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

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44 Characteristics and Elements of an Effective Employee Safety Reporting System The background research and case studies revealed both a framework for the develop- ment and implementation of an ESR system and the characteristics and elements of effec- tive ESR systems. The program design framework addressed below can be used to establish an ESR system, and the characteristics and elements of successful ESR systems are examined through the lens of this framework. The research team categorized various characteristics as “leading”—elements that exist within demonstrated, data-substantiated successes primarily examined through the background research—and “common”—elements identified by case study sites that self-reported an effective ESR system. The literature review and background research established the following data-supported leading practices that are central to the ASRS, C3RS, SafeOCS, OSHA, NATCA, and NRC ESR systems: • Investigation and corrective actions—structured and comprehensive examination of reported hazards or near misses based on defined reporting parameters; • Notification of hazard and dissemination—a formal approach to dissemination of reported hazards, close call events, and mitigation strategies; • Online reporting system—online ESR systems provide greater access to affected employees as well as both perceived and, in some cases, real anonymity; and • Protection from punitive action—the literature documents the successes achieved when employees are protected from punitive action. This success is reflected in significant growth in employee reporting in several national ESR systems. For example, a 2018 presentation of Volpe’s 2017 study of FRA’s C3RS showed that since the implementation of a C3RS, derailments decreased by 20% to 40% across three sites, transpor- tation-related injuries fell by 18% at one site, and two sites saw 39% to 90% fewer disciplinary hearings (the specific pilot locations were not disclosed).118 The authors attributed the reduc- tion in derailments to the corrective actions taken in response to employee reports and the level of reporting that now exists as a result of the protection against punitive actions that has been granted to employees. Since FAA implemented the ASRS, the number of reports submitted per month has grown from 400 in 1976 to more than 8,200 in 2019.119 A total of 1,625,738 incidents was reported from the inception of the program in January 1981 through December 2018. Similar increases were reported by other systems, such as C3RS and NRC. FAA disseminates “significant items” through several industry-targeted methods. Organizations that have established MOUs with BTS have seen successes through both the confidentiality of the ESR system and industry-wide information-sharing. For example, BTS first began collecting data on equipment component failures in the offshore oil and gas industry in C H A P T E R 4

Characteristics and Elements of an Effective Employee Safety Reporting System 45 December 2016. The 2017 annual report Oil and Gas Production Safety System Events120 summa- rized the first full year of reporting shared with the industry. These reports included 112 SPPE failures from nine of 59 Gulf of Mexico production operators. These nine operators represented 35% of active wells and 40% of total oil production in the Gulf of Mexico.121 As summarized in the 2017 annual report, the majority of these failures were attributed to internal leakages (88%); however, although these pose less risk, the thoroughness of the reporting provided by the nine operational units reflects conformance with the required reporting. Program Design Framework Several representative ESR frameworks were identified through the background research, which delineated the critical elements included within those frameworks. The research indicates a public transit agency should develop policies, procedures, and programs based on a clearly defined framework implementation strategy and standard operating practice. The framework elements listed below are shown in Figure 7. • Definition of terms associated with the process established; • Delineation of reportable events, including those that may not be considered nonpunitive; • Reporting procedure(s)/process(es), including who can report and how reports may be submitted; • Confirmation—a method of providing a receipt or other method of confirmation to the reporter; • Investigation and follow-up—a method of investigating the report and providing follow-up; • Mitigation strategies—a method of determining hazard mitigation strategies; • Outcome notifications—a method of notifying the reporter and transit workers of the out- come of the report and associated hazard; and • Strategy/process evaluation—a method of evaluating the instituted strategy to ensure there are no unintended consequences. Continuous improvement of the overall program and agency safety rests in the following elements, which are also elemental in the SMS framework: • Collecting and analyzing data for the comprehensive development of corrective actions and monitoring effectiveness consistent with established and documented performance measures; Figure 7. Program design framework.

46 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • Gathering and maintaining data in a robust information ESR system platform and providing ongoing program evaluation and support based on that data; • Establishing, promoting, and training management, employees, and CBUs on the internal and external communication strategies developed; • Establishing routine and periodic process improvement strategies that include employee feedback, program evaluation, system safety trends, and improvements made as a result of employee reporting; and • Ensuring that the structure developed includes specific strategies and processes that will promote procedural fairness, as defined in this report, across management and labor. FTA’s Close Call Reporting System Implementation Plan122 provides an excellent struc- ture for a nonpunitive ESR system and reflects the framework components listed above. This implementation plan is illustrated in Figure 8, which presents key components and work plan elements that, if adopted by public transit agencies, may lead to successful programs. Note: IMOU = implementing memorandum of understanding; OMB = Office of Management and Budget; PII = personally identifiable information. Source: Close Call Reporting System Program Implementation Plan, Federal Transit Administration, U.S. Department of Transportation, BPA Number: DTFT60-10-A-0009, 2012. Figure 8. FTA’s Close Call Reporting System Implementation Plan.

