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

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The public transportation industry currently employs a variety of practices to ensure compliance with safety-related rules. Structured interviews with representatives of transit agencies across all modes and sizes, labor, and industry as well as representatives from regulatory agencies provided the means to gather information on current industry practices. The questions used for these interviews covered initial rules communication, notification of rules changes, verifying employee rules knowledge, monitoring for rules compliance, responding to rules compliance, and measures to encourage rules compliance. The interviews also covered evaluating rules compliance program effectiveness and asked the organizational representative “What advice would you give another public transit agency with regard to fostering rules compliance?” The following sections highlight the research team’s findings with regard to each transit mode. Table 18 summarizes the number of organizations contacted as well as the number of interviews that were conducted. As Table 18 indicates, not all the public transit agencies contacted were available for interviews. The ferry operator is summarized along with the cable car operator under Other in the narrative section. As was the case with the nontransit industries, the research team assured anonymity to these organizations so this information does not appear in this report. Commuter Rail Table 19 provides a summary of the practices reported by the five commuter rail agencies that were contacted. The FRA regulations that apply to railroads also apply to the commuter railroads. This means that the commuter railroads must have a program of operational testing and their locomotive engineers must have biennial rules examinations and annual ride checks with the supervisor of locomotive engineers. All commuter railroads have training programs for their engineers and conductors. Some hire all new recruits as conductors or assistant conductors and then after some period of time allow them to apply to become a locomotive engineer. Initial training for both engineers and conductors includes rules instruction and a written examination. While FRA requires a rules class for engineers every 2 years, some commuter railroads require this annually for both engineers and conductors. One labor representative commented that the most effective training includes an explanation of the reason or need for the rule, a demonstration of practical application, and hands-on practice applying the rule. One commuter rail operator reported that prior to some rules classes, it administers a pre-test to gauge the group’s understanding prior to the class. These results are compared with the scores 83 A P P E N D I X B Rules Compliance Practices in the Public Transportation Industry

84 Improving Safety-Related Rules Compliance in the Public Transportation Industry Number of Interviews Mode Contacted Completed Commuter rail 5 Light rail 7 6 Heavy rail 8 6 Bus 12 11 Paratransit 3 Ferry 2 1 Other (cable car) 1 Labor 6 4 FTA 1 Industry Organization 2 8 3 1 1 2 Table 18. Number of transit agencies contacted by mode. Program Characteristic Industry Practices Initial rules communication Instructor-led training Onboard OJT Communicating new rules Short class or safety briefing for major rules “Meet and greet” notification from supervisor for major rules Issue as bulletin order then general order Update rule book Cover in next annual rules class Validating rules comprehension Written exam Annual rules class and exam Monitoring adherence Supervisor observations per FRA operational testing Check ride in cab Download data from onboard recorder Data from signal system Onboard spotters (cell phone use) Responding to noncompliance Minor noncompliance, supervisor coaches and counsels employee, may require retraining Decertification if FRA specified violation per regulation Dismissal for cell phone use Encouraging compliance Encourage employees to bring issues to local safety committees Post notices to emphasize consequences of serious violations Posters to heighten awareness Safety bulletins to address special situations in proactive manner Evaluating program effectiveness Monthly review of all accidents, incidents, near-misses Results of operational/efficiency testing FRA Audit reports Safety reporting mechanisms Confidential Close Call Reporting System Daily crew de-briefing Confidential report to safety department Table 19. Rules compliance practices in commuter rail operations.

