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Proceedings of the Human Factors Workshop: Improving Railroad Safety Through 

Understanding Close Calls 

6. AUTHOR(S) 

Jane Saks,* Jordan Multer, Katherine Blythe* 

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7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 

U.S. Department of Transportation 

Research and Special Programs Administration 

John A. Volpe National Transportation Systems Center 

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This document is available to the public through the National Technical Information Service, 

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13. ABSTRACT (Maximum 200 words) 

On April 23 and 24, 2003, the Federal Railroad Administration’s Office of Research and Development held a Human Factors 

Workshop: “Improving Railroad Safety Through Understanding Close Calls in Baltimore, Maryland.” The purpose of the 

workshop was to educate the railroad industry on the benefits of understanding close call events and the challenges to the 

implementation and success of a close call reporting system. The workshop provided a forum for participants to discuss issues of 

concern to the railroad industry. 

A close call was defined as “an opportunity to improve safety practices in a situation or incident that has a potential for more 

serious consequences.” 

These proceedings document the lessons learned from studying close call best practices in the railroad and airline industries. 

Included are summaries of the workshop presentations on lessons learned from existing close call systems in the airline and 

railroad industries. The proceedings also include feedback from workshop participants on lessons learned from their own "close

call" experiences, benefits and barriers to implementing a close call management system, and Planning Committee 

recommendations for next steps in implementing a close call system for the railroad industry. Appendices contain supporting 

documentation.

15. NUMBER OF PAGES 

156 

14. SUBJECT TERMS 

Aviation Safety Action Program (ASAP), BNSF Incident Reporting System, Close Call, Close 

Call Reporting System, Confidential Incident and Analysis Reporting System (CIRAS), Flight 

Operations Quality Assurance (FOQA), Incident Reporting Systems, Railroad Safety, Near Miss 16. PRICE CODE 

17. SECURITY CLASSIFICATION 

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NSN 7540-01-280-5500 Standard Form 298 (Rev. 2-89) 

Prescribed by ANSI Std. 239-18 

298-102 
ii 

METRIC/ENGLISH CONVERSION FACTORS 

ENGLISH TO METRIC METRIC TO ENGLISH

LENGTH (APPROXIMATE) LENGTH (APPROXIMATE) 

1 inch (in) = 2.5 centimeters (cm) 1 millimeter (mm) = 0.04 inch (in) 

1 foot (ft) = 30 centimeters (cm) 1 centimeter (cm) = 0.4 inch (in) 

1 yard (yd) = 0.9 meter (m) 1 meter (m) = 3.3 feet (ft) 

1 mile (mi) = 1.6 kilometers (km) 1 meter (m) = 1.1 yards (yd) 

 1 kilometer (km) = 0.6 mile (mi)

AREA (APPROXIMATE) AREA (APPROXIMATE) 

1 square inch (sq in, in2) = 6.5 square centimeters 

(cm2

) 

1 square centimeter (cm2

) = 0.16 square inch (sq in, in2) 

1 square foot (sq ft, ft2) = 0.09 square meter (m2) 1 square meter (m2) = 1.2 square yards (sq yd, 

yd2

) 

1 square yard (sq yd, yd2) = 0.8 square meter (m2) 1 square kilometer (km2) = 0.4 square mile (sq mi, mi2) 

1 square mile (sq mi, mi2) = 2.6 square kilometers 

(km2

) 

10,000 square meters (m2

) = 1 hectare (ha) = 2.5 acres 

1 acre = 0.4 hectare (he) = 4,000 square meters (m2) 

MASS - WEIGHT (APPROXIMATE) MASS - WEIGHT (APPROXIMATE) 

1 ounce (oz) = 28 grams (gm) 1 gram (gm) = 0.036 ounce (oz) 

1 pound (lb) = 0.45 kilogram (kg) 1 kilogram (kg) = 2.2 pounds (lb) 

1 short ton = 2,000 

pounds (lb) 

= 0.9 tonne (t) 1 tonne (t) =

=

1,000 kilograms (kg) 

1.1 short tons

VOLUME (APPROXIMATE) VOLUME (APPROXIMATE) 

1 teaspoon (tsp) = 5 milliliters (ml) 1 milliliter (ml) = 0.03 fluid ounce (fl oz) 

1 tablespoon (tbsp) = 15 milliliters (ml) 1 liter (l) = 2.1 pints (pt) 

1 fluid ounce (fl oz) = 30 milliliters (ml) 1 liter (l) = 1.06 quarts (qt) 

1 cup (c) = 0.24 liter (l) 1 liter (l) = 0.26 gallon (gal) 

1 pint (pt) = 0.47 liter (l) 

 1 quart (qt) = 0.96 liter (l) 

1 gallon (gal) = 3.8 liters (l) 

1 cubic foot (cu ft, ft3) = 0.03 cubic meter (m3) 1 cubic meter (m3) = 36 cubic feet (cu ft, ft3) 

1 cubic yard (cu yd, yd3) = 0.76 cubic meter (m3) 1 cubic meter (m3) = 1.3 cubic yards (cu yd, yd3)

TEMPERATURE (EXACT) TEMPERATURE (EXACT) 

[(x-32)(5/9)] °F = y °C [(9/5) y + 32] °C = x °F

QUICK INCH - CENTIMETER LENGTH CONVERSION

0 1 2 34 5

Inches

Centimeters 01 3 2 6 11 4 5 7 13 8 9 10 12

QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION

 -40° -22° -4° 14° 32° 50° 68° 86° 104° 122° 140° 158° 176° 194° 212°

 

°F

 °C -40° -30° -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 80° 90° 100°

For more exact and or other conversion factors, see NIST Miscellaneous Publication 286, Units of Weights and 

Measures. Price $2.50 SD Catalog No. C13 10286 Updated 6/17/98
Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

iii

PREFACE

Railroads can reduce risk before an accident by systematically 

studying close calls. A close call is “an opportunity to improve 

safety practices in a situation or incident that has a potential for 

more serious consequences.” When individual events are analyzed 

collectively, railroads can identify safety hazards and develop 

solutions to these threats. This is a proactive way to manage safety.

