Exploring How to Make System Safety Work in Transit

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PREFACE

This report describes the two-day workshop sponsored by the Federal Transit Administration (FTA), the New York State Public Transportation Safety Board (PTSB), and the Metropolitan Transportation Authority (MTA) that was held in New York City, on September 21-22, 1993. The purpose was to develop ideas for improving safety at the transit systems operating under the MTA through more effective use of system safety principles and the System Safety Program Plans that meet the needs of both the MTA and the PTSB. These plans are produced by each operating agency of the MTA and approved by the New York State Public Transportation Safety Board.

The report attempts to be concise and yet not lose the detail which was a valuable part of the workshop. The format presents summaries and aggregations in the body of this document, while the appendices give the details at the lowest level of transcription taken at the individual sessions. The tabulations in the appendices are informative as they often show detailed information before it was aggregated. Readers are cautioned, however, that with this type report, where information is aggregated and then ranked by vote, there is the danger that supporting material can be missed and important points obscured. Additionally, the process can influence the results by arbitrarily focusing on some activities and not on others.

Major contributors to organizing the workshop were Linda Kleinbaum, Senior Deputy Director of Planning, Metropolitan Transportation Authority; and Carmen Bianco, Assistant Vice President, Office of Safety, New York City Transit Authority, both of whom hosted the meeting; Edward Plasberg, Executive Director, New York State Public Transportation Safety Board; Ronald Kangas, Office of Technical Assistance and Safety, Federal Transit Administration, and Project Manager, FTA Safety Investigation of the New York MTA and its operating elements; and William Hathaway, John A. Volpe National Transportation Systems Center. In addition, Professor Peggy Brouse, School of Information Technology and Engineering, George Mason University, contributed to planning the workshop and she and members of her staff acted as workshop transcribers. Cheryl Kennedy, New York City Transit Authority; John Fabian, New York State Public Transportation Safety Board; and Susan Gilbert, Interactive Element, Inc., were facilitators for the three working groups which independently proposed and discussed the issues and solutions.

One of the suggestions offered at this workshop was to reconvene in a year. This short report should help focus any such follow-on, as well as offer suggestions for improving safety at other transit agencies.

TABLE OF CONTENTS

Section

1. INTRODUCTION
1.1 WORKSHOP GOAL AND OBJECTIVE
1.2 WORKSHOP FORMAT AND LOGISTICS
1.3 OVERVIEW
2. ISSUES
2.1 DISCUSSION
2.2 IDENTIFICATION OF ISSUES
3. PROPOSED SOLUTIONS
3.1 DISCUSSION
3.2 SUMMARY OF PROPOSED SOLUTIONS
3.3 IDENTIFICATION OF PROPOSED SOLUTIONS
3.4 SUGGESTED ACTION
4. CONCLUSIONS
APPENDIX A. ORGANIZATION OF WORKSHOP APPENDIX C. POST WORKSHOP CORRESPONDENCE AND ACTION

LIST OF TABLES

Table

3-1 Workshop Solutions by Groups 3-2 Solution Votes for All Groups

DEFINITIONS

In this report, the following terms and their definitions are used:

Safety Freedom from accidental harm. Safety in transit applies to patrons, employees, and the public affected by transit activity.

Security Freedom from intentional harm.

System Safety

The systematic application of sound management and engineering principles throughout all phases of a system's life cycle to achieve the highest levels of safety consonant with operational effectiveness and cost. Effective system safety programs have at least the following four key attributes:

· A commitment from highest levels of the organization to the concept of system safety;

· A plan that defines the applicable policies, codes, and standards; sets goals for the organization and its components; defines authorities and responsibilities for the components of the organization; and establishes a hazard resolution process;

· An effective organizational entity with primary responsibility for enforcing the plan and performing certain activities defined in the plan; and

· Widespread understanding and acceptance throughout the organization of the concepts of system safety.

System Safety Program Plan (SSPP)

The plan that meets the SSPP requirements stated above. (In New York state, all public transit organizations must submit an SSPP to the New York State Public Transportation Safety Board for approval.)

Hazard A condition that can cause injury or death, damage to or loss of equipment, service, property, or environmental harm.

Note: This document was prepared primarily to assist in improving safety at the operating authorities under the New York Metropolitan Transportation Authority. Throughout this report the terms referring to these operating authorities are taken directly from the workshop, reflecting the usage of the participants. The terms are used interchangeably and include "agency," "operating element," "property," and "authority."


ABBREVIATIONS

APTA

American Public Transit Association

EPA

Environmental Protection Agency

FRA

Federal Railroad Administration

FTA

Federal Transit Administration

GMU

George Mason University

LIRR

Long Island Rail Road

MSBA

Metropolitan Suburban Bus Authority

MTA

Metropolitan Transportation Authority

MNCR

Metro-North Commuter Railroad

NYCTA

New York City Transit Authority

OSHA

Occupational Safety and Health Administration

OSS

Office of System Safety

PMO

Project Management Oversight

PTSB

New York State Public Transportation Safety Board

SSPP

System Safety Program Plan

EXECUTIVE SUMMARY

In April, 1989, at the request of members of the New York congressional delegation, the Federal Transit Administration (FTA) initiated a safety investigation of the New York Metropolitan Transportation Authority (MTA) and its operating authorities. This was the largest and most comprehensive safety investigation ever conducted of a public transit system. Two main conclusions drawn from many of the 352 key findings uncovered during the investigation are as follows:

· The system safety approach to achieving safe transit, which systematically examines the people, equipment, procedures, and environment in which the transit system operates, was not being adequately followed; and,

· Implementation of the System Safety Program Plan, which formally describes responsibilities, actions, and activities necessary to implement the goals and objectives of the system safety concept, was also failing.

As a result, the MTA requested the assistance of the FTA in addressing those issues relating to an effective system safety process and an effective System Safety Program Plan. In response, the FTA, who recognized this as a national issue, acted in conjunction with the New York State Public Transportation Safety Board and the MTA to sponsor this workshop, "Exploring How to Make System Safety Work in Transit," on September 21 and 22, 1993.