Characteristics and Elements of an Effective Employee Safety Reporting System 47 Definitions of Close Call, Near Miss, and Other Terms of Relevance The seminal point in the development and execution of any formal close call reporting system is defining the terms that will be used to identify qualifying events. The terms “close call” and “near miss” are often used interchangeably, as demonstrated by the case study sites and in the literature review. As presented in FTA’s Close Call Reporting System Implementation Plan, a close call would likely include the following: • An incident that had the potential to result in serious injury or death, • A potential safety incident that occurred as the result of operator error, • A rule violation or other abnormal operating event that did not result in an accident, • A safety hazard that could have resulted in an accident, and • A near miss event that could lead to an unsafe operating environment.123 Different definitions are used in close call reporting by various transportation modes and other industries, for example: • FTA’s TRACS defines a close call as a situation or circumstance that had the potential for safety consequences but did not result in an adverse safety event.124 • In FRA’s C3RS system, a close call is any condition or event that has the potential for more serious safety consequences. In FAA’s ASRS system, both unsafe occurrences and hazardous situations are reported and ASRS analysts codify reports by using a taxonomy of event or situation types. • BSEE defines “near miss” for its SafeOCS voluntary confidential near miss reporting system as “a sequence of events and/or conditions that could have resulted in loss . . . prevented only by a fortuitous break in the chain of events and/or conditions. The potential loss could be human injury, environmental damage, or negative business impact.”125 • Nuclear industry employees can report rule violations and safety concerns, whether potential or actual safety issues, to the NRC. Violations and safety concerns can cover issues including, but not limited to, areas of design, construction, operation, maintenance, radiation protec- tion, safeguards, security, emergency preparedness, harassment, intimidation, retaliation, discrimination, wrongdoing, a work environment that discourages workers from raising safety concerns, and other matters related to NRC-regulated activities. • OSHA reporting can include any identified serious hazard or incident in which employers are not following OSHA standards. OSHA recommends that workers who believe their working conditions are unsafe or unhealthful to first bring the issue to their employer. A few of the case study public transit agencies, including BBB and King County Metro, are using NSC’s definition of near miss—“an unplanned event that did not result in injury, ill- ness, or damage but had the potential to do so.” BBB also includes the term “hazard,” defined as anything that has the potential to do harm, in its ESR system. GCRTA’s hazard ESR system defines a hazard as any real or potential condition that can cause injury, illness, or death; damage to or loss of the facilities, equipment, rolling stock, or infrastruc- ture of a public transportation agency; damage to the environment; or reduction of the ability to perform a prescribed function. LA Metro’s SAFE-7 Hazard/Near Miss Reporting System procedure defines “near miss” as an unplanned event that did not result in injury, illness, or damage but that had the potential to do so. It defines a hazard as any source of potential damage, harm, or adverse health effects to something or someone. WMATA’s MOU with its rail and bus employees defines a close call as “a situation or circum- stance that had the potential for safety consequences, but did not result in an adverse safety event.”

48 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Delineation of Reportable Events After the transit agency has defined what is considered a close call or near miss event, the next step is delineating the specific events that are considered reportable and communicating that delineation across the transit agency. This delineation may also provide the steps that report- ers must take to report events that may pose immediate threats versus those that may not. The agency may design the reporting framework to collect reports on events that vary in the level of risk, with corresponding processes for each of those levels. LA Metro’s SAFE-7 reporting program provides employees the opportunity to report any concern or complaint about any unsafe condition, hazard, or near miss event. The program has several reporting categories, each of which has subcategories from which reporters can select. Public transportation agencies should develop the definitions and delineation of the report- able events they will use for their ESR system on the basis of their own local circumstances and the input of their employees. However, the examples provided in this section may be beneficial in the development of definitions and reportable event taxonomy. Whereas establishing ESR system definitions and delineating reportable events are recom- mended practices, it is important to acknowledge that some of the case study sites reported successes in the implementation of a more informal process for reporting hazards or safety concerns. In these agencies, formal definitions are not used and transit personnel or commit- tees are used to review reports, categorize the reported hazards or safety concerns, and assign the methods and approaches used for follow-up and assigning corrective actions. These transit agencies suggest that these methods have proven effective. Reporting Process The background research and the case studies illustrate the benefits of providing employees multiple platforms for reporting. Online web-based reporting was consistently referenced, along with telephone hotlines, and, in some cases, the ability to submit hard copies of reporting forms. Transit agencies may consider an electronic reporting method if they are concerned with their ability to maintain confidentiality and provide a platform for anonymous reporting. While other methods can ensure confidentiality and anonymity, data control and custody practices must be thoughtfully developed. Electronic reporting may present a better option for transit agencies that would characterize their safety culture and the trust of frontline employees as less mature, simply because of employee perceptions that these ESR systems provide for greater protections and the ability to remain anonymous. When the reporting process and methods of reporting are being estab- lished, the number of reporting methods available may not be as important as the ease of access to a reporting platform or platforms, as reflected in LA Metro’s SAFE-7 online ESR system. Confirmation Public transportation agencies should have a mechanism in place to provide employees— even those who submitted anonymously—confirmation that the agency has received their report. The literature review and case studies provide examples of how transit agencies can perform this function. If the safety hazard has been reported online, there are ESR systems that will assign a case number or other numeric identifier that a submitter can use to track the prog- ress of the report. For example, reports submitted through LA Metro’s online reporting tool receive a confirmation ID that reporters can use to track the progress of their report. In other instances, the transit agency will send an e-mail confirmation that the report has been received.