A Planning Committee of key stakeholders worked together in 

designing a workshop to introduce the railroad industry to how 

other industries and some railroads have been benefiting from 

studying close calls. The Human Factors Workshop: Improving 

Railroad Safety Through Understanding Close Calls was 

sponsored by the Federal Railroad Administration’s Office of 

Research and Development and attended by stakeholders from 

industry, labor, and government. 

These proceedings document the lessons learned from studying 

close call best practices in the railroad and airline industries. 

Included are summaries of the workshop presentations on lessons 

learned from existing close call systems in the railroad and airline 

industries. Also included is feedback from workshop participants 

on lessons learned from their own "close call" experiences, 

benefits and barriers to implementing a close call management 

system, and Planning Committee recommendations for next steps 

in implementing a close call system for the railroad industry. 

Appendices contain supporting documentation: 

 FRA Workshop Invitation 

 Workshop Agenda 

 Speaker Presentations 

 Breakout Group Discussions 

 Workshop Attendees 

 References 

 Speaker Biographies 

 Close Calls White Paper 

 Syncrude Case Study 

For an electronic full-page version of speaker handouts, refer to WWW.CLOSECALLSRAIL.ORG.

Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

v

ACKNOWLEDGEMENTS

The success of the Close Calls Workshop was due to the efforts of 

the following groups and individuals. 

The Workshop Planning Committee of key stakeholders easily 

worked together and assumed visibility as change agents for the 

industry. They became champions of the close calls reporting 

process, both within their own organizations and throughout the 

industry. 

Matthew Reilly American Short Line & Regional Railroad 

Jeffrey Moller Association of American Railroads 

Robert Harvey Brotherhood of Locomotive Engineers 

Tim DePaepe Brotherhood of Railroad Signalmen 

Demetra Collia Bureau of Transportation Statistics 

John Grundmann Burlington Northern Santa Fe Railway 

Thomas Raslear Federal Railroad Administration 

Scott Kaye Federal Railroad Administration 

Miriam Kloeppel National Transportation Safety Board 

Jim Remines National Transportation Safety Board 

Stephen Klejst New Jersey Transit 

Steve Fritter United Transportation Union 

James Stem United Transportation Union 

Jordan Multer Volpe National Transportation Systems Center 

Jane Saks Volpe National Transportation Systems Center 

The speakers provided thought-provoking challenges to the 

participants. 

Master of Ceremonies Thomas Raslear, Federal Railroad 

Administration (FRA) 

Jo Strang, Deputy Associate Administrator for Railroad 

Development, FRA 

John Goglia, National Transportation Safety Board member 
Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

vi

Keynote speaker Christopher Hart, Assistant Administrator of 

the Federal Aviation Administration’s (FAA’s) Office of System 

Safety 

Captain Hank Krakowski, Vice President of Safety and Security, 

United Airlines 

Don McClure, Air Safety Coordinator for the Airline Pilots 

Association. 

Aidan Nelson, Executive Director, Railway Safety, United 

Kingdom 

Helen Muir, Cranfield University (United Kingdom), Professor 

of Aerospace Psychology, Head of Human Factors Group 

John Grundmann, Assistant Vice President Systems Safety, 

Burlington Northern Santa Fe (BNSF) 

The FRA’s Office of Research and Development is appreciated for 

its vision of close calls as a way of improving rail safety, its 

funding of a workshop that became progressively more complex 

and extensive, and its trust in the members of the Planning 

Committee. FRA Senior Human Factors Program Manager Tom 

Raslear played a key role in getting the workshop off the ground. 

The Volpe National Transportation Systems Center was 

responsible for the workshop planning and logistics support. The 

team was led by Jordan Multer and supported by Jane Saks, the 

workshop organizer. Lorraine Brewer was conference coordinator. 

Jane Saks, Jeff Bryan, Rachel Winkeller, and Linda Sharpe were 

facilitators. Kathy Blythe, Craig Austin, Felicity Dickenson, and 

Bob Marville were note takers. All worked tirelessly to manage 

the behind-the-scenes surprises and ensure the workshop was a 

success from every standpoint. 
Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

TABLE OF CONTENTS

EXECUTIVE SUMMARY ........................................................................................................IX

1. INTRODUCTION ................................................................................................................. 1

What is a Close Call?................................................................................................................................1

Incident/Accident Reporting Systems.......................................................................................................1

Close Call Workshop ................................................................................................................................2

2. UNDERSTANDING CLOSE CALLS................................................................................. 7

Introductory Remarks – Tom Raslear.......................................................................................................7

Welcome Participants – Jo Strang ............................................................................................................7

History of Close Calls - John Goglia ........................................................................................................8

