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

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64 The objective of this study was to produce a compilation of the best practices used in nonpuni- tive employee reporting programs at transit agencies. The best practices would include examples of how nonpunitive employee reporting programs benefit transit agencies and their employees and could be used to assist transit agencies with developing their programs. Rather than identify- ing best practices, the research team identified 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 practices also include those that are common elements in ESR systems that organizations in other industries and agency case studies have described as successful. Conclusions This examination focused not only on policy and procedural aspects but on the safety cultures reflected in the transit agencies where this reporting has been and continues to be successful. This report has described the challenges faced in the implementation phases of deploying an ESR system as well as the benefits of an ESR system, as reflected in the background research and the successes identified in the transit agency case studies. A commonality among all the case study agencies was the recognition that implementation of an SMS requires a structured, formalized ESR system with associated newly developed or updated processes and data-driven analyses against performance measures that support ongoing safety risk management and safety assur- ance functions. The case study interviews led to a better understanding of the state of the practice in ESR systems at 19 transit agencies across the country. These agencies were chosen to represent the variety in ESR system maturity and sophistication. Data gathered from the case study interviews include • ESR system program description, • Policies, • Training, • Stakeholder input, • Barriers to implementation, and • Elements of success. Employee Safety Reporting System Program Description The ESR systems at the 19 transit agencies in the case study ranged in age from less than 1 year to more than 20 years. More than 90% of the 19 agencies indicated that their ESR system provides an anonymous safety reporting option, and 85% indicated that reports can be made C H A P T E R 5 Conclusions and Recommendations for Additional Research

Conclusions and Recommendations for Additional Research 65 confidentially. Across the surveyed agencies, the ESR system reporting methods included hard copy/paper forms, online employee portals, e-mail, hotlines, mobile applications, in-person meetings, and through third-party systems. While the number of ESR system reporting options varied among the surveyed transit agencies, the respondent agencies voiced the importance of ease of access for the employees coupled with the agency’s ability to respond to safety hazard reports in a timely manner with communication throughout the hazard mitigation process. Of all public transportation agencies included as case study sites for this project, SEPTA had the most reporting options available to employees; in contrast, LA Metro had a single online submittal method. Representatives of both agencies indicated a consistent level of reporting and shared that significant agency improvements had been made as a result of the reporting. The suc- cess of both ESR systems leads to a key takeaway: that the ideal number of reporting options will not be uniform across transit agencies. The optimal type and number of ESR system reporting option(s) may vary by transit agency, so an assessment of environmental considerations should be part of the implementation of an ESR system. Policies Of the 19 transit agencies that responded to the survey, more than half (53%) indicated that they had a policy in place that explicitly distinguishes between the types of events that are reportable through the nonpunitive ESR system and the types that are considered negligent or illegal actions that may result in discipline, as recommended by TRACS Working Group 16-01.131 The remaining nine agencies reported either that they had not instituted a policy or that their policy did not distinguish between reportable nonpunitive events and punishable events. One example of a policy improvement occurred within BBB. The agency’s ESR system, which was first implemented in 2015, was cited as a contributing factor in its improved safety performance when BBB was awarded the APTA 2018 Bus Safety and Security Gold Award for its proactive approach to reducing preventable accidents. In December 2019, BBB rebranded its ESR system as the Employee Safety Hazards and Analysis Reporting Program (SHARP). The updated program included specific policy improvements to clarify the purpose of the policy, pertinent definitions, the reporting process, and specific responsibilities. In the development of their policies, transit agencies may want to consider the guidance that is available, or the regulation that applies, from FRA or, for example, the California Public Utilities Commission. FTA’s SMS Implementation Pilot was a key source for the technical assistance132 guidance that is currently available for assistance that transit agencies have available to meet PTASP rule (49 C.F.R. Part 673) requirement that public transportation agencies develop an ESR system as part of the SMS safety risk management function.133 Training An important aspect of any program or system implemented in a transit agency is the inclu- sion 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 employees who report safety hazards. Promotion is an important element to ensure that adequate use of the ESR system leads agencywide safety improvements. Of 19 transit agencies surveyed, 13 indicated that they do not tailor their ESR system train- ing by employment position, while the other six indicated their training varies by employment position, with extensive training provided to employees who are involved in investigations and implementation of mitigation.