The workshop was attended by 38 individuals, consisting of operators, overseers, regulators, and safety experts. Working in three parallel teams led by facilitators, they participated in three sessions during which issues were identified, and solutions were proposed and ranked. In the course of the two day workshop, the three parallel teams introduced 142 safety issues and proposed 69 solutions. The 69 solutions were voted upon by the participants to give a sense of their relative priority. In addition, the top 18 suggested solutions were considered sufficiently important that action be initiated in the near future. In some cases, the participants noted that, while they supported the action, they could not make formal commitments for their organizations.

The following are conclusions from the workshop, based on the discussions held at the various sessions and the proposed solutions adopted by the participants:

1. The system safety concept is supported by this workshop as the best means to achieve the highest level of safety that is practical. It provides a framework for implementing many of the proposed solutions of this workshop and for achieving the goal of safety.

2. Identified issues and proposed solutions for improving system safety and its implementation center around two areas. Both are considered necessary since safety requires both. Essential are: 1) a safety plan that meets the requirements of oversight and the features of each transit agency; and 2) the vigorous implementation of the plan.

3. The System Safety Program Plan is necessary for implementing system safety and it must meet the specific characteristics of each agency. The plan should be promoted by top management, be contributed to and designed for all management, and include all safety activities.

4. Strong top management support for implementation of system safety within the transit agencies is essential. This includes CEOs and presidents. To meet this end, the workshop stated that top management training in highly focused training sessions on system safety concepts is necessary.

5. Training at all levels in system safety and in job related safety responsibilities should also be increased. Such training could establish the basis for safety accountability.

6. Personal accountability for safety failures is a necessary addition to individual performance records. Everyone in a transit agency should be included.

7. There are safety related efforts that transit agencies can introduce to improve safety in the areas of training, assigning responsibility, and internal communication.

8. There is a need for better cost accounting of all aspects of accidents and safety.

Throughout the workshop, in formal sessions and in informal discussions, it became exceedingly apparent that to create safety at its highest practical level, it is necessary to have an effective SSPP that meets the requirements of both the operating agency and its oversight body. The participants agreed that new concepts in the field of safety should be examined to see if they could be made part of the SSPP and contribute to system safety. Receiving considerable participant approval were the proposals for personal accountability for safety, a concept that is being adopted in some private industrial companies. There was a strong message from the participants that safety accountability, from the top-down, is needed; and to insure accountability, safety performance should be part of each individual's performance review. Lastly, the participants voiced their enthusiasm throughout the workshop for the opportunity to examine common problem areas and to propose solutions with people from other organizations.

1. INTRODUCTION

In response to Section 339 of the Department of Transportation and Related Agencies Appropriations Act of 1990, the Federal Transit Administration (FTA) initiated, under the authority of Section 22 of the Urban Mass Transportation Act of 1964, as amended, a safety investigation of the New York Metropolitan Transportation Authority (MTA) and its operating elements. The investigation examined all of the safety related activities of the New York City Transit Authority (NYCTA), Staten Island Rapid Transit Operating Authority (SIRTOA), Long Island Rail Road (LIRR), Metro North Commuter Railroad (MNCR), Metropolitan Suburban Bus Authority (MSBA), and the MTA headquarters.1

The investigation findings revealed that among the many areas of concern, the System Safety Programs and, in particular, the implementation of the System Safety Program Plan (SSPP) within the MTA operating authorities, were not functioning properly. Three examples of the findings of the safety investigators were:2

· The SSPP is of little value for promoting broad acceptance of safety related activities

· The SSPP does not embody the full extent of the safety program

· The roles, responsibilities and interfaces between the operations safety and the systems safety departments are not defined clearly

Responding to these findings in their Corrective Action Plan, the MTA requested the assistance of the FTA in addressing those issues relating to an effective system safety process and an effective SSPP. Replying to this request and recognizing that it this may be a national issue, the FTA, in conjunction with the New York State Public Transportation Safety Board (PTSB) and the MTA, sponsored this workshop entitled, "Exploring How to Make System Safety Work in Transit." This document presents the results of that workshop held in New York City on September 21-22, 1993 (the workshop agenda is contained in Appendix A).

1.1 WORKSHOP GOAL AND OBJECTIVE

The goal of the workshop was to "develop a workable system safety process that meets the needs of the MTA and the New York State Public Transportation Safety Board (PTSB).3" To accomplish this goal, the workshop focused on the System Safety Program findings developed in the Section 22 investigation of the MTA transit systems. To assist the workshop attendees in addressing these findings, they were asked to first identify what issue(s) prevented the attainment of that goal and to then identify solutions or actions that might be taken to resolve those issues.

1.2 WORKSHOP FORMAT AND LOGISTICS

The workshop was attended by 38 individuals4 who, working in groups led by a facilitator and chairperson, participated in three group sessions during which the issues were identified, and solutions were proposed and then ranked. Each participant was assigned to the same group for all three sessions. The groups met concurrently and each addressed the same goals and questions as the other groups. The safety issue generation, structuring, discussion and ranking were done by the individual group participants.

After an initial plenary discussion of the workshop goals and objectives the participants were asked to convene in the preassigned groups for Session 1. At this session they were asked to identify and define the issues that prevented attainment of the workshop goal. To assist in this effort, the workshop attendees were asked to consider the following three questions in their working groups:

· What is the purpose/objective of a System Safety Program/Plan and who is it for?

· What is the best way to achieve the purpose/objective identified above?

· How can we get everyone to accept and use the System Safety Program/Plan on a daily basis?

At the conclusion of the first group sessions, the group chairpersons provided the plenary session with summaries of their findings. During Session 2, the individual groups were allowed to add to their initial lists any issues selected from the discussions of the other groups. They then proceeded to identify the solutions and actions required to address the identified issues. At the conclusion of the session, each group chairperson presented the solutions and required actions identified by their group.

