Safety Management Systems Session Three Safety Assurance APTA Webinar May 31, 2016

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

Safety Assurance Processes used to ensure safety risk controls developed under the safety risk management process achieve their intended objectives throughout the life cycle of a system. These processes may reveal hazards not previously identified and identify or assess the need for new risk controls, as well as the need to eliminate or modify existing controls Evaluates whether the transit agency implements appropriate and effective mitigations Continuous improvement process that monitors and self-corrects the safety performance of the agency

Safety Assurance Sub-Components Safety Performance Monitoring and Measurement Management of Change Continuous Improvement

Decision-Making What gets measured gets done If you don’t measure results, you can’t tell success from failure If you can’t see success, you can’t reward it If you can’t reward success, you are probably rewarding failure If you can’t see success, you can’t learn from it If you can’t recognize failure, you can’t correct it If you can demonstrate results, you can win public support Osborne & Gabler, Reinventing Government

Safety Performance Monitoring and Measurement Focuses on monitoring the safety performance of the transit agency through routine measuring of operations and maintenance activities Senior management needs this data to evaluate whether: Implemented safety risk mitigations are appropriate and effective How well the agency’s safety performance matches established safety objectives and safety performance targets

Performance Targets Acceptable/desired level of a metric to be accomplished by a future date or over a period of elapsed time Reduce the rate of fatalities to 0.25 per 100 million passenger-miles by 2017 Measurable, acceptable to stakeholders, consistent with targets set by state and federal organizations

Transit Safety Stakeholders Traveling public Transit properties and service providers Federal transportation organizations (i.e. FTA, FRA) State and local transportation agencies and oversight organizations (i.e. SSOA) Industry associations (i.e. APTA) Investigative agencies (i.e. NTSB) Transit systems planners and designers Transportation research organizations (i.e. TRB) Equipment manufacturers

Characteristics of an Effective Safety Performance Monitoring System Stakeholder involvement and acceptance Focus on agency goals and activities Clarity and precision Credibility and robustness Variety of measures Number of measures Hierarchy of measures Forward looking measures Integration into decision-making Timely reporting In context Realism of goals and targets

Getting Started- Safety Performance Monitoring System Conduct readiness assessment Agree on outcomes and activities Select key metrics Identify data needs Pilot test and collect baseline data on metrics Set targets Monitor performance and evaluate results Report findings Integrate findings into agency decision-making Sustain the performance measurement system

Safety Performance Monitoring Activities Monitor employee safety reporting programs Monitor service delivery activities (including field observations) Safety data acquisition and analysis Accident/incident reporting and investigation Infrastructure maintenance and inspection Vehicle maintenance, inspection and repair Rail corridor safety Passenger operational environment

Safety Performance Monitoring Activities Monitor operational and maintenance data Conduct safety surveys Conduct safety audits, studies, reviews and inspections Conduct safety investigations Evaluate data and information from external agencies or peers

Unsafe Acts Operator Errors Decision Errors – honest mistakes Procedural Choices Problem solving Skill-based Errors – little or no conscious thought Inadvertent activation/deactivation of switches Forgotten intentions Omitted items in checklist Due to stress, fatigue, in a hurry Perpetual Errors When sensory input is degraded Misjudge distance, speed, objects James Reason

Violations Routine Exceptional Habitual – i.e. drive 5-10 mph over speed limit Tolerated by management Exceptional Departing from authority – i.e. 100 mph in 55 mph zone Unacceptable to management

Potential Contributing Factors Leading to Unsafe Acts Environment Physical Heat, lighting, vibration, noise, toxins, weather Technological Design of equipment and controls Display/interface Checklist layout Automation

Potential Contributing Factors Leading to Unsafe Acts Operator Conditions Adverse mental states Fatigue Stress Overconfidence Adverse physiological states Illness Alcohol Drugs Physical and/or mental limitations Reaction time Vision

Potential Contributing Factors Leading to Unsafe Acts Management of Operations Personnel Failures of communication among operators Failures of communication between operators and central control/maintenance Personal Readiness Disregard of rules Sleep requirements Drug restrictions

