Strategies to encourage Near Miss Reporting Lessons Learned from the CN PREVENT Hotline Brian Kalin Director Safety and Regulatory CN Nelson Beveridge Teamsters Canada Rail Conference-CTY CN
Outline Background o Policy Committee Initiative to drive safety performance Overview of Prevent How it operates Confidentiality Update on implementation and actions taken Lessons learned to date
Background Centre of excellence within Saint Mary s University Founded in 2002 with $500,000 endowment from CN The Centre aims to promote health and safety of Canadians by: Coordinating and conducting occupational health and safety research; Building capacity for occupational health and safety research Providing mechanisms for the training of occupational health psychologists, human resource managers and other practitioners/managers; Consultation with industry and labour to provide research based guidelines for practice and intervention,
CN Policy Committee As part of the 2012 Annual HPP/SMS Conference held by CN s Policy Health and Safety Committee, an action item was developed to understand how we can influence safety performance by understanding and eliminating Near Miss Events
Near miss or incident Imperfect Defences DANGER HAZARDS Incident or near miss These are Free lessons Reason 1997
What is PREVENT? Professional Railroaders EVENT Confidential Reporting Hotline. Intended to capture near miss events and significant safety events with researchers at Saint Mary s University that will help improve safety at CN. A confidential reporting mechanism run by Saint Mary s University for all CN employees.
Why PREVENT? There is an opportunity to learn from events that are currently not reported. Provides a mechanism for employees to report situations they are aware of that may have an impact on rail safety. To better understand the nature and prevalence of near misses and safety events that we may otherwise not have known about. One of the most effective ways to avoid future accidents and/or injuries is to understand the dynamics that resulted in a safety event occurring, or how under different conditions a near miss could have resulted in an incident.
Benefits of Reporting Increased learning from near misses to prevent more serious incidents. Better understand the nature and prevalence of near misses and safety events that we may otherwise not have known about Increased focus on safety issues and communication about unsafe situations in the workplace. Reduction in the number of incidents, accidents, and injuries occurring in the workplace. Improved trust and openness to discuss safety issues among employees, management and labour unions.
Prevent process
What to report? Incidents that would not otherwise be detected or made known Near Misses: - Incident where there was no actual accident or injury, but given a slight shift in time or distance, injury or damage easily could have occurred, but did not on this occasion. Safety Events: - Events that violate a policy, procedure or rule that may or may not result in an incident occurring, which may only be known by the employee(s) involved. Differentiated from housekeeping issues. PREVENT is not intended to capture accidents or immediate safety concerns. If there is a immediate hazard or hazardous condition that needs to be managed in order to prevent harm, employees must directly contact their supervisors.
Examples Blue Flagging - I was inspecting a train but did not set blue flag protection. A locomotive was coupled on the west end of the train and began to pull. I jumped out of the way. Detraining - I was getting off a rail car too fast, as I touched the ground I tripped and fell towards the car almost getting run over.
Reporting Logistics Confidential Hotline - Employees will contact a 1-800 number and be asked to leave a name, contact info, and suitable call back time. PREVENT Website - Fillable forms are available on the website to collect call back information. - Call Back Interview - Employee describes the near miss/safety event including a timeline as well as contributing circumstances.
Confidentiality No identifiable information is collected with the call back interview Database and hardcopy information housed at Saint Mary s Aggregate quarterly/monthly reports will be shared with CN to identify trends No information that could be used to identify an individual will be shared NOT anonymous NO immunity from discipline if the incident is discovered or reported through another channel Confidential except in instances where threats are made that could lead to harm All information is subject to discoverability
Reporting Examples Issue Action Error AE Description Error Recovery ER Description Situation Awareness SA Description Threat Threat Description Did not see train Omission Spotters were not looking, did not have protection Behavioural response Crew member spotted train coming down tracks Attention Close to completion of task, Others distracting Job factors, Teamwork Dull task, spare people, low probability Car rolled Omission, Not told that Behavioural Communicat car was response ion uncoupled Spotted car rolling down hump Assumption, Decisionmaking Assumed car was coupled, did not perform a check Communicat ion Not told by transportatio n that car was uncoupled
Reporting Examples
Saint Mary s role and responsibilities Arm s length, third party organization to ensure confidentiality Run hotline and populate database Provide quarterly/monthly reports to CN to identify trends and opportunities for improvement Use of data in secondary data analysis to identify causes of near misses and safety events and role of safety culture
CN s Role Coordinate rollout in each area Identify target stakeholders and ensure onboarding Advertisement of hotline and website through appropriate channels Provide technical support to team members to ensure proper coding of data Develop / implement initiatives based on findings Provide updates to Divisions where Prevent is implemented
Prevent Implementation Prevent implementation progressing since mid 2013 Implementation Involves: St-Mary s System Safety and Policy HSC Division management and local safety committees BC to Ontario completed Quebec and Atlantic planned for implementation this fall
Implementation BC North May, 2014 Alberta June, 2013 Quebec and Maritimes Q4 2014 BC South May, 2014 Prairies Sept-Nov. 2013 Ontario Feb-March 2014
Communication
PREVENT Website
Prevent Actions Providing feedback to Policy Committee, H&S Committees and Divisions is essential Newsletter rolled-out: Provides background and process overview Roles and responsibilities Emphasizes confidentiality and value Provides examples of lessons learned and changes made
Prevent Actions Analysis of Calls: Mostly clustered around: Actions taken: Omissions - Mental lapses / complacency Communication Structured peer-peer communications added to Rule book Peer engagement programs driven by each Division / Function
Communication - Newsletter
Communication - Newsletter
Lessons learned to date Union and management support is critical Important to adopt a systematic approach to the roll out Employee Trust is key to support and use of the reporting system A small number of reports can provide valuable information Largest challenge is to encourage employee use of the system. Open Communication is key to success
Summary Service Cost Control Asset Utilization Safety People Nothing is more important to CN than operating safely Safety culture and SMS will always be a work in progress CN is committed to working with its employees to enhance workplace safety 27