Safety Event Investigation – 673.27(B)(3)

PBT currently conducts investigations of safety events. From an SA perspective, the objective of the investigation is to identify causal factors of the event and to identify actionable strategies that PBT can employ to address any identifiable organizational, technical, or environmental hazard at the root cause of the safety event.

PBT uses the Accident/Incident Procedure (Appendix ) document to identify safety and operational risks based on individual assets.

Safety Event Investigations that seek to identify and document the root cause of an accident or other safety event are a critical component of the SA process because they are a primary resource for the collection, measurement, analysis, and assessment of information. PBT gathers a variety of information for identifying and documenting root causes of accidents and incidents, including but not limited to:

1. Obtain from the Operator the following information:
   1. The location of the incident and what direction they were traveling (inbound or outbound); if in the station, indicate the situation.
   2. The bus number and the route that they are on.
   3. If there are injuries, describe how serious they appear (don't be too graphic, just generalize).
   4. Provide information about any other vehicles or pedestrians involved and their descriptions.
2. Remind the operator of the safety procedures:
   1. Turn on 4-way flashers. Place traffic warning devices (orange triangles).
   2. Recheck anyone with injuries; do not move the seriously injured.
   3. Render comfort and aid to anyone injured, as may be appropriate.
   4. Evacuate the bus, if necessary.
   5. Keep the two-way radio on and monitored.
   6. Hand out courtesy cards to the passengers and to any witnesses.
   7. Move the vehicle to the side of the road unless it is inoperable.
3. Notify the following:
   1. Call the Police. Call Emergency Medical Personnel (EMP) 911
   2. Notify/call the immediate supervisor on duty at the time or dispatch.
4. The supervisor will:
   1. Determine whether the CSO, General Manager, or Assistant General Manager needs to be contacted, but will give them a report when the supervisor finishes the initial assessment.
   2. Let the Operator know that Police and supervision have been contacted, and help is on the way.
   3. Assign a Standby Operator to pre-trip a bus in case a standby must drive the next round for the operator on that route. When needed, the Standby Operator may take a bus out to continue a route.
   4. Let the Operator know that a Standby Operator and bus have been assigned to continue the route or that support personnel are bringing another bus out to them.
   5. Refer the operator for required drug and alcohol testing in compliance with 49 CFR § 655.44 post-accident testing, if the safety event meets the definition of accident in 49 CFR § 655.4.
   6. Record all accident information on the Daily Dispatch log, any missed trips, downtime, or bus change-outs.
5. The dispatcher on duty will give the Operator an incident report to complete before the Operator leaves that day. The dispatcher will put the Operator's report in the CSO's box.
6. The CSO, working with subject matter experts, evaluates the incident report and other available information to determine the root cause of the accident/event. Follow-up with the driver or other cognizant parties may be necessary to elicit additional information.
7. The CSO identifies any hazards noted in the incident report and refers those hazards to the SRM process.

Monitoring Internal Safety Reporting Programs - 673.27(b)(4)

As a primary part of the internal safety reporting program, our agency monitors information reported through the ESRP. When a report originating through the complaint process documents a safety hazard, the supervisor submits the hazards identified through the internal reporting process, including previous mitigation in place at the time of the safety event. The supervisor submits the hazard report to the SRM process to be analyzed, evaluated, and, if appropriate, assigned for mitigation/resolution.

Other Safety Assurance Initiatives

Because leading indicators can be more useful for safety performance monitoring and measurement than lagging indicators, PBT is undertaking efforts to implement processes to identify and monitor more leading indicators or conditions that have the potential to become or contribute to negative safety outcomes. This may include trend analysis of environmental conditions through monitoring National Weather Service data; monitoring trends toward or away from meeting the identified SPTs; or other indicators as appropriate.

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