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APPENDIX A Rules Compliance Practices in Other Industries Other industries, similar to public transportation, must address safety-related rules com- pliance in an effort to prevent low-probability, high-consequence events. The research team selected aviation, railroad, motorcoach, trucking, petrochemical, and construction as industries that face low-probability, high-consequence events and might offer best practices that are appli- cable in the public transportation industry. Two criteria led to the selection of these industries: the individual operator/employee is at significant risk for personal harm as a result of noncom- pliance and the operator/employee puts the public at significant risk for harm as a result of rules noncompliance. Structured interviews with representatives from each industry provided the means to gather information on current industry practices. The interview questions covered the various activities these industries use to teach employees the rules, make sure employees understand the rules, ensure rules are followed, and respond to noncompliance. In addition, the interview explored proactive measures to encourage rules compliance and voluntary safety reporting programs designed to allow employees to self-report rule violations and near-misses. Table 12 summarizes the number of organizations contacted by industry as well as the number of interviews that were conducted. The research team assured anonymity to the organizations that were interviewed; consequently, this information is not included in this report. The interviews produced a great deal of information on each industry. The aviation, railroad, motorcoach, and trucking industries offer many best practices relevant to public transportation. To facilitate the organization and presentation of the best practices for these industries, there is a summary table for each industry that presents the best practices for the following aspects of the safety-related rules compliance program: · Initial rules communication · Communicating new rules · Validating rules comprehension · Monitoring adherence · Responding to noncompliance · Encouraging compliance · Evaluating program effectiveness · Safety reporting mechanisms Federal Aviation Administration (FAA) regulations govern the training and certification of pilots. In addition, FAA examiners conduct check rides with commercial pilots to audit their compliance with FAA safety regulations. Since these procedures do not differ from airline to airline, this information was available from published sources. Therefore, the interviews with aviation industry representatives focused on voluntary safety reporting systems for pilots. 72
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Rules Compliance Practices in Other Industries 73 Table 12. Number of organizations interviewed by industry. Number of Interviews Industry Contacted Completed Aviation 20 12 Railroad 17 15 Motorcoach 8 6 Trucking 9 6 Petrochemical 8 2 Construction 1 1 Aviation Table 13 summarizes the rules compliance and safety reporting practices of the aviation industry. FAA regulations govern flight operations as well as the certification and training of pilots (Title 14 C.F.R., although still commonly referred to as the Federal Air Regulations or FAR). A student pilot who begins training is introduced immediately to the flying regulations that apply to the student's level of flying. At each level of certification, both a written examination as well Table 13. Rules compliance practices of the aviation industry. Program Characteristic Industry Practices Initial rules communication Classroom presentations Computer-assisted training Communicating new rules Through computer-based files indicating information has been read Memorandums with copies that must be signed/initialed and returned Validating rules comprehension Written or computer-based testing Recurrent classroom training Recurrent simulator training Operational line checks Monitoring adherence Voluntary Safety Reporting Systems Operational Flight Monitoring Systems Operational error and pilot deviations and reports FAA violations Responding to noncompliance Dependent on level of deviation/violation and current labor agreement Informal conference with supervisor Formal investigation within company Formal investigation with FAA Encouraging compliance Voluntary safety programs Crew Resource Management Top-down safety culture Emphasizing the causes of safety issues rather than an emphasis on disciplinary action Evaluating program effectiveness Decrease in incidents/accidents Analysis of voluntary safety reports Benchmarking with other airlines Input from the FAA Line operational safety audits Safety reporting mechanisms Safety hot lines Aviation Safety Reporting System Aviation Safety Action Program Other company reporting systems
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74 Improving Safety-Related Rules Compliance in the Public Transportation Industry as a practical, or flying, test is required. As a pilot moves through the various levels of certification, he or she is introduced to the appropriate flying regulations, and must understand these regulations in order to complete the written, oral, and flying evaluations. In order to be hired by an airline or a corporate flight department, a pilot must be certified at the commercial level, with an instru- ment rating, and have a certain level of flying experience. During this period of preparation, the individual will have been exposed to the flight regulations through both the academic and practical flying environment. Therefore, when the pilot is then hired by a flying corporation, he or she is already expected to be familiar with the FAR. During the pilot's initial training, he or she is then presented with the flight regulations that apply to the particular type of flying that