# Presentation: 157442

## Non-Medical Examples(Modulette G4)

**Ed Dunn**
**VA National Center for Patient Safety**
- _[www.](http://www.patientsafety.gov/)__[patientsafety](http://www.patientsafety.gov/)__[.](http://www.patientsafety.gov/)__[gov](http://www.patientsafety.gov/)_

## NYC Subway Accidents 1996

- NYC Subway accidents in 1996 evoked media attention in early 1997
- 55 accidents in 1996 – passengers falling out of car
- Doors fly open before train in station (43)
- Doors open on wrong side of car (12)
- No previous records of accidents kept by TA
- Union: “shortcuts in training & mand. overtime” for conductors
- TA: no explanation
- TA conductors: “pointing fingers at each other”

**Notes:**
NYC Subway accidents in 1996 (NY Times 11/30/03, Joseph Fried) – an alarming rash of accidents noted in early1997: conductors opening doors on the wrong side or with part of the train in the tunnel (not yet in the station) and people falling out. 55 accidents in 1996, which seemed like an increase over previous years although records had not been kept. Union officials spoke of training shortcuts and conductor fatigue from mandatory overtime. Transit officials took action: new rule for conductors to point up at the black-and-white striped panels which hang at mid-station above platform edges. (when the conductors cab is under the panel, the train is completely in the station). New trains had switches that the driver must flick before the conductor can open the doors.

Annual incidence of accidents decreased: 1) pre-mature door opening dropped from 43 in 1996 to 10-17/yr (only 5 in 2003); 2) wrong-side door openings dropped from 12 in 1996 to avg. of 4-10/yr (2 in 2003). Explanations for improvement: Union – better training and conductor diligence. Random check in 11/03 among conductors – finger pointing blame to each other. 

Doors opening on moving trains are not attributable to conductors. In 2000, a 3-year-old boy died in Brooklyn when the door at the end of the car slid open and  he fell out. No mechanical explanation was found. Reports of a sliding door opening on a moving train ranged from 30 to 60 per year since 1996 – no injuries reported from these incidents. Transit official said “to put it in perspective, we have 7,950 daily train trips.” The implication here is that an incidence of 1/200 to 1/130 is not too bad, especially since there were no injuries – i.e. “no blood, no foul.”

Teaching points 
How many accidents must occur before this becomes a problem for the NYC Transit Authority? Since no records of accidents had been kept prior to 1996, the company did not appear to have this on their radar screen until media attention in 1996 forced the issue. If the quoted transit official reflects the attitude of the transit company, do they think this is a problem? No blood, no foul philosophy – a product of a safe culture? 
Answer: only one accident or a close call would be enough to shine a light on a problem requiring investigation. To continue otherwise is to deny a serious systems issue and lose an opportunity to develop countermeasures to prevent future harm to passengers or staff.

What was the cause of this rash of accidents? The Union attributed blame to training shortcuts and conductor fatigue from working mandatory overtime. What about the transit authority? Is the NYC Transit Authority a non-punitive culture? One clue is that conductors were pointing fingers of blame at each other. Do the conductors trust their employer to improve the safety of their trains?

Quality of Countermeasures - Why was the number of accidents decreased after 1996? Increased conductor diligence & training? (trying harder - weak) Or, the new rule for conductors to look at the black-and-white panels in mid-station (cognitive aid – intermediate)? Or, the new trains manufactured w/ switches that the driver must flick before the conductor can open the doors (interlock work re-design – strong)? Answer – probably the latter two. 

## NYC Subway - Countermeasures

- _Union_: improve conductor training & diligence
- _NYC TA_: 1) new rule – conductors to look for black-and-white panels hanging @ mid-station; 2) new trains will have switches that the driver must flick before conductor can open the doors
- Results: pre-mature door openings dropped to 10-17/year (from 43 in 1996); wrong-side openings dropped to 4-10/year (from 12 in 1996)

- From an article by Joseph P. Fried -  New York Times, November 30, 2003

**Notes:**
Doors opening on moving trains are not attributable to conductors. In 2000, a 3-year-old boy died in Brooklyn when the door slid open at the end of the car and he fell out. No mechanical explanation was found. Reports of a side door opening on a moving train ranged from 35-60 annually since 1996. In many instances, doors opened a few inches. Mechanical defects could not be found. and no injuries have been reported on these cases. So, is the NYC TA a safe culture?

## Staten Island FerrySeven Ferries that make daily runs between the St. George Terminal on Staten Island and Whitehall Street in Manhattan

**Notes:**
A story of accidents over the past 50 + years and what has been done about them

## Staten Island Ferry Accidents 1970-1995

- Crash of *Andrew J. Barberi *in October 2003 – killing 10 passengers - prompted a review of 1500 Coast Guard records since 1970
- “Dozens of Accidents w/ hundreds injured”
- Investigators often attributed accidents to crew members:
- Inattentiveness
- Poor judgment
- Negligence
- Review of inspections / disciplinary hearings from 1950s
- “Ferry managers for years ignored safety recommendations that could have prevented injuries”

**Notes:**
Are we to conclude all of these accidents are due to crew member negligence and/or ferry manager refusal to implement safety recommendations? What is the responsibility of the Transportation Authority here?