3. LESSONS LEARNED FROM CLOSE CALL SYSTEMS............................................. 11

Global Aviation Information Network - Christopher Hart - Keynote Speaker.......................................11

United Airlines Safety Culture: an Evolution of Learning and Cooperation - Hank Krakowski ...........16

Safety Programs that Increase the Safety Margin and Reduce the Accident Risk - Don McClure ........20

Panel Discussion .....................................................................................................................................24

4. LESSONS LEARNED FROM EXISTING RAIL INITIATIVES................................. 27

Confidential Reporting: the U.K. Rail Experience - Aidan Nelson........................................................27

Impact of CIRAS on the U.K. Rail Industry - Helen Muir.....................................................................31

BNSF Safety Hotline: Near Miss Information to Create a Safety Working Environment - John 

Grundmann .............................................................................................................................................36

Panel Discussion .....................................................................................................................................38

5. DISCUSSION GROUPS ..................................................................................................... 41

Overview.................................................................................................................................................41

Benefits of Understanding Close Calls...................................................................................................42

Barriers to Introducing and Using a Close Call System .........................................................................45

Implementation Issues ............................................................................................................................49

Themes by Stakeholder Group................................................................................................................55

6. RECOMMENDATIONS ................................................................................................... 57

Workshop Observations..........................................................................................................................57

Key Recommendations...........................................................................................................................57

Conclusion ..............................................................................................................................................59

APPENDIX A. FRA WORKSHOP INVITATION................................................................. 63

APPENDIX B. WORKSHOP AGENDA.................................................................................. 65

APPENDIX C. SPEAKER PRESENTATIONS ..................................................................... 67

APPENDIX D. BREAKOUT GROUP DISCUSSIONS......................................................... 89

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APPENDIX E. WORKSHOP ATTENDEES........................................................................ 105

APPENDIX F. SPEAKER BIOGRAPHIES ......................................................................... 109

APPENDIX G. CLOSE CALLS WHITE PAPER ............................................................... 113

APPENDIX H. SYNCRUDE CASE STUDY ........................................................................ 121

APPENDIX I. REFERENCES ............................................................................................... 137

viii
Proceedings of the Human Factors Workshop: 

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EXECUTIVE SUMMARY

What is a Close Call?

The U.S. Department of Transportation is working towards 

eliminating transportation-related fatalities and injuries in the

United States. 

The Bureau of Transportation Statistics (BTS) reports that a chain 

of contributing events precedes nearly all transportation incidents. 

If any of the events in the sequence fail to occur, that incident also 

might not occur. What you have instead is a “close call” or “near 

miss”1

. Knowing more about the sequences of events that lead to 

accidents can help prevent future accidents. BTS goes on to say

that current modal programs focus on collecting data only on 

reportable accidents and that high quality data on close calls is 

needed across all modes.

Railroads can reduce risk of an accident by analyzing close calls. A 

close call is "an opportunity to improve safety practices in a 

situation or incident that has a potential for more serious 

consequences." When individual close call events are analyzed 

collectively, railroads can identify safety hazards and develop 

solutions to these threats. 

Close Calls Workshop

In June 2002 the Federal Railroad Administration formed a broadbased Planning Committee, representing key stakeholders from 

industry, labor, and government. Their task was to decide how to 

introduce the railroad industry to the value of studying close calls 

as a way of improving safety. 

They worked together over the next 10 months to design a 

workshop to meet that objective. The committee defined the 

agenda, the small discussion group format, and selected the 

speakers from other industries and railroads that have benefited 

from studying close calls. Each member of the Committee also 

briefed their own organization to encourage their attendance and 

support at the Workshop. 

 1 HTTP://WWW.BTS.GOV/SDI/CONFERENCES/2002_01_09/PROJECT07/PROJECT7_OVERVIEW.PDF

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Proceedings of the Human Factors Workshop: 

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On April 23 and 24, 2003, the FRA’s Office of Research and 

Development held a Human Factors Workshop: Improving 

Railroad Safety Through Understanding Close Calls in Baltimore, 

Maryland. The purpose of the workshop was to educate the 

railroad industry on the benefits of understanding close call events 

and to provide a forum for participants to discuss issues and build 

trust in developing solutions. 

Workshop Agenda 

Day 1 

On the first day of the workshop, participants listened to panel 

presentations on existing close call systems in the airline industry,

the United Kingdom’s railway industry, and the Burlington 

Northern Santa Fe Railroad. 

The first panel of speakers discussed lessons learned from close 

call systems in aviation. Keynote Speaker Christopher Hart, the 

FAA’s Assistant Administrator for System Safety, advocated a 

shift in approach from a blame-the-individual culture to a systemsbased approach in addressing unsafe conditions in transportation. 

This approach included studying patterns and learning from them. 

Given that people make mistakes, it is the industry’s task to figure 

out why the systems allowed or failed to prevent the mistake. 

From Mr. Hart’s experience, “sharing safety information not only

improves safety, it saves money.” 

Captain Hank Krakowski, Vice President of Safety and Security, 

United Airlines, provided an industry management perspective. 

He talked about United Airline’s safety programs, which have 

saved lives. They are based on a Continuous Improvement 

Program, open communications, Flight Operations Quality

Assurance (FOQA), and safety awareness programs. 