of the group at the end of the class. This is done for informational purposes only and provides a means to judge the effectiveness of the training. All commuter railroads have a program for operational/efficiency testing that is driven by accident and injury experience. In addition, commuter rail operators identify rule noncompliance using data that is downloaded from the locomotive and indications from the signal system. The check ride that is part of locomotive engineer certification also may identify noncompliance. One commuter railroad reported that it uses onboard spotters to monitor handling of cash by conductors in ticket sales. These people have also been instructed to report unauthorized use of cell phones by the train crew. As with other public transit operations, commuter rail operators receive complaints from patrons which may lead to the identification of a rule violation. The most common violations are signal violations and entering a work zone without proper per- mission. On commuter rail systems with at-grade rail-highway crossings, improper protection violations occur. FRA regulations prescribe engineer de-certification for certain rule violations. For minor non- compliance, the employee’s supervisor will coach and counsel the employee and retraining may be required. Most commuter railroads have a “no tolerance” policy with regard to cell phones and anyone found using one will be terminated. Some permit the employee to have it in a grip that is on the train, but the device must be off. Since the locomotive engineer is alone in the cab, detecting cell phone use or texting is difficult. One of the NTSB recommendations following the Chatsworth accident was that video cameras be placed in the locomotive cab to detect this behavior. Commuter railroads have employed a number of proactive strategies to encourage rules compliance. Examples are the following: • For key rule changes, such as a new cell phone policy, one commuter railroad uses a “meet and greet” approach where a supervisor explains the new rule one-on-one. • Training bulletins that address special situations (e.g., taking shortcuts) in a proactive fashion are given to supervisors for distribution to their people. • Safety bulletins or alerts to give actual examples of the consequences of rule violations on the property or at another commuter railroad. These may be used in safety briefings. • Conduct of a hazard analysis to identify risks related to rule violations and unsafe situations. • Daily job de-briefing at the end of the day’s last run including review of how unanticipated situations were handled. One commuter railroad is participating in the Close Call pilot implementation. The other commuter railroads reported waiting to see the results before committing to that type of non- punitive safety reporting system. All commuter railroads review the results of operational tests as well as all accidents, incidents, and near-misses. If there is a pattern in either accidents or rule noncompliance, observations in the operational testing program may be refocused. This review may occur monthly and/or quarterly. One large commuter railroad took this review to a different level. It established a task force to look at hazards as a proactive measure to prevent rule violations and accidents. Commuter rail operators offered the following suggestions on ways to foster rules compliance: • There is no substitute for supervision. Supervisors must observe their employees. • Address a problem when it occurs. • Be proactive rather than reactive. • Encourage employees to speak up and ask for help if they don’t know how to do something. • Frontline supervisors must work with the hourly people. They must create an atmosphere of trust. The vehicle operators need to know that they are going to be supported for working Rules Compliance Practices in the Public Transportation Industry 85

safely. Supervisors must be accountable for the overall performance of their employees, not just on-time performance. • Rules compliance requires a holistic approach that is based on a safety culture that comes from the top of the organization. Light Rail and Heavy Rail Table 20 provides a summary of the practices reported by the six light rail and six heavy rail transit agencies that were contacted. The approach that most public transit agencies use for monitoring rules compliance is very similar to that used by the railroad industry. Unlike the railroad industry, oversight comes from state agencies, not a federal agency. The one exception is any light rail service that operates over track shared with a freight railroad and is part of the national railroad network. That service is subject to FRA requirements. This applies to two light rail operators that the research team interviewed. 86 Improving Safety-Related Rules Compliance in the Public Transportation Industry Program Characteristic Industry Practices Initial rules communication Instructor-led training Practice in nonpassenger operation Onboard OJT Communicating new rules Safety bulletins, employee acknowledges by signature Classroom training Posters Validating rules comprehension Written exam Practice operation Rule of the day/month Quarterly safety workshops Monitoring adherence Operational/efficiency testing Download data Observation by roving supervisor (off vehicle) Ride-along Public input Responding to noncompliance Progressive discipline depending upon severity of violation Employee counseling Retraining Encouraging compliance Quarterly workshops with LR operators Rules of the week Defensive driving course (LR) Safety award program Hazard analysis Management/labor safety audits Evaluating program effectiveness Results of efficiency tests Accidents Safety reporting mechanisms Safety committee with hourly and supervisory personnel Open door policy Confidential report to Safety Department Use of positive safety language Near-miss reporting system Table 20. Rules compliance practices in light and heavy rail operations.

