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52 CHAPTER FIVE CONCLUSIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH A 300% increase in the number of track worker fatalities and uncertainty concerning the depth and degree to which managers injuries from 2003 to 2008 clearly demonstrates an industry- can evaluate the program other than the obvious measure of wide issue regarding right-of-way (ROW) employee safety the number of accidents or incidents. Sentiments echoed and protection. The objective of this study is to report the at several of the systems were, "How safe is safe?" and state of knowledge and practice regarding wayside worker "How do we know if what we are doing is enough, too much, protection programs at selected transit agencies and to docu- or just right?" ment the state of the practice, including lessons learned and gaps in information. Down at the track level, where safety practices actually get used, front-line employees at one system stated that they The research revealed that, in the wake of these incidents, had a good understanding of the rules, but not the hazards some rail transit systems took aggressive actions to form task that the rules are intended to protect them from. This under- forces or reconstitute "Rules Committees" to revisit ROW scores the priorities that system managers must highlight on rules and procedures and make necessary improvements, a daily basis. There is a clear need to emphasize rules com- enhance employee training programs, and implement more pliance and a consistent pattern of enforcement and disciplinary comprehensive auditing and investigative processes. Most of actions for violations. This is achievable through implementing these were collaborative efforts, involving labor and manage- and communicating clear, easily understood, and structured ment representatives from several departments. rules and procedures. Yet there is also a need to focus on hazard recognition and mitigation--on both systemic and Three major findings were identified as a result of this individual levels. This can be accomplished through engaging endeavor. First, there is an effort at every one of the five systems and interactive training programs, labormanagement partner- included in the study to improve continually the safety and ships, safety campaigns, and a top-down and bottom-up level of protection for their ROW workers. Second, deviations prioritization of safe practices and principles. The two prin- in systems' program depth and complexity varied. Some of ciples or approaches are not mutually exclusive but, rather, these deviations were based on the environmental and oper- complementary. Implementing a program that incorporates ational hazards and characteristics of the systems, whereas both concepts will bring an agency closer to establishing a others reflected organizational cultural characteristics or safety culture within the organization and implementing a historical practices. Third, aside from a high-level standard sustainable and practical approach to system safety. developed by APTA for work zone safety in rail transit, there are no national resources, standards, or consensuses relating New or "out-of-the-box" approaches to reduce track worker to rail transit track worker safety programs. hazard exposure could also be explored more extensively in the rail transit sector. For example, railroads--such as Class 1 There were a number of similarities and differences in the freight railroads--have been using vehicle-mounted video track worker protection programs of the five systems studied. and sensor-based technologies for years to inspect track gauge, Collectively, the employees interviewed at each agency wear, and metal fatigue. The possible use of this technology expressed a sense of pride in their work and their affiliation in rail transit applications could significantly reduce the need with their respective organizations, as well as a sense of accom- to put lone or small groups of inspectors on the ROW. Most plishment in improving track worker safety. Without fail, every of the study interviewees concur that these small, roving employee, from senior manager to junior laborer, stated that inspection teams are at a greater risk than are crews at larger, his or her workplace was safer than in the past. The programs established work sites. are continually evolving, based on reviewing and refining practices and training programs; testing of new technologies; Specific findings within the study revealed a number of auditing rules compliance; and, in some cases, tracking and factors that the systems identified as significant in their track analyzing data on incidents, near misses, and other metrics. worker safety protection: Although there is a sense of conviction and commitment The importance of rules and procedures to provide struc- on the part of the managers responsible for daily oversight of ture, guidance, and administrative oversight of employees maintenance-of-way work and safety, there is also a level of and contractors working on, around, or near the ROW;

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53 A basic strategy of ROW-specific rules and enabling wide consistency in program implementation and procedures, supported by frequent training and consis- management. tent enforcement, has been implemented by all the 2. An assessment of current practices and programs for agencies studied, with some variation of emphasis on tracking accidents, incidents (such as minor injuries), one component or another. near misses, and rules violations with an emphasis A number of training initiatives have been implemented on trend analysisbased initiatives, as opposed to to train, inform, and prepare track workers better to disciplinary-based programs. A second phase in this carry out their duties safely. Most of the training programs effort could be to develop a standard tracking and use lecture and presentation delivery methodologies. analysis program and guideline that transit systems could use to enhance their ongoing data analysis and A number of programmatic consistencies in work site continuous improvement efforts. practices exist across the agencies interviewed, but signi- 3. The development of performance measures with which ficant deviations exist in such elements as staffing levels, transit systems could gauge the overall effectiveness, terminology, protection level determination, established from both safety and risk perspectives, of their track "safe distances," or the use of equipment in protective mea- worker protection program and consider the "value sures. Environmental and operational factors play a role in this added" of a variety of approaches and practices. This to some extent--such as the amount of elevated ROW or the tool would help answer the question, "Do we know off-peak headways between trains--however, other variations what we're doing is the right thing?" in the tolerance for lone workers, the process for setting up 4. The development of a comprehensive and interactive flagging, the length of training, and methodology for perform- ROW hazards training program and collateral materials ing audits and investigations do not appear related to these for maintenance-of-way workers to increase industry- factors. Additional research, as well as an effort to develop a wide consistency in hazard identification, reporting, and comprehensive model plan based on an industry consensus mitigation, ultimately to increase track worker safety. of successful practices, could help identify true, factor-based The program could be developed in a manner similar to deviations and establish baseline standards and consistencies. other national courses in the public transit sector, taught Such a plan could help drive the dialogue within the indus- as an off-the-shelf course or customized by an agency try and agencies regarding the need for balanced, proactive to incorporate system rules, procedures and specific approaches to improving safety, and also provide the resources hazards. to help implement or enhance safety protection programs. 5. The development of a similar, comprehensive, high- quality training course for supervisors, focusing on Post-work analysis, such as safety audits, incident reporting, hazard assessments and mitigation and on managing data analysis, and other follow-up actions, is an area that can rules compliance within the work force. Ultimately, easily be neglected owing to other demands and priorities, the way an agency practices track worker safety is the some agency personnel report. Industry efforts to develop result of how front and mid-level supervisors routinely comprehensive practices for auditing work sites, as well as inform and educate their subordinates on safe practices identifying off-the-shelf software applications and relevant and enforce rules and procedures. This program could guidelines for customizing them to efficiently track accident, be developed in a similar fashion as the training initiative near miss, and rules violations data could make these practices outlined previously. more practical, productive and widespread. 6. The exploration of the use of technology-based inspection methods, such as rolling stock- or high-rail Building on these findings, further studies could explore a vehicle-mounted video cameras and sensors in the variety of topics, including: railroad industry, their applicability to the rail transit environment, and their utility in reducing hazard expo- 1. The development of a rail transit track worker protection sures to track inspectors. program guidance document, including a "Model Plan" 7. An assessment of the current practices and system that outlines, in some level of detail, the steps in standards for defining and establishing safe zones in developing or updating a program; core practices of a rail transit environments, such as niches, platforms, program; optional practices that could be considered, between-tunnel passageways, and other areas deemed depending on specific hazards or characteristics; train- acceptable areas of refuge during train movement, ing elements; incident tracking methods; and other along with practices of marking safe zones and un- components. This document would help create a more available or restricted zones such as those with no detailed baseline for a track worker protection program clearance, or niches or passageways that are occupied than is currently available and help increase industry- by fixed equipment.