In Session 3, the solutions proposed earlier were voted on by the participants. Where possible, the participants identified action for the proposed solutions along with agencies that were considered most appropriate for taking the action. The ranking results are summarized in Section 3.

1.3 OVERVIEW

This workshop was a unique opportunity for transit operators, overseers, regulators, and safety personnel to face the common goal of improving transit safety. The approach taken in the workshop was to examine why the SSPP was not working as it should. The three workshop groups, working in parallel sessions, spent two days probing the issues and basic causes of system safety and the SSPP's difficulties. In attempting to improve these problem areas, the workshop introduced 142 safety issues and proposed 69 solutions. While there was some redundancy between the three groups, the discussions among the participants in each of the workshop sessions examined many sides of each issue.

Information disclosed in the discussion and results of this workshop may find application in many transit activities throughout the country. Various issues, proposed solutions, or elements of each, could suggest responses for those agencies where problems exist, or even where there are problems that are not being recognized.

1The Federal Transit Administration investigation included contractor performed on-site inspections of the Metropolitan Transportation Authority, New York Transit Authority, Staten Island Rapid Transit Operating Authority, Metropolitan Suburban Bus Authority, and those activities of the two commuter rail operations, Long Island Rail Road and Metro-North Commuter Railroad, that do not come under Federal Railroad Administration (FRA) regulation. The FRA conducted a parallel investigation of those activities which it regulates at the two commuter railroads.

2The FTA investigation is summarized in "New York Metropolitan Transportation Authority Safety Investigation," Federal Transit Administration, Rep. No. FTA-NY-A002-93-1/DOT-VNTSC-FTA-93-4, June 1993.

3The PTSB was created by the New York State Legislature to provide safety oversight of those transportation agencies within the State of New York that receive State Mass Transportation Operating Assistance. Included in the PTSB responsibilities is approval of System Safety Program Plans required from each transportation agency.

4A breakdown of the participants showed 19 from the MTA and its operating elements, 8 from the U.S. Dept. of Transportation, 6 from the PTSB, and 5 from industry.

2. ISSUES

2.1 DISCUSSION

In the charge to the workshop, participants were asked for a free-flowing uninhibited discussion and were specifically requested not to include solutions in the sessions on issues. The three workshop groups produced a total of 142 issues. Some of the issues had common elements; therefore, to simplify review of the workshop, they have been integrated and organized in this section (the issues presented by each group are given in Appendix B). This classification is based on the eleven general categories proposed by the workshop facilitators. For this report, the eleven categories are combined into three groups:

In Section 2.2, these three major groups are listed. Located under each are associated categories and a summary.

2.2 IDENTIFICATION OF ISSUES

1. Management Role

· System safety should be a top-down process.

· There is a lack of top management understanding the system safety process.

· Training is a need at all levels.

· Implementation of existing SSPPs is not adequately helping to improve safety.

· Accountability/responsibility for safety is everybody's business, including top management's.

· Safety departments need more resources, management support.

The issue receiving most consideration in the three group sessions on issues was the need for management training and an understanding of system safety. System safety is a top-down process and strong leadership is essential. The participants felt that top management should be more proactive to raise safety to the highest practical level.

Educating management about the need for systems safety was considered necessary because management is not sufficiently informed. This is due in part to their general lack of technical background and operations experience. System safety is parallel to a good management plan and it needs sufficient participation to assure that all elements buy into it.

Training deficiencies in systems safety were noted at all levels, from top management to the lowest level. Two of the specific needs cited were training in system safety principles and details, and developing methods for cost/benefit studies.

Several participants stated that there were other safety related activities which could improve implementation. Intra-agency communication in regard to safety issues was considered by some to be an ever present area for improvement. Coordination between the elements of the transit authority was very important.

Lack of personal accountability in current operations was given significant attention in the discussions and a strong need for accountability was presented. Along with a lack of accountability in existing transit operations, related issues included such factors as lack of responsibility for carrying out safety related tasks and, in some instances, not even knowing that safety responsibilities existed. The capacity to provide safety should be part of both initial and continued employment.

Deficiencies were noted in personal accountability, interdepartmental coordination, training, and resources. Participants stated that safety departments needed more financial support, manpower, authority, and top management support to effectively develop, implement, and evaluate the safety program at their own transit authorities.

2. System Safety Program Plan (SSPP)5

· The SSPP implementation process is not adequate to help improve safety at the agencies.

· The SSPP should be written by and for the transit organization, reflecting the organization's objectives (not satisfying an audit function).

· There is need for a comprehensive plan to promote safety.

· The current SSPP is directed toward passenger and operational safety.

Many aspects of the SSPP were discussed. The two main issues that developed were the desire for a more tailored SSPP for each agency and the need to effectively implement the plan once it is in place.

Some transit agency participants stated that the SSPP, in its present form, did not contribute to their safety activity.6 Points raised included questioning the need for an SSPP. Specific issues raised about SSPPs were: (1) problems with the guidelines for the SSPP that are imposed by an outside oversight agency; (2) extensiveness of contents (should the SSPP include environmental and health safety); (3) preparation (who prepares which parts of the SSPP); (4) format (how can the SSPP be made readable); and (5) custodial problems (how can the document be made available to those who need it).

It was suggested that the SSPP include the following: (1) interface information that lays out responsibility, accountability, and contact points for all potentially affected departments and outside agencies (the SSPP should further outline the hazard identification and resolution process for that agency); (2) a statement of the agency safety goals and a reminder that they must be realistic and achievable; (3) an implementation plan; and (4) the process by which safety and the success of the SSPP will be measured.

There was a desire indicated by participants from the agencies to give the SSPPs broader coverage than is currently required by state oversight. These participants stated that there was a need to have one plan which included safety requirements to meet areas now covered by environmental oversight (EPA) and worker health/safety, now covered by labor and occupational requirements (OSHA). It was pointed out by some participants that APTA SSPP guidelines cover more than PTSB requirements.

