1. Transit Bus Safety Oversight Program Transit Conference Presentation Ream Lazaro

2. Introductions Slide 2

3. Bus Program and MAP-21 The Need for Safety Management Systems (SMS) The Organizational Accident Practical Drift SMS Overview Four components / pillars of SMS Employee Safety Reporting Voluntary Bus Safety Technical Guidance FTA Safety and Training Resource website Presentation Agenda Slide 3

4. Bus Program and MAP-21 Slide 4

5. Voluntary oversight program Developed in collaboration with industry partners Objective – improve safety for passengers, employees, and all that share roadways with transit buses Initial focus on small urban and rural bus transit systems Now includes large urban bus transit systems and Bus Rapid Transit (BRT) Bus Safety Oversight Program Background Slide 5

6. Resource website Voluntary onsite reviews Orientation seminars Ongoing outreach Major Bus Program Elements Voluntary Onsite Reviews State DOT Orientation Seminars Bus Safety Program Website Industry Coordination and Outreach Slide 6

7. Transitioning to risk-based oversight – Establish clear expectations for safety performance and monitoring – Ensure high quality and standardized data and information so we can identify and understand our safety risk – Prioritize decisions and activities based on safety risk evaluations – Align safety risk decisions (“are we all on the same page?”) – Improve transparency and sharing with the industry Change in Approach to Safety Oversight Slide 7

8. Bus Program enters into transition period Moving from totally voluntary guidance and technical assistance program to include safety oversight Provide information on and guide transit industry through SMS implementation process Continue orientation seminars and presentations Continue onsite safety reviews Redesigned website The Bus Program and MAP-21 Slide 8

9. Introduction to Safety Management Systems (SMS) Slide 9

10. The Need for SMS Slide 10

11. What we want…from a safety perspective 1.Safety as a continued top priority 2.Services provided with highest levels of safety concern for passengers and employees 3.Regulators assured that transit agencies carry out safety mission effectively 4.Media and general public are confident system is safe Slide 11

12. What we do not want… are bus and rail accidents AFTER an accident occurs, we can only react We must be more proactive to prevent accidents from happening Slide 12

13. Transit Safety Challenges that Demonstrate Need for SMS Approaching accident and incident investigations from a systemic perspective Inconsistency in safety reporting – To and from highest agency level Lack of integration of safety across the organization Potential for operational error due to increasing complexity of transit agencies and operations Slide 13

14. Transit Safety Challenges that Demonstrate Need for SMS (continued) Changing industry service models and growth Changing asset management practice Restrictions of current and future challenging budget environment Loss of institutional knowledge Slide 14

15. Managing or Reacting When we talk about managing safety, are we really “managing” or are we simply “reacting?” Transit industry has tended towards being reactive as opposed to proactive Typically, it wasn’t until an accident or incident occurred that we focused on the safety issue and how to resolve it Slide 15

16. Change is Necessary We are a safe industry but susceptible to catastrophic accidents Current approach has taken us as far as it can “If you keep doing what you’re doing... you’re going to keep getting what you got!” –Yogi Berra Slide 16

17. What should change look like? Accountability placed at levels commensurate with assigned authorities Agency-wide reporting and communication of safety issues Proactive investigation of events Tools to monitor safety performance Effective and efficient safety assurance activities Balanced decision-making regarding safety risk within operations and planning Slide 17

18. Five questions we need to ask moving forward 1.What are our most serious safety concerns? 2.How do we know this? 3.What are we doing about it? 4.Is what we are doing working? 5.How do we know what we are doing is working? Slide 18

19. What SMS does Ensures timely information about safety risks – so executives can make informed decisions about prioritized allocation of safety resources Actively seeks to identify hazards and mitigate their potential consequences Fosters system-wide communication about safety issues up, down and across the agency Improves safety culture by involving front-line employees in hazard identification Slide 19

20. Critical Safety Concepts Two critical safety concepts at foundation of SMS – The Organizational Accident – Practical Drift Slide 20

21. The Organizational Accident Slide 21

22. Two Notions of Accident Causation Accidents are result of individual failures – Actions/inactions of people Accidents are result of organization failures – Actions/inactions of organizations Slide 22

