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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.
