WELCOME
RURAL AND SPECIALIZED TRANSIT CONFERENCE
MARCH 14-15, 2007SYRACUSE, NY
SAFETY CONCEPTS
APPLIED TO ACCIDENT
INVESTIGATION
SPEAKER: JOHN FABIAN, CHIEF INVESTIGATORNYSDOT/PTSB
PTSBINVESTIGATIONS
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
PTSB- INVESTIGATIONS
Russian_Tunnel.wmv
PTSB - INVESTIGATIONS
rear duals tire off.wmv
PTSB - INVESTIGATIONS
Driving in BoliviaStremnaya Road is nicknamed “the road of death” and it’s situated in
Bolivia
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?
Salmon.asf
PTSB- INVESTIGATIONS
CONTROL OF BEHAVIORTOOLS
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