Don McClure, Air Safety Coordinator for the Airline Pilots 

Association (ALPA), described the labor perspective. He cited the 

documented success of FOQA programs due to automated 

recording and analysis of routine flight data. He considers ASAP 

(Aviation Safety Action Program) a proactive and cost effective 

approach to flight safety, based on corporate commitment, a nonreprisal policy, mutual trust, and reporting incentives. 

The second panel then talked about best practices in several 

existing railroad initiatives. Aidan Nelson, Executive Director, 

Railway Safety, United Kingdom, and Helen Muir, Cranfield 

University (U.K.), Professor of Aerospace Psychology, Head of 

Human Factors Group and Chair of the industry steering group for 

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Proceedings of the Human Factors Workshop: 

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the Confidential Incident and Analysis Reporting System (CIRAS), 

discussed CIRAS. 

According to Aidan Nelson, the championing and development of 

CIRAS needs to come from within the industry. Operations and 

challenges are managed across organizational boundaries. 

Helen Muir talked in detail about the CIRAS reporting process. 

Success has been measured in the use and trust in the system, and 

by raising an awareness of safety issues, maintaining

confidentiality through its independence from rail companies. 

John Grundmann, Assistant Vice President Systems Safety, 

Burlington Northern Santa Fe, concluded with a description of the 

BNSF Incident Reporting System. The 13 System Safety Hotlines

were designed to capture a variety of safety information, including

near-misses. BNSF is moving in the direction of collaborating

with other railroads to aggregate and analyze data.

Day 2 

On the second day of the workshop, participants met in small 

discussion groups to discuss lessons learned from their own "close 

call" experiences. They then discussed the benefits and barriers to 

implementing a close call system for the railroad industry. Finally,

participants discussed steps needed to develop close call systems 

within the U.S. railroads. 

Results 

Participants said they were encouraged by guest speaker 

presentations on lessons learned from close call operational

systems in the railroad and airline industries. They were 

particularly impressed with the opportunity to improve data 

collection and analysis to identify better solutions. Secondary goals 

of improved trust, communication, and collaboration were 

important as well. 

In addition to the increased safety benefits of these existing

models, there is the potential for major cost savings, since the

railroad industry does not have to “reinvent the wheel” and can 

build on existing close call models. 

Many workshop participants said that while the workshop made 

them more aware of the benefits of existing close calls systems, 

they were still concerned about the barriers to implementation; 

such as the current “blaming” culture, a need for data

confidentiality, limited resources, and the current regulatory

requirements. 

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Proceedings of the Human Factors Workshop: 

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Based on the turnout, discussions, and recommendations, the 

Planning Committee called the workshop successful. They said 

they were surprised by participants’ positive reactions and 

comments. They expected more resistance from workshop 

participants to using a close call system approach, and were

pleased at the number of participants expressing interest in moving

forward. 

Recommendations

Given the positive feedback from participants, the Planning

Committee made three recommendations. 

Obtain Stakeholder Buy-In 

Just as the Planning Committee members briefed their managers in 

the fall of 2002 to obtain buy-in for this Close Calls Workshop, 

participants must brief their senior managers on what they learned 

at the workshop and seek support for the close calls concept. 

Workshop participants have all become part of a process. They

need to act as champions in their own organization to successfully

move forward. 

As part of the stakeholder buy in, the Planning Committee will 

prepare an executive briefing to inform leaders of all stakeholders 

in the railroads, regulatory agencies, and labor unions about close 

calls and obtain their buy-in. 

Initiate a Pilot Close Calls Project 

The Planning Committee felt that workshop speakers made a 

strong case and there were models from which the railroad industry

could learn. While different stakeholder groups expressed 

concerns, there was an overall consensus from all breakout groups 

to move ahead slowly with a pilot project. 

A pilot project represents a small-scale implementation and test of

a close call reporting system for the railroad industry. It will allow 

industry stakeholders to assess its usability and effectiveness 

before committing to a larger scale effort with the industry making

any changes system-wide. It will also provide a preview of a

safety culture characterized by improved trust, communication, 

and collaboration, across and within industry groups. 

In addition, the railroad industry does not have to “reinvent the 

wheel” but can instead build on existing, successful close call

models. 

Although the groups did not define the scope of the pilot project, 

the committee agreed that it was an important step. Railroads can

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Proceedings of the Human Factors Workshop: 

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try out a close call system on a small scale, using a neutral third 

party to collect and analyze the data, and then can test whether or 

not a confidential, non-punitive system can increase safety in the 

railroad industry. All committee members hoped that this pilot 

would be the beginning of a larger process. 

Continue Planning Committee Meetings 

The Planning Committee committed to continue to help the

railroad industry move forward in studying close calls, and will 

continue to meet. 

Conclusion

This process has the potential for even larger scale improvements 

in the railroad industry. In order to institute a close call system, 

railroads will need to introduce and test out certain improvements 

to the safety culture. 

• Taking a proactive, not a reactive approach to safety. 

• Focusing on studying and learning from mistakes, not 

hiding and punishing them. 

• Building trust within and between stakeholder groups. 

• Improving communication. 

These improvements will have an impact that is much larger than

the pilot, or even the close call systems. In additional to having the

potential for improving overall business practices and the safety

culture, all areas of operation will benefit from improved trust and 

communications. Indirect benefits could include improved job 

satisfaction, performance, and morale. 

xiii

Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

1. INTRODUCTION 

On April 23 and 24, 2003, the Federal Railroad Administration 

(FRA) held the Human Factors Workshop: Improving Railroad 

Safety Through Understanding Close Calls in Baltimore, 

Maryland. The purpose of the workshop was to educate all 

railroad industry stakeholders on the benefits of understanding

close call events and the challenges to their implementation. 