Characteristics and Elements of an Effective Employee Safety Reporting System 49 Transit agencies generally provide summaries of reports submitted and their progress during monthly or other regularly scheduled safety meetings. At TriMet, employees and reporters can track the progress of submitted reports through the Status Summary Report available on the agency’s intranet site. These examples present opportunities for reporters to ensure their report was received and that it is in process. Follow-up/Back to Reporter Public transportation agencies should have a structured process in place to ensure that employees who report safety hazards to an ESR system know their reports have been sub- mitted and that the transit agency is taking action to address a reported hazard. The case studies and long-standing ESR systems highlighted in the literature review provide multiple examples of this follow-up activity. This follow-up takes many forms, including e-mail cor- respondence, electronic process tracking applications, postings in transit agency common areas, verbal and written reports provided during safety meetings, and updates provided to agency management. One case study site offered that a key point sometimes lost in developing and implement- ing an ESR system is that it is not solely about reporting an event. This agency recognizes the criticality of the process but offers that the most important element in programs such as these is how the agency manages the associated safety risks once they have been identified. This is the information that should be provided to the reporter—that the agency has received his or her report, investigated and processed it in accordance with agency policies, and taken action. Data Collection and Analysis Data collection and analysis go beyond the contents of an ESR. Through both the background research and case studies, collecting, analyzing, and monitoring safety trends was demonstrated to be a central point of safety risk management and safety assurance processes. ESR systems should be performance driven, with specific performance measures identified and tracked against employee reports, accident and incident investigation findings and reports, and other public transportation agency data. Technology and Information Management As illustrated in the background research and case studies, ESR systems will become more prevalent in the public transportation industry, primarily due to the industry-wide adoption of the SMS framework and the implementation of locally developed PTASPs. In anticipation of the associated greater data collection and analysis needed, public transportation agencies will have to internally develop or purchase technologies and information management system platforms to effectively log reports (or have them generated directly to these ESR systems), analyze trends over time (including those that may be systemic in nature), generate reports, and monitor corrective actions, at a minimum. The ESR system(s) developed should support a transit agency’s practice of tracking per- formance measures, as described above. From the perspective of technology implementation and information management, transit agencies will need to ensure that they are effectively prepared for the volume of data that may be generated through these ESR systems with increased utilization. As ESR systems are established, it will be important for transit agencies to prescribe data collection and release protocols and ESR system access and to specifically delineate who has access to the raw data. This will require an ESR system with data protection controls that may include limiting ESR system access and password protections to better protect the anonymity of reporters and the confidentiality of the reporting.

50 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation The use of a third party, as previously noted, is not required for the successful implementa- tion and management of an ESR system. However, this option may present an opportunity for transit agencies that do not have the internal capacity to establish, maintain, and manage these ESR systems. Safety and security reporting platforms are becoming more prevalent in the public trans- portation industry. Agencies such as JTA, MARTA, MBTA, LYNX, and SEPTA are using the ELERTS “See Something Say Something” mobile application. These reports also generate data that may be used in a public transportation agency’s risk management and risk assurance processes. Case study sites have developed their own reporting platforms and smartphone appli- cations, such as the MDT Tracker. Whether transit agencies are using a vendor product or have the capacity to develop their own ESR systems, they should establish how they will gather and store the data, use it in support of the agency’s SMS process, track safety and security risks, and address those risks on the basis of reports submitted through this or similar applications. Outcome Notification—Internal/External Communication Strategies Internal and external communication includes all communication that takes place between employees and management within the same unit, across organizational units, and across the agency. It also includes communication between the agency and its contractors, the agency and local governments or other governmental units, and the agency and the community. As reports are submitted, employees and contractors operating within that unit should be made aware of the reported hazard or concern. This is reflected in the background review and case studies and often takes the form of bulletin board posting (including electronic message boards), statements made during regularly scheduled safety meetings, or in communication between unit employees and supervisors. For hazards or concerns that would have the potential to affect the employees or other personnel at other operating bases (as an example) or all transit agency employees and contractors, the notification should be directed agencywide from public transportation agency management. There will be hazards or concerns that involve external partners, such as local government public works departments, that may require communica- tion with those outside entities and a corrective action on their part. This could include hazards associated with specific intersections, bus stop locations, signals and signage, tree limbs that limit the field of view, or other hazards. It is important that all stakeholders, from the reporter to agency personnel to those outside the agency, including the public, recognize that safety is important and that hazards or other unsafe conditions or actions are being addressed and mitigated. These internal and external communication and coordination strategies should also be established by written policies and procedures. In some cases, this may also require MOUs with local governments or other outside agencies that may be required to respond and correct hazards that are reported. Strategy/Process Evaluation—Process for Change All the nonpunitive ESR systems and processes examined in this study provide employees and other stakeholders clearly defined processes or opportunities to provide input to the program, regardless of agency size. More advanced ESR systems, such as the C3RS and ASRS, worked with stakeholders very early in the process of establishing those ESR systems and include for- mal MOUs that delineate the process, including opportunities available to provide ongoing input to the ESR system. However, other less-advanced ESR systems also tend to solicit input from their employees and contractors through routine employee surveys and one-on-one inter- action between employees and their supervisors or with agency management. This ongoing process for change should have a well-documented, prescribed process for gaining input from employees, supervisors, agency management, and members of the CBU. At

