Transit Bus Safety Oversight Program Transit Conference Presentation Ream Lazaro.

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

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


es & Responsibiliti

es




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


es & Responsibiliti

es




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


es & Responsibiliti

es




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


& 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


OperationalSystem

Description

HazardIdentification

HazardAnalysis

Hazard Identification & Analysis

State the generic

hazard(s)

Identify hazard components

Identify specific

consequences

Collect data / info

1

2


• Provides foundation for safety risk evaluation activities

• Must be agency-wide and fully supported and promoted

Slide 62

Hazard Identification: Data Collection


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


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


OperationalSystem

Description


HazardAnalysis


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


and Mitigation

SafetyRisk

Management


& Analysis

Slide 67

Safety Risk Evaluation ProcessSafety Risk Mitigation

Index safety risk

Evaluate current

mitigations

Evaluatethe Safety Risk


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 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?


HazardAnalysis

Evaluatethe Safety Risk

Mitigate SafetyRisk

Monitor &Measure

Manage safety risks

Never-

ending

cycle

Slide 74

75Slide 75

Safety Performance Monitoring & Measurement Sub-Component


t

Managementof

change


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


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


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


t

Managementof

change


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


t

Managementof

change

SafetyAssurance


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

http://bussafety.fta.dot.gov/

Transit Bus Safety Oversight Program Transit Conference Presentation Ream Lazaro.

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