Participants from the largest transit agency, NYCTA, suggested that permitting the agencies to prepare their plan in sections, over a period of time, would greatly reduce the burden on the safety department. Difficulties were perceived by other participants who pointed out that the SSPPs can be out of date in some areas by the time they are completed and that taking a longer time would compound this problem.

Readability of the SSPP was a major discussion point in the workshop. Problems with SSPPs being too large and not presented in a user-friendly format were discussed. Participants suggested the need to limit the amount of material in the SSPP, stating that it does not have to include everything. The need for a system description in the plan was questioned. Some participants stated that the SSPP should be a framework for referencing sources. The use of appendices for containing much of the contents was discussed.

3. Safety Process

· Who is it for?

· What is the purpose/objectives of a System Safety Program?

· Why is the system safety approach followed?

· What is the cost/benefit of safety?

Safety should be a product deliverable by the transit organization to the customers, employees, and general public. Is the existing process adequately helping safety at the agencies? The current approach was questioned by some of the participants.7 Are there other processes which could do better, or be used in addition to the system safety process to create safer transit?

Safety is good business - lack of safety is very expensive. A lack of information on the costs of accidents was brought out. It was felt that not only were true total costs frequently not known, but also that accurate cost information could be used to present top management with cost/benefit analyses to show the value of supporting safety.

5SSPPs are required in New York State by all public transit organizations receiving state funds. State law mandates the New York PTSB to require, review, approve, and monitor SSPPs developed by the transit organizations. Other state agencies monitor health and environment.

6In the following session on solutions, there were no solutions proposed that eliminated SSPPs. The proposed solutions concerning SSPPs were all for making improvements.

7The issue of whether or not system safety offered the best approach to achieving a safe transit operation not only questioned the value of system safety relative to other methods, but also suggested the possibility that the system safety proponents had not convinced all safety personnel of the advantages of system safety.

3. PROPOSED SOLUTIONS

3.1 DISCUSSION

During this session the workshop participants proposed and voted on solutions for the issues identified at the previous session. The following three activities took place in the Solutions Session:

1. Each of the three groups took the issues they had produced at the Issues Session and discussed possible solutions for each of them. By having participants present who represented both operators and overseers, as well as independent experts, it was possible to examine in detail the effectiveness and impacts of the suggested solutions. After each working group finalized their solutions, they were combined to produce a total of 69 proposed solutions, which were voted on by all participants. In Section 3.2, the proposed solutions are shown by category. Votes received for each of the categories are shown in Table 3-1.

2. The 69 proposed solutions were voted on by all the participants. Each participant was allowed a total of 25 votes. The intent was to assign a sense of relative importance to the various solutions. There was no pass or fail judgement intended. All of the solutions were considered worthwhile to have emerged from the individual workshop groups. In Section 3.3, the top voted solutions are discussed briefly and a complete listing of the voting results are shown in Table 3-2.

3. One of objectives of the workshop was to identify action for the proposed solutions. The intent was to identify agencies where specific actions would be initiated. The top 18 solutions were identified by the participants as sufficiently important to initiate action soon. In some cases, participants were not authorized to commit their organizations, although there was a strong sense of commitment implied by all at the workshop. The top 18 solutions and their associated action agencies are given in Section 3.4.

3.2 SUMMARY OF PROPOSED SOLUTIONS

The 69 proposed solutions involved many belonging to common groups, thus allowing the list to be divided into the same three groups used in the Issues Session, plus a miscellaneous group. Counting the proposed solutions and the votes received for each group developed a broad sense of the workshop's priority. However, the workshop procedure prevents the drawing of fine conclusions from the voting results.

The discussion from the sessions regarding the development of proposed solutions and their importance is summarized below. Two "top" groups are shown to share the necessity for improving safety.

1. Management Role

a. Top Management Training

The large number of solutions and the high vote totals relating to management reflect the importance the participants placed on improving management's role in safety. In the Issues Session, it was suggested that mandatory training for management could make up for their lack of technical or operations background. In particular, training of the highest level transit management in systems safety was given a high priority in the workshop voting. Reflecting time pressure on chief executives for such training, the participants suggested short seminars using peer training for CEO's.

b. Management Commitment to System Safety

The importance of top management's strongly articulated commitment to system safety was emphasized in the voting. The participants felt that top management commitment is essential and that the most important step for achieving such commitment is improving the system safety awareness of top management.

c. Personal Accountability

Individual accountability for failure of safety was supported in the voting, including at the top management level. Steps to create accountability included; (1) defining safety responsibility clearly in job descriptions, (2) establishing penalties for each individual's failure to meet that responsibility (penalties should be clearly stated), and (3) requiring that everyone be accountable for their safety performance at the time of job performance reviews.

d. Training for Other Than Top Management

This grouping indicates a need for more training, particularly in system safety, for all levels of employees. However, in addition to the top-level management training noted above, the participants also indicated that mid-level management training should be emphasized. Responsibility for training was felt to be with both the agencies and the FTA.10

e. Agency Activity

This group of solutions addresses those actions (other than training) which could be implemented by agency management.

2. System Safety Program Plan (SSPP)

a. Contents

The content of the SSPP was given considerable attention and it was suggested that the SSPP be more "custom built" for each agency. Although specific features of such an SSPP were not described, the participants from the transit agencies wanted to make their SSPPs more responsive to their own transit agency's particular characteristics.

b. Agency Preparation

This group of proposed solutions shows a strong need for input to the SSPP from the entire transit agency.11

The proposal to allow the NYCTA to perform incremental preparation of its SSPP over a period of time was introduced by NYCTA participants and caused considerable discussion. Their argument was that the NYCTA is so large that the effort to produce an effective SSPP within one year would absorb an unacceptable amount of the safety department's resources. Difficulties with such an arrangement are associated with material becoming outdated.

c. User Friendly

Making the information contained in the SSPP more accessible was considered an important change. There was no opposition.

d. Distribution/Promotion

Distribution is important to insure the intent of the SSPP is fulfilled.

