Can one safety program change a railroad's safety culture?

First International Safety Culture SymposiumHalifax, Nova Scotia

October 1, 2014

What is safety culture?

2

• "The way we do things around here“ - UK Cullen Report

• “The shared values, actions, and behaviors that demonstrate a commitment to safety over competing goals and demands” 

• - U.S. DOT Safety Council

• “Safety Culture consists of the following 5 elements: informed culture, reporting culture, just culture, flexible culture and learning culture”  - James Reason

C3RS Principles

3

• Build trust– Voluntary– Partnership– Confidential– Protection from discipline

• Focus on low consequence events• Accountability through learning from failure

Procedure

4

E m p lo y e e s u b m its re p o r t

T h ird P a r ty p ro c e s s re p o r ts

R a ilro a d a n a ly z e s re p o r ts

R a ilro a d re v ie w s , p r io r it iz e s , a n d

a u th o r iz e s c o r re c tiv e a c tio n s

R a ilro a d im p le m e n ts a n d

m o n ito rs c o rre c tiv e a c tio n s

R a ilro a d s h a re s in fo rm a tio n

T h ird P a r ty a n a ly z e s tre n d s a c ro s s

c a rr ie rs a n d s h a re s w ith s ta k e h o ld e rs

R a ilro a d p re p a re s fo r p a r t ic ip a tio n

R e p o r tin g P ro c e s s

5

Received over 3,900 reports

6

C3RS Impact at one site

Cars m

oved

betw

een i

ncide

nts

Discipl

inary

case

s

-100%-60%-20%20%

31%

-51%-90%

8%

Percent Change

7

Perceptions of safety culture before, during, and after C3RS at one site

Scale Labor Mngmt Labor Mngmt

Org. Concern for Employees

Organizational Labor - Management Relations

Org. Fairness During Change 51

Supervisor Fairness

Supervisor - Employee Relationship

Managerial Management Safety

Raising Concerns with Supervisors

Work Safety Priorities 51

Respectful Workplace

Co-Worker Helping Behavior

Propensity to Safe Behavior

Coworker Safety 51

B M F B M F

Change in ScoreBaseline to Final

Mean Scale Scores

8

Management: missing or unsupported safety processes

Understand the Problem

Identify and Select Solu-

tions

Implement Solutions & Evaluate

Impact

Provide Feedback

1. Select Reports

2. FillGaps

3. AnalyzeProblems

4. Define Measures

5. Identify Cor-rective Actions

6. Select CorrectiveActions

7. Identify Unintended Consequences

8. Implement Cor-rectiveActions

9. Deal with Con-sequences

10. ShareLessonsLearned

Regulator: Regulatory mechanisms support existing safety culture

9

• Reporting Systems focus on individual behavior and technology

• No acknowledgement of organizational factors or interdependencies between individuals, groups and technology

• Regulations foster negative safety culture

Labor: Incentives strongly influence behavior

10

• Protection from discipline – contributes to events involving rules violations– One report can protect all team members

reduces number of reports

How do we move to a more positive safety culture?

11

Secrecy Transparency

12

What reporting systems really look like

13

Can C3RS create a more positive safety culture?

Yes, but you have to WANT to change

“If you think safety is expensive, try an accident” – Trevor Kletz

•$10 Billion Implement PTC

• $200 million Litigation- Chatsworth, CA

• $58 million: Clean up Graniteville, SC

14

Imagine if the problems that caused these accidents were discovered and fixed before they occurred

15

For more information:

Jordan MulterVolpe Center617-494-2573jordan.multer@dot.gov

http://www.closecallsrail.orghttp://c3rs.arc.nasa.gov

Thomas RaslearFederal Railroad Administration202-493-6356thomas.raslear@dot.gov