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50 implemented. Progress on the actual implementation of the RULES VIOLATIONS corrective actions is usually tracked and reported to agency management and the oversight organization. None of the agencies interviewed had a structured process for employees reporting rules violations. Generally, reports and complaints would be made by MOW employees about NEAR MISSES train operators violating speed restrictions, or by train oper- ators about improper flagging arrangements or unprotected NYCT was the only agency interviewed that followed a employees on the tracks. These reports are made verbally to structured process for reporting near miss incidents. The the Control Center or supervisory personnel. The reports are process includes an analysis of Potential Employee Contact investigated by management, and disciplinary actions are (PEC)-type near miss incidents and Non-PEC-type near miss taken when warranted. incidents. A PEC-type near miss incident is an incident involv- ing a train or a ROW operation that could have resulted in Several agencies have implemented structured manage- an employee fatality or serious injury. A Non-PEC-type near ment processes to identify and take corrective actions on rules miss incident is an incident involving a train or a ROW oper- violations. These approaches go beyond what is required by ation that could have resulted in a customer injury or prop- the State Safety Oversight program to audit job sites. The erty damage but does not present the potential for an employee MBTA Safety Department conducts approximately 100 ran- fatality or serious injury. dom safety audits of work sites each year to check for proper use of equipment and flagging procedures. If inadequate flag- PEC near miss incidents include: ging protection or equipment is observed, work is stopped until the situation is corrected and a determination is made on General Order violations; how work may proceed safely. Employees cited for violating Improper flagging; rule book procedures can be subject to discipline. Potential employee contact with trains while working on the roadbed; The TTC has a Quality Assurance unit within its Safety Portable trip overruns; Department. It includes seven staff members and a unit super- Failure of train to blow horn when passing yellow caution visor who focus on safety performance in operations, ROW lights; and maintenance, and vehicle maintenance. The information from Train passing work area at excessive speed. their audits and evaluations is used to develop reports and analyze trends in rule compliance and overall system safety. NYCT Division of Subways personnel are required to report all PEC near miss incidents immediately to their super- The NYCT Office of System Safety conducts 350 to visors. The reporting protocol for supervision is as follows: 400 safety inspections of on-track work each year in conjunc- tion with union representatives. The purpose of these surprise Notify RCC immediately; inspections is not to "catch" workers doing the wrong thing, Notify the Divisional Chief Officer immediately; but rather to identify safety issues and take corrective actions. Notify the Office of System Safety immediately; and The inspections are executed primarily at night when most Initiate an investigation within 24 h of the incident to construction and maintenance work is performed and includes determine the causative factors involved. work with both NYCT and contractor crews. An inspection report is completed and reviewed with the job supervisor and An incident report must be issued within 30 days of the forwarded to management. Issues identified through the incident to the Divisional Chief Officer of the employees inspection process are investigated to determine if system-wide involved and submitted to the Office of System Safety. That measures are needed (e.g., rules changes, employee infor- office produces and distributes quarterly reports that analyze mation). Feedback from the inspections is also funneled to the incidents by type, department, and operating division training personnel so information can be incorporated into (14, p. 10.6). existing courses. In 2010, supervisors who received consis- tently good marks on safety inspections were recognized. The NYCT Office of System Safety shared a copy of its 2010 Year End Near Miss Trend Analysis with the study team. In addition, to the Office of System Safety efforts, the During the calendar year 2010, 15 PEC-type near miss incidents Department of Subways has implemented auditing initiatives. were reported, the same amount as in calendar year 2009 The Senior Vice President of Subways convenes a quarterly (15, pp. 12). The report provided a detailed analysis of the audit team that conducts inspections of work activities on the different types of incidents (i.e., portable trip overrun, improper tracks. The results of the inspections are forwarded directly flagging, potential employee contact/miscellaneous) and a to him or her for corrective actions. The MOW Division also review of the incidents, contributing causes, and departmental recently began conducting weekly "Safety Blitzes." The blitz responsibilities. It also requested corrective action plans from team usually consists of about 26 management (superintendent departments with multiple related incidents. and manager level) representatives from inside the various