3. Safety Process

a. System Safety Policy

While the basic philosophy of system safety came under discussion, the tone of the workshop was to insure that the best possible safety approach be used. Participants suggested that other safety processes be examined for possible inclusion in transit safety.

b. Need for Better Cost Information

Although there was little prior indication from both the Section 22 investigation and discussions before the workshop, the participants thought more attention was needed to determine the full cost of accidents and to communicate the cost-benefit of safety with top management in order to justify and increase the role of system safety in transit.

4. Miscellaneous


· Develop a program for certification of safety professionals

(#7 - 19)

 

· Standardize the reporting process that is acceptable to all agencies

(#28 - 12)

 

· Unions must be included in the safety process and become part of the solution

(#41 - 10)

 

· Public awareness program

(#44 - 9)

 

· Perform accident trend analysis

(#48 - 8)

 

· Include accident rates as accident indicators

(#53 - 6)

 

· Conduct site-specific seminars

(#60 - 4)

 

· Include in FTA triennial review a system safety module

(#61 - 4)

 

· Include in FTA project management oversight process a system safety module

(#65 - 3)

 

· Regular safety performance reports

(#67 - 3)

 

· Colorful brochure for a selling campaign

(#68 - 2)

 

· SSPP needs to be continually promoted in a positive manner

(#69 - 2)

This group of solutions included a variety of approaches to improve transit safety. The first several in the voting should be noted. Certifying safety professionals has been suggested in the state oversight mandated by legislation and was given strong support in the workshop. Other noteworthy proposals included developing standardized reporting and including unions in the drive for improved safety. Analyses of performance and accident/incident records to indicate trends was also supported.

3.3 IDENTIFICATION OF PROPOSED SOLUTIONS

This section gives a listing of the proposed solutions in the order in which they were voted by the participants.12 The rank order of the voting for the complete list of proposed solutions is shown in Table 3-2. Comments are shown below for the individual solutions receiving the top votes.

No.1 (27 votes) After training, establish management accountability for safety performance through the performance evaluation process

This proposed solution combined several of the issues which had been given strong support throughout the workshop: (1) accountability for safety performance, (2) involvement of management, and (3) the need for top management training. This particular solution was supported by many of the participants.

No.2 (22 votes) Need to train top executives

The number two vote winner was a subset of number one and reinforced the need for top executive training.

No.3 (22 votes) Safety performance should be included in performance

As in number two, number three reflected the top vote receiver and indicated the need for personal accountability in safety. Furthermore, it showed one way of creating accountability -by including safety performance in annual personnel reviews.

No.4 (21 votes) Top management must own and support the plan with active and enforceable policy statements

This proposed solution, which was fourth in votes, indicated one specific action for top management in their proactive safety role - they should show direct support for the System Safety Program Plan. This proposed solution went further by designating that top management must sign for the plan.

No.5 (21 votes) Develop a national criteria for system safety plans from which detailed agency-specific plans can be evaluated

The fifth ranked solution supported the concept of the plans being more directly related to the conditions and needs of each operating agency.

These top five vote receivers mirrored the two main themes from much of this workshop:

· Top management must be knowledgeable, proactive, and responsible

· System Safety Program Plans should reflect the specific conditions at each agency

Table 3-2, below, lists the 69 solutions in the order of the votes received.

3.4 SUGGESTED ACTION

One of the objectives of the workshop was to identify actions for the proposed solutions. The intent was to identify agencies where specific actions would be initiated.13 The top 18 solutions in Table 3-2 were identified as sufficiently important to warrant immediate action. In some cases, participants were not authorized to commit their organizations, although there was a strong sense of commitment implied by all at the workshop. Correspondence after the workshop relating to actions is shown in Appendix C. Shown below are the suggested actions for the solutions, listed by agency and solution number. Identifying agencies with the specific solutions reinforces the need for the proposed solutions to be further developed and implemented.

Federal Transit Administration

Volpe Center(VNTSC) (the John A. Volpe National Transportation Systems Center performs transit research and program support under direct control of the FTA)

New York State Public Transportation Safety Board (PTSB)

Metropolitan Transportation Authority (MTA)

Properties

Miscellaneous

American Public Transit Association (APTA)

Union


· Unions must be included in the safety process and become part of the solution (Property/Union Management)

(#41 - 10)

8In this tabulation, "No. of Solutions" refers to the number of solutions proposed. For example, in the first entry, "Top management training," there were seven solutions proposed that called for top management systems safety training. Similarly, the column, "No. of Votes," refers to the total votes given to those eight solutions.

9(#2 - 22), "#2" refers to the rank of this solution and "22" refers to the number of votes it received.

10The need for more training shows confidence in and justification of the training programs offered by the operating agencies and by the Transportation Safety Institute under FTA sponsorship. The participants indicated that these programs should be accelerated to include more of the employees.

11This group of solutions presents a need for all parts of the agency to contribute to the SSPP. Implied in these solutions is the realization that outside of the safety departments there is little or no recognition given to the SSPP.

12While the individual vote count for the proposed solutions shows a measure of priority, readers are urged to review the complete listing of solutions as details important to individual readers may be buried in the summarization of this document.

13Identification of the individual authority associated with each proposed solution was taken directly from the names on the voting list. In addition, where no responsible authority was shown, but the authority was obvious, identification was included.

4. CONCLUSIONS

Two observations from the workshop were that the system safety concept is strong and that the System Safety Program Plan is supported. And, as a result of the changes in the plan and its implementation, as discussed at the workshop, it would become an integral part of an agency's safety activity.

The following workshop conclusions were based on the session discussions and solutions:

1. The system safety concept is supported by this workshop as the best means to achieve the highest level of safety that is practical. It provides a framework for implementing many of the proposed solutions of this workshop and for achieving the goal of safety.

