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CHAPTER 5 Safety Reporting System Best Practices This chapter presents best practices for a safety reporting system for the public transportation industry. Table 11 presents a checklist of the integral components of a safety reporting system based on a review of effective systems in other industries. Appendix C describes these in detail. While the initial project objectives called for the development of an incident reporting system, the research team's review of safety reporting systems revealed that the majority of reports (nearly 80% for some systems) did not relate a specific incident but rather general safety concerns and issues. As such, these systems saw great success in the identification of safety risks that did not necessarily result in an incident. Therefore, the proposed system should encompass both types of reports. The term "system" in this chapter refers to the processes, procedures, and mechanics associated with reporting safety concerns and incidents. The term "program" is reserved for the oversight and management of the system. The safety reporting systems reviewed in Appendix C varied from centralized reporting systems such as the Aviation Safety Reporting System (ASRS) to organization-based systems such as the Aviation Safety Action Program (ASAP) and the Confidential Close Call Report- ing System (C3RS). The general recommendation for the public transportation industry is that the safety reporting system should reside at the level of the transit agency. The reason is that the information gleaned from locally based systems is more easily related to transit manage- ment in contrast to centralized systems where it can take months to years for the information to become beneficial. A pilot implementation of the design suggested herein should be the next step. Scalability of a Safety Reporting System Table 11 presents the recommended core elements of a full-scale safety reporting system. Implementing such a system can be a lengthy process thereby delaying the benefits of implemen- tation. While the safety reporting system best practices presented in this chapter describe the most effective approach, intermediate steps can be adopted in the interim before a full-scale implementation. The simplest form of a safety reporting system is a comment box. Employees can be supplied with comment cards to submit to their supervisors whereby they voluntarily relate rules non- compliance or general safety issues and/or concerns. An anonymous system may yield a higher input of reports with the disadvantage being that the supervisor or safety manager does not have the opportunity to follow up with the employee to gain more information about the event. While a completely anonymous system will assure employees that no retribution for their comments will be incurred, a confidential system is more useful. A confidential system ensures that the employees' supervisor(s), or other direct management, will not be privy to the identification of 60

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Safety Reporting System Best Practices 61 Table 11. Best practices checklist for implementing a safety reporting system. Identify relevant stakeholders (e.g., transit management, labor, industry organizations) and obtain program "buy-in" Form a committee composed of stakeholder representatives to oversee pilot and system implementation Provide stakeholder training regarding building consensus and conflict resolution Pilot system Negotiate MOU between labor and management Provide assurances for the safety reporting system to be voluntary, nonpunitive and confidential Recruit a non-biased third party to manage pilot system and assign role of system liaison and support staff Identify/develop data collection and analysis software Assemble report review team and provide appropriate training Provide training prior to roll-out of pilot system Pilot system with at least two transit agencies Refine report taxonomy based on initial reports Evaluate system success Make system available to entire transit industry Disseminate the results of the pilot safety reporting system to stakeholders Provide implementation assistance Provide on-going training regarding the importance of a safety reporting system Disseminate system information Provide timely follow-up to reporting employee Conduct analyses and distribute to management and employees Newsletters Use reports as tools for training the employee supplying the information. To implement a confidential system, a public transit agency should assign an impartial safety representative to review reports from comment boxes or other sources so that employees will not be "outed" to their supervisors. This option will also allow the safety representative the opportunity to follow up with the employee to further explore the contributing factors of the incident. The importance of confidentiality for safety reports is discussed later the System Assurances section. The most important factor to consider when adopting an interim safety reporting system is that the richness and number of reports will be enhanced if the transit agency can ensure a no-blame culture. This means that the transit agency will value any information obtained about an incident stemming from noncompliance more so than punishing the individuals involved in the incident. This is true for all but the most egregious events that involve criminal or malicious intent. A safety reporting system of any size is only useful if it yields information about the reasons why noncompliance or some other safety breach occurred. To the extent that a public transit agency is able to ensure confidentiality within a no-blame culture for submitting voluntary reports, the detail of reports should yield sufficient information to conduct a root cause analysis, that is, provide the reason(s) why an event occurred. The taxonomy and root cause questions presented in Chapter 3 may be used to analyze reports of safety-related rules noncompliance to determine the factors involved.