Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation (2020)

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1 The Moving Ahead for Progress in the 21st Century Act (MAP-21) and its successor, the Fixing America’s Surface Transportation (FAST) Act, prompted the Federal Transit Administration (FTA) to establish the safety management system (SMS) framework as the basis for its National Public Transportation Safety Program [49 United States Code (U.S.C.) Section 5329]. The establishment of a proactive employee safety reporting (ESR) system is one key aspect of the SMS safety assurance function and is elemental in the implementation of an effective SMS. The Public Transportation Agency Safety Plan (PTASP) rule [49 Code of Federal Regulations (C.F.R.) Part 673] includes a requirement that public transportation agencies develop an ESR process as part of its SMS safety manage- ment policy function: §673.23(b) A transit agency must establish and implement a process that allows employees to report safety conditions to senior management, protections for employees who report safety conditions to senior management, and a description of employee behaviors that may result in disciplinary action.1 The objective of this study was to produce a compilation of the best practices used in nonpunitive employee safety reporting systems at transit agencies. The best practices would include examples of how nonpunitive employee safety reporting systems benefit transit agencies and their employees and could be used to assist transit agencies with developing their systems. TCRP Research Report 218: Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation will support the public transportation industry’s efforts to institute nonpunitive ESR as a critical element in SMS implementation. The term “public transportation agency” is synonymous with the terms “public transit agency” and “transit agency,” which are also used throughout this report. This examination focuses on not only policy and procedural aspects, but on the safety cultures reflected in the public transit agencies in which this reporting has been, and continues to be, successful. For the purposes of this study, the success of an ESR system, or successful elements, were determined by the agency that implemented the ESR system. The research team did not perform a statistical modeling or evaluation method to deter- mine success. The researchers also addressed the challenges faced throughout the implementation phases of the deployment of the ESR system, as presented through the literature review and transit agency case studies. The literature review and background research were the first steps in the development of the project report and helped frame the subsequent narrative and findings from interviews with public transportation agencies. S U M M A R Y Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation

2 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation This executive summary is provided to identify the overarching themes examined within this report, findings from the literature review and background research, and highlights from the case studies. The research findings, detailed case study narratives, sample tools and resources provided by the case studies, and recommendations for addi- tional research are examined more fully and presented in the full report and corresponding appendices. Literature Review and Background Research Summary The National Transportation Safety Board (NTSB) investigated catastrophic collision events that resulted in loss of life, injuries, and costly damage and deduced that many of these events could have been avoided had an effective nonpunitive ESR system been in place for reporting hazards. One of those events, the 2009 Washington Metropolitan Area Transit Authority (WMATA) train-on-train collision near the Fort Totten Station, resulted in nine fatalities, 52 injuries, and an estimated $12 million in damages. This event led to NTSB recommendation R-10-004 to FTA: Facilitate the development of non-punitive safety reporting programs at all transit agencies to collect reports from employees in all divisions within their agencies and to have their safety departments; representatives of their operations, maintenance and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of their agencies.2 NTSB made a similar recommendation (R-10-017) to WMATA. The importance of safety culture in the discussion of implementing a nonpunitive ESR system cannot be overstated and requires a shift in the approach to public trans por- tation safety management. TCRP Report 174 defines safety culture as “shared values (what is important to all public transportation system members who are responsible for safe, efficient revenue service) and shared beliefs and attitudes (how the transportation system works and what individual roles should be) that interact with all system members, safety policies, procedures, and rules to produce behavioral norms (the way we do our jobs, whether observed or not).”3 Through the literature review, the authors suggest that, within an organization, a cultural shift is necessary across the board to ensure that safety is the goal, with root cause analysis and corrective actions developed and disseminated throughout that organization. This safety culture shift requires the transition from a reactive approach to a proactive approach, which includes focused efforts on four cultural aspects—a reporting culture, an informed culture, a learning culture, and a just culture, according to a report titled Implementing Safety Management System Principles in Rail Transit Agencies4 by the Transit Advisory Committee for Safety. FTA’s SMS frame- work reflects this proactive approach. Unfortunately, safety culture is not easily measured as a specific set of characteristics. Additionally, due to the complexity of safety culture elemental improvements, measuring safety culture change is a slow and longitudinal process. The background research addresses ESR and safety culture across industries. The research discussion includes an examination of the initial impetus behind some of the more advance nonpunitive ESR systems in the United States and the history and maturation of safety culture. Stakeholder Interviews The research team performed case studies of 19 public transportation agencies that have implemented ESR systems (Figure S-1). Initially, a survey instrument was used to gather general information about the ESR systems in place. The maturity levels of the ESR systems

