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Confidential Close Call Reporting System

Jeff Moller

Association of American RailroadsInternational Railroad Safety ConferenceOctober 2008, Goa

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What is a ‘Close Call?’

“Opportunity to improve safety practices based on a condition / incident with a potential for more serious consequences.”

July 26, 2000

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One Component of a Safety Management Process

• Mandatory reporting of accidents / incidents

• Inspection and enforcement activities

• Close Call Reporting System

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INCIDENTS

ACCIDENTS

UNREPORTEDOCCURRENCES

Heinrich Pyramid

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Features of a Close Call System

• Voluntary / Confidential

• Accidents Often Preceded by Close Calls

• Identify and Manage Risk

• More Information Collected / Shared

• Data Collected by Third Party

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A New Approach

Let’s IMPROVE THE SYSTEM!

How It Should Be . . .You are human

Humans make mistakes

Let’s also explore why the system allowed, or failed to accommodate, your mistake

How It Is Now . . .You are highly trained

and

If you did as trained, you would not make mistakes

so

You weren’t careful enough

so

You should be PUNISHED!

and

so

and

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Potential Barriers

Concerns About:

• Public Disclosure

• Job Sanctions/Enforcement

• Criminal Sanctions

• Civil Litigation

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Everyone Wins

• Non-Attributable Safety Information that Otherwise Would Not be Reported

• Everyone Focuses on Safety

• Better Public Image: Transportation Safer and Less Costly

• Wider Awareness of Human Factors

• Enhances Partnerships, Trust and Communications Within Organizations

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Benefits for Labor

• “Instead of the brunt of blame / punishment, labor becomes a valuable source of information about potential problems and proposed solutions to accomplish what everyone wants – improved safety and reduced costs.”

• Independence from management and regulators ensures reporter’s anonymity

• More teamwork

• Work less stressful

• The reporter can be advised of the outcome

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Benefits for Industry

• Improved safety: Supports a safety culture with more public accountability

• Permit errors/deficiencies/discrepancies to be reported without attachment of blame

• Cost savings (insurance, accident, injury claims, litigation, loss of time, property, damage)

• Improved effectiveness of remedies and greater cost effectiveness implementing the remedies.

• Better employee morale and productivity

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Benefits for Regulator

• Less need for regulations

• Fewer enforcement activities

• Easier to understand what is not working and why

• Remedies are more effective and credible

• Better management–labor relations

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Lessons Learned from Other Close Call Systems

• Encourage full disclosure / build and maintain trust• Focus learning, not punishment: Assure anonymity and

(limited) protection from liability and enforcement• Include all stakeholders, engage front-line staff in system

design• Structure system for easy organization and analysis• Use 3rd party for data collection and analysis• Provide timely feedback to reporting employee• Continuous feedback to all key stakeholders, including

reporter of close call

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Close Call Planning Committee

First meeting; May 2002

• White Paper: Improving Safety through Understanding

Close Calls

• Designed / oversaw FRA Human Factors Workshop:

Improving Railroad Safety Through Understanding

Close Calls

• Committee Evolved to Current Steering Committee

14http://www.fra.dot.gov/downloads/Research/ord0403.pdf

2003 Workshop

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Model Memorandum of Understanding (MOU)

• Signed March 30, 2005• Describes provisions of project • Explains rights, roles, & responsibilities of

participants, • Purpose: gain full agreement from all

parties• Implementing MOUs still needed for each

carrier pilot site

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Criteria for Optimal Pilot Site

• Representative of industry; learning can be generalized

• Site supports participation at managerial / local levels

• Carrier rates average or above in safety

• Organizational culture supports project

• Existing cooperative relationship; management & labor

• Carrier provides resources to support project

• A contained region with local autonomy

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Carrier Resources Needed

• Training• Mentoring• Nurture change process• Develop / implement communication plan• Planning / conducting quarterly Peer Team

meetings• Join Steering Committee

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First Pilot Project

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• More than 300 Cases in First 7 Months

• Some Initial Issues• Slow orders

• Use of Derails

• Run through switches

• Derailment

• Permanent Speed / Max Authorized

• Stop and Proceed

Pilot Project

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Pilot Project – Initial Outcomes

• Countermeasures

• Cultural Changes

• Dispute Resolution – Needs Work

• Other Pilot Sites Coming