Role of Human Factors in Preventing Cargo Tank Truck Rollovers (2012)

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22 Whereas the prior chapter looked at the tank truck indus- try within the U.S., this one looks at the industry outside the country to achieve cross fertilization. The objective was to identify other industry and international best practices that could be used to minimize or eliminate driver errors in the cargo tank truck industry. The most noteworthy finding outside the United States was the VicRoads Heavy Vehicle Rollover Prevention Program (see Case Study 1, Chapter 6). Furthermore, a number of companies in other industries had practices in BBS and fitness for duty that can be brought to the cargo tank truck industry; they are treated in Case Studies 2 and 3, respectively. Case studies are presented in Chapter 6. 5.1 Unique Practices and Circumstances of Overseas Operations Much of what the respondents outside North America had to say corresponded to their domestic counterparts’ remarks and do not need to be repeated. A few unique circumstances are mentioned here. One carrier of specialized liquids says its drivers jog around the truck three times before unloading. Besides the informal check of the equipment, the driver’s blood gets circulating and the mindset changes from driving to unloading. The daily fitness-for-duty assessment in some regions outside the United States is more rigorous: it may include a breathalyzer test or a blood pressure measurement. Hourly pay in Thailand is low, requiring workers to have two or three jobs. A carrier there frequently and randomly checks for amphetamines to ensure that drivers are not using drugs to help stay awake. When asked about striking the balance between safety and efficiency, an operator in the Pacific Rim frankly allowed that it is always a struggle to get that balance in developing countries. Improvement is seen with the involve- ment of multi-national companies, but some countries are decades behind the United States in their high regard for worker safety. One respondent who had been a driver trainer for many years was recently promoted to the position of terminal man- ager. He found that he had different performance metrics than previously and that some of them competed with what he had preached to drivers for years. He had to make choices of safety over production metrics. He says that, without changes in perspective, he and the organization would lose credibility. His opinion is that the message has to be the same from all levels; otherwise, workers are left scratching their heads and wondering, “What should I believe today?” A carrier in a predominantly Muslim country noticed an increase of incidents during Ramadan, when adults fast during daylight. Day drivers rise early to eat a large breakfast and then stay awake after dark for their other large meal. Sleep can be short and, on a full stomach, not the best. Enforcement of traffic laws varies considerably from country to country. In some places, it is virtually non-existent; in others, it is stricter than in the United States. Singapore requires dangerous goods trucks to have an OBC and global positioning system (GPS) tracking so the truck can be remotely shut down by the government if necessary. New Zealand has a graduated license program. A driver must go through a progression of lighter vehicles while progress- ing to driving a heavy, articulated vehicle. During his or her learning period, the driver must be accompanied by a licensed trainer who has held a full New Zealand license for the same class for at least 2 years. A theory test and a medical certificate are required for a learner license. The sequence is 1. A full car (Class 1) driver license for at least 6 months before applying for a Class 2 learner license. 2. A full Class 2 license for at least 6 months (3 months for applicants 25 years or older) before applying for a Class 3 or 4 learner license. C h a p t e r 5 Good Practices of Other Industries and Countries

23 3. A full Class 4 license for 6 months (3 months for appli- cants 25 years or older) before applying for a Class 5 learner license. In lieu of experience, applicants over the age of 25 can take an approved course to accelerate the license upgrade to the next class of vehicle. Drivers who train others for pay must have a separate endorsement on their license. The endorsement requires at least 2 years’ experience on the class of vehicle on which training will occur, passing a classroom course, good vision, a medical exam, a check ride, and a “fit and proper person” check. The fit and proper check looks for • Criminal convictions, including any charges or convictions relating to violent or sexual offenses, drug or firearm offenses, or offenses involving organized criminal activity; • Transport-related offenses, especially relating to safety; • History of behavioral problems; • Past complaints about a transport service the driver has operated; and • History of persistent failure to pay fines for transport-related offenses. 