he or she has been hired to do. Follow-on simulator and in-flight training re-emphasize the general flight regulations, as well as the specific regulations. Thus, when the pilot begins operational flying, he/she has been exposed to, and is expected to know, all the flight regulations that apply to the new flight environment. In summary, then, as a baseline, the new employer has trained the new pilot to understand any specific regulation that applies to the particular type of flying, and has also re-emphasized general flight regulations. Once a pilot is employed, the FAA requirements for continuous recurrent training apply. The basic requirement calls for a certain amount of annual ground school, a certain number of simulator periods that include flight checks, and the requirement that Pilots-in-Command (Captains) receive a periodic operational line check. In addition, a flight crew may receive an unannounced random line check from an FAA flight inspector at any time. In recent times, many airlines have moved to the Advanced Qualification Program, another voluntary program through the FAA that emphasizes training outcomes and scenario-based training. In general terms, this type of training moves away from the pass/fail checkride mode, and highlights training and proficiency goals. This type of training also uses a simulator exercise called Line Oriented Flight Training (LOFT), which accomplishes the training in an operational scenario, rather than simply dealing with specific flight maneuvers. This type of training is a major change to the older concept of periodic checkrides and results in more effective training and pilot proficiency. In the distant past, once a pilot began operational flying, the pilot's major concern involved incidents and potential violations, resulting in discipline from the FAA or the airline. This resulted in a mentality in which any potential safety issue that was not detected by the system was kept secret. Pilots feared potential discipline, especially certificate suspension or revocation. In addition, it was common for a company to terminate a pilot for such incidents or violations. Needless to say, this did not encourage an environment where a pilot was willing to voluntarily disclose any safety issue. To help combat this perception, the Aviation Safety Reporting System (ASRS) was created in the 1970s. ASRS encouraged pilots to report safety data so that safety trends could be analyzed and system corrections could be made. A detailed description of this system is in Appendix C. Data gathered in ASRS revealed that the most common incident or violation involved an altitude deviation. As a result, a program was developed whereby airlines and corporate aviation departments could develop a voluntary system for reporting these events, and in return the pilot would again receive protective provisions. The Aviation Safety Action Program (ASAP) is explained in more detail in Appendix C. This successful voluntary safety program, which is classified as confidential and nonpunitive, is today a leading contributor to overall flight safety, and has been fully accepted by the FAA, the airlines, and the labor unions. Aviation groups, unions, industry groups, and the FAA offered the following comments regarding ASAP: · The system emphasizes the root cause of incidents and violations, rather than a punitive discipline program.
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Rules Compliance Practices in Other Industries 75 · Approximately 90% more incidents and violations are being uncovered due to the nonpunitive aspect of the program. · All the stakeholders have a high level of confidence in the system. · Safety concerns are now being examined by all parties and system corrections are being made so that these concerns do not develop into accidents/incidents. The FAA's Flight Operations Quality Assurance Program (FOQA) is another example of a successful voluntary program. This program allows airlines to download information regarding the movement of an aircraft from one point to another via flight data recorders. The program is confidential and negotiated through a memorandum of understanding among the FAA, labor, and airlines. The information obtained is not used punitively. Rather, it provides information about aircraft handling that otherwise would go unnoticed. Railroad Table 14 summarizes the rules compliance practices of the railroad industry. The Federal Railroad Administration (FRA) regulations prescribe a program of operational or efficiency testing (40 C.F.R. 217) to determine compliance with operating rules. As of January 1, 2009, this program must place emphasis on those operating rules that cause or are likely to cause the most accidents or incidents. In addition, FRA requires that locomotive engineers be certified every 3 years. Each engineer must have a check ride every year. Each railroad sets the frequency of rules exams but Federal Regulations require that the railroad's program/policy be filed with FRA. Because of these requirements, the approach of all railroads to validating rules compliance is similar. Labor agreements and the Railway Labor Act prescribe procedures for progressive discipline for rules violations so the response is similar from railroad to railroad. In spite of these common requirements, there are significant differences in each railroad's approach to the overall rules compliance process. Locomotive engineers and conductors are trained by the railroad that hires them. The length of this training may vary but all railroads use some combination of instructor-led classroom training and action-based training, and sometimes CBT. Feedback from labor indicates that the most effective rules training is instructor-led, involves practical application or illustration of the rule, and includes an explanation of the purpose of the rule. Railroads use written tests or computer-based