Characteristics and Elements of an Effective Employee Safety Reporting System 51 a minimum, a transit agency should conduct initial surveys during the design period, after any beta testing that might occur, after the initial training or promotion has occurred, after initial implementation, and then routinely after full implementation. Along with this input, and to inform frontline workers of program benefits, the need for their input, and its value to the agency, transit agencies should make reporting the successes generated through the program a matter of routine. Public transportation agencies can share successes during regularly scheduled safety and unit meetings and via agency postings, electronic message boards, and agency newsletters or other publications. If employees recognize that the agency is listening to them, that actions that have improved the overall safety of the agency have been taken, and that the agency also values their comments on the ESR system, they may be more likely to more effectively present their observations of the ESR system and any recommended improvements. Organizational Strategies for Promoting Procedural Fairness The research team defined procedural fairness as the systematic development of processes and procedures, employee understanding of the process, and management compliance with and execution of those processes and procedures without prejudice to the individual or the process to ensure effective and fair outcomes. Reflected strategies include those that protect employees, improve the safety of their operating environment, and allow the opportunity to challenge or appeal the investigation and corrective action outcomes. Procedural fairness begins with employee involvement in the design and implementation of the program, train- ing in or promotion of the ESR system, and ease of access to reporting platforms. Further, it includes • The ability to provide input through the investigation and determination of outcomes; • Well-defined feedback loops; • Written policy or a procedural statement that protects employees from punitive actions or retribution, except in situations that involve a blatant disregard of agency policies, proce- dures, or safety operating practices; • Notification of investigation findings and follow-up actions; and • Written policy or procedural presentation of the steps that a reporter can take to challenge or appeal an investigation outcome or mitigation strategy used. ESR processes should establish target time frames by which the agency will initiate and complete the procedural steps in the investigation process and associated corrective actions. If there are points along the continuum at which committee meetings are held or manage- ment presentations are given, reporters should be aware of these steps in the process and the estimated times by which these steps will occur. Employees should know that their voices are heard and that the agency is actively taking the steps required to address concerns, hazards, or other issues. Finally, and as reflected in the background research, even though a system is nonpunitive, it may not establish that all reported behavior is acceptable.126 Every nonpunitive ESR system should establish a formal policy and corresponding implementing procedure that clearly defines the types of protections that are being afforded by reporting and how identifiable information will be used.127 As stated in the final report of TRACS Working Group 16-01,128 Fair treatment of employees also requires fairness and consistency in dealing with rule violations. When rule violations occur, there should be a fair appeals system in place to dispute them in case of a disagreement. Employees must be made aware of what is punishable when there appears to be a blatant dis- regard for any rules and an action is determined to be intentional or due to negligence.129

52 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Common Characteristics and Elements of Effective Employee Safety Reporting Systems The 19 public transportation agencies in this study found varying degrees of success in the design, implementation, and ongoing management of their ESR systems. The research team identified common practices from these case study participants, including • Participation of the local CBU in the design, implementation, investigation, and corrective action processes. • Employee access—multiple reporting options or ease of reporting. • Well-defined procedural processes for collecting, investigating, and correcting the reported hazards. • A robust investigation process that involves multiple players from across the agency. • Feedback to reporters, from initial receipt of the report through the process and follow-up once the hazard has been corrected. • Methods to ensure anonymity and confidentiality. • A written agreement between the agency and its employees that reporters can remain anony- mous and that if contact information is provided, no punitive actions will be taken for those events or behaviors that do not represent cardinal rule violations, such as drug and alcohol- related actions, or blatant disregard of agency policies. The agreement would also provide protections against retaliation, intimidation, or discrimination against the reporter. These statements could be included as part of a CBA or MOU. • A precise statement of what would be considered nonpunitive and what would result in puni- tive action, such as the events or behaviors listed above and 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(s) taken. • Training and program promotion. • Ongoing tracking of safety data, common agency hazards, and the effectiveness of mitigation strategies. • Periodic process and program evaluation. These practices are reflected within eight overarching themes described below and illustrated in Figure 9 in alphabetical order. Access—Ease of Reporting All of the public transportation agency case study sites provide anonymous reporting options and take the steps necessary to ensure confidential reporting, as applicable. Examples of transit 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 9. Case study common practices.

Characteristics and Elements of an Effective Employee Safety Reporting System 53 agencies with multiple avenues for reporting and one that provides only a single method of reporting are described below. LA Metro has a single online submittal method, the SAFE-7 form. To accommodate the agency’s employees and ensure their ability to report, LA Metro installed desktop computers at each division and provides access to every employee. Conversely, MDT provides multiple reporting options to its employees, including a hard copy form, online, or via the agency’s smartphone application, the MDT Tracker, which it developed internally. Anonymity is ensured through both the online reporting portal and the MDT Tracker, which are used by both employees and the public. The Transport Workers Union of America (TWU) shop steward or officers may also bring safety concerns forward on behalf of employees. Of all public transportation agencies included as case study sites for this project, SEPTA has the most reporting options available to employees: • Notify their managers verbally, • Complete a Hazard Report Form, • Notify their location safety committee (LSC) representative, • Complete the SEPTANow online form, • Submit an e-mail to systemsafety@septa.org, • Submit concerns through the nonemergency safety hotline, and • Use the VERITAS Customer Service Tracking System to report hazards. Employees of SEPTA’s commuter rail system may also report through NASA under the FRA C3RS program. In these examples, the transit agencies indicate a consistent level of reporting and significant ESR system improvements that were made as a result of the reporting. The success of the 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 An appeal process is important for employees who do not feel a reported safety hazard was reasonably mitigated. Several respondent case study transit agencies have appeal processes in place for their employees. Capital Metro, GCRTA, MBTA, and SEPTA have instituted the good faith challenge pro- gram at their transit agencies, in accordance with the FRA procedures defined in 49 C.F.R. 218.97 for commuter rail operations. These procedures afford right-of-way employees the right to challenge, in good faith, procedures that violate FRA regulations or railroad operating rules. LA Metro employees can request a reevaluation of their safety concern if they do not feel management’s response has adequately addressed their concern. This reevaluation process is not defined in a specific policy. MARTA’s Safety Hazard Notification and Escalation Process establishes the steps that must be taken to gather, investigate, and correct the reported hazard. It also delineates an appeals process in the event the reporter is dissatisfied with the action taken or the response. MARTA’s Safety Hotline Procedure (SQA-SOP-1020) provides the scope and purpose of the hotline, the definitions used, various responsibilities of MARTA personnel involved in the process, and the details of the Safety Hotline notification and investigation process.

