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TRANSIT TCRP REPORT 149 COOPERATIVE RESEARCH PROGRAM Sponsored by the Federal Transit Administration Improving Safety-Related Rules Compliance in the Public Transportation Industry

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TCRP OVERSIGHT AND PROJECT TRANSPORTATION RESEARCH BOARD 2011 EXECUTIVE COMMITTEE* SELECTION COMMITTEE* CHAIR OFFICERS Keith Parker VIA Metropolitan Transit CHAIR: Neil J. Pedersen, Administrator, Maryland State Highway Administration, Baltimore VICE CHAIR: Sandra Rosenbloom, Professor of Planning, University of Arizona, Tucson MEMBERS EXECUTIVE DIRECTOR: Robert E. Skinner, Jr., Transportation Research Board John Bartosiewicz McDonald Transit Associates Michael Blaylock MEMBERS Jacksonville Transportation Authority J. Barry Barker, Executive Director, Transit Authority of River City, Louisville, KY Raul Bravo Raul V. Bravo & Associates Deborah H. Butler, Executive Vice President, Planning, and CIO, Norfolk Southern Corporation, Terry Garcia Crews Norfolk, VA Metro Cincinnati William A.V. Clark, Professor, Department of Geography, University of California, Los Angeles Carolyn Flowers Eugene A. Conti, Jr., Secretary of Transportation, North Carolina DOT, Raleigh Charlotte Area Transit System Angela Iannuzziello James M. Crites, Executive Vice President of Operations, Dallas-Fort Worth International Airport, TX Genivar Consultants Paula J. Hammond, Secretary, Washington State DOT, Olympia John Inglish Michael W. Hancock, Secretary, Kentucky Transportation Cabinet, Frankfort Utah Transit Authority Adib K. Kanafani, Cahill Professor of Civil Engineering, University of California, Berkeley Paul Jablonski San Diego Metropolitan Transit System Michael P. Lewis, Director, Rhode Island DOT, Providence Sherry Little Susan Martinovich, Director, Nevada DOT, Carson City Spartan Solutions, LLC Michael R. Morris, Director of Transportation, North Central Texas Council of Governments, Arlington Jonathan H. McDonald Tracy L. Rosser, Vice President, Regional General Manager, Wal-Mart Stores, Inc., Mandeville, LA HNTB Corporation Steven T. Scalzo, Chief Operating Officer, Marine Resources Group, Seattle, WA Gary W. McNeil GO Transit Henry G. (Gerry) Schwartz, Jr., Chairman (retired), Jacobs/Sverdrup Civil, Inc., St. Louis, MO Michael P. Melaniphy Beverly A. Scott, General Manager and CEO, Metropolitan Atlanta Rapid Transit Authority, Motor Coach Industries Atlanta, GA Bradford Miller David Seltzer, Principal, Mercator Advisors LLC, Philadelphia, PA Pinellas Suncoast Transit Authority Frank Otero Lawrence A. Selzer, President and CEO, The Conservation Fund, Arlington, VA PACO Technologies Kumares C. Sinha, Olson Distinguished Professor of Civil Engineering, Purdue University, West Peter Rogoff Lafayette, IN FTA Thomas K. Sorel, Commissioner, Minnesota DOT, St. Paul Jeffrey Rosenberg Amalgamated Transit Union Daniel Sperling, Professor of Civil Engineering and Environmental Science and Policy; Director, Institute of Richard Sarles Transportation Studies; and Interim Director, Energy Efficiency Center, University of California, Davis Washington Metropolitan Area Transit Authority Kirk T. Steudle, Director, Michigan DOT, Lansing Michael Scanlon Douglas W. Stotlar, President and CEO, Con-Way, Inc., Ann Arbor, MI San Mateo County Transit District James Stem C. Michael Walton, Ernest H. Cockrell Centennial Chair in Engineering, University of Texas, Austin United Transportation Union Gary Thomas EX OFFICIO MEMBERS Dallas Area Rapid Transit Frank Tobey Peter H. Appel, Administrator, Research and Innovative Technology Administration, U.S.DOT First Transit J. Randolph Babbitt, Administrator, Federal Aviation Administration, U.S.DOT Matthew O. Tucker Rebecca M. Brewster, President and COO, American Transportation Research Institute, Smyrna, GA North County Transit District Anne S. Ferro, Administrator, Federal Motor Carrier Safety Administration, U.S.DOT Pam Ward LeRoy Gishi, Chief, Division of Transportation, Bureau of Indian Affairs, U.S.DOT Ottumwa Transit Authority Phillip Washington John T. Gray, Senior Vice President, Policy and Economics, Association of American Railroads, Denver Regional Transit District Washington, DC Alice Wiggins-Tolbert John C. Horsley, Executive Director, American Association of State Highway and Transportation Parsons Brinckerhoff Officials, Washington, DC EX OFFICIO MEMBERS David T. Matsuda, Deputy Administrator, Maritime Administration, U.S.DOT William W. Millar Victor M. Mendez, Administrator, Federal Highway Administration, U.S.DOT APTA William W. Millar, President, American Public Transportation Association, Washington, DC Robert E. Skinner, Jr. TRB Tara O'Toole, Under Secretary for Science and Technology, U.S. Department of Homeland Security, John C. Horsley Washington, DC AASHTO Robert J. Papp (Adm., U.S. Coast Guard), Commandant, U.S. Coast Guard, U.S. Department of Victor Mendez Homeland Security, Washington, DC FHWA Cynthia L. Quarterman, Administrator, Pipeline and Hazardous Materials Safety Administration, TDC EXECUTIVE DIRECTOR U.S.DOT Louis Sanders Peter M. Rogoff, Administrator, Federal Transit Administration, U.S.DOT APTA David L. Strickland, Administrator, National Highway Traffic Safety Administration, U.S.DOT SECRETARY Joseph C. Szabo, Administrator, Federal Railroad Administration, U.S.DOT Christopher W. Jenks Polly Trottenberg, Assistant Secretary for Transportation Policy, U.S.DOT TRB Robert L. Van Antwerp (Lt. Gen., U.S. Army), Chief of Engineers and Commanding General, U.S. Army Corps of Engineers, Washington, DC Barry R. Wallerstein, Executive Officer, South Coast Air Quality Management District, Diamond Bar, CA *Membership as of July 2011. *Membership as of June 2011.