tests to validate the employee's rules knowledge. When there is a change in a rule or a new rule, the method for conveying this information will depend upon the complexity and impact of the rule. For major changes, a class or video and job briefing will occur. Other changes will be covered in a general order or system bulletin and then be incorporated into the rule book. All railroads use operational/efficiency testing to monitor rules compliance. In addition, some download locomotive event recorder data to monitor an engineer's performance relative to operating and train handling rules. One railroad reported that this method allows it to identify red light run-throughs that it would not otherwise have known about. Labor expressed the concern that this technology can be overused and in some cases have a negative impact. Most railroads also review radio transmissions. Per FRA requirements, all railroads use accident and injury data to focus their testing programs. One railroad reported focusing on human factors accidents for possible rules problems. There is some variation in the responses to noncompliance. Some railroads do not discuss the operational test results with the employee unless there is unacceptable performance. Many railroads have a policy that supervisors are to give feedback but the positive feedback usually comes later while failures are handled at the time of the test. One railroad reported that it gives feedback immediately, regardless of the outcome. Labor prefers this approach. The supervisor
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76 Improving Safety-Related Rules Compliance in the Public Transportation Industry Table 14. Rules compliance practices of the railroad industry. Program Characteristic Industry Practices Initial rules communication Instructor-led classroom training with scenarios Computer-based training Action-based training Communicating new rules Track Bulletin, System Bulletin, Timetable Class or video and job briefing for major change Validating rules comprehension A minimum of biennial rules class and testing Scenario-based simulator for train handling Operational/efficiency testing Monthly meeting of management/labor committee discusses problematic rules Review test results to identify areas that need more attention Monitoring adherence Operational/efficiency testingmay be scenario-based Review accident/injury data with focus on human factors accidents Download locomotive event recorder data to monitor operating and train handling rules Audit teams to validate testing FRA violations Review radio transmissions One-day safety assessment of co-workers Responding to noncompliance Discuss test failure with employee immediately so cause can be identified Progressive discipline per labor agreement Alternative process with minor, serious and major violation instead of formal investigation Supervisor interview to determine appropriate actions, e.g., training, coaching Encouraging compliance Safety briefings Train supervisors how to coach and counsel employees Mutual accountabilityboth supervisor and employee hold each other to standard of accountability Crew Resource Management Signal awareness forms (conductor records each signal passed) Safety audit program not part of discipline process Safety Assurance and Compliance Program at System and Division levels Debriefing of every accident and incident with no discipline attached 7Cs Programconfirming,correcting, caring, collaborating, coaching, conciliating, clarifying Evaluating program effectiveness Relationship between results of operational testing and accidents/incidents and FRA violations Change in number of accidents and injuries Change in operational/efficiency test failures Benchmarking with other railroads Safety reporting mechanisms Close Call Reporting System Pilot Program Safety hotline Open communication between supervisors and their people
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Rules Compliance Practices in Other Industries 77 may discuss unsatisfactory test results with the employee and recommend an appropriate action such as training or coaching. Railroads reported a variety of proactive strategies for encouraging rules compliance. These include training supervisors how to coach and counsel employees, adopting a policy of mutual accountability between the employee and supervisor, conducting safety audits that are not part of the discipline process, and conducting a debriefing of every accident with no discipline attached. The railroad industry has been characterized by some as having a culture of blame but there are efforts to change this. The ongoing Confidential Close Call Reporting System (C3RS) pilot will determine whether a nonpunitive near-miss reporting system will identify hazardous situations before an incident or rule violation occurs. (See Appendix C.) Aside from C3RS, one Class I railroad is implementing a nonpunitive reporting mechanism that will be managed by the labor organizations that represent its employees. There are also efforts to promote open communica- tion between supervisors and their people. Advice from railroad industry and labor representatives to public transit agencies included the following: · Train the first line supervisor to deal with individuals that violate an operating rule in a non-confrontational way. · Discuss noncompliance issues with other transit agencies and similar industries. · Implement programs such as job briefings and increased rules classes that promote more communication between first line supervision and labor. · Know your people and listen to them. Make sure supervisors are spending time in the field getting to know their people and talking to them. · Make sure employees know the rule, the intent of the rule and how the rule is applied. · In order to take safety and rules compliance to the next level you have to understand why the violation