Summary 3 in the case studies varied, ranging from systems that had been in place for less than 1 year to systems implemented more than 20 years ago. The methods by which ESR can occur include hard copy forms; online submissions through apps, intranet, or e-mail; and through the phone via hotlines, texts, or voicemail. Many of the case study transit agencies had multiple methods available for reporting hazards and expressed that this has resulted in greater participation. A few of the ESR systems used a third party to manage and maintain the data collected through their ESR system. The survey questions revealed that the majority of ESR systems instituted at the transit agencies surveyed provided for both reporter anonymity and confidentiality. Nearly 8 out of 10 (79%) of respondent transit agencies indicated they had solicited employee feedback on their ESR system to improve the program and employee acceptance. A total of 53% of the responding transit agencies had a policy in place with definitions of what may be reported through the ESR system and the events or actions that may result in punitive measures; 47% had no formal policy or their policy did not distinguish between reportable events and those reportable events for which punitive measures may apply. All respondent transit agencies included an introduction to their ESR system and reporting procedures during new hire training, and 68% of those transit agencies did not tailor the training by employment position. Finally, transit agencies were asked to share what performance measures were estab- lished to determine the efficacy of their ESR system. Some of the performance measures tracked included, but were not limited to, the volume of reports received, the status of reports, average days to closure, target closure dates, hazard classification, root cause, claims costs, lost time, and accident rates. Figure S-1. Case study transit agencies.

4 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation The research team conducted interviews with each case study transit agency to discuss its responses to the survey and gain additional insight. Questions posed during these interviews and additional communication centered on these themes: • Elements of effective nonpunitive ESR systems, • Barriers to implementation, and • Common practices identified by case study transit agencies as central to the success of their ESR system. Appendix A contains detailed case study narratives. Elements of Effective Nonpunitive Employee Safety Reporting Systems The case study transit agencies found varying degrees of success in the design, imple- mentation, and ongoing management of their ESR systems. Researchers identified consis- tently represented ESR system elements from case study transit agencies, which also served to verify the findings from the background research. These elements or factors of success included: • Participation of the local collective bargaining unit in the design and implementation of the ESR system, investigation, and corrective action processes; • Employee access (ease of reporting); • Well-defined procedural process for collecting, investigating, and correcting reported hazards; • Robust investigation process that involves multiple players from across the agency; • Feedback to reporters, from initial receipt of the report through the process and once the hazard has been corrected; • A method to ensure anonymity or confidentiality, or both; • A written agreement between the agency and its employees that reporters can remain anonymous and that provides protections against retaliation, intimidation, or discrimina- tion against the reporter; these statements were included as part of collective bargaining agreements (CBAs) and memoranda of understanding (MOUs); • A precise statement of what would be considered nonpunitive and what would result in punitive action (e.g., drug- and alcohol-related activities, blatant disregard for other agency policies and directives, or other actions as defined by the transit agency); • A method that provides reporters an opportunity to challenge or appeal the outcome of the investigation or the corrective action taken; • Training on and promotion of the ESR system; • Ongoing tracking of safety data, common ESR system hazards, and the effectiveness of mitigation strategies; • Periodic process and ESR system evaluation; and • Utilization of a third party when warranted or necessary due to the safety culture of the organization or the ESR system’s complexity. Barriers to Implementation The primary barriers to implementation identified through the research and expressed by a few case study sites include gaining employee buy-in, lack of confidence in the ESR system, and gaining employee trust. Employees want to know that, when they submit a safety report, the agency will investigate and correct the hazard; they want to understand the process; and they want to be informed of the outcome. In addition, it is important for employees