54 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation To appeal hazard mitigation measures that employees feel are inadequate, MBTA encour- ages employees to use the ESR system again to clarify the hazard and report a mitigation measure as ineffective. Additionally, if employees consider themselves in danger from the inadequately mitigated safety hazard, they may issue a good faith challenge. At MDT, if an employee is not satisfied with the evaluation and associated resolution of the reported concern, he or she may request a Transit Safety Review. MDT’s chief of transit safety and security provides the final approval of either the initially prescribed resolution or other cor- rective action. MTA employees who are not satisfied with a hazard mitigation may bring that concern to the safety officer assigned to resolve that concern. MTA has no policy that describes how anonymous reporters would appeal the response or mitigation strategy. SEPTA has a dispute resolution process defined in the TWU Local 234 CBA, which focuses on the use of the Joint Health and Safety Committee to resolve the issue. If the employee remains unsatisfied with the resolution, he or she may seek resolution through the grievance process, which could include arbitration, as defined in the CBA. Track workers are also able to submit a good faith challenge through the procedures developed in accordance with FRA’s 49 C.F.R. 218.97, under the roadway worker protection requirements. SEPTA expanded the good faith challenge to include transit employees who are not governed by FRA. The program initially started as a way for employees to report uncomfortable levels of protection; however, this has been expanded to include reports of any safety concern of an employee. At TriMet, employees who feel that their concern was not fully answered or adequately resolved may ask that the request for safety assessment (RSA) be reviewed again or reopened. If an employee requests a review, he or she is encouraged to provide additional information to ensure the review adequately addresses all aspects of the concern. WMATA employees who are not satisfied with the resolution of a hazard have the option to contact BTS again to report that the hazard was not mitigated. When this occurs, the peer review team will revisit and reevaluate the preventive action that was instituted to improve the hazard resolution. WMATA has also instituted the good faith challenge program in accordance with the FRA procedures defined in 49 C.F.R. 218.97 within its Roadway Worker Safety program for rail workers. The variation in the use of appeal processes for safety hazard mitigation among the respon- dent transit agencies reveals that no single type of appeal process will necessarily work for every transit agency. Rather, transit agencies should consider the types of resolution process that will work best for them on the basis of transit agency size, resources, and the frequency of use of the ESR system and of appeals. Data Utilization and Performance Measurement All participants in the public transportation agency case study 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 frame- work and are using the data gathered in response to these reports to identify both lagging and leading risk indicators for their agencies. Seven of the 19 case study agencies track and trend various performance measures related to their employee reporting program, including metrics related to the volume and status of hazard reports, the description of the hazard or event, contributing factors, and results. The performance metrics related to report volume and status include

Characteristics and Elements of an Effective Employee Safety Reporting System 55 • Number of reports per month, • Customer complaints, • Open versus closed report status, • Average days to closure, and • Target closure date. In addition to the performance metrics related to report volume and status, there are also perfor- mance metrics related to the description of the hazard or event and possible contributing factors that are reported, including • Hazard/event classification, • Reports by area (facility, equipment, system, security), • Mode, • Date of hazard/event reported, • Party responsible, and • Root cause. Finally, there are resultant performance measures that are tracked and trended to determine the efficacy of a nonpunitive ESR system; these include • Workers’ compensation claims and costs, • Lost time and non-lost-time injury rates, • Vehicle accident rates, and • The experience modifier, which is determined by the workers’ compensation insurance system. SEPTA discussed its process for measuring and tracking the efficacy of its hazard ESR system, which is based on the data and documents submitted and collected during the investigation process. SEPTA reviews and trends the data and information submitted or obtained during the investigation process and tracks performance measures, including • Lost-time and non-lost-time injury rates per 200,000 work hours, • Customer complaints, • Issues reported, • Length of time taken to address issues, and • Vehicle accident rates per 100,000 miles. From the perspective of the individual report and the agency, data collection and analysis brings concerns about access to that data. The third parties that oversee the FAA and FRA safety report- ing systems, as an example, have evidentiary protections granted to them in federal law. As of the writing of this report, Congress had not yet granted these evidentiary protections to public transportation agencies collecting ESR and accident/incident-specific data in support of SMS implementation. During the interviews with case study transit agencies, the majority stated that state law also does not protect the data they currently collect. Documented and Prescribed Reporting and Investigative Processes As established in Dekker’s Just Culture, getting employees to report is difficult, but keeping the rate of reporting once an ESR system is up and running can be equally difficult.130 He sug- gests that getting people to report is about two major things: maximizing accessibility to report- ing platforms (discussed above) and minimizing anxiety. He suggests that this anxiety and the associated lack of motivation to report can be addressed by leaving little ambiguity in the reporting process, including employee protections that are self-evident. This means public transportation agencies should formally establish, adopt, and promote a well-documented and

