promoting a positive safety culture a positive safety culture ... adopted from the aviation...

Jeff P. Kovacs

NJ TRANSIT Rail

Deputy General Manager Rail Safety and Training

Newark, New Jersey

C3RS

Promoting A Positive Safety Culture

Background

Concept

Development

Design Challenge

Process Steps

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Peer Review Team

Data

Corrective Actions

Transferability

Summary

Participants

C3RS – Confidential Close Call Reporting System

Federally funded research project sponsored by:

Federal Railroad Administration

U.S. Department of Transportation’s Bureau of Transportation Statistics (BTS)

U.S. Department of Transportation Volpe Center

Designed to improve safety, based on confidential, non punitive reporting of conditions or incidents that have the potential for more serious consequences.

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Adopted from the Aviation Industry: Aviation Safety Reporting System (ASRS)

Global Aviation Information Network (GAIN)

Example of an accident preceded by several close calls:

The Concorde Jet over 23 years suffered a series of tire blowouts on landing gear that ruptured fuel tanks, hydraulic lines, electrical wires, and engines which caused damage to the aircraft but resulted in no fatalities.

July 26, 2000 an Air France Concorde jet blew a tire, ruptured a fuel tank and caught fire. The plane crashed shortly after takeoff killing 109 passengers and crew.

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There are many more incidents than accidents.

(note the conceptual “Safety Iceberg”)

However, “accidents” are reported and ”incidents”

typically are not reported.

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Employees are reluctant to report incidents due to

fear of “getting in trouble,” and perceived

management retaliation.

For the C3RS process to work, confidentiality must

be maintained.

C3RS can provide a tool for the railroad to

proactively analyze close call data to find trends

and patterns before an accident occurs.

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Boundaries of NJT Close Call

Reporting Program

Defined as all NJ TRANSIT owned

and/ or operated territory, including

the Southern Tier and Pascack

Valley Line (excluding Conrail and

Amtrak territories)

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Note: Currently the FRA is conducting C3RS pilot projects on

four railroads: Union Pacific Railroad (UP), Canadian Pacific

Railway (CP), NJ TRANSIT (NJTR) and Amtrak (ATK) with NJ

TRANSIT being the only railroad with the program implemented

system wide in all services (main tracks and yards).

Threshold must be set to decide on what

events count as “close calls.”

Events that happen frequently, but have low

consequences.

Events that happen infrequently but have the

potential for high consequences.

Events that cause an accident that is below the

Federal Railroad Administration (FRA) reporting

threshold.

Events that are above the FRA threshold where the

potential exists for a far greater accident.

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C3RS event examples:

A train in dark territory that proceeds beyond its limits

of authority.

A train that does not comply with a restrictive signal.

A train that exceeds maximum authorized speed.

Failure to follow specific operating and safety rules

and procedures.

Run through switch that does not result in

derailment.

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Participation in the Program NJTR, Labor, and FRA created an “Implementing

Memorandum of Understanding (IMOU),” which is the legally binding document that cooperates with existing collective bargaining agreements and outlines how the confidential close call reporting system works at NJTR.

The memorandum was developed by local representatives of the American Train Dispatchers Association (ATDA),

Brotherhood of Locomotive Engineers and Trainmen (BLET),

United Transportation Union (UTU),

United Transportation Union - Yardmasters (UTU-Y),

NJTR Management, and

Federal Railroad Administration (FRA) 10

Shift from discipline orientated safety culture to a

root cause, non punitive “safety first” culture.

Participation between NJTR Management, Labor,

and the FRA in the joint Peer Review Team to

review close call data.

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Employee reports a “Close Call” to the federal government

Bureau of Transportation Statistics (BTS) by toll-free number

as an “initial report”.

BTS contacts employee for details of incident.

BTS “sanitizes” employee information to ensure

confidentiality.

BTS provides information to the Peer Review Team (PRT).

PRT meets monthly to review incidents and develop

Corrective Actions to recommend to the Support Team (ST).

ST meets quarterly with PRT to discuss Recommended

Corrective Actions.

ST meets independently to review Recommended

Corrective Actions.

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4 BLET members,

4 UTU members, and

2 members each from ADTA, UTU-Y, FRA, and

NJT.

The minimum requirement for the PRT to meet and

work on cases requires a minimum of a process

manager (NJTR), a facilitator, a scribe, and one

member each from the UTU, BLET, UTU-Y, ADTA,

and FRA.

The PRT Lead Team meets once a month along with

Case Working Team meeting twice a month.

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Based on the sanitized data received by the PRT

from the BTS, it was shown that “run through

switch” incidents were the single most frequent

type of incident (28%) of those reported through

C3RS.

By allowing protection from discipline under the

C3RS program, the number of “run through switch”

incidents that the employees were willing to report

to management increased, which has lead to more

timely repairs, along with preventing derailments.

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This chart reflects derailments per

year that occurred 3 years prior to

the implementation of C3RS and

two years after.

The reporting of these incidents

has provided management a

valuable tool to help understand the

root causes of these incidents.

With this information the PRT has

been able to implement many

initiatives to help reduce the

hazards.

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PRT to address “run through switches”

On-site training by PRT on how to make outbound

reverse movements in train yards.

Installing loud speakers to improve yard

communication.

Painting of track switches to enhance visibility.

Lighting improvements.

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Creation of C3RS Poster

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PRT developed a separate daily speed restrictions

bulletin order, reducing the amount of written

directives (Form D).

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Changing the cab design to allow paperwork to be

kept in sight.

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Posting speed restriction “reminder” signs at station stops that fall within the temporary speed limits.

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Creating a new safety job briefing checklist.

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Creating a new safety job briefing checklist.

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Replacement of side-door windows (tinted to clear)

on multilevel coaches to improve crew visibility of

platforms at night.

These activities are due to C3RS employees reporting

incidents that had gone unreported before the

implementation of C3RS. This increased reporting now

allows the PRT to recommend corrective actions to help

prevent incidents from becoming accidents.

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According to the FRA, Human Factor Causes attributed to nearly 38% of Total Train Accidents in 2012.

With the primary focus of C3RS being the reduction of Human Factor Accidents, this program addresses current trends in rail accident data.

Helps to further the goal of creating a positive safety culture in the railroad industry.

Can help shift the overall railroad culture from discipline based to non punitive by demonstrating the railroad’s commitment to reducing accidents and incidents.

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Along with improvements to safety and operations,

a benefit of the program is better communication

between labor and management, as both groups

work towards a common goal.

Increases level of individual safety awareness

through co-worker interaction in the C3RS process.

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Suggestions

or

Questions?

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