23. Organizational Accidents “Organizational accidents have multiple causes involving many people operating at different levels of their respective companies.” – Professor James Reason, “Managing the Risks of Organizational Accidents Slide 23

24. Organizational Accidents Involve Active and Latent Factors Organizational processes Workplace Conditions Active failures – Errors – violations System defenses Slide 24

25. Swiss Cheese Model Safety Breakdown Some holes due to latent conditions Hazards Some holes due to active failures Slide 25

26. Organizational Accident and SMS Critical tool of safety risk management – Identifying and analyzing latent organizational factors that may contribute to accidents and incidents Slide 26

27. “The discovery of human error should be considered the starting point of the investigation, not the ending point.” - ISASI Forum Slide 27

28. Practical Drift Slide 28

29. Practical Drift Defined A drift from the performance of work as imagined to performance of work as it is actually carried out Slide 29

30. Slide 30 Practical Drift System and Tasks as designed and engineered Local Reality Why? What happened? Service delivery pressures Procedure no longer practical Short cuts are more efficient Supervisor allows it Informal processes Training inadequately conveyed risk “Work as imagined” “Work as actually done” “ Uncoupling of practice from procedure” Practice Procedure Over Time Imperfect Systems – The Practical Drift Start of Operations

31. Practical Drift Operational Performance Baseline Performance Organization The difference between “where we are” and “where we thought we were” Navigating the Drift – The Need for Data Slide 31

32. SMS Overview Slide 32

33. What is SMS? Formal, top-down, organization-wide, data- driven approach to managing safety risk and assuring effectiveness of safety risk mitigations. Includes systematic policies, procedures, and practices for management of safety risk. Slide 33

34. SMS in General A management system Systematic Safety management is a core agency function – (e.g., financial management, HR management, IT management) Provides decision-making tools for management Slide 34

35. 4 Components (Pillars) of SMS Safety Management Policy Safety Risk Management Safety Assurance Safety Promotion Slide 35

36. SMS Framework Institutionalizes SMS components and sub- components Establishes a common language for transit community Provides platform for advancing SMS SMS Framework Slide 36

37. SMS Framework Components 1.Safety Management Policy 2.Safety Risk Management 3.Safety Assurance 4.Safety Promotion Slide 37

38. Safety Management Policy The Safety Management Policy statement Safety accountabilities and responsibilities Integration with public safety and emergency management SMS documentation and records Slide 38

39. Safety Risk Management Hazard identification and analysis Safety risk evaluation and mitigation Slide 39

40. Safety Assurance Safety performance monitoring and measurement Management of change Continuous improvement Slide 40

41. Safety Promotion Safety communication Competencies and training Slide 41

42. Safety Management Policy Slide 42

43. Safety Management Policy Pillar and its Sub-Components Safety Management Policy Establishes necessary organizational structures, roles, and responsibilities Ensures safety is addressed with same priority as other critical organizational functions Provides direction for effective: Safety Risk Management Safety Assurance Safety Promotion Helps ensure sufficient resources are provided to meet established safety performance Safety Management Policy Statement Safety Accountabilities & Responsibilities Integration with Public Safety & Emergency Management SMS Documentation & Records Slide 43

44. The Safety Management Policy Statement Sub-Component Safety Management Policy The safety management policy statement is the charter of an SMS It must clearly and succinctly frame fundamentals upon which transit agency SMS will operate Safety management policy statement should not exceed a page or two Safety Management Policy Statement Safety Accountabilities & Responsibilities Integration with Public Safety & Emergency Management SMS Documentation & Records Slide 44

45. Safety Management Policy Statement – Six Crucial Aspects 1.Must be signed by highest executive in agency 2.Includes clear statement about providing resources for managing safety to maintain service delivery 3.Commits to safety reporting program and outlines safety reporting procedures 4.Defines conditions under which exemptions from disciplinary action are applicable 5.Spells out unacceptable operational behaviors 6.Is communicated, with visible endorsement, throughout the transit agency Slide 45

46. Management Commitment The Safety Management Policy statement documents management’s commitment to: Allocate necessary safety resources – Leading from the front - “walking the talk” Utilize an effective safety reporting program – Create a positive safety culture Continuous safety improvement – Demonstrate that safety matters Slide 46