occurred. A misunderstanding or lack of knowledge should be treated differently than conscious disregard of a rule. · Involve employees in the development of operating rules and procedures. · Consider additional regulations for the public transportation industry that will help improve its safety performance. Motorcoach Table 15 summarizes the rules compliance practices of the motorcoach industry. Other than medical standards and commercial driver's license (CDL) requirements, Federal Motor Carrier Safety Administration (FMCSA) has no oversight of driver rules compliance. Most over-the-road motorcoach companies provide both classroom and over-the-road training. One company did report that it only hires experienced drivers with a CDL. This company does a review of all candidates including an extensive background check and a psychological profile test to be sure that the individual meets the company's requirements for drivers. Orientation at this company covers company rules and policies and also includes a crisis management program. Most companies have written exams but one smaller motorcoach operator reported that it relied on the recommendation of an experienced driver who trains the new hire. Motorcoach operators use a variety of methods to monitor compliance with safe driving rules. These methods are the following: · A majority of the companies that the research team contacted reported that they use a video- based system for monitoring driver behavior. The system is triggered by an unsafe driving
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78 Improving Safety-Related Rules Compliance in the Public Transportation Industry Table 15. Rules compliance practices of the motorcoach industry. Program Characteristic Industry Practices Initial rules communication Initial training that may include self-directed study via CBT, classroom and over-the-road training Communicating new rules Notices mailed to drivers' homes Memorandum posted in drivers' area Safety meetings Update training Validating rules comprehension Written exam Check out by veteran driver or trainer Discussion at safety meetings Monitoring adherence Onboard cameras for video recording GPS tracking data Mystery riders Public feedback via internet or 800-number On-road observation by field safety staff Ride-along by operations staff Responding to noncompliance Coaching Retraining Progressive discipline Encouraging compliance Awards or financial incentive for no preventable accidents or other safety violation such as cell phone use while on duty Evaluating program effectiveness Track at fault collisions, customer complaints Accident Review Board Review events from video data recording system Safety reporting mechanisms 800-number for reporting; treated as confidential Safety committees Driver suggestion box Management open door policy behavior such as hard braking or speed. When the event occurs, the system saves a video recording of the event along with engine data. · Some companies hire mystery riders who purchase a ticket and ride the bus to observe the driver with regard to speed, customer service, distracting activities while driving, following distance, and other safety behaviors. · Some companies have GPS tracking systems on their vehicles. These systems provide position and speed data. · Some companies rely on observation by safety managers from a trailing vehicle. In addition to the above activities, motorcoach operators also review customer complaints that come through an 800 number or email. When management becomes aware of an unsafe driving behavior through one of the methods described above, the driver's supervisor will meet with him or her to discuss the observation. The driver may be coached or sent for retraining. The information from the video monitoring system is used as a training tool, not as a means to discipline drivers. In every place where this system is in operation, labor initially resisted it. After a number of instances where the video data showed that the driver was not at fault in an accident, that is, it was a non-preventable accident, the drivers began to support its use. Discipline is an option when the driver does not respond to coaching and training. All motorcoach companies evaluate their compliance programs based on the number of avoidable accidents. Those with video monitoring also look at the number of events that are
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Rules Compliance Practices in Other Industries 79 reported. Motorcoach operators that use video monitoring all reported a decline in accidents after the system was installed. Nearly all of the motorcoach companies have an incentive program to reward safe driving. Many of the people interviewed stressed that the drivers value these programs because the programs recognize the drivers as professionals. Both labor and management made this point. In some companies, compensation is based on safe driving. Motorcoach industry and labor representatives offered the following advice to the transit industry: · The most important way to encourage safe driving is to have open communication between the employees and management. Have an open-door policy and do one-on-one counseling. · Safety must be a goal for everyone. Management sets the tone for safety, starting at the top. · Conduct periodic safety meetings that include a review of actual situations that have occurred. · Do a thorough background check and conduct a comprehensive road test before hiring a driver. If you hire the right people, there are fewer performance issues. Trucking Table 16 summarizes the rules compliance practices of the trucking industry. FMCSA has no direct oversight of driver rules compliance. Therefore, the agency thought the interview efforts of this project would best be suited for specific fleets and industry organizations. The following summarize these efforts. Table 16. Rules