2. Identified issues and proposed solutions for improving system safety and its implementation center around two areas. Both are considered necessary because safety requires both. Essential are: 1) a safety plan that meets the requirements of oversight and the features of each transit agency; and 2) the vigorous implementation of the plan.

3. The System Safety Program Plan is necessary for implementing system safety and it must meet the specific characteristics of each agency. The plan should be promoted by top management, be contributed to and designed for all management, and include all safety activities.

4. Strong top management support for implementation of system safety within the transit agencies is essential. This includes CEOs and presidents. To meet this end, the workshop stated that top management training in highly focused training sessions on system safety concepts is necessary.

5. Training at all levels in system safety and in job related safety responsibilities should also be increased. Such training could establish the basis for safety accountability.

6. Personal accountability for safety failures is a necessary addition to individual performance records. Everyone in a transit agency should be included.

7. There are safety related efforts which transit agencies can introduce to improve safety in the areas of training, assigning responsibility, and internal communication.

8. There is a need for better cost accounting of all aspects of accidents and safety.

Throughout the workshop, in formal sessions and in informal discussions, it became exceedingly apparent that to create safety at its highest practical level, it is necessary to have an effective SSPP which meets the requirements of both the operating agency and its oversight body. The participants did suggest that new concepts in the field of safety be examined to see if they could be made part of the SSPP and contribute to system safety. Receiving considerable participant agreement were the proposals for personal accountability for safety. This is an approach being adopted in some private industrial companies. There was a strong message from the participants that safety accountability from the top down is needed; and to insure accountability, safety performance should be part of each individual's performance review.

Throughout the workshop, the participants voiced their enthusiasm for the opportunity to examine common problem areas and propose solutions with people from other organizations.

APPENDIX A. ORGANIZATION OF WORKSHOP

A WORKSHOP

ON

EXPLORING HOW TO MAKE SYSTEM SAFETY WORK IN TRANSIT

SEPTEMBER 21-22, 1993

New York CityTransit Authority, Human Resources Building

1250 Broadway, Manhattan

Workshop Goal:

Develop a workable system safety process that meets the needs of the NYMTA transit systems and the PTSB.

Tuesday, September 21, 1993

Wednesday, September 22, 1993

NEW YORK SYSTEM SAFETY WORKSHOP

LIST OF ATTENDEES

September 21-22, 1993

APPENDIX B. TABULATION OF IDENTIFIED ISSUES

Blue Team Issues After Organizing

What is the purpose/objectives of a system safety program/plan and who is it for?

The plan should be a framework for safety.

1. Need a comprehensive plan to promote safety

1.1 For customers-i.e., passengers, employees, and the general public

1.2 Safety plan is for the entire transit system

2. System safety should be a top down process

2.1 Parallel to good management plan

2.2 Need sufficient participation to assure that all elements buy into the program

3. Accountability/responsibility for Safety is everybody's business

3.1 Responsibilities for interfacing and coordination

3.2 Communications tool for understanding and awareness

3.3 Coordination is a most important part of communication and accountability

4. Safety should be a deliverable product by the transit organization to customers-passengers, employees, and the general public

4.1 Safety is good business-lack of safety is very expensive

5. SSPP should be written by and for the transit organization, reflecting the organization's objectives (not solely satisfying an audit function)

5.1 The plan must state what the agency intends to implement in its program

5.2 The plan needs to include realistic/achievable goals

5.3 The plan must be all inclusive and formally document how to implement the stated goals

5.4 A SSPP should contain, as a minimum, interface information that lays out responsibility, accountability, for all potentially affected depts. and should outline the hazard identification and resolution process.

6. Comments:

6.1 Need flexibility with plan development

6.2 Having plan does not necessarily mean you have a program

6.3 Executive summary of the system safety program plan-separated into two levels-philosophy and mission; detail and operation

6.4 Security is an intentional act; safety addresses accidental acts

6.5 Lack of safety is a hazard

6.6 Security issues should be separate workshop

6.7 PTSB guidelines set up to interface only concerned with the Public - no dictate that cannot be concerned with environmental issues

6.8 PTSB has no mandate to be involved with environmental and OSHA type issues

6.9 APTA guidelines are much greater than PTSB

6.10 Organizations are trying to conform to PTSB instead of the necessary safety problems

6.11 PTSB gave some basics to guidelines for safety-everyone could still add their particulars

6.12 Organizations are concerned about audits because of being public agency

6.13 Current guidelines are too generic

6.14 Audit checklist turned into guideline

6.15 APTA doc. is only doc. with specific guidelines concerning safety applications

6.16 Many issues deal with security and not everyone has security force

7. Problems:

7.1 Largeness is problem

7.2 People think in limited scope

7.2.1 Com: Bus don't fit lifts

7.3 Incorrect perception is that safety is solely the safety dept. business

7.4 Currently begins and ends in safety dept.

7.5 Conflicting goals; time constraints, budget

7.6 Upper level mgt. education - Very top mgt.

7.7 Resentment in implementing some safety requirements

7.8 Safety perceived to be detrimental to operation

7.9 Security is important part of safety - or is it the Police Dept.'s job?

7.10 Reverse incentives - operators being paid for retraining and filling out accident reports

7.11 FELA process encourages the injury claim process

7.12 Another neg. incentive is decreased budget if increase in safety

7.13 Can't put every detail because the plan becomes to detailed and cumbersome

8. Potential items for "solutions" discussion:

8.1 The plan should have an executive policy statement, which should be simple, concise, short to give people an idea of responsibility - it should be followed by a detailed implementation plan

8.2 i.e., time frames to develop plan, more details of the particular topics, etc.

