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

Incident or

near miss

Near miss or incident

Imperfect

Defences

DANGER

HAZARDS

‘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, Communication

Not told that car was uncoupled

Behavioural response

Spotted car rolling down hump

Assumption, Decision-making

Assumed car was coupled, did not perform a check

Communication

Not told by transportation 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

BC North

May, 2014

BC South

May, 2014

Alberta June,

2013

Prairies

Sept-Nov.

2013

Ontario

Feb-March

2014

Quebec and

Maritimes Q4 2014

Implementation

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:

Omissions - Mental lapses /

complacency

Communication

Actions taken:

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

27

• 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

People Service Cost

Control

Asset

Utilization

Safety