Safety Management Systems Session Two Safety Risk Management APTA Webinar April 28, 2016

4 Components (Pillars) of SMS Safety Management Policy Safety Risk Management Safety Assurance Safety Promotion

A process to identify the bad things that could happen and develop strategies to reduce the likelihood of the event occurring, or the severity of the outcome should it occur A process to assess system design and verify that the system adequately controls risk A formal risk management process that describes a system, assesses hazards, analyzes those hazards to evaluate the risk, and establishes controls to manage those risks Pillar 2- Safety Risk Management

Safety Risk Hazard- any real or potential condition that can cause injury, illness, death; damage to or loss of a system, equipment or property; damage to the environment Risk – the combination of the probability (or frequency of occurrence) and the severity (or consequence) associated with a hazard; the assessed potential for undesirable consequence resulting from a hazard Safety- the state in which the risk of injury to persons or damage to property is reduced to, and maintained at or below an acceptable level through a continuing process of hazard identification and risk management Safety Risk- an expression of possible loss over a specific period of time or number of operational cycles. It may be expressed as the product of hazard severity and probability

Safety Risk Management Sub-Elements Hazard Identification and Analysis Safety Risk Evaluation

Hazard Identification and Analysis Sources for hazard identification – Employee safety reporting program – Observations of operations – Inspections – Internal safety investigations – Accident reports – Compliance programs – Committee reviews – Industry data – Governmental sources (FTA, NTSB, SSOA) – Customer and public feedback or complaints

Hazard Identification Tools Accident/incident investigations Hazard/incident reporting systems to identify latent unsafe conditions Safety surveys to elicit feedback from front-line personnel about areas of concern and unsatisfactory conditions that may have accident potential Operational inspections or audits of all aspects of operations to identify vulnerable areas before accidents or incidents confirm that a problem exists

Data Sources More comprehensive data sources foster management confidence that safety concerns are being identified Training employees on proper identification and reporting of safety concerns increases the likelihood that hazards can be addressed Focus on the collection of safety concerns while safety representatives work with operations and management personnel to identify the exact hazards Promote and support agency-wide safety concern reporting and hazard identification

Hazard Identification- Risk Factors Design Factors: vehicles, tracks, equipment Operating Procedures and Practices: documentation, checklists Communications: medium, terminology and language Personnel factors: agency policies for recruitment, training and renumeration Organizational Factors: corporate safety culture, resource allocation, operating procedures Physical Defenses: adequate detection and warning systems, traffic control devices, signaling, barriers Regulator and Oversight Factors: application and enforcement of regulations; certification of equipment, personnel and procedures; and adequacy of safety audits

Safety Risk Evaluation and Mitigation Safety risk is expressed and measured by predicted probability and severity of a hazard’s potential consequences Safety risk evaluation considers existing mitigations to determine whether further measures are needed to mitigate the potential consequences of the hazards Safety risk mitigation – Actions taken to reduce the likelihood and/or severity of the potential hazard – Enables a transit agency to actively manage safety risk aligned with safety performance targets – Consists of initial, ongoing and revised mitigations

Safety Risk Assessment Likelihood of the hazard precipitating an unsafe event Severity of the consequences of an unsafe event if the hazard is allowed to remain Exposure to the hazard (number of passenger- miles per day; number of pedestrians using a grade crossing during the peak-hour; number of vehicles per hour; characteristics of transit users). Probability of adverse consequence is greater with increased exposure to unsafe conditions

System Safety Process of Controlling Hazards During the Acquisition Cycle SMS Pillar 2: Safety Risk Management PLAN IDENTIFY ANALYZE ASSESS RESOLVE CONTROL TRACK

Monitor for -Effectiveness -Unexpected Hazards Define the System Identify Hazards Assess Hazards Resolve Hazards Follow-Up Assume Risk of the Hazard or Implement Corrective Action -Eliminate the Hazard or -Control the Hazard Determine -Severity -Probability and Decide -to accept risk or -eliminate/control the Hazards Identify -Hazards -Undesired Events and Determine -causes and -contributing factors of the Hazards Define -Physical Characteristics -Functional Characteristic and Understand and Evaluate -People, -Procedures, -Facilities,and Equipment, -Environment. Hazard Resolution Process

Severity Probability of occurrence Institute special procedures Add warning devices Add safety/security devices Design to eliminate the hazard Cost Considerations Measures Trade-Offs of Hazard Management

Safety Risk Assessment Matrix MIL-STD-882E Safety Risk Assessment Matrix Severity Probability Catastrophic 1 Critical 2 Marginal 3 Negligible 4 A - Frequent1A2A3A4A B - Probable1B2B3B4B C - Occasional1C2C3C4C D - Remote1D2D3D4D E - Improbable1E2E3E4E F - Eliminated 1A, 1B, 1C, 2A, 2B 1D, 2C, 3A, 3B 1E, 2D, 2E, 3C, 3D, 3E, 4A, 4B 4C, 4D, 4E Unacceptable Undesirable with management decision required Acceptable with review by management Acceptable without review High Serious Medium Low

Hazard Frequency Categories FrequencyLevelQualitative DefinitionQuantitative Definition Probability of Occurrence FrequentALikely to occur frequently in an individual item or the system; may be continuously experienced in fleet MTTHE<2 mosP>10-1 ProbablyBLikely to occur several times in the life of an individual item or the system; will occur frequently in fleet 2 mos<MTTHE<1 yr10-1>p>10-2 OccasionalCLikely to occur sometime in the life of an individual item or the system; will occur several times in fleet 1 yr<MTTHE<10 yrs10-2>p>10-3 RemoteDUnlikely but possible to occur in the life of an individual item or the system; unlikely but can be expected to occur in fleet 10 yrs <MTTHE <100 yrs 10-3>p>10-6 Highly UnlikelyESo unlikely that it can be assumed occurrence may not be experienced in the life of an individual item or the system; unlikely but possible to occur in the fleet MTTHE>100 yrs10-6>p

Risk Mitigation Safety Actions Physical defenses: objects and technologies that are engineered to discourage, warn against, or prevent inappropriate action or mitigate the consequence of events (traffic control devices, fences, safety restraining systems, signals, automatic train monitoring systems, safety redundancies, equipment crashworthiness)

Risk Mitigation Safety Actions Administrative defenses: procedures and practices that mitigate the likelihood of accident/incidents (safety regulations, standard operating procedures, personnel proficiency, supervision, inspection, training)

Risk Mitigation Safety Actions Behavioral defenses: behavioral interventions through education and public awareness campaigns aimed at reducing risky and reckless behavior of motorists, passengers and pedestrians; factors outside the control of the transit agency (Operation Lifesaver)

Hazard Identification and Risk Management Checklist Formal mechanisms for systematic identification of hazards(such as safety assessments and safety audits) are in place An occurrence reporting system is in effect Management has provided adequate resources to support hazard identification programs including staff training Competent personnel administer the hazard identification program Management fosters a non-punitive and just environment- employees involved in reported incidents are aware that they will not be penalized for normal errors

Hazard Identification and Risk Management Checklist Hazard identification data are systematically analyzed and saved Criteria are established for assessing identified safety risks Risks are analyzed and ranked by competent personnel Viable risk control measures are evaluated Management takes action to mitigate the risks Actions taken to eliminate or mitigate identified hazards are communicated to staff Procedures are in place to confirm that the actions taken are working as intended Significant safety concerns potentially affecting other transit agencies are shared across the industry