47. Safety Accountabilities & Responsibilities Sub-Component Safety Management Policy Safety management is not sole responsibility of Safety Manager or Safety Department Critical to detail safety accountabilities and responsibilities for:  Accountable Executive  Safety/SMS Manager  Managers and supervisors  Front line employees Organizational structure and arrangements defined here Safety Management Policy Statement Safety Accountabilitie s & Responsibilitie s Integration with Public Safety & Emergency Management SMS Documentatio n & Records Slide 47

48. Accountable Executive Responsibilities Ensure safety concerns are considered in ongoing budget planning process Ensure transparency in safety priorities for Board of Directors/oversight entity and employees Establish guidance on level of acceptable safety risk Assure safety policy is appropriate and communicated throughout agency Slide 48

49. SMS Manager/Key Safety Personnel Responsibilities Manages SMS implementation plan on behalf of Accountable Executive Directs hazard identification and safety risk evaluation Monitors mitigation activities Provides periodic reports on safety performance Maintains safety documentation Plans and organizes safety training Scale of this function varies depending on size of organization Slide 49

50. Safety Responsibilities, Accountabilities and Authorities must be: Documented Communicated throughout organization Include definition of management levels that have authority to make decisions regarding safety risk tolerability Slide 50

51. Integration with Public Safety & Emergency Management Sub-Component Safety Management Policy Ensures integration of programs that have input into or output from SMS Identifies and describes interface with external organizations Ensures coordination in plans for dealing with emergencies and abnormal operations and return to normal operations Safety Management Policy Statement Safety Accountabilities & Responsibilities Integration with Public Safety & Emergency Management SMS Documentation & Records Slide 51

52. Integration – Public Safety and Emergency Management Index of transit agency procedures and plans for public safety and emergency preparedness Addresses need for coordination of various internal and external programs that may impact safety management Slide 52

53. SMS Documentation & Records Sub-Component Safety Management Policy  Agency ensures that it formalizes and documents key elements of SMS, such as:  Safety management policy statement  SMS requirements  SMS processes and procedures  Accountabilities, responsibilities, and authorities for processes and procedures Documentation is scalable, but must be sufficient to help institutionalize processes within SMS Safety Management Policy Statement Safety Accountabilities & Responsibilities Integration with Public Safety & Emergency Management SMS Documentation & Records Slide 53

54. SMS Documentation and Records Documentation including: – Safety management policy statement – Descriptions of SMS processes, activities and tools Records of: – Outputs of safety risk management process – Outputs of safety assurance process – SMS training for and safety communication with employees Slide 54

55. Safety Risk Management Slide 55

56. SRM Pillar and its Sub-Components Vital to the success of SMS Key safety management process Safety risk management is a continuous process Hazard Identification & Analysis Safety Risk Evaluation & Mitigation Safety Risk Management Slide 56

57. Hazard Identification & Analysis Sub-Component Hazard Identification & Analysis Safety Risk Evaluation and Mitigation Safety Risk Management Slide 57

58. Three Key Terms in Hazard Identification and Analysis: Safety deficiency Hazard Consequence Slide 58

59. Safety Deficiency A system-wide condition that allows hazards to exist – Lack of management support for employee safety reporting system – Deficiencies in documented key activities, such as hazard identification – Shortcomings in personnel resources or training in safety-critical areas – Unclear operational procedures – Staffing key operational positions with personnel not meeting required qualifications Slide 59

60. Hazard Condition or object [always present] with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function Slide 60

61. Consequence Potential outcome(s) of a hazard Slide 61

62. Hazard Identification & Analysis Safety Risk Mitigation Safety Risk Evaluation Operational System Description Hazard Identification Hazard Analysis Hazard Identification & Analysis State the generic hazard(s) Identify hazard components Identify specific consequences Collect data / info 1 2 Hazard Identification & Analysis Provides foundation for safety risk evaluation activities Must be agency-wide and fully supported and promoted Slide 62

63. Hazard Identification: Data Collection Hazard Identification Collect data / info 1 Data and Information Collection Multiple sources for data collection Supports reporting of identified new or existing hazards Quality and integrity of data and information is essential Slide 63