What is a Close Call? 

A close call is: 

“When individual events are

analyzed collectively,

railroads can identify safety

hazards and develop

solutions to these risks” 

“An opportunity to improve safety practices in a situation 

or incident that has a potential for more serious 

consequences.

2

” 

Analyzing close calls provides railroads with a proactive way to 

manage safety. When individual events are analyzed collectively,

railroads can identify safety hazards and develop solutions to these 

risks. 

Incident/Accident Reporting Systems 

There is a growing trend within the transportation industry to 

proactively identify factors that contribute to unsafe events, and 

prevent or minimize the likelihood of their occurrence. To that end, 

the railroad industry is trying to identify some of the factors that 

contribute to accidents, and propose countermeasures that address 

those sources. 

Existing Incident/Accident Databases

Over the last decade, the number of reportable events in the FRA’s 

accident/incident reporting systems has declined. The lower 

accident frequencies make it more difficult to detect emerging

trends related to unsafe events and conditions. 

An alternative approach is needed to further reduce unsafe events

in the railroad industry. Further reductions in the accident rate 

 2 Adapted from James Phimister et al., Near-Miss Management Systems in the Chemical Process Industry, Wharton

School of Management, University of Pennsylvania.

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Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

require new approaches for collecting precursors to accidents and 

develop countermeasures. More proactive methods are needed. 

Other transportation modes have developed incident reporting

systems that collect information about close call events and 

hazardous incidents. 

In addition, there are limits to the use and effectiveness of existing

databases. Federal regulations require railroads to submit a report 

whenever the threshold for an incident is met. The perspective of 

others involved in the incident or who observed the incident may

not be taken into account. The end result is that these databases 

provide an incomplete picture of the factors that contributed to the 

incident. 

A Close Call Incident Reporting System

Developing an incident reporting system based on close call events

can enable the railroad industry to better identify the factors that

contribute to unsafe events and develop more effective 

countermeasures. It can also serve as an early warning system, 

addressing problems proactively before they result in unsafe 

events. 

“Developing an incident

reporting system based 

on close call events...

serves as an early

warning system” A successful close call reporting system involves building trust to 

encourage the disclosure of close call information. Most reporting

systems in other industries use a third party to collect and store the 

confidential information. To address the reluctance to report an

incident when disciplinary actions could be imposed, systems 

should provide protection from liability or enforcement to 

individuals disclosing legitimate data. 

Close Call Workshop 

Background

In the spring of 2002, the FRA’s Office of Research and 

Development decided to sponsor a workshop for the railroad 

industry to learn more about the safety benefits of understanding

close calls and the challenges to implementation. 

The FRA formed a Close Call Workshop Planning Committee, 

with 14 representatives from key management, union, and 

government stakeholder groups. The committee first addressed 

industry concerns that the FRA was planning to mandate an 

industry-wide close call system and/or further regulations in this 

area. When FRA assured the Planning Committee that this was not 

the case, and that it would be up to each carrier to decide whether 

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Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

they wanted to institute such a system, the group agreed to 

proceed. 

During subsequent committee meetings, it became clear that

preliminary work was necessary to ensure the workshop would be 

well attended and successful. The Planning Committee requested 

the Volpe National Transportation System Center (Volpe Center) 

to write a White Paper introducing the need for and the possibility of

implementing a close call system for the railroad industry. This White

Paper: Improving Railroad Safety through Understanding Close Calls, 

is included in the appendices of these Proceedings.

“(The workshop) creates 

a dialog among industry 

stakeholders about the

potential risks and

benefits of establishing 

a close call system” 

Committee members used this White Paper to brief the management

of their respective organizations. Next they designed the Close 

Calls Workshop to create a dialog among industry stakeholders 

about the potential benefits and risks of establishing a close call 

system within the industry.

Planning Committee 

The Committee included the following industry stakeholders: 

Matthew Reilly American Short Line and Regional Railroad 

Jeffrey Moller Association of American Railroads 

Robert Harvey Brotherhood of Locomotive Engineers 

Tim DePaepe Brotherhood of Railroad Signalmen 

Demetra Collia Bureau of Transportation Statistics 

John Grundmann Burlington Northern Santa Fe Railway

Thomas Raslear Federal Railroad Administration 

Scott Kaye Federal Railroad Administration 

Miriam Kloeppel National Transportation Safety Board 

Jim Remines National Transportation Safety Board 

Stephen Klejst New Jersey Transit 

Steve Fritter United Transportation Union 

James Stem United Transportation Union 

Jordan Multer Volpe National Transportation Systems Center

Jane Saks Volpe National Transportation Systems Center

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Proceedings of the Human Factors Workshop: 

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Planning Committee members, left to right: Miriam Kloeppel,

Robert Harvey, Tim DePaepe, Thomas Raslear, Jeffrey Moller,

James Stem, and Stephen Klejst

Goals 

The Planning Committee recognized that for the workshop to be 

successful, cooperation and support by all stakeholders was 

essential. While the FRA provided the funding, the Planning

Committee agreed on the goals and recommended the workshop 

content and the format that would achieve those goals. 