Training for rail transit operators is always a combination of instructor-led classroom and field training. The representative for one light rail operator mentioned that since situational awareness is a key skill, this agency screens for this skill during the recruitment process. There is a written exam to validate the candidate’s knowledge of the rules. Rules recertification, including signals, beyond the initial test varies by location. For example, California requires annual rules exams for all rail operators. Other rail transit systems require biennial recertification. In addition to periodic testing, rail transit agencies use a number of strategies to validate rules knowledge. These include having a rule of the day that is discussed at safety meetings or a rule of the month that the supervisor reinforces with each operator. One heavy rail transit operator queries vehicle operators during their shift and asks them to repeat back the rule of the day. One light rail transit operator conducts quarterly workshops with vehicle operators. These are half-day informal events that are intended to communicate information regarding recent industry accidents or incidents, or rulemaking that has occurred. There is no testing at these workshops. The common element in all rail transit safety-related rules compliance programs is operational/ efficiency testing. The rail transit agency has a written plan with goals for the number and types of tests that must be done each month. These tests are planned, but supplemental unannounced tests may occur. Some rail transit agencies report that they make these tests transparent to their vehicle operators while others feel they should be done without operator knowledge. Only one rail transit agency reported giving positive feedback to the operator after successfully passing a test. Failures are always communicated immediately. Other techniques for monitoring compliance include download of vehicle data, roving supervisors who observe operations, and supervisor ride-along with the operator. Public input received via toll-free number, Internet, or email may also identify rules violations. When asked about the most frequent types of violations, rail transit agency representatives mentioned failing to sound the horn in a work zone and accepting an improper route at a switch as light rail violations. Heavy rail operators mentioned failure to stop or hold at a specific location and closing the door on a passenger. When a violation is detected, the response will depend upon the severity of the violation. The supervisor may counsel or coach the operator, or retraining with follow-up observations may be recommended. Most rail transit systems have prohibitions regarding the use of cell phones and texting while on duty. Some have a “no tolerance” policy requiring immediate dismissal. Others apply progressive discipline. Progressive disciplinary action occurs for serious rule infrac- tions. Union agreements prescribe the discipline process. One labor representative commented that if a vehicle operator has a bad attitude and does not want to come to work, forcing the oper- ator to take off 3 days without pay is not punishment. He added that this individual needs retraining, not punishment. More than one labor representative pointed to the need for root cause analysis to identify any underlying problems that are responsible for or contribute to safety-related rules violations. The researchers learned of two noteworthy examples where root cause analysis identified the underlying contributing factors. They are the following: • NJTransit’s River Line experienced a number of red signal violations that exceeded the indus- try average over a 3-year period. A thorough investigation of these incidents revealed that the majority of LRV operators who had violated the stop signal reported that they presumed that the signal would be permissive by the time they reached it. Understanding that it was presumption not distraction or some other reason led River Line management to the appropriate way to reduce these violations. • Two track worker fatalities on the New York City Transit (NYCT) subway system led to the formation of a labor/management task force to identify the underlying reasons for these Rules Compliance Practices in the Public Transportation Industry 87