## Chronicle of High Profile Accidents

- 1995 – ferry crashed into dock injuring 16
- Investigators: “lax safety rules... it could have been much worse”
- 1978 – rush hour crash into seawall injuring 200
- Investigators: “good fortune that no one was killed”
- 1963 – collision sinking ferry Verrazano
- Judge:“captain failed to exhibit unremitting vigilance”

**Notes:**
Investigators attribute causes in high profile cases to:
	1) failure to follow rules
	2) lack of captain vigilance

They breathe a sigh of relief that it wasn’t worse. Does this sound like “no blood, no foul” philosophy?

How many accidents does it take or how many injuries or how many lives lost are necessary before this is a problem?

## New York Times Investigation   via Freedom of Information Act:“Human error is the prime suspect in the October 15, 2003 Barberi accident.” 

**Notes:**
Is human error really the prime suspect or does the NYT investigation stop short of what they could really learn from this accident?

Dekker would say that human error is the start of an investigation and not the conclusion. Human error is symptomatic of a deeper problem – the “new view” of human error in the role of accidents.

## US Merchant Marine Academy Review of Coast Guard Records

- 50 accidents since 1978: ferry crashes, slips & falls, fingers slammed in gates, etc.
- Causes attributed to accidents;
- Inexperienced captains – allowed to practice mooring skills by docking fully loaded ferry
- Poor judgment of captain – eg.navigating in fog
- Failure to enforce rule keeping passengers seated and away from bow during landings
- Deficient voice announcements in clarity, volume, content
- Poor signage on ferries
- Poor equipment on ferries to keep people away from dangerous areas during landings

**Notes:**
These attributable causes violate the 5 Rules of Causation of Marx:
 Causal statement must link a direct relationship between cause and effect
 Negative descriptions should not be used in causal statements. (What is important is not that someone failed to do something, but why did he/she fail?) 
 Human error must have a preceding cause. (Why did human error occur?) 
 Violations of procedure must have a preceding cause. (Why was the procedure not followed?)
 Failure to act is only causal when there is a pre-existing duty to act.

Marx, David. “Maintenance Error Causation.” A technical report prepared for the Federal Aviation Administration; June 9, 1999.

## Coast Guard Solutions

- Automated announcements to keep passengers informed
- Add signs for safety precautions
- After Barberi accident, investigators concluded that ferry operators had not implemented the Coast Guard’s recommendations

**Notes:**
What about the Coast Guard recommendations? Were they strong, intermediate, or weak?

Beware of automation as a solution for a systems’ vulnerability. It often adds another layer of complexity without solving the problem it was intended to solve. In effect, automation can create new problems.

Warning signs to “Be more careful” – weak solution

## NYC Transportation Authority adoption of CG recommendations

- Deckhands will use _**rope barriers**_ to keep passengers away from bow during landings
- Three people in wheelhouse until ferry docks
- Lookouts on each ferry
- 1958 ferry Dongan Hills collided w/ a tanker. It was found that 2 “lookouts” had abandoned their posts.

- "History of Human Error Found in Ferry Accidents" by Mike McIntire, New York Times - November 1, 2003

**Notes:**
What about these solutions from the NYC TA?
From a human factors perspective:
	1) Rope Barriers = physical work redesign: strong action step
	2) Upgrading (or redistribution) workforce staffing: intermediate action step...  not bad!
	3) Lookouts on each ferry: a form of hypervigilance, which is a weak action step. But, it could be viewed as part of the new 	staffing model if these will be new employees rather than the same employees with a different work distribution.

On the Dongan Hills case, the question is why did the “lookouts” abandon their posts? Were they reassigned to other duties? Were their look out sites clearly defined? Can lookouts prevent accidents in the 1st place? These questions imply that “lookouts” as an action step depends upon humans being more vigilant – not a very strong action that would predictably reduce the probability for recurring ferry accidents.

Did firing the two “lookouts” in 1958 reduce the potential for ferry accidents recurring in subsequent years?

The New York Times said that “ferry managers and their employees had not been attuned to the role of human error in accidents.” Is that the problem or is there a deeper problem? Given the track record of the Staten Island Ferry with accidents, isn’t the incentive for managers and crew members to tune out accidents? To pretend they don’t happen and avoid personal blame? As long as the Transportation Authority attributes individual blame, gives lip service to weak action steps but doesn’t enforce their implementation, what message are they sending to their employees?