Summary 5 to feel confident that if a safety report is submitted anonymously or in confidence that the transit agency has effective protocols for ensuring that anonymity. Finally, employees are unlikely to report near misses or close calls if they do not trust that they can report with impunity and be protected against harassment, intimidation, retaliation, or discrimination. Common Practices The background research and case studies reflect common threads to success specifically delineated above. The research team organized case study common practices within the eight categories illustrated in Figure S-2 and further described below in alphabetical order. The use of a third party when warranted, while not a case study agency common practice, is also discussed. Access—Ease of Reporting Of all public transportation agencies included as case study sites for this project, the Southeastern Pennsylvania Transportation Authority (SEPTA) has the most reporting options available to employees: • Notify their managers verbally, • Complete a Hazard Report Form, • Notify their location safety committee representative, • Complete the SEPTANow online form, • Submit an e-mail to systemsafety@septa.org, • Submit through the nonemergency safety hotline, and • Submit through the VERITAS Customer Service Tracking System to report hazards. Employees of SEPTA’s commuter rail system also report through the National Aero nautics and Space Administration (NASA) under the Federal Railroad Administration (FRA) Confidential Close Call Reporting System (C3RS) program. Conversely, the Los Angeles County Metropolitan Transportation Authority (LA Metro) has a single online submittal method, the SAFE-7 Form. To accommodate its employees and ensure their ability to report, LA Metro installed desktop computers at each division and provides access to every employee. While there is only one method of reporting, employee access to the system has expanded, as has the number of reports submitted. In both examples, SEPTA and LA Metro representatives indicated a consistent level of reporting and shared that significant agency improvements were made as a result of the Access—ease of reporting Appeal process Data utilization and performance measurement Documented/prescribed reporting and investigative processes Feedback loops Periodic process and program evaluation Third-party utilization Training and program promotion Union participation Figure S-2. Case study common practices.

6 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation reporting. The success of both ESR systems leads to a key takeaway that the ideal number of reporting options will not be uniform across transit agencies. Rather, the number of options should optimize employee access along with the agency’s ability to document and follow up on reported hazards. Appeal Process While some respondent transit agencies reported that their ESR policies did not include specific details on appeal processes, employees at those transit agencies do have the opportunity to submit subsequent hazard reports. The Metropolitan Atlanta Rapid Transit Authority (MARTA) and SEPTA have the most comprehensive appeal process details included in their operating procedures or bargaining agreement. Additionally, the employees of the Capital Metropolitan Transportation Authority (Capital Metro) of Austin, Texas, the Greater Cleveland Regional Transit Authority (GCRTA), the Massachusetts Bay Transportation Authority (MBTA), Miami-Dade Transit (MDT), SEPTA, and WMATA have the option to submit a good faith challenge in accordance with 49 C.F.R. 218.97 (for FRA-regulated systems) if the employee feels he or she is in immediate danger. LA Metro and other case study sites have a similar structure in place for rail operations not covered under FRA’s good faith challenge. Data Utilization and Performance Measurement All public transportation agency case study participants are champions of SMSs and recognize the value of data-driven priorities in risk abatement and process improvement. Transit agencies understand that ESR systems are central to the effectiveness of the SMS framework and are using the data gathered in response to these reports to identify both lagging and leading risk indicators for their agencies. The performance measures tracked include, but are not limited to, the volume of reports received, status of reports, average days to closure, target closure dates, hazard classification, root cause, claims costs, lost time due to injuries, and accident rates. Well-Documented and Prescribed Reporting and Investigative Processes Capital Metro designed its ESR system with time points that correspond to each process step, including a 30-day standard for disposition of an investigation report. Once a concern has been reported through the hotline or online, an employee reporting system program manager reviews the safety report and forwards it to the department and the Metro service provider assigned the responsibility of investigating the concern and providing a response to the reporter within 30 days. GCRTA’s Standard Operating Procedure (SOP) 8 provides the purpose, objectives, and guidance for various mechanisms available for reporting conditions that may be safety critical. The SOP provides a standardized method for categorizing, tracking, and resolving hazards and reducing incidents and injuries through the resolution of the identified hazards. The Jacksonville Transportation Authority’s (JTA’s) draft policy (under development at the time of this writing) includes a goal of closing out all reported safety hazards within 7 days of receiving the report. Once corrective measures are identified and implemented, JTA conducts follow-up evaluations at 30, 60, and 90 days after implementation to ensure the mitigation has worked as intended and not resulted in unintended consequences.

