WELCOME RURAL AND SPECIALIZED TRANSIT CONFERENCE MARCH 14-15, 2007 SYRACUSE, NY
SAFETY CONCEPTS APPLIED TO ACCIDENT INVESTIGATIONSPEAKER: JOHN FABIAN, CHIEF INVESTIGATORNYSDOT/PTSB
PTSB • INVESTIGATIONS • SYSTEM SAFETY • TRAINING
PASSENGER CARRIER SAFETY BUREAU • INCLUDES THE BUS SAFETY SECTION • RESPONSIBLE FOR BUS INSPECTIONS • INSPECTS COACHES, TRANSIT, VANS, CARS • CONDUCTS 140,000 INSPECTIONS A YEAR • SETS THE BAR AT 80% PASS RATE
PTSB – SYSTEM SAFETY PLANS • REQUIRED OF EVERY SYSTEM (STOA) • APPROVED FOR 2 YEAR TERM • RECERTIFIED AND AUDITED BY STAFF • S/M/L GUIDELINES ON INTERNET • WWW.DOT.STATE.NY.US
PTSB – SYSTEM SAFETY PLANS • SENATOR LEVY BUS SAFETY AWARD COMPETITION – Performance Measures • Operations Performance • Bus Collisions; injuries, fatalities • Customer Accidents; injuries • Service Performance • Daily % pullout performance • MDBF • Fires • Completed daily trips
PTSB - TRAINING • BAITFISH- ALL SYSTEMS MUST BE CERTIFIED IN THREE CLASSES • Class 1: ACCIDENT INVESTIGATION • Class 2: DETERMINATION OF PREVENTABILITY • Class 3: HAZARD ASSESSMENT AND MITIGATION
PTSB - TRAINING • BAITFISH- • CERTIFICATION IS GOOD FOR FOUR YEARS • RE-CERTIFICATION STARTS THIS YEAR • LATE SUMMER/EARLY FALL • TEST FOR BASIC KNOWLEDGE • ADVANCING TECHNIQUES
PTSB- INVESTIGATIONS 2005 ANNUAL REPORT • ACCIDENT TRENDS • REPRESENTS 130 SYSTEMS- (NYC) • FIRES : ELECTRICAL, PMI’S, HUMANS • PEDESTRIAN FATALITIES: • LEFT SIDE • RETRAINING • NATIONAL ISSUE • HUMANS
PTSB- INVESTIGATIONS • RESPONSIBLE HUMAN BEHAVIOR • UTOPIA (not a country in Africa) • DOES IT EXIST AT YOUR WORKPLACE? • CAN IT BE MANAGED AND EVALUATED?
PTSB- INVESTIGATIONS • MANAGEMENT OF BEHAVIOR • LEADERSHIP • STANDARDS • TRAINING • SUPPORT
PTSB- INVESTIGATIONS • MANAGEMENT OF BEHAVIOR • INDIVIDUAL EMPLOYEE • CARELESS • ATTITUDE • HASTE • FATIGUE • CHEMICAL IMBALANCE • ILLNESS • SKILL AND ABILITY
PTSB- INVESTIGATIONS DOES THE END…. JUSTIFY THE MEANS?
PTSB- INVESTIGATIONS • CONTROL OF BEHAVIOR TOOLS TRAINING VS. ENFORCEMENT • ON BOARD CAMERAS- VERIFIES INCORRECT BEHAVIOR • SIMULATORS- TEACHES CORRECT BEHAVIOR
PTSB- INVESTIGATIONS • SIMULATORS • TEACHES CORRECT BEHAVIOR • The process is to learn the concepts of perception and then immediately apply those concepts in a controlled environment. • This process sets the stage for committing knowledge learned to memory and is the beginning of “habit formation”.
PTSB- INVESTIGATIONS • HABIT FORMATION vs. NATURAL REACTION • habit formation - learning a specific behavior requiring practice or rehearsal of the response. How much repetition or how many trials are necessary for learning to occur differs by event. It probably differs between cognitive problem solving and simple physiological or muscular reactions. • natural reaction – action without thought
PTSB- INVESTIGATIONS • HABIT FORMATION vs. NATURAL REACTION • Probies • Training, training, training • Evaluate • Enforce • Employees • Evaluate • Retrain • Enforce
PTSB- INVESTIGATIONS • HABIT FORMATION vs. NATURAL REACTION • Motor Coach Accident – NY I87, August ’06 • Bus traveling 78mph, rounding right curve, lane 2 • Front tire blowout • Bus operator immediately applied heavy braking • Bus veered to left, over guiderails, into median • Bus rolls, striking rock outcroppings, 5 fatals • NYSP ruled out driver error stating heavy braking was “natural reaction”.
PTSB- INVESTIGATIONS • HABIT FORMATION vs. NATURAL REACTION • QUESTION 1: • Motor Coach, on a charter with 53 passengers • Traveling at 65 mph, two lane highway, the shoulder is nine feet wide • Deer enters the lane directly in front of the bus and stops, two seconds to impact • Which way do you swerve? What else?
PTSB- INVESTIGATIONS • HABIT FORMATION vs. NATURAL REACTION • QUESTION 2: • Motor Coach, on a charter with 53 passengers • Traveling at 65 mph, two lane highway, the shoulder is nine feet wide • A child on a bike enters the lane directly in front of the bus and stops, two seconds to impact • Which way do you swerve? What else?
PTSB- INVESTIGATIONS • IN CLOSING, WE NEED TO HAVE AN UNDERSTANDING: • If you are responsible for any of the categories we discussed, please be sure to use the “multiple causation theory” to analyze what happened during an incident. • If you are a manager of a system, please be aware that YOU are ultimately responsible for the safety of your employees and actions surrounding accidents they are involved in.
PTSB- INVESTIGATIONS • DEAL OR • NO DEAL