cause process here. Table 9. Root cause questions for organizational and regulatory factors (Level IV).

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TRB’s Transit Cooperative Research Program (TCRP) Report 149: Improving Safety-Related Rules Compliance in the Public Transportation Industry identifies potential best practices for all of 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, include screening and selecting employees, training and testing, communication, monitoring rules compliance, responding to noncompliance, and safety management.

The report also outlines the features of a prototype safety reporting system for public transportation.

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