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