1. Lessons Learned: Key Considerations and Real World Learnings of a Large Transit Safety Culture Improvement Initiative
May 4, 2015
Gary Webster

2. TTC Context Ridership 540 million annually
Third largest system in North America
Fleet
678 subway cars
28 SRT
248 streetcars
1800 buses
60 year old subway

4. Early 1990s – Leader in North America
TTC Reputation
Early 1990s – Leader in North America
Ridership growth 1970s and 1980s
Subway and system expansion
New streetcar fleet
ICTS technology – SRT
APTA, CUTA Safety Awards

5. Subway train rear-ended a stopped train
August 12, 1995
Subway train rear-ended a stopped train
3 customers killed, numerous injuries
“Failsafe” system failed
block signal system with trip cocks and train stops
“Accident couldn’t happen”
TTC publicly accepted responsibility

6. Maintenance standards/ practices not acceptable Training not adequate
Conclusions
Maintenance standards/ practices not acceptable
Training not adequate
culture of operation too “loose”
Rail maintenance not well managed
Lack of systems approach/ integration
Didn’t know what we didn’t know

7. More to the Story Action Followed – Management Tools
New org structure
Asset management
Safety oversight
Strengthened “public” safety
We recognized “culture of operation too loose”
We missed the poor safety culture – deeply embedded at TTC – public safety plus employee safety

8. Employee Incidents 2006 “Wake up Call”
8 workers overcome by carbon monoxide almost died
Procedures in place, workers trained
Procedures not followed
Why not?
When happen again?
No good answers – unacceptable
TTC
Our workers
Their families
“Wake up Call”

10. Then – We Realized Initial Action Focused on procedures
specific incident never happen again
Then – We Realized
Needed to understand WHY employees behave the way they do
Sought external help – get this right

11. Consultant Partnership
Reduce lost time injuries by 50%
Plan – “Leading with Safety®”
Leadership training and coaching
More employee involvement/ observations
Improve safety systems

12. 2007 – employee killed, 2 seriously injured
Then
2007 – employee killed, 2 seriously injured
procedures not followed
Reinforced need for different approach
Employee feedback – very critical of leadership’s attitude to safety
Very Painful

13. Leadership – training and coaching Worker Engagement
Leading with Safety®
Leadership – training and coaching
Worker Engagement
Worker-led committees
Behavioural Accident Prevention Process® (BAPP®)
Union support – key
Improved Safety Systems

14. Work Safe – Home Safe Program Lost-Time Injury Avoidance

15. Three Year Results
25% not 50% reduction, but pleased
Leading with safety/ safety culture change  journey
Addressing the root problem – safety culture
Actions need to be consistent with good safety culture

16. Lessons Learned Better processes – only part of solution Leadership
actions consistent with words
address problems
Employees
real engagement
identify behaviours, problems
Unions
do not underestimate their role

17. Lessons Learned – Specifics
Improved Safety Culture
More commitment everywhere- employees see we care
Absenteeism
Labour relations, customer service
How to deal with problems, etc.
Needs to be engrained at every level
Address the “frozen middle”
Fine tune/ modify existing safety structures
Incorporate new roles, address problems/behaviours
Employee, union roles

18. Lessons Learned – Specifics cont’d
Leadership – good safety culture must be core value
Corporate strategy – easy
Corporate action – challenging/ ongoing
Transit – difficult environment
Transportation
Maintenance
Finally understood- System Safety Management Plan (SSMP)
1 on 1 challenges
Strong leadership
Employee engagement effective
Most high risk/ catastrophic outcomes

19. So What?
Do you know what you do not know?
Are you really okay?
Are your actions consistent with your words?
Do you have a right safety attitude/ culture?
Is it engrained in “how you do business”?

20. Why Lead with Safety? Why Change Approach to Safety?
Reaction:
No need to act.
Not a problem.
We can manage our issues.
TTC winner of APTA and CUTA Awards for years – thought there was no problem…

21. Why Lead with Safety? Why Change Approach to Safety? Cont’d
We Were Wrong
Procedures and training only are NOT enough
Need to understand behaviour to change it; i.e., why are procedures not followed?
Safety Culture
Value we place on safety
Leadership and employee involvement

22. We missed the signs of our public and employee safety problems
Final Thoughts
We missed the signs of our public and employee safety problems
but, we responded well to the crises
Better to react to symptoms by dealing with root problems before crises result