compliance practices of the trucking industry. Program Characteristic Industry Practices Initial rules communication Instructor-led training Practice in nonrevenue service Read and sign policy Communicating new rules Read and sign policy Safety briefing Validating rules comprehension Periodic safety quizzes Periodic driver re-certification Quarterly Internet-based safety training Monitoring adherence Ride-along Public reporting via 800 phone number Private monitoring services for covert observation Hard braking data from engine recorder Responding to noncompliance Remedial training Peer coaching Progressive discipline Conduct root cause analysis Encouraging compliance Periodic safety meetings Monthly newsletter Posters Incentive award system for positive safety behavior Employee recognition program (nonmonetary) No tolerance policy for use of electronic devices Defensive driving program Evaluating program effectiveness Evaluate rule book and modify for clarity Hard braking frequency Safety reporting mechanisms Confidential report to safety department
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80 Improving Safety-Related Rules Compliance in the Public Transportation Industry The trucking industry is a proud proponent of safe operating practices. These companies realize they can either pay up front for proactive safety measures, or they can pay later (most likely at greater loss to the company) for accidents resulting in injury and claims. Therefore, they consider safety to be an investment. The industry hires inexperienced as well as experienced drivers and uses various employee screening methods. The most predictive of these methods are the drug and alcohol offender screening process and the review of moving violations. The types of initial training for each differ based on experience. Subsequent information regarding rules may be relayed during periodic safety briefings. Some have traditional types of training (e.g., biennial spring/winter training). In the winter, specific types of safety rules can be revisited such as driving in icy weather, whereas spring training will highlight different driving challenges (e.g., fatigue resulting from the driver pushing him- or herself because of the extra daylight hours). There is a trend toward moving from these traditional types of training to more frequent (sometimes five times a year) CBT along with an annual rules recertification and in-truck assessment. One company recently revised its rulebook examining each operating rule for relevance. It assigned employees, including drivers, to working groups for each section of the operating manual. The process took 3 months and uncovered areas where retraining was necessary. The end product was a streamlined version of the rulebook that was driver-friendly and provided much-needed clarity of the written rules. The trucking profession consists of primarily two types of drivers. Some have dedicated routine assignments while others are long-haul operators. Both types of drivers present unique challenges to the companies that employ them. It is particularly difficult to manage long-haul drivers and create a sense of cohesiveness among the workforce. Large companies feel the need to create an atmosphere of individual responsibility given the sometimes geographically distributed workforces. In addition to fostering self-monitoring, these companies will require periodic ride-alongs, monitor motorist reports, as well as review automated truck-handling reports. They also keep track of accident data to inform risk assessment. These monitoring strategies act as proactive ways to prevent accidents, but they also provide a means for the company to identify noncompliant individuals, intervene through coaching or procedural changes, and then track subsequent behavior. The industry is proactive in many regards. One trucking company reported that it looks beyond the cause of accidents attributed directly to driver error. This company recognizes the fact that 65% of accidents are due to reasons other than faulty driving. As a result, the company looks at these incidents to identify ways to improve driver ability to prevent similar occurrences. To facilitate this proactive approach, the company relies heavily on a private methodology geared toward teaching drivers to be aware of their surroundings. These companies rely on incentive programs to engage their employees. They report traditional bonus programs, but also use non-monetary rewards like safety recognition (e.g., the CEO of the company might send a personalized letter to a valued employee). One trucking company reported that it believes these programs are undervalued. The interviewee stated that many trucking companies spend so much time identifying when things potentially go wrong, that they sometimes forget the importance of acknowledging the people who provide safe and efficient transport services. A labor representative commented that it is important to train and recognize vehicle operators as professionals. While much of the responsibility of professionalism falls on the shoulders of the drivers, the companies that employ these individuals are responsible for providing the opportunity for professional certification, honoring good driving behavior, and compensating their drivers competitively. These company actions will go a long way toward encouraging safe driving behavior