Potential Contributing Factors Leading to Unsafe Acts – Organizational Influences Organizational climate: prevailing vision with the organization, including policies, command structure and culture Operational process: formal process by which the organization’s vision is implemented including operations, procedures, oversight Resource management: how human, monetary and equipment resources are managed

Potential Contributing Factors Leading to Unsafe Acts – Unsafe Supervision Inadequate supervision: oversight and management of personnel and resources- training, professional guidance, operational leadership Planned inappropriate operations: management and assignment of work – risk management, crew pairing, operational tempo Failed to correct known problems: supervisor knows deficiencies among individuals, equipment, training or other safety areas but does not correct them Supervisory violations: willful disregard of existing rules, regulations, instructions or SOPs by managers

Leading Indicators Input based measures that have an indirect relationship to an end product or goal and can influence lagging indicators Measure and track performance before a problem arises Examples Running red signals Risk or hazard assessments and job hazard analysis Railway worker protection violation Use of cell phones while operating vehicles or machinery Complaints per 100,000 passengers Workplace inspections Audits Percentage of safety training completed vs. expected Near misses Reported anomalies

Lagging Indicators Outcome-based measures that are directly related to an end product or goal Measure performance against prior goals Examples Fatal accidents per specified time period Number of preventable accidents per specified time period Employee work days lost to injuries per specified time period Workers compensation payments per specified time period OSHA citations (number and type) Workers’ compensation claims (trends and amounts)

Safety Performance Measures Fatalities per time period Injuries per time period Fatal accidents per time period Injury accidents per time period Property damage accidents per time period

Safety Performance Measures Work day lost to injuries by type Work related fatalities Workers compensation payments

Safety Performance Measures Percent positive drug/alcohol tests Number rail station overruns Number of red signal violations Number of traffic tickets issued to bus operators Number of anomalies reported

Safety Performance Measures Number of safety improvement ideas submitted by employees per quarter Number of employees attending weekly safety meetings Number of close calls reported per month

Safety Performance Measures Number vehicle defects reported by operators Number of infrastructure defects reported by operators Number of fires by location Customer satisfaction surveys Percent preventive maintenance inspections competed within 10% of scheduled mileage Percent employees scoring greater than 85% on proficiency tests

Data Sources and Data Management Identify data elements Identify data source Develop data collection procedures and instruments Identify the data owner/manager of the data Develop a schedule for updating data

Management of Change Configuration Management- process that ensures that all property, equipment, system design elements are documented as to configuration, both accurately and completely. Any changes to individual subsystems or fleet/inventory wide changes should be recorded on as-built drawings, addressed in training courses, maintenance guides and procedures Standards/Design Control System Modification- New Processes/Equipment Document Control

Management of Change- Safety and Security Certification Series of processes that collectively verify the safety and readiness of a project for public use Identification and assessment of hazards/vulnerabilities along with resolutions Codes, guidelines and standards related to safety and security are included in design criteria Drawings and specifications are in conformance with design criteria Facilities, systems, equipment are designed, constructed, built, inspected and tested in accordance with specifications, codes, standards and criteria Tests, plan and rulebooks are developed for operations Personnel are trained to handle normal and emergency situations Emergency response personnel are familiar with the transit system and emergency procedures

Continuous Improvement Agree on outcomes critical to safety performance Select metrics for monitoring outcomes Gather baseline data on current conditions Set specific targets and dates for reaching these targets Collect data on regular basis to assess whether the targets are being met Analyze performance data and report results Integrate performance results in decision-making

Continuous Improvement- Safety Assessment Internal Safety Management Reviews Follow formal written process Determine compliance with safety policies, rules, regulations, codes, procedures, assigned safety activities and requirements External Safety Management Reviews Compliance to policies, plans, procedures, milestones or other requirements Performance reviews focus on the product, process and system to determine how well they meet the customer’s needs and identify areas for improvement Peer Reviews to assess all aspects of transit operations and functions

Continuous Improvement- Safety Culture Assessment Employee surveys Written questionnaires Face to face interviews Focus group interviews Ability of agency to focus on long term performance How the agency handles conflicts How the agency views errors and mistakes How the organization focuses on improving safety defenses instead of assigning blame Agency’s proactive stance toward safety