National Academies Press: OpenBook

Improving Safety-Related Rules Compliance in the Public Transportation Industry (2011)

Chapter: Chapter 5 - Safety Reporting System Best Practices

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Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Page 63
Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
Page 63
Page 64
Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
Page 64
Page 65
Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
×
Page 65
Page 66
Suggested Citation:"Chapter 5 - Safety Reporting System Best Practices." National Academies of Sciences, Engineering, and Medicine. 2011. Improving Safety-Related Rules Compliance in the Public Transportation Industry. Washington, DC: The National Academies Press. doi: 10.17226/14593.
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Page 66

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60 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 C H A P T E R 5 Safety Reporting System Best Practices

Safety Reporting System Best Practices 61 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. 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 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Table 11. Best practices checklist for implementing a safety reporting system.

Stakeholder “Buy-In” A strong foundation for a safety reporting system begins with encouraging a cooperative environment for the reporting system’s stakeholders, otherwise known as obtaining “buy-in.” By getting the interested parties to agree up front about the goals and objectives of the safety reporting system, deadlock and dispute may be minimized as the system evolves. All of the safety reporting programs reviewed were successful in getting “buy-in” from their respective regulators, industries, management, and labor unions. None had a formal process for encouraging stake- holder “buy-in”; however, there were activities the stakeholder representatives engaged in that facilitated cooperation. One of these activities involved assembling a planning committee or implementation group with representation from each of the stakeholder groups. The members of these committees worked toward the common goal of creating a safety reporting system. In doing so, trust developed over time. A second successful activity included having exploratory workshops whereby stakeholder representatives invited safety leaders from other industries to discuss and present the merits of their approaches to safety reporting systems. Stakeholder attendees then had the opportunity to discuss the benefits and limitations of these safety reporting systems for their own industry. This provided a means for these individuals to express concerns and issues prior to the imple- mentation phase. System Assurances Barriers to a reporting culture include fear of individual or organizational retribution, the incorrect assumption that human error is a measure of competence, and the legal complications associated with discovery of error reports. There are three necessary assurances that minimize these barriers and encourage employees to report. The most successful systems are voluntary, nonpunitive, and confidential. Mandatory safety reporting systems require an individual to file a report. However, most errors have many underlying causes and may involve more than one individual, which makes it unclear who should file a report. As such, reporting responsibility for mandatory systems often places the reporting burden on the supervisor. Because the supervisor did not experience the event and is only reporting it secondhand, the fidelity of the information may be lacking and not reveal sig- nificant information regarding the root cause(s) of the event. Voluntary systems encourage the employees who experienced the events firsthand to report them. A culture of blame will most certainly deter widespread safety reporting. Many reporting systems offer reporting incentives that minimize or eliminate any disciplinary action for an incident except for the most egregious violations. The nonpunitive aspect of these systems eliminates any fear of retribution. Last, confidentiality is a hallmark feature of a successful safety reporting system. However, this assurance may be one of the most difficult to implement. In blame-ridden organizational cultures, management may resist keeping the information confidential. The rationale in a culture of blame is that those committing errors and violations are inherently inadequate employees in need of punishment. A cultural shift is necessary and requires educating middle management that it is more important to identify the root cause(s) of errors and violations than to assign blame and punish. Root causes can be mitigated; however, punishing someone for something he or she could not prevent is not an effective practice. Because this last assurance is key to a successful safety reporting system, the stakeholders of the systems reviewed took great care to ensure this feature. The reports from many of the systems 62 Improving Safety-Related Rules Compliance in the Public Transportation Industry