Summary 7 The Lane Transit District’s (LTD’s) nonpunitive safety reporting activities, including reporting methods, follow-up activities, data collection, and development and tracking of corrective actions to eliminate or mitigate issues reported, are outlined in two policies and LTD’s CBA with Amalgamated Transit Union (ATU) Local 757. LTD makes its policies—the LTD Operator Policy and Procedure Manual and the Administrative Employee Handbook—available to drivers online and in hard copy form. MBTA and SEPTA participate in FRA’s C3RS for their commuter rail operations. The reporting process and procedures associated with investigating and correcting reported hazards is well vetted and documented in a negotiated MOU with their unions, FRA, and the third-party administrator, NASA. WMATA contracts with the Bureau of Transportation Statistics (BTS), U.S. Depart- ment of Transportation (DOT), for confidential collection and management of employee safety reports submitted through the agency’s C3RS program. In the development of its program, WMATA reviewed existing programs and processes, including FRA’s C3RS program through NASA. It cited the confidentiality protection of BTS as a contributing factor in the selection of BTS as its third-party administrator. Feedback The literature review and the case studies emphasized the importance of a feedback loop—constant communication between reporters and those responsible for imple- menting the hazard elimination or mitigation measures. This feedback loop is impor- tant to fostering an environment in which employees feel appreciated and empowered to improve the safety of their working environment through the ESR. Feedback is also important even when the hazard is reported anonymously or confidentially, and many transit agencies have found ways of sharing safety improvements in safety meetings and using various bulletins or other information dissemination methods. Periodic Process and Program Evaluation The findings from the literature review and the case studies corroborate the impor- tance of iteratively evaluating the program to ensure that it is performing as intended. One very valuable way of evaluating the success of an ESR system is through employee surveys that garner feedback on suggested improvements. By giving employees an oppor- tunity to provide input on the process, transit agencies may foster increased reporting as well. These evaluations are also related to the feedback noted previously, which builds morale and improves overall safety culture. Third-Party Utilization MBTA and SEPTA have C3RS embedded in their ESR options, WMATA uses BTS, and the Tri-County Metropolitan Transportation District of Oregon (TriMet) uses Navex Global for anonymous reporters through its ESR system. No other case study sites reported the use of a third party to collect, analyze, report, or maintain safety data. How- ever, the research team obtained feedback from case study sites that, with the implemen- tation of SMSs and the adoption of PTASPs, a national safety reporting platform would be quite valuable and would likely ensure greater ESR. This feedback and the findings of the literature review suggest there is benefit to the confidentiality and data protection characteristics of an ESR system that is managed by a third party.

