NJ TRANSIT
2013 APTA RAIL SAFETY AWARDS SUBMISSION
NJ TRANSIT (NJTR) Rail is nominating its “Confidential Close-Call Reporting System
(C3RS)” for the 2013 APTA Rail Safety Awards.
Background
Based on the historic relationship of management and labor in the railroad industry, the
US Department of Transportation (USDOT) determined that safety in the railroad
industry can be enhanced by the introduction of a structural process for reporting
“incidents” that do not result in “accidents.” These incidents, known as “close calls” or
“near misses,” are typically not reported by the individual involved. By developing and
implementing a reporting system for these “close call” events, the railroad industry will
have a tool to better identify these events and contributing factors. This “close call”
reporting program can also serve as an early warning system for a railroad to
proactively address these incidents before they result in accidents.
This belief led to Federal Railroad Administration (FRA) development of the C3RS
program which includes voluntary confidential reporting of near miss or unsafe events to
a neutral third party, analysis of reported data by a peer review team (PRT),
implementation of corrective actions, tracking the results of change, and reporting the
results of change to employees.
Currently the FRA is conducting C3RS pilot projects on four railroads: Union Pacific
Railroad (UP), Canadian Pacific Railway (CP), NJ TRANSIT (NJTR) and Amtrak (ATK)
with NJ TRANSIT being the only railroad with the program implemented system wide in
all services (main tracks and yards).
Starting November 17th, 2009 NJ TRANSIT implemented the C3RS program in
agreement with the following labor unions: American Train Dispatchers Association
(ATDA), Brotherhood of Locomotive Engineers and Trainmen (BLET), United
Transportation Union (UTU) and United Transportation Union - Yardmasters (UTU-Y).
The labor signatories of the “Implementing Memorandum of Understanding” felt strongly
that by including a “run-through switch” incident as a “close call” in the agreement would
help focus on the immediate cause of derailments.
APTA EVALUATION CRITERIA
Effectiveness
Since its implementation the C3RS program has received great support from its senior
management, including Kevin O’Connor, Vice President and General Manager. Having
such large support from senior management has helped strengthen the positive safety
culture at NJ TRANSIT. Kevin O’Conner’s belief in the program is that “It’s a benefit to
employees and the railroad (C3RS). [Railroaders] can honestly come forward with
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serious issues, mistakes, whatever you want to call them.” The significant value of the
program is that it allows NJ TRANSIT to identify the incidents that go unreported on the
railroad. The C3RS program allows NJ
TRANSIT to be made of aware of these
“close call” incidents that would otherwise
go unreported until the situation results in
an accident.
The foundation of the program is that
employees are more reluctant to report
incidents due to fear of “getting in trouble”
or perceived management “pushback”.
Therefore, the C3RS program provides the following process to report these incidents.
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Employee reports a “Close Call” to the federal government Bureau of
Transportation Statistics (BTS) by toll-free number as an “initial report”.
BTS contacts employee for details of incident.
BTS “sanitizes” employee information to ensure confidentiality.
BTS provides information to the Peer Review Team (PRT).
PRT meets monthly to review incidents and recommends corrective actions to
the Support Team.
Support Team meets independently to review Recommended Corrective Actions.
Support Team meets quarterly with PRT to proceed or decline Recommended
Corrective Actions.
Based on the sanitized data received by the PRT from the BTS, it was shown that “run
through” switch incidents were the single most frequent type of incident of those
reported through C3RS.
By allowing protection from discipline under the C3RS program, the number of “run
through” switches that the employees were willing to report to management actually
increased, which allowed more timely repairs, along with preventing derailments.
Regardless of statistics, an indicator of the C3RS program is the positive collaboration
and implementation of problem solving actions by the PRT. The PRT is able to provide
different points of view on a safety concern along with a range of possible of solutions.
By providing a range of possible incident causes, such as behavior by operating
employees, supervisors, condition of equipment, workplace procedures and processes,
corrective actions were able to be recommended.
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The PRT team has implemented corrective actions such as:
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On-site training on how to make outbound reverse movements in train yards.
Installing squawk boxes to improve yard communication.
Painting of track switches to enhance visibility.
Lighting improvements.
Replacement of side-door windows (tinted to clear) on multilevel coaches to
improve crew visibility of platforms at night.
Issuing a separate daily speed restrictions bulletin order (attachment 1)
Changing the cab design to allow paperwork to be kept in sight (attachment 2)
Posting speed restriction “reminder” signs at stations that fall within the specified
limits (attachment 3)
Creating a new Safety Job Briefing checklist (attachment 4).
Benefit Level
This chart Safety reflects derailments that occurred 3 10
years prior to the implementation of C3RS and two
years after. However, the number of incidents and 8
monetary totals may not clearly spell out the success
story of this program. NJ TRANSIT is confident that 6
C3RS is creating a safer workplace when operating
employees are willing to report safety hazards. 4
Following the implementation of the program,
derailments as a result of run-through switch have 2
been consistently then pre C3RS. This, along with 0
increased reports of incidents of run though switch
incidents without derailments for the first year of the
program, is indicative of the employee’s commitment
and acceptance of the program.
21% reduction
9.19
since C3RS
7.2
Average
Average
derailments
derailments
per year
per year
due to run-
due to run-
through
through
switch
switch
1/2006 to
11/2009
12/2009 to
12/2011
The addition of the C3RS program as a pro-active non-punitive tool in achieving higher
levels of safety in the railroad workplace is due to the acceptance by all parties involved.
