Post on 29-Jan-2016
Transit Bus Safety Oversight Program
Transit Conference PresentationReam Lazaro
Introductions
Slide 2
• 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
Bus Program and MAP-21
Slide 4
• 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
• 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
• 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
• 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
Introduction to
Safety Management Systems (SMS)
Slide 9
The Need for SMS
Slide 10
What we want…from a safety perspective
1. Safety as a continued top priority2. 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
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
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
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
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
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
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 planningSlide 17
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
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
Critical Safety Concepts
• Two critical safety concepts at foundation of SMS
– The Organizational Accident – Practical Drift
Slide 20
The Organizational Accident
Slide 21
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
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
Organizational Accidents Involve Active and Latent Factors
• Organizational processes• Workplace Conditions• Active failures– Errors– violations
• System defenses
Slide 24
Swiss Cheese Model
DefensesPeopleWorkplaceOrganization
SafetyBreakdown
Some holes due tolatent conditions
Hazards
Some holes due toactive failures
Slide 25
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
“The discovery of human error should be considered the starting point of the investigation, not the ending point.” - ISASI Forum
Slide 27
Practical Drift
Slide 28
Practical Drift Defined
• A drift from the performance of work as imagined to performance of work as it is actually carried out
Slide 29
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
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
SMS Overview
Slide 32
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
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
4 Components (Pillars) of SMS
SafetyManagement
Policy
SafetyRisk
Management
SafetyAssurance
SafetyPromotion
Slide 35
SMS Framework
• Institutionalizes SMS components and sub-components
• Establishes a common language for transit community
• Provides platform for advancing SMS
SMS Framework
Slide 36
SMS Framework Components
1. Safety Management Policy2. Safety Risk Management3. Safety Assurance4. Safety Promotion
Slide 37
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
Safety Risk Management
• Hazard identification and analysis
• Safety risk evaluation and mitigation
Slide 39
Safety Assurance
• Safety performance monitoring and measurement
• Management of change
• Continuous improvement
Slide 40
Safety Promotion
•Safety communication
•Competencies and training
Slide 41
Safety Management Policy
Slide 42
Safety Management Policy Pillar and its Sub-Components
SafetyManagement
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 Accountabiliti
es & Responsibiliti
es
Integration with Public Safety &
Emergency Management
SMS Documentation & Records
Slide 43
The Safety Management Policy Statement Sub-Component
SafetyManagement
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 Accountabiliti
es & Responsibiliti
es
Integration with Public Safety &
Emergency Management
SMS Documentation & Records
Slide 44
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 behaviors6. Is communicated, with visible endorsement,
throughout the transit agencySlide 45
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
Safety Accountabilities & Responsibilities Sub-Component
SafetyManagement
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 Accountabilit
ies & Responsibilit
ies
Integration with Public
Safety & Emergency
Management
SMS Documentati
on & Records
Slide 47
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
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
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
Integration with Public Safety & Emergency Management Sub-Component
SafetyManagement
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 Accountabiliti
es & Responsibiliti
es
Integration with Public Safety &
Emergency Management
SMS Documentation & Records
Slide 51
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
SMS Documentation & Records Sub-Component
SafetyManagement
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 Accountabiliti
es & Responsibiliti
es
Integration with Public Safety &
Emergency Management
SMS Documentation & Records
Slide 53
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 employeesSlide 54
Safety Risk Management
Slide 55
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
SafetyRisk
Management
Slide 56
Hazard Identification & Analysis Sub-Component
Hazard Identification
& Analysis
Safety Risk Evaluation
and Mitigation
SafetyRisk
Management
Slide 57
Three Key Terms in Hazard Identification and Analysis:
• Safety deficiency
• Hazard
• Consequence