56 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation prescribed detailed process. In addition, reporters should feel confident that they are protected and that their concerns are being addressed in a timely manner. One of the most important elements of reporting and investigative processes is establishing time lines. Public transportation agencies that are establishing ESR systems should define the process well and state clearly the steps that will be taken from the receipt of an initial report to its resolution to the ongoing monitoring of associated hazards and mitigation strategies. Processes or a procedure document should include specific time lines for • Notifying a reporter that the report has been received; • Reviewing the report and determining the validity of the hazard or reported concern; • Assigning the investigator (investigating department); • Completing the investigation, including any follow-up necessary with the reporter; • Developing the corrective action plan; • Performing the corrective action; • Notifying the reporter and agency personnel of the concern reported and the steps that were taken to correct the hazard or concern; and • Revisiting the mitigation to ensure that it worked as intended and did not created un intended consequences. Capital Metro’s ESR system is structured with time points that correspond to steps in the process. For concerns reported on Metro’s hotline, messages must be reviewed within 24 hours of the time the message was received. Once a concern has been reported through the hotline or online, an ESR program manager reviews the report and forwards the content of the report to the department and/or Metro service provider assigned the responsibility of investigating the concern and providing a response to the reporter. The department assigned to investigate the report has to respond with a resolution within 10 days of the assignment, and a response to the reporter must be provided within 30 days. During this time, the program manager monitors activities to ensure the disposition of the report by the end of the 30-day period. GCRTA’s Standard Operating Procedure (SOP) 8.1, Hazard Reporting & Management Procedure, provides definitions of the purpose and objectives of the SOP and guidance on various mechanisms available for reporting conditions that may be safety critical. SOP 8.1 also outlines the process adopted to have uninhibited reports of incidents, hazards, occurrences, and risks that may compromise safe operations. It provides a standardized method for categoriz- ing, tracking, and resolving hazards and reducing incidents and injuries through the resolu- tion of the identified hazards. GCRTA trains all accident investigators and supervisors with investigative responsibilities to use the TapRooT® methodology to investigate hazards and events with the Root Cause Tree.® With this tool, investigators can discover the root cause of an accident, incident, or hazard and can ultimately assist in the mitigation of the risks associated with the identified hazards. JTA’s policy includes a goal of closing out all reported hazards within 7 days of receipt of a report. Once corrective measures are identified and implemented, JTA conducts follow-up evaluations at 30, 60, and 90 days after the measure was instituted to ensure that the mitigation has worked as intended and not contributed to or caused any separate issues. LA Metro’s System Safety Program Plan includes a safety policy that regulates the reporting process. This policy obligates every employee to report unsafe conditions encountered on agency premises, including any type of near miss. The same policy also mandates management to investigate any event reported through SAFE-7 and to inform the originator of the report of the status of his claim. Reports have to be closed within 30 days of origination, unless the mitigation is classified as a long-term resolution item, and the results have to be published or the originator notified of the report and related actions within this time frame.

Characteristics and Elements of an Effective Employee Safety Reporting System 57 LTD’s nonpunitive 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. The policies—the LTD Operator Policy and Procedure Manual and the Admin- istrative Employee Handbook—are made available to drivers online and in hard copy form. These documents highlight the distinction between the issues that can be reported through the non- punitive ESR system (Blue Cards and Hazard Cards) and actions considered negligent or illegal that require disciplinary action. The roles of the Safety Committee, comprising 11 members from different departments and two director-level senior management members, are also delin- eated in the policies. MARTA’s Safety Hazard Notification and Escalation Process establishes the steps that must be taken to gather, investigate, and correct the reported hazard. It also delineates an appeals pro- cess in the event the reporter is dissatisfied with action taken or the response. MARTA’s Safety Hotline Procedure (SQA-SOP-1020) provides the scope and purpose of the hotline, the defini- tions used, various responsibilities of MARTA personnel involved in the process, and the details of the Safety Hotline notification and investigation process. MBTA and SEPTA participate in FRA’s C3RS program for their commuter rail operations. The reporting process and procedures associated with investigating and correcting reported hazards through this ESR system are well vetted and documented in negotiated MOUs with their unions, FRA, and NASA. TriMet’s RSA system and associated processes were put in place to support the safety risk assessment function of the agency’s SMS. The agency-implemented Operating Procedure SSE-053, Request for Safety Assessment, last revised in August 2016, defines the purpose of the program, specific responsibilities by role, and definitions related to TriMet’s RSA. The purpose of the RSA program and the associated procedure is to provide a means for any TriMet employee to communicate safety concerns and standardize the submission and review of the information that is communicated. RSAs typically include issues or hazards that cannot be resolved by the employee’s immediate supervisor or manager. The procedure establishes deadlines for the steps involved in the process. Feedback Loops Every case study participant has established processes to ensure reporters will be notified of receipt of their report, the investigation outcome, the steps that were taken to correct a reported event or hazard, and any additional follow-up actions taken in response to the reported concern. Transit agencies with electronic report submittals include an autogenerated confirmation to the reporter. At LA Metro, SAFE-7 provides a confirmation to the reporter that the report has been received and assigns a confirmation identification number that stays with the report until the process concludes. The employee can track his or her report through the process via the online system. If an employee submits a report anonymously, transit agencies take care to ensure that the report and outcomes are disseminated throughout the agency in safety meetings, newsletters or other promotional postings, electronic message boards, and through the local employee union representatives. If the employee included contact information, the majority of the case study sites will communicate directly with that individual and maintain the dialogue until the process has concluded. Regardless of the reporting method, MDT notifies reporting employees of the outcome of the investigation and associated resolutions. If a report is submitted anonymously, a reporter will

