Improving Safety-Related Rules Compliance in the Public Transportation Industry (2011) / Chapter Skim
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Pages 21-38
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From page 21... ...
Combining the results of a review of transit accidents with some of the classic taxonomies, the authors present the following information, which is tailored for public transit agencies to use to investigate the cause of safety-related rule noncompliance. Because this taxonomy is tailored to the needs of public transit agencies to investigate noncompliance, the user is discouraged from comparing other taxonomies to this one as there may be subtle but meaningful differences.
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In an environment where the employee fears disciplinary action, he or she may not be forthcoming about intentionally violating a rule. Some employees 22 Improving Safety-Related Rules Compliance in the Public Transportation Industry Figure 3.
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One transit agency investigated signal noncompliance and found that the event recorder data, specifically speed, was useful for identifying the underlying reasons for these events. The agency Classifying Noncompliance 23 Figure 4.
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The transit agency identified that train handling, a skill-based technique error, was sometimes the culprit. At a different transit agency, a root-cause investigation of signal noncompliance showed that the majority of light rail vehicle operators who had violated the stop signal reported that they presumed that the signal would be permissive by the time they reached it.
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From page 25... ...
When an employee fails to comply because of a lack of understanding of a rule or how to execute it, a knowledge-based decision error has occurred. A knowledge-based error occurred when a novice dispatcher was called by a light rail operator faced with a fire in a tunnel.
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3.4 Situational Violations These occur because an employee is conflicted regarding the balance between adherence to the rules (e.g., procedures designed to ensure safety) and meeting performance goals (e.g., on26 Improving Safety-Related Rules Compliance in the Public Transportation Industry
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From page 27... ...
Classifying Noncompliance 27 Category Subcategory Description Potential Causes Error Perceptual Error Employee's perception of work conditions is different from reality Degraded signage, radio communications and the employee's expectations Skill-Based Slip Habit capture, misordering, repeating or inserting erroneous steps in a task sequence Distraction, fatigue, loss of situation awareness Skill-Based Lapse Failures of short-term memory resulting in the omission of some part or all of a task Distraction, multitasking, high workload Skill-Based Technique Error Personal technique places an operator at risk for rule noncompliance Personality, maladaptive operating practices Strategy-Based Decision Error Applied the wrong rule or misapplied the correct rule to a work situation Vague rules, lack of or inadequate rule training Knowledge-Based Decision Error Employee did not understand or was unaware of a rule Lack of experience or inadequate rule training Violation Egregious/Criminal Act Acts for which a transit agency has zero-tolerance such as drug or alcohol abuse Personality and psychopathology Routine Violation Occurs when a shortcut or quicker way to the end goal presents itself and is taken on a regular basis Inadequate supervision, overconfidence in skill, pressure to adhere to performance goals Exceptional Violation Occurs when employee is required to handle an unexpected circumstance Lack of or inadequate training, vague rules Situational Violation Occurs when there are competing performance goals (e.g., safety v. on-time performance)
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Mental fatigue can occur when a person is well-rested but may be required to be vigilant for long periods during his or her job; vigilance is known to produce mental fatigue. 28 Improving Safety-Related Rules Compliance in the Public Transportation Industry
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From page 29... ...
This can involve the simple discourse between a commuter rail engineer and dispatcher or the more complex interactions among track maintenance crew members. This factor may contribute to noncompliance when there is a failure in communication or coordination among peer staff members, when employees fail to use all available resources, or when there is a failure of leadership in the workgroup.
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The employee fell asleep on duty and rear-ended another train. Another example involving inadequate rest occurred when a work schedule only allowed 8 hours between consecutive work periods that involved an 30 Improving Safety-Related Rules Compliance in the Public Transportation Industry Category Examples Environmental Factors Natural environment Climate, weather, time of day, glare, etc.
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During times of economic prosperity, public transit agencies may be able to satisfactorily balance the requirements associated with safe operating practices with the performance goals of the agency (e.g., customer satisfaction and on-time performance)
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Instead of being proactive and preventive, the managers in this type of environment are reactive, looking to blame an employee when there is noncompliance or an accident. 32 Improving Safety-Related Rules Compliance in the Public Transportation Industry Category Examples Inadequate oversight Failed to provide guidance Failed to provide training opportunities Poor leadership Lack of oversight Failed to monitor employee qualifications Failed to track performance Inadequate work schedule Provided inadequate opportunity for employee rest Inadequate information/resources Failed to properly brief employee Failed to give the employee necessary information Provided inadequate staffing Failure to correct known problem Did not call out at-risk employee Did not report unsafe tendencies Did not initiate remedial or corrective action Supervisor rule noncompliance Authorized employee to break the rules Failed to enforce rules or regulations Allowed unqualified employees to perform job Table 4.
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For example, prior to the FTA requirement that all rail systems have system safety plans with state oversight, public transit agencies did not necessarily have formal rules compliance programs. Table 5 presents the factors associated with Level IV of the taxonomy.
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This information will aid in identifying strategies to mitigate the contributing factors. 34 Improving Safety-Related Rules Compliance in the Public Transportation Industry Questions Does it apply?
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3.1 Egregious/Criminal Acts 3.1.1 Was the noncompliance the result of the employee intending harm? Did the employee engage in criminal behavior?
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. 36 Improving Safety-Related Rules Compliance in the Public Transportation Industry
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Did the supervisor actively encourage the employee to bend or ignore safety rules or punish the employee for following the rules? If yes, then supervisor rule noncompliance was a factor; proceed to next question.
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Was there a lack of, or an inadequate, safety reporting system that would have helped to identify patterns of noncompliance that could have prevented the incident being investigated? Did upper-level management or an agency executive bend or violate either internal or external procedures, processes or regulations?
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