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TRANSIT COOPERATIVE RESEARCH PROGRAM TCRP REPORT 149 Improving Safety-Related Rules Compliance in the Public Transportation Industry Judith Gertler Amanda DiFiore QINETIQ NORTH AMERICA, INC. TECHNOLOGY SOLUTIONS GROUP Waltham, MA Gordon Hadlow Fort Collins, CO Alan Lindsey Lantana, TX Roy Meenes Carlsbad, CA Subscriber Categories Public Transportation Research sponsored by the Federal Transit Administration in cooperation with the Transit Development Corporation TRANSPORTATION RESEARCH BOARD WASHINGTON, D.C. 2011 www.TRB.org

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TRANSIT COOPERATIVE RESEARCH PROGRAM TCRP REPORT 149 The nation's growth and the need to meet mobility, environmental, Project A-34 and energy objectives place demands on public transit systems. Current ISSN 1073-4872 systems, some of which are old and in need of upgrading, must expand ISBN 978-0-309-21355-4 service area, increase service frequency, and improve efficiency to serve Library of Congress Control Number 2011938000 these demands. Research is necessary to solve operating problems, to 2011 National Academy of Sciences. All rights reserved. adapt appropriate new technologies from other industries, and to intro- duce innovations into the transit industry. The Transit Cooperative Research Program (TCRP) serves as one of the principal means by which the transit industry can develop innovative near-term solutions COPYRIGHT INFORMATION to meet demands placed on it. Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously The need for TCRP was originally identified in TRB Special Report published or copyrighted material used herein. 213--Research for Public Transit: New Directions, published in 1987 Cooperative Research Programs (CRP) grants permission to reproduce material in this and based on a study sponsored by the Urban Mass Transportation publication for classroom and not-for-profit purposes. Permission is given with the Administration--now the Federal Transit Administration (FTA). A understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, report by the American Public Transportation Association (APTA), FMCSA, FTA, or Transit Development Corporation endorsement of a particular product, Transportation 2000, also recognized the need for local, problem- method, or practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment of the source of solving research. TCRP, modeled after the longstanding and success- any reprinted or reproduced material. For other uses of the material, request permission ful National Cooperative Highway Research Program, undertakes from CRP. research and other technical activities in response to the needs of tran- sit service providers. The scope of TCRP includes a variety of transit research fields including planning, service configuration, equipment, NOTICE facilities, operations, human resources, maintenance, policy, and The project that is the subject of this report was a part of the Transit Cooperative Research administrative practices. Program, conducted by the Transportation Research Board with the approval of the TCRP was established under FTA sponsorship in July 1992. Pro- Governing Board of the National Research Council. posed by the U.S. Department of Transportation, TCRP was autho- The members of the technical panel selected to monitor this project and to review this rized as part of the Intermodal Surface Transportation Efficiency Act report were chosen for their special competencies and with regard for appropriate balance. of 1991 (ISTEA). On May 13, 1992, a memorandum agreement out- The report was reviewed by the technical panel and accepted for publication according to lining TCRP operating procedures was executed by the three cooper- procedures established and overseen by the Transportation Research Board and approved by the Governing Board of the National Research Council. ating organizations: FTA, the National Academies, acting through the Transportation Research Board (TRB); and the Transit Development The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessarily those of the Transportation Corporation, Inc. (TDC), a nonprofit educational and research orga- Research Board, the National Research Council, or the program sponsors. nization established by APTA. TDC is responsible for