5.2 Industries Other than Cargo Tank Motor Vehicles To seek insights in safety from outside the trucking business, team members interviewed representatives from the following industries in which safety is important: • Pipeline, • Railroad, • Mining, • Aviation, • Nuclear laboratory, • Chemical manufacturing, and • Construction. Many of the same themes expressed by cargo tank truck carriers emerged—the importance of a safety culture with involvement from all levels of the operation, the need to handle the fatigue that accompanies odd work schedules, and the importance of training. Significant notes taken during the interviews are reported herein. 5.2.1 Culture A pipeline company recognized a need to shift its safety culture from a “have to” attitude to a “want to” attitude. This required giving employees a larger role in safety and operations, establishing consistency across operational boundaries, placing an emphasis on open communication, and encour- aging planning and participation at the field level. By doing so, they are espousing the belief that people matter most. Similarly, a construction company reported that the indus- try culture is moving toward a commitment to safety as a team effort. It has therefore become important to spend time get- ting to know the people who work in the organization. This has come about from recognizing that the industry needs to adjust a culture that had been driven too much by meeting schedule and cost considerations. The contacts here were among those who expressed the theme that emphasis should be placed on motivating employees to follow safe practices, not because they have to do it, but rather because they want to do it. This same theme of “have to” versus “want to” was mentioned by tank truck carriers. A particular transportation company’s safety principles articulated the attitudes that have been heard from other companies on and off the highway. The message is conveyed from top management that safety is paramount: • All injuries and serious incidents can be prevented, • Every hazard can be managed, • Managers are responsible for injury and incident prevention, • Managers are responsible for knowing how work is actually accomplished in the workplace, • Everyone’s involvement is critical to the success of the corporate safety effort, • Training is an essential element in an ongoing effort to achieve an injury-free work environment, • Working safely is a condition of continued employment, • It is essential to investigate incidents that have the potential to injure or damage health and the environment, • Safety is good business, and • Safety off the job is an important component of success in safety. A transportation company embraces the concept of “behavior-based safety,” where the employee is expected to practice safety by focusing on the surroundings. An employee who notices a problem is encouraged to bring it forward without fear of being insubordinate. A railroad uses peer observation groups to examine at-risk operations. Here, one employee observes how another is performing their work, documenting things that could be improved. These suggestions are meant to be constructive and are non-punitive to the employee whose work habits have been shown to warrant improvement. Out of this process have come better tools and improved procedures that remove risky behaviors. The company considers the time spent by the peer observer to be well worth the effort. (The ability to implement this program required agreement with the appropriate unions.)

24 The pipeline industry had been on the National Transporta- tion Safety Board’s (NTSB’s) “Most Wanted List” as needing to address fatigue of control room operators. PHMSA studied the problem and identified that the most frequent human factors contributing to past pipeline accidents were 1. Controller training, 2. Task workload and complexity, 3. Displays and controls, and 4. System information accuracy and access. The agency subsequently recommended 1. Developing shift rotation practices that minimize fatigue, 2. Limiting controllers to 12-hour shifts unless extraordinary or emergency situations are involved, 3. Scheduling at least a 10-hour break between shifts, 4. Developing guidelines for scheduling controllers that consider the effects of fatigue, 5. Training controllers and supervisors about fatigue, and 6. Ensuring that the control room environment does not induce fatigue. This subsequently led PHMSA to issue a final rulemaking in 2009 wherein affected pipeline operators must define the roles and responsibilities of controllers and provide them with the necessary information, training, and processes to fulfill them (PHMSA, 2009). Operators must also implement methods to prevent controller fatigue, manage alarms, ensure that con- trol room operations are taken into account when changing pipeline equipment or configurations, and review reportable incidents or accidents to determine whether control room actions contributed to the event. A transportation company frequently communicates its list of Safety Absolutes, the riskiest behaviors that can get a worker killed. There has been a generational change in the culture of the mining industry from being production-oriented to recognizing that safety and environmental concerns are bottom line issues that must be carefully managed. The more open culture has led to a savvier workplace, so employees feel