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49 CHAPTER FOUR SAFETY AUDITS, INCIDENT REPORTING, ANALYSIS, AND FOLLOW-UP ACTIONS INTRODUCTION conform to the system safety program plan, and must list measures being taken to bring these areas into compliance. This chapter explores the processes agencies use to evalu- ate the effectiveness of their ROW worker protection pro- In addition, rail transit agencies must have a hazard manage- gram. The most obvious measure of effectiveness is the ment process in place that includes the ongoing identification number and type of accidents that occur within an agency. As of hazards, the evaluation and prioritization of elimination or investigation reports reveal, accidents do not just happen; control measures, a mechanism to track identified hazards to they result from what could be a simple failure to a complex resolution, thresholds for notification and reporting hazards combination of a variety of situations and circumstances. to the oversight agency, and ongoing reporting of hazard Agencies that experience accidents conduct investigations to resolution activities to the oversight agency (13, pp. 3238). understand what happened and learn how to prevent similar events from occurring. All the agencies studied had baseline The State Safety Oversight rules apply to all of the agencies policies and procedures in place to provide for the ongoing interviewed for this study, except TTC. The primary responsi- evaluation of their program. Some had implemented more bility for demonstrating compliance with 49 CFR Part 659 comprehensive approaches to data collection and analysis to rests with System Safety. The Office of System Safety serves enable the ongoing refinement of their efforts. as the primary liaison between the State Safety Oversight orga- nization and the agency. System Safety develops the System STATE SAFETY OVERSIGHT PROGRAM Safety Program Plan with input from the rest of the organiza- tion and conducts the internal auditing. Generally, the auditing In 1991, Congress required for the first time that the FTA consists of ensuring that rules, policies, and procedures are in establish a program providing for the state-conducted oversight place and are effectively communicated to employees, and of the safety and security of U.S. rail systems not regulated tracking employee and customer accidents and incidents. by the FRA. In April 2005, the FTA issued a Final Rule making changes to the substance and format of the existing 49 CFR part 659. The intent of the changes was to improve the perfor- ACCIDENT INVESTIGATIONS mance of the State Safety Oversight Program and to ensure the following outcomes: Rail transit agencies investigate any accident that involves a collision with an individual on a rail ROW. Usually, safety 1. Enhance program efficiency; department personnel conduct the investigation with assistance 2. Increase responsiveness to recommendations from the from the operating department where the accident occurred. NTSB and emerging safety and security issues; 3. Improve consistency in the collection and analysis of In general, the investigators: accident causal factors through increased coordination with other federal reporting and investigation programs; Question all witnesses; and Compile all documentary evidence; and 4. Improve performance of the hazard management process Ascertain all applicable safety rules. (12, Part IV, p. 22563). Upon completion of the investigation, the investigators Under the 2005 Final Rule, rail transit agencies must prepare a written report that sets forth the material facts lead- develop a system safety program plan, review it annually, ing to and causing the incident; determines the principal and and modify it as needed. As part of the process, all elements contributing causes; reaches conclusions as to the persons, of the system safety program must be reviewed in an ongoing policies, procedures, and practices responsible for the inci- manner over a 3-year cycle. The agency's chief executive dent; and provides recommendations for changes in safety must submit a statement of compliance or noncompliance rules, work rules, or other policies, practices, and procedures with its system safety program plan, along with the agency's to prevent the occurrence of similar incidents. The recom- annual report, to the oversight agency. If an agency is in mendations are vetted through the affected departments. noncompliance, the report must identify the areas that do not A set of corrective actions are agreed upon and planned to be