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Classifying Noncompliance 27 Table 2. Employee noncompliance (Level I). Category Subcategory Description Potential Causes Error Perceptual Error Employee's perception of Degraded signage, radio work conditions is different communications and the from reality employee's expectations Skill-Based Slip Habit capture, misordering, Distraction, fatigue, loss repeating or inserting of situation awareness erroneous steps in a task sequence Skill-Based Lapse Failures of short-term memory Distraction, multi- resulting in the omission of tasking, high workload some part or all of a task Skill-Based Personal technique places an Personality, maladaptive Technique Error operator at risk for rule operating practices noncompliance Strategy-Based Applied the wrong rule or Vague rules, lack of or Decision Error misapplied the correct rule to a inadequate rule training work situation Knowledge-Based Employee did not understand Lack of experience or Decision Error or was unaware of a rule inadequate rule training Violation Egregious/Criminal Acts for which a transit agency Personality and Act has zero-tolerance such as drug psychopathology or alcohol abuse Routine Violation Occurs when a shortcut or Inadequate supervision, quicker way to the end goal overconfidence in skill, presents itself and is taken on a pressure to adhere to regular basis performance goals Exceptional Occurs when employee is Lack of or inadequate Violation required to handle an training, vague rules unexpected circumstance Situational Violation Occurs when there are Inconsistent supervision competing performance goals and/or disciplinary (e.g., safety v. on-time action performance) 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.
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28 Improving Safety-Related Rules Compliance in the Public Transportation Industry 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 HumanWork 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.