comfortable pointing out safety problems and recommending potential solutions without fear of reprisal. An approach first developed by the DuPont Corporation, behavior-based safety is a program whereby the employee is expected to practice safety by focusing on the surroundings. CTBSSP Synthesis 11: Impact of Behavior-Based Safety Tech- niques on Commercial Motor Vehicle Drivers (Hickman et al., 2007) explored how this approach could be brought to the trucking industry. If a problem is noted, the employee is encouraged to bring it forward without fear of retribution. This “coach and counseling” approach is becoming an impor- tant element of safe management practice. Elements of this approach include use of peer observation groups, whereby one employee observes how another is performing his or her work and documents activities that could be improved. These suggestions are meant to be constructive and are non-punitive to the employee whose work habits have been shown to warrant improvement. Out of this process have come better tools and improved procedures that remove risky behaviors. Other activities can include voluntary reporting of an employee who appears to be under the influence of a drug or alcohol addiction, which results in the employee receiving counseling, rather than in immediate disciplinary action. 5.2.2 Hiring and Training A transportation company’s rigorous initial training pro- gram’s high attrition rate effectively weeds out unsuitable candidates who passed the initial employment process. The turnover rate of those who finish the training is low. A mining company found the leading causes of unsafe operator behaviors to be 1. Inadequate supervision (lack of training and oversight); 2. Technical (equipment design or condition, availability of warnings) and physical working conditions; 3. Lack of worker coordination and communication; and 4. Errors in operator judgment due to routine disruptions or poor decisionmaking. Within this latter category, the most frequent unsafe acts are attention failure, not following procedures, errors in technique, and poor situational and risk assessment. 5.2.3 Operations The Federal Railroad Administration has funded a Confi- dential Close Call Reporting System, a demonstration project to improve safety practices (www.closecallsrail.org/). It is based on learning about potentially unsafe conditions, or close call events, that pose the risk of more serious consequences. The system provides an environment in which railroad employees can voluntarily and confidentially report close calls without fear of discipline or punishment. Information is analyzed to identify trends, new sources of risk, and corrective actions to address them. A laboratory that does not perform daily routine opera- tions has pre-job briefings so that the supervisor can discuss safety challenges and mitigation strategies, as well as judge the extent to which all involved comprehend what they need to know. On-site safety for the construction company often begins in the design phase, when the management team can examine all aspects of a construction site to identify potential safety risks that could arise during construction and to develop

25 a plan for effectively addressing these concerns. The resulting safety plan can then be reviewed by the construction team. Some companies have each crew member sign off on the plan as evidence that they understand and will follow the accom- panying guidelines. Weekly safety meetings are held during construction. A transportation company’s comprehensive reward program includes individual and group recognition. Supervisors are given a discretionary budget from which they can issue rewards. A seamless man-machine interface has significant benefits for safety and productivity. As more warning and communi- cation aids and EOBRs come into truck cabs, careful thought should be given to integrating them in a single man-machine interface rather than adding separate devices individually. Modern control rooms for pipelines and power plants are carefully designed according to human factors principles. Drivers would benefit if such principles were applied in their “control room.” This will help drivers not only to avoid dis- tractions, but also to improve response times. If designers heed the psychology of the interface, it will truly aid the drivers, with the components enhancing safety as they were intended. Kletz (1999) has compiled a set of vignettes from the chem- ical processing industry. Although the book has no chapter devoted to the overall lessons to be learned from the categorized incidents, it does note that similar or nearly identical events can occur at different plants. One of its recommendations is for safety meetings to review prior incidents so that the knowledge stays fresh as staff changes over the years. 