66 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation Many transit agencies contract specific services (e.g., paratransit services) and, thus, may have contracted employees who report to a separate management company or other subcontractor. Representatives of the surveyed transit agency were asked whether they provide nonpunitive ESR system training to their contracted personnel, and the majority (12 of 19) indicated that they do not, although contracted employees have the same options to report safety concerns as any other employee at 90% of the interviewed agencies that use contracted services. Three agencies, LA Metro, MTA, and MBTA, indicated that their contracted employees typi- cally report safety concerns to their respective employers, who then share the details with the transit agency when necessary. However, the transit agency representatives indicated the chal- lenges involving access to data in this type of scenario. MTA representatives mentioned that the agency is currently working with various contracted service providers to transition to MTA’s reporting tools to ensure the maintenance of a centralized, all-encompassing hazard log. In addition to working to overcome the challenges in coordinating more than one ESR system, transit agencies are also working to promote the use of the ESR system to increase reporting: • 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 its SAFE-7 reporting program and how to submit reports. Additionally, the agency prepared and currently dissemi- nates 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 a form of refresher training and have been effective in preparing employees for the transition to the online form. • LeeTran has a comprehensive training program for its bus operators that includes ESR as a key SMS principle. LeeTran also holds an annual safety campaign that includes digital mes- sage boards, posters, advisories, and an information table with raffle tickets for prizes. • MARTA developed an e-learning presentation of its program that can be viewed at any time. • To proactively identify and address potential hazards, MTA provides employees with an SMS card (Figure 11) that outlines the frontline employee’s responsibility to work safely and wear proper personal protection equipment, remain compliant with procedures and regulations, and report hazards, safety concerns, and safety suggestions. • SEPTA has robust training and employee awareness programs that support its ESR system. SEPTA devotes 30 minutes of new-hire orientation to informing employees about how to identify and report safety concerns, including the opportunity to do so anonymously. During semiannual internal employee safety days, 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 BOCIT, which has been instrumental in pro- ducing solution alternatives for the various reported RSAs. BOCIT provides a unique opportu- nity to foster employee buy-in from the reporting to the mitigation phases of the RSA process. Through training and promotion of the use of their ESR systems, transit agencies are afforded the opportunity to proactively eliminate or mitigate risk due to safety hazards that would not have been identified without an ESR system. The active use of an ESR system and subsequent feedback and mitigation lead to an improved safety culture throughout the transit agency. Stakeholder Input Another characteristic of a nonpunitive ESR system that is imperative to consider is the role of stakeholder input in the design and implementation phases of a reporting program. Examples

Conclusions and Recommendations for Additional Research 67 of stakeholders include accountable executives, managers and supervisors, operations and safety representatives, and labor union representation. CBUs played a role in the original design or implementation of nearly half (nine of 19) of the hazard or near miss reporting programs of the responding transit agencies, whereas seven of the 19 agencies indicated their CBA contained no language related to their ESR system. Several representatives of the case study transit agencies noted benefits related to union participation in the development and encouragement of use of ESR systems: • The BBB CBU, 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. • Capital Metro consulted with ATU during the initial design and implementation of its ESR system and provides ongoing opportunities for ATU input and engagement. • At King County Metro, ATU is actively participating in the current redesign of the employee reporting program. • MARTA reported that it conducted an in-person soft survey with ATU management and union stewards before the rollout of the program to gain input on how to report and how members could use the ESR system. • MDT established a UMSC with membership prescribed by an MDT administrative policy and defined in the CBA. The UMSC includes seven TWU representatives who actively assisted in the development of the Report of Safety Concern form. When union representation supports ESR efforts and encourages employee participation, the safety culture of an organization improves through the proactive mitigation of identified hazards. Barriers to Implementation Throughout ESR system development or improvement, barriers to implementation are likely to occur. The barriers noted below can serve as lessons learned for peer transit agencies that may implement similar ESR systems. As efforts are focused on the improvement of system safety from each elemental perspective, it is important to understand challenges and solutions to those challenges, just as it is important to understand successes. Many of the surveyed case study transit agencies experienced at least minimal barriers to the implementation of their ESR system: • BBB’s ESR system was designed to include near miss reporting as well as safety hazard report- ing, yet few of these near miss types of safety reports are received, and the ESR system is mostly used to report safety hazards. • Capital Metro reported lack of anonymity in recordings through its hotline as the most sig- nificant concern it encountered in its outreach to frontline employees. The current safety culture of the agency has presented challenges in employee trust of an ESR system. Challenges in obtaining reports of safety hazards from contracted employees were also identified as an ESR system barrier. • CTA indicated that any adversarial relationship between a transit agency and the CBU could become a significant barrier to implementation. • GCRTA indicated that the majority of reports that are currently received through the ESR system are minimal in nature and primarily related to issues such as first aid kits that need to be replenished. • JTA found it necessity to brand the ELERTS See & Say app with its own name to ensure it can be found in app stores and will be identifiable to JTA. Additionally, specific technological barriers were counteracted with an informative index card that describes steps to download and use the app.