forming the The Transportation Research Board of the National Academies, the National Research independent governing board, designated as the TCRP Oversight and Council, and the sponsors of the Transit Cooperative Research Program do not endorse Project Selection (TOPS) Committee. products or manufacturers. Trade or manufacturers' names appear herein solely because Research problem statements for TCRP are solicited periodically but they are considered essential to the object of the report. may be submitted to TRB by anyone at any time. It is the responsibility of the TOPS Committee to formulate the research program by identi- fying the highest priority projects. As part of the evaluation, the TOPS Committee defines funding levels and expected products. Once selected, each project is assigned to an expert panel, appointed by the Transportation Research Board. The panels prepare project state- ments (requests for proposals), select contractors, and provide techni- cal guidance and counsel throughout the life of the project. The process for developing research problem statements and selecting research agencies has been used by TRB in managing cooperative research pro- grams since 1962. As in other TRB activities, TCRP project panels serve voluntarily without compensation. Because research cannot have the desired impact if products fail to reach the intended audience, special emphasis is placed on dissemi- Published reports of the nating TCRP results to the intended end users of the research: tran- sit agencies, service providers, and suppliers. TRB provides a series TRANSIT COOPERATIVE RESEARCH PROGRAM of research reports, syntheses of transit practice, and other support- are available from: ing material developed by TCRP research. APTA will arrange for Transportation Research Board workshops, training aids, field visits, and other activities to ensure Business Office that results are implemented by urban and rural transit industry 500 Fifth Street, NW Washington, DC 20001 practitioners. The TCRP provides a forum where transit agencies can cooperatively and can be ordered through the Internet at address common operational problems. The TCRP results support and http://www.national-academies.org/trb/bookstore complement other ongoing transit research and training programs. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. On the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, on its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. The Transportation Research Board is one of six major divisions of the National Research Council. The mission of the Transporta- tion Research Board is to provide leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Board's varied activities annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individu- als interested in the development of transportation. www.TRB.org www.national-academies.org

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COOPERATIVE RESEARCH PROGRAMS CRP STAFF FOR TCRP REPORT 149 Christopher W. Jenks, Director, Cooperative Research Programs Crawford F. Jencks, Deputy Director, Cooperative Research Programs Dianne S. Schwager, Senior Program Officer Jeff L. Oser, Senior Program Assistant Eileen P. Delaney, Director of Publications Kami Cabral, Editor TCRP PROJECT A-34 PANEL Field of Operations Mark Miller, Washington Metropolitan Area Transit Authority, Washington, DC (Chair) Melvin Clark, Capital Metro, Austin, TX Bobby J. Griffin, Consultant, Flower Mound, TX Ronald Heintzman, ATU International, Mt. Angel, OR Paul W. King, California Public Utilities Commission, San Francisco, CA Loren Lintner, Austin-Bergstrom International Airport, Austin, TX Rodney P. Massman, Missouri DOT, Jefferson City, MO Gerald P. McGill, Continental Airlines, Kirtland, OH Terrence Spratt, Southeastern Pennsylvania Transportation Authority, Philadelphia, PA James A. Stem, Jr., United Transportation Union, Washington, DC Joseph J. Vacek, University of North Dakota, Grand Forks, ND Gretchen Wolfe, Charlotte Area Transit System Rail Operations Division, Fort Mill, SC David H. Wright, II, Chicago Transit Authority, Chicago, IL Douglas Farrow, FAA Liaison Miriam Kloeppel, FRA Liaison Carole Ferguson, FTA Liaison Kevin Dow, APTA Liaison Jeffrey Marcus, NTSB Liaison Rich Sampson, CTAA Liaison Christine Gerencher, TRB Liaison