Safety Reporting System Best Practices 63 were handled by a third-party agent who was responsible for de-identifying the reports and in some instances coding the incident factors. Pilot Implementation Prior to full-scale implementation, piloting the system is recommended. The merits of instituting a pilot system are as follows: • Allows the safety reporting system to be tested at a few choice sites or departments to identify program strengths and weaknesses • Gives the implementation team an opportunity to monitor program effectiveness and make any necessary adjustments before full-scale implementation • Lowers the overall cost of the system because the system design is optimized before its adoption The research team learned that one of the most important practices for implementing a pilot system is that it must have high visibility. Ways to market a pilot safety reporting system include posters, news conference at trade shows, and trade publications. One program used direct mail with a program kit to encourage reporting. Most safety reporting programs held town hall-like meetings with representatives from labor and management whereby employees could raise concerns and have their questions answered. One program used focus groups conducted with employees to evaluate the reporting form and reporting system features. These methods are highly recommended before rolling out a pilot safety reporting system. Training for the program stakeholders should include the following: • Provide consistent information across all stakeholders. • Educate how program addresses transit agency’s safety goals and culture. • Educate how safety reporting removes threats to safety. • Clearly define and explain reporting incentives. • Make sure stakeholders fully understand the safety reporting process. • Provide training on the principles of trust and how to develop it. • Develop teamwork skills for report review teams. • Explain how to use the taxonomy to classify events and the related causal and contributing factors including root cause analysis. • Stress importance of responding to recommendations of report review teams. • Provide periodic refresher training. • Integrate with new hire training. Memorandum of Understanding For existing organization-based safety reporting systems (i.e., not a centralized repository of incident reports such as ASRS), an agreement between the organization’s management (e.g., airline or railroad), the labor union, and the regulatory agency had to be negotiated. Originating from the airline industry model of safety reporting systems, this agreement is referred to as an MOU. The basic (core) information included in an MOU is as follows: • Describes how the information obtained from the reports will be analyzed • Authorizes nonpunitive response to noncompliance including skill enhancement or system corrective action to help solve safety issues; reports accepted under the program will result in lesser action or no action, depending on whether it is a sole-source report

64 Improving Safety-Related Rules Compliance in the Public Transportation Industry • Describes the egregious events that are not acceptable; examples include gross negligence, criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification of information • Describes the reporting process and the role of the report review team • Outlines the provisions for information dissemination from the safety reporting system For both the aviation and railroad safety reporting systems, the template MOU was devel- oped by committees composed of stakeholders representing all facets of their respective industries. The program managers of the safety reporting systems reported that negotiating the final Implementing Memorandum of Understanding (IMOU) was the lengthiest part of the implementation. This was due in large part to the numerous stakeholder requirements. Team- and consensus-building training for the stakeholders will facilitate negotiations. In addition, the language of the MOU template needs to be amenable to the changes that may be required during negotiations (i.e., a single MOU suitable for all public transit agencies is not practical). Reporting Process Figure 14 presents a diagram of the recommended reporting process as well as the report review as described in the next section. The most important aspect of the report submission process is to encourage timely submission. For a voluntary safety reporting system, the only way to accomplish this is to incentivize the process by setting a time limit for submittal of reports that will be covered by protective provisions (i.e., immunity). For some safety reporting systems, the time limit ranges from 24 hours to 10 days. It is important for the reporter to relate the event before Figure 14. Safety reporting process.