68 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation • King County Metro reported the cost of implementation as the key barrier encountered, with specific reference to the ability to demonstrate a return on investment. • MTA cited the necessary improvement in the safety culture of an organization as the biggest barrier to the implementation of an ESR system. The volume and minimal nature of the safety hazards that are reported reveal room for safety culture improvement throughout the transit agency. • MBTA representatives described a ripe disciplinary culture and history of punitive reactions as a challenge in implementing a nonpunitive ESR system. Thus, gathering the volume of reports necessary to perform trend analyses has been challenging. • SacRT described union pushback as the main barrier in the developmental stages of the nonpunitive ESR system. The agency found it difficult to encourage employees to report any hazards or near miss events prior to the institution of the anonymous report- ing option. • SCAT described the tracking of hard copy forms as a challenge, which it reduced through the introduction of electronic submission alternatives, which also streamline the tracking and trending of hazard reports within the agency. SCAT recognizes that the low volume of safety hazard reports reflects the maturity of the safety culture, noting that the necessary level of trust takes time to improve. • SEPTA defined the need for a mature safety culture to ensure that all safety hazards are reported without fear of retaliation or retribution, which is something that SEPTA represen- tatives are working to improve through safety surveys to focus targeted improvement efforts. • TriMet reported the biggest challenge to the implementation of its RSA process was estab- lishing the trust necessary for employees to feel that their voices are heard, their opinions matter, and they can be part of the solution. • WMATA representatives stated that the barriers to implementation are mostly related to spreading the word that the program exists and how to use it properly. Some of the surveyed transit agencies revealed similar challenges or barriers, such as immature safety cultures resulting in the need for improved trust, challenges with feedback and follow-up, and challenges in quantifying returns on investments in ESR systems. Elements of Success In creating a culture of safety, APTA cites a nonpunitive near miss policy as one of the indica- tors of an effective SMS.134 While safety culture is not changed through short-term efforts, many organizations beyond the public transit industry have developed successful ESR systems that can be used as guidance in the industry’s transition to SMSs, such as • FAA’s Aviation Safety Reporting System, • NATCA’s Air Traffic Safety Action Program, • NRC’s Allegation Program, and • FRA’s C3RS program. The surveyed transit agencies also noted many successes. While some of these may seem mini- mal, the improvement in safety culture that results from even minimal ESR system successes leads to improvements in safety performance metrics throughout the transit agency: • BBB experienced a decrease in fixed-object strikes that it attributes to the hazard and near miss ESR system. A data analysis revealed multiple collisions at one location where overgrown trees were reported to be a hazard. BBB worked with external organizations to have the trees trimmed or removed. Operators were encouraged by removal of the hazards and the agency’s responsiveness, which led to an increase in reporting over the following 6 months, a decrease in fixed-object collisions, and fewer vehicle repairs.