8.3 Comment: System Safety Program Plan (SSPP) should be one small document that tells where to find details pertaining to particular problem

Green Team Issues After Organizing

1. Why are we doing it - Policy?

2. What is the purpose/objectives of a system safety program?

2.1 Commitment by top management to use the plan

2.2 No ownership/empowerment of plan

2.3 Should it be proactive program vs. reactive program

2.4 A fundamental vision endorsed by top management

2.5 Define basic principles

2.6 Establishing responsibilities/accountability

3. Lack of safety awareness by management

3.1 Safety is a condition of employment

3.2 Must communicate to all levels

3.3 Must be flexible

3.4 Need create corporate safety consciousness

3.5 Must create a corporate safety culture

4. What is the cost benefit of safety?

5. Who is it for?

5.1 Should plan be concerned with public and/or employee safety

5.2 Should it address the concerns of oversight agencies

6. Development of the plan

6.1 Plan must assist individuals in transit authority do their job

6.2 Who develops the format for the plan

6.3 What are the elements of the plan

6.3.1 Reduce to a manageable size

6.3.2 Standard operating procedures developed

6.4 Use as a management tool should address the concerns of oversight agencies

6.5 Should the plan document what is being done or develop a plan that documents what we ought to be doing - Iterative process

6.6 Why is there a description of the system

6.7 Reduction of accidents part of performance reviews

6.8 Is it possible to develop a generic plan

6.8.1 Rigidity of documents

6.8.2 Must represent the culture and each individual organization

7. Maintenance of the plan

7.1 Testing the plan

7.2 Auditing results in revisions

7.3 How to make/implement revisions and changes to safety plan

7.4 Who is responsible for making/implementing plan revisions?

8. Communication

8.1 Word is not getting out

8.2 Not sufficient resources given for implementation of plan

8.3 Top management do not understand beyond the mission statement what system safety is

8.4 Need a document that all levels of users can/will utilize

9. System safety is out there but the focus is on preparing the document and training of personnel

10. Implementation

10.1 Auditing

10.2 Monitored performance of system

10.3 Should be a self guidance tool

10.4 Oversight is part of implementation

10.5 Rewards and recognition

11. Is there another safety process?

11.1 Regulatory process

11.2 Responsibility process

11.3 Ownership/accountable process

11.4 Companies don't have corporate plans but have guidelines

11.5 Principles are set and structure should follow

11.6 Interactive process

Red Team Issues After Organizing

1. Management Commitment

1.1 Lack of continual top management safety support and safety accountability due in part to:

1.1.1 Managers in transit agencies don't understand the system safety concept and philosophy

1.1.2 Lack of system safety training and experience

1.1.3 The safety department lacks the resources, authority, and corporate support to effectively, develop, implement and evaluate safety
program

1.1.4 Not effectively utilizing departments within authority

2. The SSPP

2.1 The process is not adequately helping improve safety at the agencies

2.2 The true potential of the plan is not being realized due in part to:

2.2.1 SSPP should be for the agency

2.2.2 Document has been developed and used to comply with state regulations only

2.2.3 PTSB guidelines are cumbersome; written for auditing process

2.2.3.1 Not well understood, poorly put together not very helpful

2.2.3.2 Format is too structured and detailed to incorporate in a transit agency - not a workable document

2.2.4 Program should help all the managers understand system safety

2.2.5 Perception of users that plan does not have payback and worth to the employees

2.2.6 More difficult to apply this philosophy to a system with equipment that is aged, not state of the art

2.2.6.1 Trying to apply safety standards to a large, complex, old, and changing system

2.2.7 PTSB guidelines do not include all aspects of safety - currently passenger oriented, small portion of what a safety program is
supposed to be

2.2.8 Writing the plan to fit the operations, not what it ideally should be

2.2.8.1 Plan needs to also fit strategic business plan

2.2.9 There are no performance indicators for the plan

2.2.9.1 Should be included in the plan

2.2.9.2 The plan should be used as a tool for accident reduction

2.2.10 Perception of users that plan does not have payback and worth to the employees

2.2.11 The safety department lacks the resources, authority, and corporate support to effectively implement a safety program

2.2.11.1 Not effectively involving departments within the authority

2.2.12 Jargon associated with system safety is not well defined - difficult to understand

2.2.12.1 Program and plan are two different things

2.2.13 Is the plan truly inflexible, or is that a perception

3. Training

3.1 Training is an issue for all employees, especially managers at all levels

3.2 All employees, including line supervisors and managers at all levels don't have a sense of what their everyday responsibility to system safety

4. Implementation

4.1 Process is not adequately helping improve safety at the authority

4.2 Program should help all the managers understand system safety

4.3 Need a common sense approach to make it a part of everyday responsibilities

4.3.1 An important part of their regular duties

4.4 Inadequate information dissemination of plans

4.5 Dealing within a large operating environment

4.5.1 Trying to apply safety standards to a large, complex, old, and changing system

4.6 The safety department lacks the resources, authority, and corporate support to effectively implement a safety program

4.6.1 Not effectively involving departments within authority

4.7 Inadequate policies and procedures to effectively support the system safety program

4.8 There is more than one agency to report to (i.e. PTSB and FRA)

4.8.1 Standardized the reporting process

APPENDIX C. POST WORKSHOP CORRESPONDENCE AND ACTION

Metropolitan Transportation Authority

State of New York


347 Madison Avenue

New York, NY 10017-3739

Telephone: 212 878-7000

 

September 30, 1993

Mr. Gordon J. Linton

Administrator

Federal Transit Administration

400 Seventh St., SW

Washington, D.C. 20590

Dear Mr. Linton

I want to thank you and your staff for your assistance in sponsoring the very successful workshop on System Safety Program Plans (SSPP's) that was held in New York on September 21 and 22. The workshop, prompted by the findings of the FTA safety investigation which found shortcomings in the SSPP's prepared for the Public Transportation Safety Board (PTSB), focussed on the development and effective implementation of SSPP's. Representatives of FTA, FRA, the Volpe Center, the New York State Public Transportation Safety Board (PTSB), MTA and its operating agencies, as well as some of the nation's top consultants in this field participated in the workshop.