“For the workshop to

be successful it must

be run by the industry,

not the FRA” The Planning Committee decided that the participants would 

define the outcomes of the workshop. The Committee proposed 

the following workshop goals: 

• Inform the railroad industry about the safety benefits of 

understanding close calls through the lessons learned 

and best practices from existing systems. 

• Create a dialog among railroad industry stakeholders 

about safety. 

Agenda 

The FRA’s Senior Human Factors Program Manager, Tom

Raslear, introduced FRA Deputy Associate Administrator for 

Railroad Development, Jo Strang, who welcomed participants to 

the workshop. Next, John Goglia from the National 

Transportation Safety Board (NTSB) Board, provided a history of 

safety in the railroad industry, noting the current difficulty of

reducing accidents below the current level. 

The first panel of speakers discussed lessons learned from close 

call systems in aviation. 

• Keynote speaker, Christopher Hart, Assistant 

Administrator of the FAA’s Office of System Safety

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Proceedings of the Human Factors Workshop: 

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shared lessons learned from close call systems in the 

airline industry. 

• Captain Hank Krakowski, Vice President of Safety and 

Security, United Airlines, provided an industry

management perspective. 

• Don McClure, Air Safety Coordinator for the Airline 

Pilots Association, described the labor perspective. 

The second panel then talked about best practices in several 

existing railroad initiatives. 

• Aidan Nelson, Executive Director, Railway Safety,

United Kingdom, and Helen Muir, Cranfield University

(U.K.), Professor of Aerospace Psychology, Head of 

Human Factors Group and Chair of the industry steering

group for the Confidential Incident and Analysis 

Reporting System (CIRAS), discussed CIRAS. 

• John Grundmann, Assistant Vice President Systems 

Safety, Burlington Northern Santa Fe, concluded with a 

description of the BNSF Incident Reporting System. 

“[Participants] discussed 

lessons learned, [and] 

benefits and challenges to

implementing a close call

system in the U.S. railroad

industry” 

Participants spent Thursday morning in small discussion groups, 

made up of railroad industry stakeholders. Each discussion group 

consisted of similar numbers of stakeholders from government, 

labor, management and others. 

They discussed lessons learned, benefits and challenges to 

implementing a close call system in the U.S. railroad industry, and 

the next steps to begin developing a close call approach for the 

railroad industry. Representatives from the individual breakout 

groups then shared what they learned with the whole group. 

The Planning Committee then reviewed the comments from the

breakout groups and recommended next steps for the industry. 

The workshop concluded with a question and answer session. 

Audience 

The workshop was designed for Vice Presidents of Safety, Safety

and Rules Directors and managers from the railroad labor unions. 

Participants also included individuals from the government, 

academia, and consultants. 

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Proceedings of the Human Factors Workshop: 

Improving Railroad Safety Through Understanding Close Calls

2. UNDERSTANDING CLOSE CALLS 

Introductory Remarks – Tom Raslear 

Federal Railroad Administration 

Tom Raslear is the Senior Human Factors Program Manager in 

the FRA’s Office of R&D. He is a member and former chair of the 

Department of Transportation’s Human Factors Coordinating 

Committee. 

Master of Ceremonies 

Tom Raslear, FRA 

Tom Raslear acted as Master of Ceremonies and greeted workshop 

attendees. He gave the background leading to the workshop and 

reviewed the workshop goals and agenda. After defining close 

calls, he gave a brief history, pointing out the benefits and 

challenges. He then introduced Planning Committee members and 

described their role. 

Welcome Participants – Jo Strang 

Federal Railroad Administration 

Jo Strang is currently the Deputy Associate Administrator for 

Railroad Development in the FRA. She oversees a variety of 

programs including research and development and the passenger 

and freight programs. She is the past Associate Director for 

railroad and transit accident investigation at the National 

Transportation Safety Board (NTSB), where she was responsible 

for rail and rail transit accident investigation in the United States. 

Jo Strang followed Mr. Raslear in welcoming workshop attendees. 

She pointed to the rail industry's progress towards the goal of 

achieving zero accidents and incidents. The number (as of 2002) 

of accidents and incidents (13,926) is down by 17% (from 16,918 

in 2000). Ms. Strang said this is where studying close calls comes 

into play. Close calls are used to analyze data and learn what goes 

wrong before accidents happen. In turn, this will help prevent 

accidents. 

Jo Strang, FRA 

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History of Close Calls - John Goglia 

National Transportation Safety Board 

Mr. Goglia has served on the NTSB since August 1995. He was 

instrumental in raising awareness of airport safety issues and 

recently hosted a joint government-industry conference to 

highlight airport safety trends and facilitate improvements. Mr. 

Goglia has participated in numerous high profile air, rail and bus 

accident investigations, including the ValuJet crash into the

Florida Everglades in May 1998 and Amtrak's City of New 

Orleans fatal train crash at Bourbonnais, Illinois in March 1999. 

Mr. Goglia’s presentation focused on the history of close calls in 

the rail industry. He began his presentation by saying that the 

current aviation approach used to study close calls would be a 

great benefit to the railroad industry. He pointed out even though 

there is the expected resistance to trying something new, the 

railroad industry could benefit from studying close calls. 

John Goglia, NTSB 

“The current aviation

approach used to study 

close calls would be a

great benefit to the

railroad industry” 

Current Safety Trends 

Mr. Goglia gave an overview of current railroad and rail employee

accident/incident trends. He pointed to a rapid decline in the 1980s 

and early 1990s from the peak years of 1978 and 1979, but said 

this rate had flattened out since the mid 1990s. 