Conclusions and Recommendations for Additional Research 69 • Capital Metro eliminated or mitigated risks that were identified through the tracking and trending of the safety concerns reported through its ESR system. The agency has also invested in an evaluation the ESR system’s effectiveness, including the benefits associated with the ESR system. Following are some hazards that were eliminated or mitigated: – Overgrown vegetation around bus stops that were trimmed or removed, – Overgrown tree limbs that were trimmed or removed, – A hole in a walkway that presented an imminent hazard for passengers and employees was repaired, – A bus rapid transit station that left boarding or alighting customers vulnerable to collisions with motor vehicles was redesigned, and – Reports of homeless individuals gathering at transit facilities led to improvements in the park-and-ride lot such as fencing to restrict unwanted access. • CTA emphasized that ESR systems are critical for transit agencies to gather the information necessary to manage risk, noting that frontline employees have the best information related to the existing agency hazards. CTA recognizes that all resource-constrained environments benefit from targeted prioritization of resources to mitigate the most concerning hazards first and is confident that the information collected through the ESR system will be valuable in the SMS framework. • GCRTA’s ESR system reports from employees have led to improved maintenance procedures, which also resulted in asset management benefits that use updated asset trees and condition tabs to ensure optimal maintenance attention. • JTA encourages hazard reporting through the See & Say app to improve the autonomy of updating hazard logs and prioritizing resources. Following are examples of specific hazard elimination or mitigation measures: – Lighting improvements at one shelter located on the community college campus were installed after the hazardous condition was reported through the app accompanied by a photo and short video that showed how dark the conditions were. – An exposed broken drainpipe located near a bus shelter was submitted through the JTA See & Say app along with photos. The city was able to assess the hazard and respond within a week of the report. – Instances of homeless persons who have either permanently encroached on or vandalized bus stops or shelters are also being addressed by the city. • King County Metro noticed a change in the agency’s safety culture, in that employees are more aware of their surroundings and more likely to report issues. The volume of reports has increased since the inception of the hazard reporting program. • LTD has implemented many safety improvements as a result of the successful implementation of the Blue Card operator hazard reporting opportunity: – A tree limb was reported as a hazardous situation, and LTD worked with the City to get the tree trimmed to remove the hazard. – A bus stop was relocated to accommodate the safety of a regular customer in a mobility device after an operator reported the unsafe condition. – Lighting at bus stops was replaced. – Erroneous route information on bus head signs was reprogrammed. – Leaks were repaired at the transit agency restroom facilities. • LA Metro’s accident data collection system was the impetus for two very important and impactful agencywide changes: – A pilot program that installed gates that control left-turn movements along light-rail corridors. The gates close the left-turn lane for motor vehicles when the traffic light for the left-turn movement is red and a train is approaching. Because of the success of these gates, LA Metro had made them its design standard for its Crenshaw Line scheduled to open in 2021.

70 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation – Pedestrian warning barriers implemented on the Blue Line. The agency invested $34 million in pedestrian warning strategies at grade crossings. These strategies include the use of small gates that close simultaneously with the vehicular gates described above. With these gates, the intersection is completely sealed when a train is approaching, as it crosses the intersection, and as it clears the intersection. This investment has led to a considerable reduction in pedestrian versus train events. • MBTA understands the importance of establishing and encouraging a mature safety culture that will support a well-developed and fully utilized ESR system. The agency also connects mature safety culture to the ability to gain a better understanding of the overall risk of oper- ations from frontline workers and, subsequently, to focus limited resources on areas that present the greatest risk to the agency. Following are some examples of specific hazard mitiga- tion measures at MBTA: – Installation of a railing on a set of stairs leading to the right-of-way without any return, – Mitigation to keep an identified tripping hazard off the ground, – Improvement of lighting configurations by adding more trackside headlamps to allow better views for nighttime track workers, – Purchase of upgraded flashlights for track workers to provide better illumination, and – Updating of software on a specific bus to remove a manufacturer error. • MARTA’s Maintenance Department repaired reported potholes that were causing damage to bus suspensions, wheels, and structural elements, thereby mitigating damage to its transit buses. MARTA personnel also developed a mitigation strategy that allowed bus operators to maneuver on a particularly challenging apartment complex property with less risk. • MDT representatives provided two examples of ESR system reporting that led to improved safety: – MDT modified its practices during a construction period, disembarking passengers in an area with better lighting. – In response to reported close calls, MDT rerouted an existing bus route to avoid a very tight right turn. • SCAT is an example of a transit agency with a successful informal hazard reporting pro- cess. Although the program is not mature in its policy development, the process has matured and improved overtime. The ESR system is at least partially credited with the reduction of exposure to potentially violent situations. SCAT credits its success to thorough follow-up with anyone who reports and the engagement of the Safety Committee and the entire agency through newsletters and videos. Examples include – Closure of a minimally used bus stop after a report was received detailing the garbage and loitering issues at the stop, – Trimming of overgrown trees that were blocking operator views and those of waiting passengers, – Route change/scheduling improvements, and – Implementation of de-escalation training. • TriMet successfully promoted the involvement of frontline employees through the develop- ment of BOCIT, which has been instrumental in producing solution alternatives for RSAs and has provided a unique opportunity to foster employee buy-in to the ESR system. Safety reports led to an ergonomic study of all 3000-series buses, which ultimately led to – Reducing the width of the steering wheels from 20 inches to 18 inches for easier use, – Relocating the kneel/ramp switch off the dash, – Upgrading the control handle to reduce repetitive strain, – Relocating key indicator lights from the overhead light board to the dashboard for ease of view, – Widening of turn-signal light buttons so that the left foot could fit between them, – Lowering fare boxes and removing pedestals to increase visibility,

