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Report on Voluntary Reporting-5-30-03 Voluntary Reporting of Safety Information: The Feasibility of Developing Such Programs in the US Railroad Industry and A Proposed Pilot Demonstration Project Patrick Sherry, Ph.D. Karen E. Philbrick, Ph.D. Intermodal Transportation Institute University of Denver Funding for this project was provided by a grant from the Federal Railroad Administration Office of Safety. Voluntary Reporting Programs Executive Summary......................................................................................................................................................3 Background................................................................................................................................................................. 4 Methodology............................................................................................................................................................... 7 Question #1 -- the Aviation Industry........................................................................................................................7 ASRS/NASA Program......................................................................................................................................... 7 Confidentiality ................................................................................................................................................. 8 Immunity........................................................................................................................................................... 9 Reporting Procedures.................................................................................................................................... 10 Analysis of Reports....................................................................................................................................... 12 Table 1. ASRS Database Report Sets ................................................................................................... 12 Aviation Safety Action Program (ASAP)....................................................................................................... 13 Corrective Action .......................................................................................................................................... 15 Event Review Committee (ERC)................................................................................................................ 16 Consensus in the ERC .................................................................................................................................. 17 Industry and Labor Satisfaction with ASAP............................................................................................. 17 ASAP Programs Accepted by the FAA.......................................................................................................... 19 Voluntary Reporting in Non-US Airlines....................................................................................................... 20 Lufthansa Airlines ......................................................................................................................................... 20 British Airways.............................................................................................................................................. 21 Summary .............................................................................................................................................................. 23 Question #2 – Voluntary Reporting in the Railroad Industry........................................................................24 UK Railways .................................................................................................................................................. 24 Making a Report to CIRAS.................................................................................................................... 25 The Core Facility...................................................................................................................................... 26 The Regions .............................................................................................................................................. 26 Confidentiality .......................................................................................................................................... 27 Independent Ownership .......................................................................................................................... 27 Summary of Recent Findings................................................................................................................. 27 Question #3 - Current Developments and Next Steps ......................................................................................30 Discussions with US Railroad Personnel............................................................................................. 30 Management ........................................................................................................................................ 30 Labor Organizations........................................................................................................................... 31 Pilot Web Based Reporting Project....................................................................................................... 32 Conclusions and Reccomendations.........................................................................................................................34 Proposed Pilot Project........................................................................................................................................ 34 References......................................................................................................................................................................36 Appendix A . Sample ASAP Memorandum of Understanding ......................................................................37 Appendix C. Perceptions of a Confidential Voluntary Reporting Program...............................................48 Overview................................................................................................................................................................... 48 Descriptive Statistics ............................................................................................................................................... 48 Discussion................................................................................................................................................................. 50 Sherry & Philbrick – May ’03 Page 2 Voluntary Reporting Programs Executive Summary An investigation of the current status of voluntary incident reporting programs in the US, the United Kindgdom, and Germany was conducted. In addition, disucussions with key railroad labor and management leaders were held to consider the possiblity of developing voluntary reporting programs in the US rail industry. Finally, a sample web-based reporting form and web site was constructed for use in pilot projects. Results of the study suggest that these programs are widely accepted in other industries and countries. In addition, their utility is demonstrated by the fact that there has been a steady increase in voluntary reporting, especially in the aviation industry. Most noteworthy, however, is the additional fact that in the aviation industry, all voluntary reports are followed by corrective actions designed to remedy or prevent potential unsafe situations or practices. While there is interest in undertaking a pilot program among railroad labor, railroad management remains cautious. A demonstration of the utility of the project in the railroad industry is needed. Sherry & Philbrick – May ’03 Page 3 Voluntary Reporting Programs Background The importance of information that can be used to determine the factors that influence the occurrence of accidents and incidents can not be understated. Safety managers, operations managers, and workers themselves need to have accurate information in order to be able to address the types of decisions that can be made to improve safety. Historically, the kind of information that has been available to persons in the safety industry has consisted of numbers of accidents, the location of their occurrence, and whether those accidents are the result of an object striking the individual or the various body parts that have been injured. Such information has been useful in developing a number of various intervention programs that have led to awareness and reduction of incidents. The NTSHA recall of Firestone tires used on Ford Explorers is a perfect example of the use of this type of statistical information. Additionally, another form of information can be obtained from accident reports. These are reports compiled by experts who have interviewed accident participants, and various other experts associated with a particular incident. The results of these types of investigative reports have led to recommendations that have been used to address safety concerns. As can be seen, the key ingredient to being able to improve safety in the industry is information as to the factors, or the root causes, of accidents. It is this type of information that is very useful in developing interventions, changing operational procedures, identifying unsafe or hazardous circumstances and improving training of individuals involved in safe work activities. Figure
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