fatalities. In addition to measures to improve track worker safety, the task force investigated the safety culture and current perceptions of safety. Among the recommendations of this task force effort are joint labor/management safety audits that are nonpunitive, injury and illness data analysis, root cause analysis of accidents and near-misses, and an ongoing evaluation of the safety consciousness and culture. The final report from the Joint Track Safety Task Force is impressive. Other materials that the research team obtained indicate that changes were made in operating rules for train operators, track workers, and flaggers. Rail transit agencies employ a variety of measures to encourage rule compliance. NYCT conducts safety audits to reinforce compliance with safety rules and identify hazards before there are problems. Appendix C contains a description of this NYCT program. Other strategies include quarterly workshops with operators, focusing on a Rule of the Week in safety meetings or via bulletins, selecting a rule for operator coaching sessions, and safety incentive programs. Some public transit agencies conduct a hazard analysis to identify problem areas that are a risk for a rule violation or accident. One labor representative commented that vehicle operators become complacent after 5 to 7 years of experience and that for this reason they need reminders as to how to operate in accordance with the rules. This same individual also commented that, in his experience, peer coaching can and does reduce this complacency. All public transit agencies evaluate the effectiveness of their compliance programs in terms of the results of their efficiency tests and number of accidents. Agencies review these data on a periodic basis, usually monthly, and adjust their test plans accordingly. There is a variety of mechanisms for transit employees to report safety issues but only NYCT has a system that is specifically designed to encourage reporting of near-miss incidents. (Appendix C contains a description of this program.) Transit agency and union safety committees accept issues from operators and most safety departments provide a confidential 800 number for reporting safety issues and near-misses. Labor believes that if there are honest good faith efforts by man- agement to listen and act on problems, then employees will report these situations. Lacking trust, the reporting will not happen. Rail operators offered numerous suggestions on ways to foster rules compliance. These suggestions included the following: • Get the employees actively involved in safety. This occurs when management removes the motivation for “gotcha” actions to penalize the employees and fosters dialog on the underlying reason for each rule and how it protects the operator. • Build a training curriculum that teaches using both classroom methods and practical appli- cation of rules and procedures. • Line supervisors must be able to coach vehicle operators. Not every operational deviation requires harsh discipline. • Remain consistent in training and communication with operators. • Let people know they are appreciated. Bus Table 21 provides a summary of the practices reported by the 11 bus transit agencies that were contacted. Safety rules compliance programs for bus operators are similar to those in the trucking and motorcoach industries. However, many of these properties are small, which has advantages and disadvantages. The main advantage of small transit agencies is that they have open-door policies and managers personally know their employees. This aspect fosters the communication necessary 88 Improving Safety-Related Rules Compliance in the Public Transportation Industry

Rules Compliance Practices in the Public Transportation Industry 89 Program Characteristic Industry Practices Initial rules communication Instructor-led training Onboard OJT Communicating new rules Written and video presentation during orientation, refresher training, and following incident Monthly driver safety meetings Monthly employee newsletter National Safety Council publications Rule of the week program Read/Sign policy for new rules Bulletin board Broadcast email, data messages on screens in buses and radio alerts Weekend safety retreat Validating rules comprehension Periodic supervisor ride-along Employee interview and field observation following incident Review of safety incidents Random ride check with instructor Monthly performance evaluations Periodic safety rules quizzes Exams following orientation and retraining sessions Safety discussions at periodic driver meetings Monitoring adherence Periodic supervisor ride-along Onboard camera f or video recordingand GPS monitoring Ghost riders Passenger reports Operational testing Responding to noncompliance Supervisor disciplinary discretion based on interviews and review objective incident information (e.g., camera) Demerit/point system Coaching and counseling; retraining when necessary Progressive discipline Union input if property is represented Accident Review Committee recommendation for discipline Encouraging compliance Video training Rules revision in response to risky procedures Increase length of initial and refresher training No tolerance policy for specific types of risky behavior (e.g., cell phone use) Regular evaluations linked to incentive program Expansion of video monitoring Operator self-assessment programs Accident reduction team Safety campaigns Adopt improved safety policies Annual awards program Evaluating program effectiveness Field and written exams Quantitative risk assessment Accident frequency statistics Accident trends Safety point system for employee evaluation Passenger reports Annual safety audit Safety reporting mechanisms May be reported on accident/incident form submitted to supervisor or safety department Table 21. Rules compliance practices in bus operations.