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Rules Compliance Practices in Other Industries 81 and helping drivers not feel the need to take shortcuts or make unsafe actions in the interest of generating more income (e.g., violating hours of service, speeding, etc). When asked what advice to offer the public transportation industry, one company remarked that you "must start with a foundation of safety culture." Management commitment from the top-level down is the only way this can be accomplished. Labor also remarked on the importance of fostering a safe culture. Petrochemical The research team conducted interviews with two petrochemical companies. Table 17 summarizes the practices of these two petrochemical companies. All employees, including office workers, receive safety training as part of their initial orientation. Those employees who handle chemical products are trained in the standards relevant to their particular job. Some training is computer-based/online, but most is on-the-job with an experienced employee. In addition, one petrochemical company reported holding monthly safety meetings. This company emails new or changed rule details to employees if the monthly meeting is scheduled more than a few days after a rule change is effective. One company conducts safety audits of all hazardous material remediation projects as well as its plant operations. Audit results are summarized in a Safe Act Index. Any employee found to be non-compliant during the safety audit will be educated appropriately. The other petrochemical company relies on its shift supervisors in the plant to monitor adherence to safety rules. This is the primary way that management becomes aware of rule noncompliance. Employees at both companies are also strongly encouraged to self-report incidents as well as near-misses, also referred to as unanticipated occurrences (UO). Remedial training may be recommended when there is a safety violation. Dismissal would occur only in the most egregious cases or if there are repeated willful actions. One company reported that management expects supervisors and managers to intervene and coach on the spot for any actions that do not follow policy, regardless of whether or not it results in an event. Both companies use leading/lagging indicators to monitor the effectiveness of their safety compliance programs. Examples of leading indicators are monthly safety meeting attendance, Table 17. Rules compliance practices of the petrochemical industry. Program Characteristic Industry Practices Initial rules communication Computer-based training OJT Communicating new rules Email changes Monthly safety meetings Validating rules comprehension Safety audit Monitoring adherence Safety audit Supervisor observation Responding to noncompliance Remedial training Coaching Encouraging compliance Monthly safety meetings Coaching Safety audit Evaluating program effectiveness Leading/lagging indicators Safety reporting mechanisms Self-report incidents and near-misses
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82 Improving Safety-Related Rules Compliance in the Public Transportation Industry completion of UO reports on time, and the requirement for one safety contact per employee quarter. Safety contacts can be providing training at monthly safety meetings, audit completion, completing a Project Safety Analysis, or calculating a Safe Act Index. Lagging indicators are environmental deviations, incidents, and injuries. The petrochemical companies report that they use safety training, safety meetings, peer coaching, and auditing to encourage compliance. Representatives at one company reported that "Safety is not an option; it is a culture." Management expects employees to comply. When asked for advice to public transportation industry management, interviewees offered the following: · You will achieve the level of safety excellence that you demonstrate that you want to achieve. · There must be a way to check if rules are being followed. · A clear focus from senior management that safety is important and is a fundamental policy of the company will set the tone for how people work. Construction The research team contacted a major construction company based in Massachusetts to learn about its safety rules. Because this industry involves the use of construction equipment and large trucks, there was a possibility that some useful practices with application to transit operations would exist. (Its vehicles cover 3 to 5 million miles a year in total.) Most of the initial training to new hires involves personal safety but the training also covers driving safety. The company has the employee sign a safety "agreement" after reviewing the safety handbook. New hires are assigned a mentor, usually a senior foreman, who works with them to help them identify and avoid hazards. There is no formal rules compliance testing or evaluation. Foremen are responsible for monitoring employees. If an incident occurs, a superintendent or project manager may then increase monitoring of the foreman and the foreman's people. The company keeps a record of all safety infractions. Depending upon the nature of the safety infraction, there is a progressive discipline policy. The company evaluates the effectiveness of its safety program by monitoring the number of injuries requiring first aid, number of recordable injuries, and lost-time injuries per hours worked. The company treats near-misses as an incident and asks employees to report them on the incident report form. These reports, which go to the safety director, are confidential but not anonymous. The safety director reported that the company tries to maintain a culture of safety but that this requires personal involvement from management. When asked what advice he would offer to public transit management, his comments were more about safety culture than rules compliance. He offered the following: · Share information with everyone, be it good or bad. Report the what and why, not the who. · Management involvement and support is very important. If the management is involved, then the employees will follow. · Be constantly alert; just because there has not been an incident does not mean it cannot happen. Since the practices of the construction industry did not appear to offer any practices or strategies that were not present in the other industries, there were no additional interviews with construction companies.