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Classifying Noncompliance 33 Table 5. Organizational and regulatory factors (Level IV). 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 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?
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34 Improving Safety-Related Rules Compliance in the Public Transportation Industry · 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. Table 6. Root cause questions for employee noncompliance (Level I). Does it Questions 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. (continued on next page)
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Classifying Noncompliance 35 Table 6. (Continued). Does it Questions 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.
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36 Improving Safety-Related Rules Compliance in the Public Transportation Industry Table 7. Root cause questions for preconditions for employee noncompliance (Level II). Does it Questions 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.
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Classifying Noncompliance 37 Table 8. Root cause questions for supervisory factors (Level III). Does it Questions 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.
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38 Improving Safety-Related Rules Compliance in the Public Transportation Industry Table 9. Root cause questions for organizational and regulatory factors (Level IV). Does it Questions 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.