to ensure people understand safety rules. The major disadvantage of smaller agencies is smaller revenue. As a result, this group of transit agencies is challenged with respect to acquiring expensive monitoring and training programs. With respect to communicating safety rules, transit agencies rely on the following traditional types of methods: • Video presentations • Rulebook • Safety meetings • Various safety publications • Bulletin boards Some transit agencies reported innovative ways to relate safety rules to their employees. These include weekend safety retreats where employees take part in intensive safety training sessions. Additionally, one transit agency has an accident review committee (ARC) that operates much like event-review committees in aviation safety reporting systems. That is, the ARC reviews accident reports and disseminates information regarding safety breaches and potential safety enhancements. To determine that employees understand the rules, transit agencies conduct ride-alongs, perform employee evaluations, and test for rules knowledge. Assessing knowledge retention occurs by using informal methods such as safety discussions as well as formal methods that include exams after orientation and retraining sessions. Bus transit agencies also use ride-alongs to make sure their employees are adhering to safety rules. Often, these ride-alongs occur covertly, a.k.a., ghost rides. These agencies also rely on passenger reports of unsafe behavior. However, bus operators sometimes feel pressured to avoid customer complaints and as a result will break rules. One transit agency reported that one of its most frequent safety violations was stopping to pick up passengers between stops. Obviously, bus drivers feel pressured to appease the riding public at the expense of safety. Many transit agencies rely on video-monitoring equipment. Several commercial systems are available and in use at a number of bus transit agencies. These systems record continuously but only maintain data for a pre-set time before and after an incident and can be reviewed later. Initially, labor was opposed to this type of system. However, subsequent accidents have shown that the camera system can be used to determine that the driver was not at fault. Bus transit agencies also report using this tool non- punitively, purely as a training tool. Transit agencies providing bus service report various actions when they discover noncompliance. They use traditional progressive discipline, demerit or point systems, as well as more progressive interventions. The latter includes coaching and counseling as well as recommended interventions from a non-biased group like an ARC. Not surprisingly, the most commonly reported bus driver violations were cell phone use, following too closely, and speeding. Many transit agencies have found that an enforced zero tolerance policy for cell phone use is an effective deterrent. One labor representative pointed out that management pressure to meet a schedule may cause a vehicle operator to compromise safety. Labor encourages members to make safety their top priority. Their priorities are “Safety, service, schedule.” When asked what advice these transit agencies had for other transit agencies, the most notable responses included the following: • Be proactive with instilling safety culture rather than reactive. Be adaptable. • Provide clear communication of rules compliance to employees. • Give constant feedback from management to employees. • Use driver performance review programs. • Establish safety incident point system for employee evaluations. 90 Improving Safety-Related Rules Compliance in the Public Transportation Industry

• Use driver incentive programs. • Use state of the art technology for observation of safety-related rules compliance. • Provide training, explain expectations and have a clear disciplinary process. • Use simulator video driver training programs. • Be vigilant every day to ensure employee adherence to rules compliance. Paratransit The approach to safety-related rule compliance in paratransit is very similar to the programs identified in the bus transit interviews. These transit systems inform their employees of the rules initially at orientation, during periodic retraining, and in response to incidents and/or accidents. Some use instructor-led training to explain safety rules. Most disseminate safety information and changes to existing rules via the company bulletin board and/or employee newsletter. They assess employees’ knowledge of rules through ride-alongs, employee performance reviews, and by word-of-mouth gathered by the supervisor. Like bus transit, these systems are also beginning to rely on video-camera technology to monitor rule adherence. These systems have their own safety noncompliance issues such as vehicle backing accidents, improper wheelchair tie down, and under- or overestimating vehicle size because drivers often switch between operating mini-vans and cut-away buses. This can result in serious injury and damage to vehicles because the operator forgets which vehicle he or she is operating and fails to adhere to clearance height. All these systems point out that open communication between employees and management is key to safe operations. Many paratransit systems provide service in small communities and as such provide a vital link for the patrons that they serve. Because these services operate in small communities where everyone in town knows everyone else, patrons readily share feedback on the service and the manager of the service knows how the drivers perform. A key motivator to the drivers is that they most likely know the riders (and know that they will tell others about their experiences), so they tend to provide safe service in accordance with the agency’s safety rules. Other Transit The research team spoke with one ferry system. Its safety rules compliance program is similar to other transit modes. It does not have a formal safety reporting system, but does rely on comment cards that can be submitted anonymously. The ferry system makes a point to implement worthy suggestions. It did mention that educating via shipboard drills is an effective practice that may benefit other modes. This is akin to simulator or scenario training in other industries. The research team spoke with one cable car operator. The operator’s methods are the same as those that apply to the light rail operation. Rules Compliance Practices in the Public Transportation Industry 91