Industry Safety Improvements

Based on investigations of numerous railroad accidents over the 

years, the NTSB has made many safety recommendations to the

railroad industry. Mr. Goglia said these recommendations have 

contributed to safety improvements in many areas.

Railroad Operating Rules

Mr. Goglia pointed to improvements in dispatcher operations 

workloads and the working culture. The industry has also 

improved periodic operating rules testing of employees, and has 

eliminated unsafe rules such as the restricted proceed signal. 

“(NTSB)

recommendations have

contributed to safety

improvements in many

areas” Mechanical Conditions 

Recommendations have resulted in the following improvements: 

• Nationwide adoption of two-way end-of-train devices 

• Use of top and bottom shelf couplers on hazmat tank 

cars 

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• Nationwide removal from service of defective wheels 

• Improved manufacturing and testing of airbrake 

components in cold weather conditions 

• Improved traction motor mounts in transit operations 

Track Conditions

Mr. Goglia pointed to improvements in track conditions, including

switches and turnouts. 

Railway Worker Protection

Recommendations to industry and government agencies have

resulted in Federal regulations safeguarding workers on railroad 

rights-of-way, and new or improved railroad emergency response 

training and procedures. 

Crashworthiness 

“Develop a close call

system to better 

understand the 

underlying causes of 

accidents” 

Recommendations have included improved locomotive crew cabs, 

nationwide crashworthiness standards for passenger equipment, 

and improved locomotive fuel tank integrity. 

Human Performance 

Recommendations to industry and government agencies have

resulted in improvements to drug and alcohol testing requirements, 

fatigue awareness, and crew resource management. 

Transit Safety 

Mr. Goglia said there have also been gains in State oversight of rail 

rapid transit safety and improved attitudes of employees and 

management. 

Future Challenges 

The proceeding safety improvements came about from NTSB

recommendations. The railroad industry will receive greater 

benefits from becoming more proactive, collecting and analyzing

data, and then initiating its own improvements. 

Despite the reduction in the number of railroad accidents and 

incidents, Mr. Goglia said that other approaches are needed to

lower this number further. He pointed out the downward trend in 

accidents is misleading since results of accidents are analyzed as 

they occur. In fact, in recent years the percentage of accidents 

and incidents involving fatalities has risen. 

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Recommendations 

Mr. Goglia recommended the development of a close calls 

reporting system to better understand the underlying causes of 

accidents. 

He concluded by saying the benefits of a close call system can be 

judged by looking at the airline industry’s approach to lowering

costs and the number of incidents. An airline may spend $72 

million on ground damage a year, direct costs associated with 

flights canceled, ticket upgrades, or hotel stays. An estimated 

$0.5B billion a year is spent on ground damage and indirect costs. 

He recommended that the railroad industry “listen to all groups,” 

not only to save money, but also to improve safety.

“Listen to all 

groups, not only to

save money but to

improve safety” 

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3. LESSONS LEARNED FROM CLOSE CALL 

SYSTEMS 

The first panel of speakers discussed lessons learned from close 

calls in the airline industry. 

• Christopher Hart (Keynote Speaker), Global Aviation 

Information Network 

• Captain Hank Krakowski, United Airlines Safety

Culture – an Evolution of Learning and Cooperation 

• Don McClure, Safety Programs that Increase the Safety

Margin and Reduce Accident Risk 

There was a question and answer session for all panelists at the end 

of the presentations. 

This section summarizes each speaker’s presentation. To view the 

full text of PowerPoint presentations, refer to the appendices, or 

the “More” link at the current website 

WWW.CLOSECALLSWORKSHOP.ORG.

Global Aviation Information Network - 

Christopher Hart - Keynote Speaker 

Assistant Administrator for System Safety, Federal Aviation 

Administration 

Mr. Hart is the FAA Assistant Administrator for System Safety, 

reporting directly to the FAA Administrator. The Office of System 

Safety supports numerous FAA and worldwide aviation safety 

program. It spearheads industry-wide safety activities, such as the 

Global Aviation Information Network (GAIN); and helps to 

identify key safety issues and emerging trends affecting safety. 

Mr. Hart was formerly Deputy Administrator of the National 

Highway Traffic Safety Administration (NHTSA) and was a 

member of the NTSB. 

His presentation focused on the Global Aviation Information 

Network (GAIN). Chris Hart, FAA 

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Sharing Safety Information 

Mr. Hart said GAIN promotes the voluntary collection and sharing

of safety information by and among users in the international 

aviation community. The goal is to develop tools and processes to 

enable the aviation community to make data-driven decisions 

beyond accidents or incidents. He said the GAIN approach is 

applicable to many other transportation modes. “The hands-on front 

line folks are going to

tell you they already 

knew about that

problem” 

Mr. Hart agreed with John Goglia’s comment about listening to 

your employees; “the hands-on, front line folks are going to tell 

you they already knew about that problem.” 

To illustrate this point, Mr. Hart gave the following example. In

1974 strong winds forced a TWA plane to land on a rarely used 

Dulles runway. United Airlines pilots had previously reported that 

the approach chart was confusing but this information had not been 

shared with other airlines. The TWA plane hit a hill. 

Mr. Hart said there are many links in the accident chain, which, if 

severed at any point, would avert an accident. He suggested that, 

while we must always maintain the accountability of the operator, 

we must also look at the system to determine not only how to 

reduce the likelihood of human error, but also how to reduce the 

seriousness of the consequences of human error. 