I understand that the workshop was a terrific success, with consensus reached on those actions most important to developing meaningful safety plans. Two principal recommendations are of particular note to our two agencies given the findings of the FTA safety investigation. The first recommends that the PTSB allow the transit agencies it oversees in New York State greater flexibility in development of their SSPP's. It was agreed that the MTA family along with FTA will follow up with the PTSB to insure that the plan development process is revised in a way that will allow New York State agencies the ability to develop SSPP's that will embody a real action plan for safety. I foresee these plans developing much like MSBA's new plan, with guidance from FTA, and the cooperation of PTSB and input from all departments of the agencies.

The second recommendation called for improved or additional training of top management at the MTA agencies. The members of the workshop recommended that FTA extend its training program to top level management, either funding such training through a consultant who currently has such a curriculum or by developing such a training program itself. I would welcome such assistance from FTA.

Members of the Board

Peter E. Stangl
Chairman and
Chief Executive Officer

Daniel T. Scannell
First Vice Chairman

Lilyan H. Affinito
Bernard B. Beal
E. Virgil Conway
Warren S. Dolny
Barry Feinstein

Barbara J. File
Prema Mathai-Davis
Neil Novesky

Lucius J. Riccio
Joan Spence

Edward A. Vrooman
Alfred E. Werner

Gordon J. Linton

Federal Transit Administration

September 30, 1993

I believe that in working together on these two issues, we can establish a model for improving safety not only on the MTA properties but on transit systems throughout the nation. I look forward to your assistance in this effort.

Sincerely,

Peter E. Stangl

Chairman and

Chief Executive Officer

cc: C. Hoppe

A. Kiepper

D. Nelson

H. Williams

 

The Administrator 400 Seventh St., S.W.

Washington, D.C. 20590

U.S.Department
of Transportation

Federal Transit
Administration

 

Mr. Peter Stangl

Chairman and Chief Executive Officer

Metropolitan Transportation Authority

347 Madison Avenue

New York, New York 10017-3739

Dear Mr. Stangl:

I want to take this opportunity to thank you for the outstanding efforts of you and your staff in preparing the Implementation Plans for the Metropolitan Transportation Authority (MTA) and each of the operating authorities. The level of expertise and dedication of the MTA is clearly reflected in the comprehensive nature and responsiveness of the Plans. We have noted in our review of the MTA plan that you have taken the initial step by providing a policy which expresses the-MTA's commitment to safety, and endorses the adoption of the system safety concept in the MTA and its operating elements. This need for management commitment was the top ranked action identified at the recent workshop in New York on "Exploring How To Make System Safety Work In Transit." With this policy and the information provided in the Plans, we are approving the Implementation Plans dated August 1993. We note that a number of actions have been successfully completed, and are therefore considered closed. We also are informing you that all of the Federal Railroad Administration findings have been successfully resolved and are considered closed.

The Federal Transit Administration (FTA) Region II staff will work with your staff in monitoring the implementation of the Plans. We expect that your own internal auditing of the identified corrective actions will assist the FTA in determining which actions are closed and when.

I appreciate your recent letter commending the FTA on the success of the recent workshop in New York on System Safety. We believe that the agreements reached on System Safety, once implemented, fully satisfy the issues raised during the recent Section 22 investigation. FTA supports the need for top level management safety training and believes that one approach for obtaining that training is through the National Transit Institute (NTI) at Rutgers. NTI would have the ability to establish such a course, if it could be designed with an industry-wide audience in mind. Since you are on the board of the NTI, a direct request from you identifying the need for such training could get the course initiated. Furthermore, we believe that such an action would provide a very meaningful leadership role for the MTA that would have industry-wide value.

If you require any further clarification or additional information, please do not hesitate to contact Ronald Kangas of my staff on (202) 366-0212.

Sincerely,

 

Gordon J. Linton

Metropolitan Transportation Authority

State of New York


347 Madison Avenue

New York, NY 10017-3739

Telephone: 212 878-7000

January 26, 1994

Mr. Gordon J. Linton

Administrator

Federal Transit Administration

400 Seventh St. S.W.

Washington, D.C. 20590

Dear Mr. Linton

Thank you for your recent letter approving the MTA Implementation Plans to the FTA Safety Investigation. As you. know, I have a strong personal commitment to make our system as safe as possible and I appreciate your recognition of the comprehensive nature and responsiveness of these plans. I believe we have assembled many of the top safety experts in the country on our staff whose expertise is, as you point out, clearly demonstrated in these safety action plans. The MTA family saw this effort as an excellent opportunity to enhance the safety of our system and strove to make these implementation plans a blueprint to do just that.

The high quality of these plans also reflects the expertise and dedication of the FTA staff who managed this effort Ron Kangas' coordination of this effort, with the assistance of William Hathaway of the National Transportation Center (NTSC), resulted in the development of investigation findings that provided us with the opportunity to enhance the safety of our system. We greatly appreciated their assistance in this effort and look forward to continuing to work with them to monitor implementation of the plans.

I also appreciate, and will follow up on, your suggestion that the National Transit Institute (NTI) develop a safety training program for top management. I believe that all top management at the MTA and its operating agencies will benefit from a better understanding of the system safety concept. With the enactment of the Federal Transit Act provision requiring states to oversee the safety of fixed rail guideway systems such training will become of even greater importance across the Industry. I am contacting NTI immediately to pursue the possibility of NTI developing and offering a new program that will meet not only the needs of the New York public transportation community, but those of the entire transit industry as well. I hope I can count on FTA to continue to provide its guidance to NTI in the development of this program.

Thank you, once again, for your support of our efforts.

Sincerely,

Peter E. Stangl

Chairman and

Chief Executive Officer

Members of the Board

Peter E. Stangl
Chairman and
Chief Executive Officer

Daniel T. Scannell
First Vice Chairman

Lilyan H. Affinito
Bernard B. Beal
E. Virgil Conway
Warren S. Dolny
Barry Feinstein

Barbara J. File
Prema Mathai-Davis
Neil Novesky

Lucius J. Riccio
Joan Spence

Edward A. Vrooman
Alfred E. Werner

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