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FOREWORD By Dianne S. Schwager Staff Officer Transportation Research Board TCRP Report 149: Improving Safety-Related Rules Compliance in the Public Transportation Industry was developed as a resource for improving safety-related rule compliance in the public transportation industry. Transit agencies should view the practices as ideas for consideration when looking for ways to improve an existing rules compliance program or when designing a program for a new operation. This report will be of interest to public tran- sit professionals who play a role in a transit agency's rules compliance program, including the safety director, rules program officials, training director, or supervisors involved in daily oversight of transit operations and maintenance. The critical importance of safety to the public transportation industry makes compliance with safety-related rules a key concern. Despite the industry's solid safety record, one major accident stemming from rule noncompliance can call into question the safety of the entire industry. While APTA's adoption of a voluntary standard for rule compliance in 2004 is an important step, more remains to be done. Of particular concern are safety-related rules that are designed to prevent high-consequence events, especially those where the public is affected or where there may be harm to transit agency employees. Safety-related rules apply to employees involved in the operation and maintenance of the transit system. This includes vehicle operators, dispatchers, and other operations person- nel, as well as those who maintain the vehicles and track infrastructure. With few excep- tions, the practices described in this report are applicable to all public transit modes and are scalable to the size of the transit agency. QinetiQ North America conducted the research for TCRP Project A-34. The research began with a comprehensive review of safety-related and organizational research that iden- tified proven approaches for improving rules compliance in public transportation and other safety-critical industries, including the railroad, aviation, trucking, motorcoach, and petro- chemical industries. Using criteria relevant to public transportation, the research team selected best practices for improving safety-related rule compliance. Achieving safety-related rule compliance requires more than monitoring for noncompli- ance and responding to it when it occurs. It requires preventive actions designed to encour- age compliant behavior. This document suggests best practices for all of the elements of a comprehensive approach to safety-related rules compliance. The categories of best prac- tices, which correspond to the elements of a safety-related rules compliance program, are the following: Screening and Selecting Employees Training and Testing

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Communication Monitoring Rules Compliance Responding to Noncompliance Safety Management The report also presents best practices for a prototype safety reporting system for public transportation. The safety reporting systems for aviation, railroading, and firefighting as well as two systems in the public transportation industry were investigated and were the basis for the prototype safety reporting system. The focus of this investigation was on under- standing how the safety reporting system was developed, stakeholder concerns during sys- tem design, key features and provisions of each, and experiences to date.

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CONTENTS 1 Chapter 1 Introduction 1 Intended Report Usage 2 Development of TCRP Report 149 2 How to Use TCRP Report 149 6 Chapter 2 Understanding Rules Noncompliance 6 Framework for Understanding Noncompliance 8 Perceptual Errors 8 Distraction 9 Workload 9 Fatigue 10 Workstation Design 10 Risk Taking 12 Training 14 Incentive and Discipline Programs 17 Measuring Compliance with Leading and Lagging Indicators 17 Safety Culture, Management, and Rules Compliance 21 Chapter 3 Classifying Noncompliance 22 Level I: Employee Noncompliance 27 Level II: Preconditions for Employee Noncompliance 29 Level III: Supervisory Factors 31 Level IV: Organizational and Regulatory Factors 33 Investigating the Causal and Contributing Factors of Safety-Related Rules Noncompliance 39 Chapter 4 Best Practices You Can Use 39 Screening and Selecting Employees 39 Training and Testing 43 Communication 47 Monitoring Rules Compliance 56 Responding to Noncompliance 57 Safety Management 60 Chapter 5 Safety Reporting System Best Practices 60 Scalability of a Safety Reporting System 62 Stakeholder "Buy-In" 62 System Assurances 63 Pilot Implementation 63 Memorandum of Understanding 64 Reporting Process 65 Report Review Team 66 Review Process 66 Disseminating Safety Reporting System Information

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67 References 70 Abbreviations 72 Appendix A Rules Compliance Practices in Other Industries 83 Appendix B Rules Compliance Practices in the Public Transportation Industry 92 Appendix C Safety Reporting Systems 109 Appendix D Rules Compliance Program Success Stories 115 Appendix E Effectiveness Metrics Note: Many of the photographs, figures, and tables in this report have been converted from color to grayscale for printing. The electronic version of the report (posted on the Web at www.trb.org) retains the color versions.