5.3 Lessons from a Prior Study of Disasters Abkowitz (2008) has analyzed 17 disasters, from natural to man-made to intentional terrorist acts, and has assembled a list of lessons that can be learned from them. Those lessons that are most applicable to the communication and management practices of preventing cargo tank rollovers are discussed below. • Risk factors work together to generate an event with disastrous consequences. The cargo tank truck industry, like most systems and processes, is designed with a built-in margin of safety. When new programs are instituted, they must be treated as a way to increase that margin, not to shift the margin from one place to another. Perhaps the best example of this is that drivers must understand that roll stability control is intended to be a supplement to and not a substitute for professional driving judgment. The adage holds: “Anything an engineer designs into a vehicle, the driver can take back out by going 2 miles per hour faster.” • Communication failure is a risk factor in every disaster. Failure can occur when individuals neglect to pass along vital information. This can occur at several levels within a tank truck carrier organization such as between senior management and line supervisors, line supervisors and dispatchers, and dispatchers and drivers. Temporary con- ditions such as road closures or construction must be promptly conveyed to drivers so that a suitable alternative route can be found or, at a minimum, time can be added to a schedule. Greater awareness of chronically troublesome locations also addresses this lesson. Effective communica- tion is so important to one company that their safety division is bilingual, so as to remove any language barriers in ensur- ing that every person involved in the operation understands their safety responsibilities. • Take planning and preparedness seriously. Preparedness is often considered a means of dealing with the consequences of a disaster that has occurred, but effective planning and pre- paredness can also avert or mitigate an impending disaster. In the case of rollovers, this would apply to training drivers to deal with undesirable situations that may develop. One driver said that the training was often an admonition to avoid particular situations, but little training was offered on what to do if one such situation is encountered. For example, keeping all the tires on the road is desirable, but a driver should be prepared in case one tire is suddenly in the gravel shoulder. Another driver commented that passenger car drivers who are unaware of their effect on heavy trucks may put a cargo tank truck in a situation that the professional driver knows is unsafe. The TIFA analysis confirmed what was understood by those familiar with the industry—that many rollovers occur as the result of an evasive maneuver. A dangerous situation can materialize in the blink of an eye. Drivers can learn how to handle dangerous conditions by instruction or, as some carriers do, by simulator experience. • Economic pressure is a chronic problem. One of the inter- viewees who works with a number of carriers noted that whereas some companies are able to make operations and safety work together for common benefit, for other com- panies these objectives seem to be continually at odds. As a whole, however, carriers recognized that enhanced safety makes for a more efficient operation. Upper management must therefore clearly communicate to the entire organiza- tion that safety is paramount and that they will not brook shortcuts (literal or figurative). • Not following procedures is a significant problem. Imposing a structure and discipline to the performance of repetitive tasks ensures that they are done properly every time. The carriers who were interviewed meet this need by carefully explaining and demonstrating their procedures to new hires, riding with them often for weeks until the new hire is trusted to drive solo. Recurring safety meetings at most carriers and ride-alongs at some carriers ensure that standards are maintained. Written journey plans help

26 provide consistency between drivers, and drivers are admonished to avoid distractions on the road. Beyond these policies and procedures is an organizational culture that motivates the employee to want to do the job properly rather than have to do it according to procedure. • Arrogance among individuals and organizations is per- haps a far more significant risk factor than previously imagined. “Cowboy” is a derogatory term for a driver who disregards safety procedures and traffic laws. Part of the better carriers’ screening process is to eliminate individuals who may have the basic skills of operating a commercial vehicle but whose attitude is incompatible with handling hazardous materials. Applicants who are considered more likely to take risks or deem themselves invincible are not hired. In those cases in which this screening process is not successful in removing the high-risk driver, the training program presents an additional opportunity to weed out these individuals before they get behind the wheel of a hazmat shipment. • It usually takes a disastrous event to convince people that something needs to be done. Larger carriers have experi- enced rollovers through the years and appreciate the need for precautions to avoid them. Well-informed smaller carriers have not experienced a disaster, but also realize the impor- tance of a sound safety program. There was no hint that any of the contacts in Task 3 were cavalier, but this lesson from prior research must be taken to heart for the benefit of the entire industry.