64. Hazard Identification: Operational System Description Operational System Description Hazard Identification Collect data / info 1 Operational System Description Establishes scope of hazard analysis and risk evaluation activities Provides tool for better understanding location in the “practical drift” Takes place early in SRM process Slide 64

65. Hazard Analysis Safety Risk Mitigation Safety Risk Evaluation Operational System Description Hazard Identification Hazard Analysis Hazard Identification & Analysis State the generic hazard(s) Identify hazard components Identify specific consequences Collect data / info 1 2 Hazard Analysis Defines what will be analyzed Defines who will do analyses Clarifies evaluation of safety risk through ABCs of hazard analysis Slide 65

66. ABC’s of Hazard Analysis A.State the generic hazard B.Identify the components of the hazard C.Identify specific consequences Slide 66

67. Safety Risk Evaluation & Mitigation Sub-Component Safety Risk Evaluation and Mitigation Safety Risk Management Hazard Identification & Analysis Slide 67

68. Safety Risk Evaluation Process Safety Risk Mitigation Index safety risk Evaluate current mitigations Evaluate the Safety Risk Safety Risk Evaluation Express probability of consequence Express severity of consequence 3 Hazard Identification & Analysis Safety Risk Evaluation Quantifies potential consequence of identified hazards Takes into consideration existing defenses Determines whether safety risk is acceptable Data driven Acceptable level of mitigations? Slide 68

69. Five Safety Risk Evaluation Steps 1.Express safety risk probability 2.Express safety risk severity 3.Evaluate current mitigations 4.Indicate safety risk 5.Determine level of acceptability Slide 69

70. Safety Risk Tolerance Unacceptable Region Acceptable Based on Mitigation Region Acceptable Region Safety risk of consequence is not acceptable Safety risk of consequence is acceptable based on existing or new mitigation Safety risk of consequence is acceptable as it stands AsAs Low AsAs Reasonabl y Practicable Slide 70

71. Safety Risk Mitigation Safety Risk Evaluation Hazard Identification & Analysis Safety Risk Mitigation “Manage” safety risk Aim is to reduce safety risks to acceptable level Provides course of action to be monitored by Safety Assurance function Mitigate Safety Risk 4 Slide 71

72. Safety Assurance Slide 72

73. Slide 73 Safety Assurance Pillar and its Sub-Components Safety performance monitoring & measurement Management of chang e Continuous improvement Safety Assurance A continuous process, constantly interacting with Safety Risk Management Where safety performance data is collected and analyzed Systematic and ongoing monitoring and recording of agency’s safety performance Helps verify that agency’s safety performance is in line with safety objectives and targets 73

74. Relationship between Safety Assurance and SRM Ensure that safety mitigation activities are being implemented Verify that safety mitigation activities are appropriate and effective Identify new hazards, safety deficiencies or latent conditions that were not originally identified and addressed during SRM Are safety risk mitigations working? How do we know? Hazard Identification Hazard Analysis Evaluate the Safety Risk Mitigate Safety Risk Monitor & Measure Manage safety risks Never- ending cycle Slide 74

75. Slide 75 Safety Performance Monitoring & Measurement Sub-Component Safety performance monitoring & measurement Management of change Continuous improvement Safety Assurance Safety management requires feedback on safety performance to complete the safety management cycle 75

76. Safety Performance Monitoring 1– Continuous Monitoring Safety Assurance activities and tools must be established and exercised Ongoing capture of data and information is critical Collected data and information need to be examined for hazards and measured against safety performance objectives Continuous monitoring Safety Performance measures Safety performance monitoring & measurement Slide 76

77. Safety Performance Measurement 2 – Safety Performance Measurement Provides indicators for Executive Management and Oversight Agency Provides assurance that agency is achieving its safety performance Provides assurance that SMS and safety risk mitigations are working as anticipated Continuous monitoring Safety performance measurement Safety performance monitoring & measurement Slide 77

78. Measuring Safety Performance Safety Performance – quantification of effectiveness in achieving safety goals Safety Performance Indicators – parameters representing safety status of a system Safety Performance Targets – statements of proposed improvements referencing safety performance indicators to be achieved Slide 78