C3RS is an inherently innovative method to encourage employees who were previously
reluctant to come forward and report un-safe conditions because they “didn’t want to
“get in trouble”. C3RS has resulted in an enhanced safety culture at NJ TRANSIT since
the core of the program is putting “safety first” over punitive actions. The large benefit
of the program is that management is now able to identify incidents that previously went
unreported. This reporting of these incidents has provided management a valuable tool
to help understand the root causes of these incidents. With this information the PRT
has been able to implement many initiatives to help reduce the hazards.
The Rail Safety Department also has a “Safety Hot-Line” which provides employees an
opportunity to raise safety concerns through a 1-877-806-8283 toll-free number. C3RS
has now taken this concept and provided a stronger tool by allowing for non-punitive
reporting. With non-punitive reporting, less time is spent by the railroad in disciplinary
actions against an employee and more time is used instead to collaborate on
constructive corrective measures through the PRT.
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The C3RS program has provided a substantial benefit to the safety culture at NJ
TRANSIT, which in turn results in fewer accidents and injuries to both employees and
customers as safety culture expands. There are no limits to the degree of safety that
can be achieved with this type of an improvement in safety culture, with rail employees
and management working together more than ever in the rail industry.
Innovation
In the C3RS program, NJ TRANSIT is the first and only railroad to have implemented
the program system wide. To achieve this system wide implementation unique
obstacles had to be overcome.
The first major obstacle to overcome for the C3RS program to succeed was to achieve
participation with the labor unions whose members would support the program. The
biggest concern from the labor unions was that individual confidentiality must be
maintained. NJ TRANSIT was able to secure an agreement with BLET, UTU, UTU-Y,
and ATDA in regards to participation in C3RS and non-punitive reporting standards.
An example of this ground breaking program was noted by Pat Reilly, recently retired
Chairman of UTU Local 60. Pat Reilly was one of the leaders to negotiate a required
Memorandum of Understanding between the labor unions, NJ TRANSIT, and FRA.
Reilly said “By far, this is the best safety program I’ve seen.” He also said how “close
call” reporting has brought management and labor closer together, especially since
“near misses” through C3RS take an alternate track, even if railroad management later
finds out.
Instead of discipline to the employees, C3RS provides confidentiality and protection
from retribution. Once the incident is reported through C3RS the employee instead is
interviewed by a Close Call Investigator who asks questions about circumstance leading
up to the incident, and the employee’s frame of mind before, during, and after the
accident. This information, once it is “sanitized”, provides a valuable tool in that it
provides more than just the “who, what, where, and when.” With this additional
information the PRT can find the root cause. As a result of the PRT meetings,
corrective changes can be made in areas such as operating employee behavior,
equipment, and conditions of workplace processes and procedures.
The main example of the collaboration between NJ TRANSIT, unions, and the FRA is
the joint Peer Review Team. At NJ TRANSIT the PRT consists of 4 BLET members, 4
UTU members, and 2 members each from ADTA, UTU-Y, FRA, and NJT. The
minimum requirement for the PRT to meet and work on cases requires a minimum of a
process manager (NJTR), a facilitator, a scribe, and one member each from the UTU,
BLET, UTU-Y, ADTA, and FRA. The PRT Lead Team is meets once a month along
with Case Working Team meeting twice a month.
Besides the improvements to safety and operations, a benefit of the C3RS is also the
teamwork and cooperation between labor and management. Not only do both sides
work together on a common goal and take their management or labor hats off to
achieve this, this program has fostered a cooperative relationship between labor and
management.
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The PRT team has been able to develop and recommend corrective actions based on
the information they have received through C3RS. The collaborative effort between the
parties in the PRT has been able to identify and determine the root causes of “close
calls.” This information has resulted in the formation and implementation of corrective
actions such as painting track switches, on-site training on making outbound reverse
movements in train yards, improved lighting, replacement of side-door windows on
multilevel coaches (tinted to clear) to improve crew visibility of platforms at night, and
creating a new Safety Job Briefing checklist.
(Safety Job Briefing Roll-Out)
Transferability
Under the tutelage of the Federal Railroad Administration (FRA) and the Volpe National
Transportation System Center, the C3RS program originally made the transfer from the
airline industry to the railroad industry. The program for the railroad still maintains ties
to the airline industry in that the C3RS data is initially received by the Bureau of
Transportation Statistics in the handing of confidential calls. The program logistics are
adaptable not only throughout the railroad industry, but in any industry.
With the C3RS program incorporated among other agencies, both APTA and FRA have
the availability of a greater data picture of previously unreported incidents that may be
occurring industry wide. According to the FRA, Human Factor Causes attributed to
nearly 38% of Total Train Accidents in 2012. With the primary focus of C3RS being the
reduction of Human Factor Accidents, this program addresses current trends in rail
accident data.
As a result C3RS, NJ TRANSIT has successfully implemented several safety initiatives
as a direct result of the data collected through the program. The use of this program by
other railroads would also help identity the root cause of incidents that may be occurring
on their system. With a goal of creating a positive safety culture on the railroad, the
adoption of a C3RS program can be a great step. With the shift from discipline to nonpunitive reporting, it can emphasize the railroad’s commitment to reducing accidents
and incidents, and ensure a safe workplace.
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Attachment 1
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Attachment 2
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Attachment 3
(xx) NEW SPECIAL INSTRUCTION 296-1 – TEMPORARY SPEED LIMIT
REMINDER SIGN (Effective xx/xx13)
New Special Instruction 296-1 – Temporary Speed Limit Reminder Sign in effect
as follows:
296-1.
TEMPORARY SPEED LIMIT REMINDER SIGN
The Temporary Speed Limit Reminder Sign will be placed approximately 500 feet from
the end of the station platform and will serve as a reminder to the crew that they are
within the limits of a temporary speed restriction.
SR
Orange background
Black lettering
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Attachment 4
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