58 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation learn of the resolution through Safety Committee reports or directly from his or her division manager. MDT consistently performs report follow-up activities and has an ongoing process and program evaluation function. Public transportation agencies may use the employee survey included in the MDT case study in Appendix A as a model format for gaining employees’ valuable input. At MTA, if the reporting employee provides contact information, he or she receives a follow-up confirmation within 24 hours. However, if the report is provided anonymously, the mitigation measures implemented as a result of the report are shared at monthly modal department meetings. Periodic Process and Program Evaluation Providing employees an opportunity to share their opinions and input on what works best about an ESR system and what could be improved introduces a performance metric on which to base ESR system improvements. Periodic evaluation of processes within the ESR system is important to ensure the system is performing as intended. Capital Metro has included frontline employees, including both bus operators and mainte- nance technicians, in its efforts to gather feedback on the ESR system and reports that employees voice their support for the program. In addition, Capital Metro has contracted with the Texas Transportation Institute to study its ESR system. Part of this process will seek input from Metro employees, including those under the bargaining unit. One of the projected outcomes of the study will be the identification of methods to make the ESR system more transparent so that concerns can be shared across the entire workforce. One such method would be a central site or repository that would allow all employees and service providers to access safety reports. Metro continues to examine various options for improving employee reporting and gathering employee input. During the interview process, Metro representatives indicated that they have also discussed instituting an employee focus group. GCRTA conducts an annual safety culture survey each summer that gives the agency the opportunity to assess employee satisfaction regarding the nonpunitive ESR system. The survey also enables employees to provide suggestions on how to improve the ESR system from a user perspective. Recognizing the importance of employee feedback, LA Metro conducted two employee surveys to assist in evaluating the agency’s safety culture. In both instances, a consultant was used to interpret the survey responses related to safety culture and the SAFE-7 Program. On the basis of the results of these surveys, LA Metro determined that the current ESR system worked well and that no changes were necessary. The use of employee feedback surveys is a standard practice for LA Metro. MDT surveys it employees about the ESR system each year, and participation averages 5% to 10%. In addition, MDT’s audit and compliance section interacts with employees on a regular basis and asks about the methods available to them for reporting hazards. Employees are also asked about any reluctance they may have about repercussions or punitive actions in response to their reporting. MTD representatives indicated that no reports from this effort have reflected concerns about the ESR system and that employees view it favorably. Third-Party Utilization Of the public transit agencies included in the case study, only those with C3RS embedded in their ESR options [MBTA and SEPTA (FRA/NASA) and WMATA (BTS)] and TriMet, which

Characteristics and Elements of an Effective Employee Safety Reporting System 59 employs the anonymous reporting option provided by Navex Global, are using a third party to collect, analyze, report, or maintain safety data. The background research examined the experience of industries that use third parties and the associated benefits. Implementing a nonpunitive ESR system through an independent third party could be a valuable option for transit agencies whose safety culture is less mature. They can ensure confidentiality, provide an impartial analysis of the reported hazard or event, and protect the reporter from punitive measures or retaliation by the agency, directors, super- visors, or other employees. The use of a third party may remove any real or perceived barriers to procedural fairness and increase employee willingness to report. Case study agencies recognized the benefits of using an external party to administer and manage their ESR system. A commonly stated benefit was the greater likelihood that employees would report safety events because they perceived that the associated punitive or retaliatory consequences would be less likely. In addition, when reflecting on the increase in the quan- tity and flow of report submittals that might result from SMS implementation and the actions necessary to provide an initial response, investigate the reported event or circumstance, effec- tively provide feedback to reporter, and track and trend areas of risk, most case study sites favorably viewed the use of a third party. However, concern was also voiced about the costs of instituting the program through a third party. The availability of a national reporting platform, such as those represented in the literature review, may be a consideration. In systems such as BSEE’s, which uses BTS, and FRA’s C3RS, the dissemination of reported risks and associated mitigation or abatement strategies has been beneficial to the participating industries. A national reporting platform for the public transpor- tation industry might advance the safety of this industry. Training and Program Promotion An important aspect of any program or system that is implemented in a transit agency is the inclusion of training and program promotion. Training for an ESR system ensures that all existing and new employees understand the ways in which safety hazards can be reported and the ways the mitigation measures are reported back to the employees that report safety hazards. Promotion is an important element to ensure that adequate use of the ESR system leads to agency wide safety improvements. To increase reporting, Capital Metro worked with its marketing and communication teams, vice-presidents, directors, and others to develop a strategy for promoting the program. One of the methods it is using is to inform employees about federal public transportation and pas- senger transportation laws and regulations that protect them from harassment and aggression from their employers and direct supervisors when they report system hazards, close calls, and near misses. Capital Metro stated that it wants employees to be confident that they are protected from being fired, harassed, suspended, or treated differently because of their reporting and to know that there are mechanisms in place to protect them. Further, it wants employees to under- stand that their participation in the program is necessary and that management wants to know when there are concerns or hazards to report. GCRTA promotes the reporting of significant hazards and improvement suggestions through the agency’s Suggestion-of-the-Year Award. LA Metro has a comprehensive new-hire training program that includes the SAFE-7 reporting program and how to submit reports. Additionally, it prepared and currently disseminates training materials to all employees. The materials produced, which include a memo, program flyers, pocket cards, frequently asked questions, and brochures describing the ESR system, serve as

60 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation a form of refresher training and have been effective in preparing employees for the transition to the online form. LA Metro’s SAFE-7 pamphlet is an explanatory tool that guides employees through the online ESR system and contains a section of questions and answers to resolve the most typical doubts an employee might have regarding the completion of the form. LeeTran has a comprehensive training program for its bus operators that includes ESR as a key SMS principle. During these sessions, operators are instructed in the different options for reporting hazards and near misses by using either the hard copy form or the online report form, which is LeeTran’s preferred reporting method. LeeTran is also in the process of developing a campaign to reintroduce the near miss reporting options and advantages. The campaign will include • A digital message board that plays videos of operators and staff demonstrating the ease of filling out a form; • A poster detailing what types of events should be reported and why that is displayed in the operators’ break room; • A trifold poster that displays the near miss form; • A time clock advisory placed above both time clocks in the operator break room; and • An information table at which a safety specialist explains the near miss policy and hands out raffle tickets for a prize drawing that will take place at the end of each weeklong campaign (Figure 10). MARTA developed an e-learning presentation of its program that can be viewed at any time. Transit agencies that are implementing a nonpunitive ESR system would benefit from having training options across multiple platforms. E-learning products can be used during initial training or can serve as refresher training for employees, who may access modules and progress through the modules at their own pace. MBTA trains employees to report hazards and near miss events in its new hire, occupational health and safety, and right-of-way worker training courses. Additionally, MBTA emphasizes hazard reporting via written Safety Flashes and management blitzes. Figure 10. LeeTran’s information table.