8 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Training and Program Promotion Training is an important element in the successful implementation of any ESR system. All interviewed transit agencies introduce the opportunity for employees to report hazards that are identified in their working environment during new hire training. Several transit agencies also remind their employees of the reporting opportunities at safety committee meetings, refresher training, and other safety outreach events. Most transit agencies inter- viewed by the research team do not tailor their training by employment position and do not provide training to contracted employees. Union Participation Several of the case study transit agency representatives expressed benefits related to union participation in the development and encouragement of use of ESR systems. When union representation is supportive of ESR efforts and encourages employee participation, the safety culture of an organization may improve through the proactive mitigation of identified hazards. Representatives of the Big Blue Bus (BBB) reported that the positive relationship between the Safety Department and union management was pivotal in implementing a strong safety culture, which provided the platform on which the ESR system could be constructed and implemented. King County Metro described union management as supportive of the SMS and the positive changes it will bring to the transit agency. The positive relationship established between the organization and the local union has been and continues to be central to the successful maturity of the agency’s safety culture. MARTA reported that it conducted an in-person soft survey of ATU management and union stewards before the rollout of the ESR system to gain input on how to report and how members could use the ESR system. At that time, ATU viewed the ESR system favor- ably; however, ATU members established that when reports were given, they wanted to see action taken. While the initial design of MDT’s current ESR system did not include participation from the Transport Workers Union of America, the union currently remains very engaged and integrated into the decision-making process. Sacramento Regional Transit (SacRT) reported that its ESR system was designed with union input and continued support through employee encouragement of use. Union representation assisted the management of Sarasota County Area Transit (SCAT) in the development and implementation of the ESR system reporting formats used, which ensure anonymity when desired. SEPTA works closely with its labor representatives to ensure continuous improvement of the processes in place. Employees who are actively involved in location safety com- mittees are encouraged to offer ideas for improvements in the safety reporting process. Program Design Framework and Elements for Continuous Improvement Several representative frameworks for ESR systems were identified through background research that delineated the critical elements included within those frameworks. At a mini- mum, a public transit agency should develop policies, procedures, and programs based on

Summary 9 a clearly defined implementation strategy and standard operating practice. On the basis of background research and case studies, the research team recommends the program design framework reflected in Figure S-3. The success of ESR systems rests in elements of continuous improvement centered in SMS principles. These success factors are represented in Figure S-4 and further discussed in Chapter 4. Specific performance measures should be developed for each of these factors. Conclusions and Recommendations for Additional Research The objective of this study was to “produce a compilation of the best practices used in nonpunitive employee reporting programs . . . (to) assist transit agencies with develop- ing their programs.” Rather than identifying “best practices,” the research team identified Figure S-3. Program design framework. Data analytics - comprehensive data collection, analysis, corrective actions, and effectiveness monitoring Information system platform - gathering and maintaining data in support of ongoing program evaluation and support Training - establishing and promoting training and conducting training of management, employees, and contractors Process improvement - establishing routine and periodic process improvement strategies Procedural fairness - developing a structure that includes strategies and processes to promote and evaluate procedural fairness Figure S-4. Success factors for program improvement.

10 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation practices as “leading” when they could stand as model practices due to the effectiveness illustrated through the case study examinations and the literature review. The research team also reported the challenges faced throughout the implementation phases of the deployment of an ESR system and the benefits of an ESR system, as reflected in the background research and the successes identified in the transit agency case studies. In the background research, the research team identified the benefits associated with wide dissemination of commonly reported hazards and methods of addressing them. National reporting systems such as the Aviation Safety Reporting System, FRA’s C3RS, Safe Outer Continental Shelf, the Occupational Safety and Health Administration, the National Air Traffic Controllers Association, and the U.S. Nuclear Regulatory Commission all provide national dissemination to stakeholders. Research to examine the options available to develop a central repository for reporting hazards, close calls, and near miss information in the public transportation industry to produce aggre- gated national reports would be beneficial to the industry. The research recognizes the benefits of using an external party to administer and manage an ESR system, which include increasing the likelihood that employees will report safety events and reducing the likelihood that there will be associated punitive or retaliatory consequences. However, concern was voiced about the costs of instituting the program through a third party. This presents a research opportunity to develop a strategy for examining opportunities for a national ESR system for the public trans- portation industry and the steps that the industry can take to institute such a system. This report contains resource materials from the case study sites that were included in this study. The industry would benefit from a nonpunitive ESR toolkit or online resource repository that could build upon the sample policy statements, marketing/ outreach materials, sample procedures, and sample CBA and MOU language included as a part of this project, which public transportation agencies could then use as they develop and implement their own ESR systems. Finally, it is important that employees who report and public transportation agencies that collect, analyze, and maintain safety data in support of SMSs are assured that the data can remain confidential. Without evidentiary protections, the ability of an agency to protect employee-submitted data or accident/incident data is limited. The more protections granted to employees, including industry evidentiary protections, will ensure greater reporting and, in turn, safer public transportation agencies.