79. Slide 79 Management of Change Sub-Component Safety performance monitoring & measurement Management of change Continuous improvement Safety Assurance 79

80. Monitoring for Change Ongoing data capture Among other activities: Monitor service delivery activities (must include field observations) Monitor operational and maintenance data Assess external information Assess employee safety reporting program Conduct evaluations of the SMS Conduct safety audits, studies, reviews and inspections Conduct safety surveys Conduct safety investigations Examples of changes: External Regulations Audits Environment Passengers Internal Organization Personnel Procedures Equipment Systems Changes Slide 80

81. Change Needs to be Evaluated Evaluate safety risk of the change – This identifies impact of change on safety performance Analyze existing safety risk mitigations – Are they still appropriate? Determine if new mitigation strategies need to be applied Prior to implementing change, establish mitigation and monitoring strategies Slide 81

82. Slide 82 Continuous Improvement Sub-Component Safety performance monitoring & measurement Management of change Safety Assurance Continuous improvement 82

83. Evaluating the SMS Techniques for monitoring and reviewing effectiveness of the SMS help to determine: – Sources of deficiencies in SMS – Areas that need improvement – Effectiveness and applicability of procedures – Areas of non-compliance with requirements – Corrective actions needed Slide 83

84. Measuring SMS Performance Performance measures are established to monitor various components of SMS – May include audits, training, surveys, reviews This helps ensure safety risk mitigations are working and agency safety performance objectives are being met Slide 84

85. Safety Promotion Slide 85

86. Safety Promotion Pillar and its Sub-Components Safety Promotion Competencies and Training Safety Communication Slide 86

87. Safety Promotion and the SMS Sets the tone for your agency’s safety culture Provides ongoing communication – up, down and across Communicates lessons learned and safety information Demonstrates management commitment Develops skills to support safety performance improvements Slide 87

88. Safety Communication Sub-Component Safety Promotion Competencies and Training Safety Communication SMS is dependent on ongoing management commitment to communication One of management’s most important responsibilities under SMS is to encourage and motivate others to want to communicate openly, authentically and without concern for reprisal Slide 88

89. Importance of Communication Essential areas of effective safety communication: – Safety concerns – Safety risks – Safety risk tolerance – Status and effectiveness of mitigations Slide 89

90. Communication Platforms & Tools Safety policies and procedures Safety committees Safety meetings and briefings Safety bulletins and notices Safety newsletters Safety training Safety posters Electronic distribution Slide 90

91. Competencies & Training Sub-Component Safety Promotion Competencies and Training Safety Communication Executive management responsibility because of allocation of resources to training Safety training development process Relationship between safety training and Safety Risk Management and Safety Assurance Slide 91

92. Competencies and Training Commitment to Training Safety Management Policy addresses importance of safety training and executive management shows commitment by ensuring sufficient resources to carry out effective safety training programs SMS Training Everyone needs to be trained/educated on the SMS to understand their roles and responsibilities and agency’s safety performance objectives Safety Skill Training Everyone needs to acquire the competencies and knowledge for consistent application of their skills as they relate to safety performance objectives Slide 92

93. Employee Safety Reporting Slide 93

94. SMS and Safety Reporting: Facts SMS does not work without data Nobody knows actual system performance better than employees delivering service Power of safety reporting – Safety data capture on previously unanticipated safety deficiencies – Safety data to confirm effectiveness of existing safety risk mitigations Slide 94

95. Effective Safety Reporting - Attributes Training the messengers – People are not “natural messengers” Ease of reporting – Simple requisites Timely, accessible, and informative feedback – No feedback; program crumbles Protection – Information only used for the purposes it was collected Vehicle for change – Issues reported are solved Slide 95

96. Safety Reporting Programs Types of safety reporting programs – Mandatory – Voluntary Employee reporting of safety hazards and concerns Near miss / close call reporting Confidentiality considerations Slide 96

97. Voluntary Bus Safety Technical Guidance Slide 97

98. FTA’s New Safety and Training Resource Website http://safety.fta.dot.gov/ Slide 98