Conclusions and Recommendations for Additional Research 71 – Moving mobile data terminals closer to the operator for easier reach, – Reducing the glare from interior lights through the use of red diffusers and configuration changes, and – Adjusting the configuration of bus mirrors to improve operator line of sight. • WMATA has implemented many documented preventive safety actions that resulted from employee safety reports: – Communication methods for new-hire training were improved. – Switch-movement communication between the rail operations control center and the roadway worker in charge was improved. – Awareness of train operator procedures for entering the shop have increased. – A logbook that includes maintenance records was established for all company vehicles to reduce the likelihood of operating defective vehicles. – Improved bulkhead door seals were installed on the 2000 and 3000 series rail car models to reduce water infiltration. – The agency’s Controller Handbook was updated to include a decision-making matrix to respond to system malfunctions. – To create more turn space for bus operators, a median was trimmed, and “No Parking” signs were installed by a local jurisdiction. – The Roadway Access Guide in the agency’s Right-of-Way Worker Protection Manual was revised to reflect accurate descriptions of risk throughout the system. – Training on the proper disposal of wastewater was instituted to deter plant maintenance employees from dumping onto track beds. – The decibel levels of the Stinger System (power supply for rail vehicles located in main- tenance and repair areas) were adjusted from a piercing sound to a comfortable level for shop workers. – Older bus shuttles were replaced with newer buses to reduce obstruction issues for operators. While the surveyed transit agencies are all working toward improved safety cultures, many have displayed elements of success through the ESR systems they have implemented. These elements of success should be seen as examples of the benefits that other transit agencies have the potential to obtain from the implementation of an ESR. Recommendations for Additional Research In the background research, the research team identified the benefits associated with wide dissemination of commonly reported hazards and methods to address them. In each exam- ple examined in the background research, reports were collected, trends and emerging safety/ environmental concerns identified, safety risks that present systemic industry concerns estab- lished, and potential causal factors in near miss events presented. Aggregated statistical reports were made available to the industry and the public. National reporting systems such as the ASRS, FRA’s C3RS, SafeOCS, OSHA, NATCA, and NRC all provide national stakeholder dis- semination. A central repository of public transportation industry reported hazards, close calls, and near miss information may present an opportunity to improve the safety of the nation’s public transportation industry and establish the effectiveness of the National Public Transpor- tation Safety Program and the SMS framework. Research to examine the options available to develop this data portal or produce aggregated national reports would be beneficial. One of the methods identified may be the use of a third-party data collection and analysis platform. 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.

72 Characteristics and Elements of Nonpunitive Employee Safety Reporting Systems for Public Transportation In addition, when the case study sites reflected on the quantity and flow of report submittals in response to SMS implementation, they viewed the use of a third party favorably. However, concern was voiced about the costs of instituting the program through a third party. Two transit agencies suggested that a centralized national third-party ESR system (or option) would improve the effectiveness of close call reporting for all public transportation agencies and lead to better safety outcomes. Research can examine the opportunities for creating a national ESR system for the public transportation industry and the steps the industry can take to insti- tute such an ESR system. This report contains resource materials from the case study sites that were included in this study. The industry could benefit from a Nonpunitive Employee Safety Reporting toolkit or online resource repository that would build upon the sample policy statements, marketing/ outreach materials, sample procedures, and sample CBA or MOU language included as a part of this project (see Appendices C and D), which public transportation agencies could use as they develop and implement their own ESR systems. Although the case studies included public transportation agencies with long-standing ESR systems, many of those transit agencies are in the processes of revising or formalizing their policies and procedures. This is an area in which guidance is needed in the form of sample tools and resources. Finally, TRB’s Special Report 326: Admissibility and Public Availability of Transit Safety Planning Records,135 discusses evidentiary protections for safety planning records, which would include ESR data collected and maintained by public transportation agencies through SMS practices performed in accordance with the requirements of 49 U.S.C. § 5329. The report recommends that evidentiary protections be extended to public transportation agencies. Further, it made a specific recommendation to the U.S. Congress: Congress should prohibit, by establishing an admissibility bar, the introduction of the records gener- ated by public transit agencies in fulfilling the safety planning requirements of MAP-21 into legal pro- ceedings. This bar should apply only to data, analyses, reports, and other similar information prepared in response to or used in support of the MAP-21 mandate and FTA’s corresponding safety program requirements.136 It is important that employees who report and that 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. Granting employees more protections, including industry evidentiary protections, will ensure greater reporting and, in turn, safer public transportation agencies.