Remember The Four Tops? I do. I remember the Tops and the Temptations and the Miracles and Martha and the VDs, and The Monitors ("Say You") and The Fantastic Four ("The Whole World is a Stage") and Edwin Starr ("Agent Double O Soul") because.., like Edwin, I dig/dug rock and roll music, and I could (and can) do the twine and the jerk, although I won't. Doing so would turn my daughters to stone, although I think the grandchildren would dig it.
Anyway, the Tops released "It's the Same Old Song" back in 1965 after releasing "I Can't Help Myself," and nobody could help thinking that "It's the Same Old Song" was the same old song as "I Can't Help Myself." Didn't stop me then from buying the 45-- it had a good beat and you could dance to it--and it doesn't stop me now from humming it when the occasion so warrants.
The latest occasion? A friend sent me an article, "How Transit Managers Can Stop the Blame Game to Create a Culture of Safety," from a digital transit magazine, Metro. The article is written by Mike Anderson, VP of Safety & Security for RATP Dev USA.
Now RATP is the French agency that runs the Paris Metro, and I have spent many wonderful days in Paris, eating, drinking, walking, riding the Metro, visiting the Musee Picasso, or staring wide-eyed and open-mouthed at Monet's Water Lilies (greatest paintings ever)at the Marmottan and L' Orangerie, all the while, of course, humming Motown pick hits to myself-- the point being I have nothing but respect and affection for RATP, Paris...but......
But this ain't Paris. Mike has a bone to pick, and it's an old bone. Mike says, regarding metropolitan transit agencies:
When a bus is in an accident or experiences a mechanical issue that causes service delays, the incident typically prompts an investigation to determine the root cause, assign blame, and hand down a punishment. This may satisfy the needs of management and the public for action, but it does little to prevent that incident from happening again. It only serves to demoralize the entire workforce, which in turn stunts any progress to improving safety levels. Transit system management can break out of that blame cycle by building a culture into the safety management system (SMS) that encourages employees to assume a more proactive role in hazard identification and reporting.
I don't know how things are done in transit bus systems but I know I've heard that song somewhere before, with almost the exact same lyrics. I know the same things have been said and sung about railroads. So let's get to it:
1. yes, the investigation is held to determine a root cause by examining the circumstances that led to the incident.
2. no, the investigation is not held to assign blame. The investigation is held to determine responsibility. There is a world of difference between determining responsibility and assigning blame. The two are not necessarily nor even distantly related. The railroad, transit, bus operation cannot function without a system of responsibility. No remedial action of any sort can be taken without making a determination of responsibility.
3. no, the investigation is not held to hand down punishment. The investigation is held to determine if supplementary enforcement of the rules is required due to a failure of an employee or employees to properly conduct transportation, the carrier's business after all, in accordance with the explicit operating procedures of the carrier. There is a world of difference between enforcement and punishment. Enforcement is designed and is essential to consistency, fairness, and equitable treatment of all employees. It is required to reduce incidents, and incidents of arbitrary treatment of employees.
Mike says:
More often than not, an incident is the result of multiple factors that are beyond the control of the employee at the wheel or holding a wrench. The weather, faulty organizational processes such as poor communications channels among employees or departments, local working conditions, or undiagnosed equipment failures can all play roles.
Of course, and again I don't know what happens in the bus transit world but never in my railroad career did an investigation ignore the weather, faulty organizational processes, faulty management procedures, local working conditions, or equipment problems in determining the root cause, the responsibility and the need for enforcement. Never.
OK, never say never. Is the investigation process subject to error and even abuse, leading to the disregarding of the weather, faulty procedures, working conditions or equipment problems? Yes. Like all human practices, this one is subject to human error. But the investigation process is not organized as an abusive system, as a system dependent upon error, failure, arbitrariness, or ignorance of all the contributing factors that go into the review of circumstances and the determination of responsibility.
Contributing factors are just that, contributing factors. They are not causes. They may converge and coalesce in an environment, a moment, a condition, that makes its impossible for an employee to properly discharge his or her responsibility in dealing with a circumstance, but that determination is part of the investigatory process.
Moreover, less than optimal circumstances do not and cannot relieve an employee of responsibility. Example: Back in the day when I was just an assistant superintendent, we had a series of stop signal violations on the lower level of Grand Central Terminal at the same signal. Now operations south of 59th street were governed by restricted speed requirements, not to exceed 10 mph. Grand Central was designated cab signal territory, and the most favorable cab signal indication possible was a "restricted cab."
For every violation we conducted a formal investigation. We measured sight-distance from the previous signal to our incident signal, and in every instance, the locomotive engineer had sufficient time and distance from the location where the "stop" was first observable to the signal location itself to stop the train with a service brake application.
Nevertheless, our measurements also indicated that we had not properly calculated the equated distance, the distance we should have allowed for the sight-distance based on the grade (downhill) of the track. So we moved the signal, and we decided also to install a pedestal to raise the signal and provide a longer preview.
End of the repeated stop signal violations at this location.
What we did not do was absolve any locomotive engineer involved in the violations prior to the relocation. Why? Because the governing rule, the governing signal indication, the governing operating procedure stated the locomotive engineer could only proceed prepared to stop within one-half the range of vision. The responsibility was the locomotive engineer's.
Mike wants to foster a "culture of safety" based on "trust" that "that encourages and rewards employees for providing safety-essential information, even if it is self-incriminating, without fear of reprisal."
I've heard that one before, too. Let me point out the original experience, and principles, behnd that "self-incrimination" without reprisal on the railroad, and that goes back to the "Red Block" type programs that accompanied the introduction mandatory drug and alcohol testing. Under these programs an employee could report himself or another employee for substance abuse, without reprisal, in confidence, and receive assistance provided the referral occurred without any coincident operating rule violation that exposed the substance abuse. IF a rule violation did occur and if, in the investigation of the violation it was determined that the employee was in violation of drug and alcohol prohibition, the employee could not claim, and would not be afforded a "by-pass."
Now I'm all for that type of "close-call confidential" pre-incident referral. I can't see how providing immunity after an incident advances a safety culture, anymore than automatically providing a "Rule G bypass" after an incident works to prevent others from committing the violation.
Oh yeah, and just so nobody thinks I'm completely heartless, in a couple of instances I did approve a "bypass" for an employee or two who did test positive after a rule violation. What can I say? Sue me. I'm human.
Meanwhile, it's time to work on my electric boogie. Remember, no twerking!
David Schanoes
May 16, 2018
"All the squares, fall out!"
Sly, "Dance to the Music"
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