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Classifying Noncompliance 29 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.

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30 Improving Safety-Related Rules Compliance in the Public Transportation Industry Table 3. Preconditions for employee noncompliance (Level II). Category Examples Environmental Factors Natural environment Climate, weather, time of day, glare, etc. Physical environment Workspace Humanwork system interface Humanmachine 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 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