Transcript Document
Confidential Close Call Reporting System Jeff Moller Association of American Railroads International Railroad Safety Conference October 2008, Goa 1 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 2 One Component of a Safety Management Process • Mandatory reporting of accidents / incidents • Inspection and enforcement activities • Close Call Reporting System 3 Heinrich Pyramid ACCIDENTS INCIDENTS UNREPORTED OCCURRENCES 4 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 5 A New Approach How It Is Now . . . How It Should Be . . . You are highly trained You are human and If you did as trained, you would not make mistakes so You weren’t careful enough so You should be PUNISHED! and Humans make mistakes so Let’s also explore why the system allowed, or failed to accommodate, your mistake and Let’s IMPROVE THE SYSTEM! 6 Potential Barriers Concerns About: • Public Disclosure • Job Sanctions/Enforcement • Criminal Sanctions • Civil Litigation 7 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 8 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 9 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 10 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 11 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 12 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 13 2003 Workshop http://www.fra.dot.gov/downloads/Research/ord0403.pdf 14 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 15 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 16 Carrier Resources Needed • • • • • Training Mentoring Nurture change process Develop / implement communication plan Planning / conducting quarterly Peer Team meetings • Join Steering Committee 17 First Pilot Project 18 Pilot Project • 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 19 Pilot Project – Initial Outcomes • • • • Countermeasures Cultural Changes Dispute Resolution – Needs Work Other Pilot Sites Coming 20