memory of it becomes contaminated or begins to degrade. Twenty-four hours with the option of requesting to extend the time limit to 72 hours is a sufficient timeframe for reporting. It is also imperative that the reporting process be as simple and efficient as possible for the reporter. To do so requires a user-friendly electronically available system, which ideally is accessible from home. The system should have the following features at a minimum: • Data fields pre-populated with relevant information, e.g., employee name • Drop-down boxes for commonly used responses • Format that guides the submitter through a series of questions that when answered, automati- cally directs him/her to other related data fields • Ability to upload attachments used as part of the investigation process • Email capability (allows communication to be tracked but kept confidential) • System-generated-acknowledgment of receipt of report Report Review Team Ideally, the report review team should be a three-person group composed of individuals that rep- resent labor, management, and the regulatory agency. Since there is no federal regulator for transit, as there is for aviation and railroads, the third member of this team might be a representative from the state safety oversight agency, FTA, or an impartial arbitrator. The presence of a third person on the review team prevents deadlock from occurring during the report deliberation process. The pur- pose of this group is to review the report and supporting documentation to determine if there are any corrective actions or recommendations to be made regarding the reporter as well as the public transit agency. Remedial training is an example of a recommended action for an employee; whereas, adopting a new safety-related rule is something a transit agency might be asked to do. To accomplish their tasks, the report review team needs specific types of training, which include consensus-building, conflict management, team-building, and root cause analysis (RCA). There are specific attributes that help qualify someone for a position on a report review committee. These include the following: • Expert knowledge about the work processes the reports will involve • Knowledge of safety principles • Effective communication skills • Ability to compromise It is important to document the review team’s processes and procedures in a manual; it should include important contact information and procedures for handling difficult situations. Additionally, the team should set aside one meeting annually to review program guidelines, the review process, and member roles and responsibilities. New members should be required to shadow veteran members and observe other review teams before full group membership. In addition to the members of the report review team, the transit agency should assign program management responsibility to a liaison. As a nonvoting member of the report review team, the program liaison is an objective staff member that oversees the information capture process and facilitates the activities of the team. In addition, this person is the point of contact for the transit agency management as well as labor with regard to the safety reporting system. This person would most likely be on the staff of the transit agency’s safety department. For additional information regarding report review teams, the American Institutes of Research (2009) reviewed the best practices of “event review committees” in the context of the Aviation Safety Action Program (ASAP). This document is a valuable resource for implementing a report review team. Safety Reporting System Best Practices 65

66 Improving Safety-Related Rules Compliance in the Public Transportation Industry Review Process After submittal, the report will go through a multistep process before it reaches the attention of the report review team (Figure 14). The safety reporting program liaison or an appointed report analyst managed by the liaison must perform several intermediary steps. These include coding the report with respect to the event and report taxonomies, clarifying any vagaries during a callback with the reporter and de-identification. The analyst needs to be a subject-matter expert familiar with the transit operations he or she will be reviewing. The taxonomy presented in Chapter 3 can be used as an initial prototype classification system for a pilot safety reporting system. The taxonomy may be modified based on the types of reports and comments received from the results of a pilot safety reporting system. Just as the reporting process needs to occur in a timely manner, the review process needs to be expedited to ensure that the review team’s corrective actions and recommendations are relevant. Timely feedback will be a testament to the system’s effectiveness and therefore promote system trust among public transit agency employees. Therefore, team meetings should be scheduled as often as possible. Report review teams should meet either weekly or monthly depending on the number of reports they must review. Some recommendations for the review process include the following: • Reports should only be reviewed when sufficient/required information is available for the review team to deliberate on. • Review old reports first to close them out then review the newer ones. Prioritize the new reports by risk level, if possible. • Corrective actions and recommendations should be the end-product of risk assessment and root cause analysis. • Maintain complete records of the report review process. • Follow up with appropriate persons to make sure recommendations have been implemented and are successful; examine trends from reports before and after implementation to judge success. Disseminating Safety Reporting System Information To fully realize the benefits of a safety reporting system, there must be a process for the data to be disseminated to the reporting employees, the workforce in general, and transit management. To accomplish this, the data management system must have a user-friendly way to provide mean- ingful analyses. There are two levels of analyses: (1) the report level containing the narrative, which informs corrective actions for individuals and (2) the event level, which informs organizational improvement. It is important to summarize the data to identify trends. Important ways to summarize the data include the following: • Event characteristics • Causal and contributing factors • Risk assessment • Corrective actions and recommendations The following are common ways data are disseminated from safety reporting systems: • Newsletters • Report of the month • Reports to enhance training and safety drills • Periodic reports of data trends • Periodic reports to management by the review team

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TRB’s Transit Cooperative Research Program (TCRP) Report 149: Improving Safety-Related Rules Compliance in the Public Transportation Industry identifies potential best practices for all of the elements of a comprehensive approach to safety-related rules compliance.

The categories of best practices, which correspond to the elements of a safety-related rules compliance program, include screening and selecting employees, training and testing, communication, monitoring rules compliance, responding to noncompliance, and safety management.

The report also outlines the features of a prototype safety reporting system for public transportation.

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