Characteristics and Elements of an Effective Employee Safety Reporting System 61 To proactively identify and address potential hazards, MTA provides employees with an SMS card (Figure 11) that outlines the frontline employee’s role: to work safely and wear proper personal protection equipment; remain compliant with procedures and regulations; and report hazards, safety concerns, or safety suggestions. At SCAT, employee announcements and the minutes of all labor–management meetings explicitly state that it shall be the policy of Sarasota County Area Transit that any unsafe act, close call, or accidental risky behavior will not be penalized as long as the issues is self-reported prior to a loss. We want to hear about it and prevent future risk! SCAT introduces its anonymous safety reporting process during new-hire initial training, and the reporting alternatives are refreshed on the safety television located in the employee lounge, which displays different safety messages throughout the day. SEPTA has robust training and employee awareness programs that support its ESR system. During new-hire training, SEPTA addresses the importance of identifying and reporting workplace hazards. In addition, 30 minutes of new-hire orientation is devoted to informing employees about how to identify and report safety concerns, including the opportunity to do so anonymously. During semiannual internal employee safety days, which are generally held in the fall and spring of each year, managers review various safety topics, discuss trends and issues at SEPTA and within the industry, and remind employees of the options they have to report hazards. One method TriMet used to successfully promote the involvement of frontline employees in its ESR system was through the development of the Bus Operator’s Continuous Improvement Figure 11. Maryland DOT SMS card.

62 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Team (BOCIT). BOCIT is instrumental in producing solution alternatives for the various reported RSAs, which provides a unique opportunity to foster employee buy-in from the report- ing to the mitigation phases of the RSA process. Since its development, BOCIT has been so successful that it was awarded the Oregon Governor’s Occupational Safety and Health division award in 2015 for its “extraordinary contributions to the field of workplace safety and health.” Union Participation Several representatives of the case study transit agencies noted benefits related to union participation in the development and encouragement of use of ESR systems. When union rep- resentation supports ESR efforts and encourages employee participation, the safety culture of an organization can improve through the proactive mitigation of identified hazards. The BBB CBU, the International Association of Sheet Metal, Air, Rail, and Transportation Workers (SMART), was involved from the inception of the reporting program, and SMART union management works in tandem with BBB safety management to encourage employee reporting. Agency representatives reported that the positive relationship between the Safety Department and union management was pivotal in implementing a strong safety culture that provided the platform on which the safety reporting program could be constructed and implemented. Capital Metro consulted with ATU during the initial design and implementation of the ESR system. The agency provides ongoing opportunities for ATU input and engagement. The local ATU president is a member of the System Safety Committee, to which the agency presented the report- ing application and the associated procedures, and indicated that ATU was pleased with the pro- cess and procedures. A labor union representative is also present at all System Safety Committee and other agency safety meetings, at which he or she is afforded the opportunity to review and comment on all plans developed in response to reported concerns prior to implementation. At King County Metro, ATU is actively participating in the current redesign of the employee reporting program. ATU plays an important role in encouraging employees to use the pro- gram to report hazards and to provide safety suggestions. Union management is described as supportive of the SMS and the positive changes the SMS will bring to the agency. The positive relationship established between the organization and the local union has been and continues to be pivotal to the successful maturity of the agency’s safety culture. King County Metro offi- cials suggested that their example could serve as a model for other transit agencies interested in understanding how safety culture should work. MARTA’s Joint Health and Safety Committee, which includes an ATU representative, was involved in the development of the program and is responsible for any review of or updates to the process. In addition, this body is actively involved in the progression and resolution of Safety 1st reports. MARTA also reported that it conducted an in-person soft survey of ATU manage- ment and union stewards before the rollout of the program to gain input on how to report and how members could use the ESR system. At that time, ATU viewed the ESR system favorably. However, ATU members noted that when reports are given, they want to see action taken. MDT’s labor union inclusion with input opportunities for TWU is highlighted as a model practice. While union representatives were not involved in the initial design of the ESR sys- tems in place, they are very engaged and integrated into the decision-making process. MDT established a Union–Management Safety Committee (UMSC) with membership prescribed by an MDT administrative policy and defined in the CBA. The UMSC includes seven TWU representatives. In an effort to ensure participation across the agency, the UMSC also includes Metrobus operations, Metrobus maintenance, Metrorail operations, Metrorail

Characteristics and Elements of an Effective Employee Safety Reporting System 63 maintenance, Metromover maintenance, track maintenance, power, labor relations, and safety and security. The committee was actively involved in the development of the Report of Safety Concern form. Union representation assisted SCAT management in the development and implementation of the reporting formats used. SCAT’s safety manager, members of the Safety Committee, and ATU worked collaboratively to define what was needed to develop a nonpunitive hazard reporting program. ATU is also included in the hazard report review process to ensure anony- mity when it is desired. SacRT collaborated closely with its two labor unions to develop and implement the non- punitive anonymous employee near miss reporting program. ATU represents SacRT’s transit operators, while the International Brotherhood of Electrical Workers represents the agency’s mechanics. Union representatives provided input to the design of the forms and were instru- mental in spreading the news of the near miss reporting opportunity and encouraging all employees to report all identified near miss events and hazards. SEPTA works closely with its labor representatives to ensure continuous improvement in the processes in place. There are more than 30 LSCs at SEPTA, each of which is a union management working group of employees who meet monthly to discuss safety concerns and review accident/injury trends. Employees who are actively involved in the LSCs are encour- aged to offer ideas for improvements to the safety reporting processes.