Slide 58
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
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
Consequence
• Potential outcome(s) of a hazard
Slide 61
Hazard Identification & AnalysisSafety Risk Mitigation
Safety Risk Evaluation
OperationalSystem
Description
HazardIdentification
HazardAnalysis
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
Hazard Identification: Data Collection
HazardIdentification
Collect data / info
1Data 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
Hazard Identification: Operational System Description
OperationalSystem
Description
HazardIdentification
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
Hazard Analysis
Safety Risk Mitigation
Safety Risk Evaluation
OperationalSystem
Description
HazardIdentification
HazardAnalysis
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
ABC’s of Hazard Analysis
A. State the generic hazardB. Identify the components of the
hazardC. Identify specific consequences
Slide 66
Safety Risk Evaluation & Mitigation Sub-Component
Safety Risk Evaluation
and Mitigation
SafetyRisk
Management
Hazard Identification
& Analysis
Slide 67
Safety Risk Evaluation ProcessSafety Risk Mitigation
Index safety risk
Evaluate current
mitigations
Evaluatethe Safety Risk
Safety Risk Evaluation
Express probability of consequence
Express severity of
consequence
3Hazard Identification & Analysis
Safety Risk Evaluation• Quantifies potential
consequence of identified hazards
• Takes into consideration existing defenses
• Determines whether safety risk is acceptable
• Data drivenAcceptable level of mitigations? Slide 68
Five Safety Risk Evaluation Steps
1. Express safety risk probability2. Express safety risk severity3. Evaluate current mitigations4. Indicate safety risk5. Determine level of acceptability
Slide 69
Safety Risk Tolerance
Unacceptable Region
AcceptableBased on Mitigation
Region
Acceptable Region
Safety risk of consequence
is notacceptable
Safety risk of consequence is acceptable
based on existing or
newmitigation
Safety risk of consequence is acceptable as it stands
AsLowAs
ReasonablyPracticable
Slide 70
Safety Risk MitigationSafety 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 SafetyRisk
4
Slide 71
Safety Assurance
Slide 72
73Slide 73
Safety Assurance Pillar and its Sub-Components
Safety performance monitoring & measuremen
t
Managementof
change
Continuous improvement
SafetyAssurance
• 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
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?
HazardIdentification
HazardAnalysis
Evaluatethe Safety Risk
Mitigate SafetyRisk
Monitor &Measure
Manage safety risks
Never-
ending
cycle
Slide 74
75Slide 75
Safety Performance Monitoring & Measurement Sub-Component
Safety performance monitoring & measuremen
t
Managementof
change
Continuous improvement
SafetyAssurance
Safety management requires feedback on safety performance to complete the safety management cycle
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
Continuousmonitoring
SafetyPerformance
measures
Safety performance monitoring & measuremen
t
Slide 76
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
Continuousmonitoring
Safetyperformancemeasurement
Safety performance monitoring & measuremen
t
Slide 77
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
79Slide 79
Management of Change Sub-Component
Safety performance monitoring & measuremen
t
Managementof
change
Continuous improvement
SafetyAssurance
Monitoring for Change
Ongoing data captur
e
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
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
82Slide 82
Continuous Improvement Sub-Component
Safety performance monitoring & measuremen
t
Managementof
change
SafetyAssurance
Continuous improvement
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
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
Safety Promotion
Slide 85
Safety Promotion Pillar and its Sub-Components
SafetyPromotion
Competencies and
Training
Safety Communicati
on
Slide 86
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
Safety Communication Sub-Component
SafetyPromotion
Competencies and
Training
Safety Communicati
on
• 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
Importance of Communication
• Essential areas of effective safety communication:– Safety concerns– Safety risks– Safety risk tolerance– Status and effectiveness of
mitigations
Slide 89
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
Competencies & Training Sub-Component
SafetyPromotion
Competencies and
Training
Safety Communicati
on
• 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
Competencies and TrainingCommitment to TrainingSafety Management Policy addresses importance of safety training and executive management shows commitment by ensuring sufficient resources to carry out effective safety training programsSMS 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
Employee Safety Reporting
Slide 93
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
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
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
Voluntary Bus Safety Technical Guidance
Slide 97
FTA’s New Safety and Training Resource Website
http://safety.fta.dot.gov/
Slide 98