Worldwide Safety Statistics 

Mr. Hart discussed the benefits of routine flight data recorder use. 

He pointed out that airlines with mature programs that review 

flight data recorders after every flight, have an accident rate six

times lower than airlines that do not have such programs. He said 

that in the U.K., airlines have been routinely reviewing flight data 

recorders for more than 30 years, adding “there really is gold in

those flight data recorders if we could just mine the information.” 

“There really is gold

in those flight data

recorders if we could 

just mine the 

information”

Mr. Hart said that since 1996, when Norway introduced a nonpunitive reporting program, the rail industry has seen an increase

in the number of reported and analyzed near misses, and reported 

and analyzed events. At the same time there has been a reduction 

in lost time and accidents. 

Safety Data – the Challenge 

Currently, only a minute percentage of safety data is collected and 

analyzed. Mr. Hart referred to the Heinrich Pyramid, in which a 

small number of accidents are reported, a slightly larger number of 

incidents are reported, and a very large number of close call 

occurrences go unreported. 

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Mr. Hart quoted from the National Civil Aviation Review 

Commission’s 1997 report on avoiding aviation gridlock and 

reducing the accident rate; “the aviation community must look 

deeper than accidents and incidents to identify latent and emerging

problems, and fix them before a mishap occurs.” 

“The aviation

community must look 

deeper than accidents

and incidents to

identify latent and

emerging problems,

and fix them before a

mishap occurs” 

He asked whether the solution is to regulate more, punish more, 

increase training, or share information to fix the system. 

Information that is sought is on events (actions or failures to act)

that are inadvertent, happen repeatedly and could be part of a link 

in an accident chain. Accidents typically result from the alignment

of a combination of events. 

Mr. Hart said the main challenges to information sharing are public

disclosure of information, due to job sanctions and/or enforcement, 

criminal sanctions, and civil litigation, which, in the U.S., is the 

biggest fear. He said the scenario has changed in a very short time

from “I’m afraid to collect information” to “I’m afraid to NOT 

collect information.” 

He advocated shifting the current way of thinking from: 

• you are highly trained, and if you did as you are trained 

you would not make mistakes, so this means you are not 

careful enough and should be punished... 

to: 

• you are human and humans make mistakes so let’s

explore why the systems allowed or failed to 

accommodate your mistake, and let’s improve the

system!

Mr. Hart said all accidents involve human factors. It is more 

helpful to assume that the problem resides largely in the system, 

not only in the individual. 

GAIN – an Information Network

GAIN is a network of information, not a large central database, 

providing the tools and processes to help the aviation safety

analysts better manage safety information. It is an international, 

cooperative effort that will be privately owned and operated. 

GAIN is a voluntary program. 

“GAIN (provides) the

tools and processes to

help the aviation safety

analysts better manage

safety information” The conceptual predecessor to GAIN was the Aviation Safety and 

Reporting Program (ASRS) initiated in 1975; funded by the FAA 

and operated by NASA. Pilots, mechanics, and controllers were

the primary users. [There was limited transaction immunity.] 

ASRS is now one of GAIN data sources, along with Flight 

Operations Quality Assurance (FOQA), Aviation Safety Action 

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Program (ASAP), Line Operations Safety Audit LOSA), and Air 

Traffic Control (ATC). 

Mr. Hart stated that the analytical tools being developed by GAIN

could help experts and analysts by: 

• Identifying issues

• Prioritizing risks “GAIN is one of our

best hopes for

enhancing aviation 

safety in the next

century” 

• Developing solutions 

• Evaluating effectiveness

Former FAA Administrator Jane Garvey called GAIN “one of our 

best hopes for enhancing aviation safety in the next century.” 

GAIN Infrastructure 

Five Working Groups and the FAA’s Office of System Safety

(ASY) Program Office support a top level Steering Committee. 

Indirectly, a Government Support Team reports to the Steering

Committee.

Industry takes a lead role. The Steering Committee, led by

industry, consists of representatives from various airlines 

worldwide, aircraft manufacturers, unions, general aviation, the 

U.S. military, and the Flight Safety Foundation. 

The Working Groups, whose members are primarily from industry,

focus on five areas: 

• Aviation Operator Safety Practices 

• Analytical Methods and Tools 

• Global Information Sharing Prototypes 

• Government Support Team (representatives from several 

countries) 

• Flight Ops/ATC Ops Safety Information Sharing

• Making GAIN Work 

Mr. Hart said the key to a successful GAIN program is that “all

segments of the industry must work together; management, labor, 

manufacturers, and governments.” He stressed the importance of 

the labor organizations buying into the program. 

“All segments of the 

industry must work

together; management, 

labor, manufacturers,

and government”

“All segments of the 

industry must work

together; management, 

labor, manufacturers,

and governments” 

As these groups collect and analyze information, they begin to 

work together in sharing information. The FAA, the U.K.’s Civil 

Aviation Authority (CAA), and the U.K.’s Royal Aeronautical 

Society sponsored the first two GAIN conferences. Several 

airlines in the U.S. and Europe have hosted the conferences. 

As collaborative and legal hurdles are overcome, GAIN has been 

able to focus on improving its analytical tools. 

Mr. Hart said other government agencies and industry groups are 

now starting to take a look at GAIN and express an interest in 

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developing their own versions. These include other U.S. 

Department of Transportation agencies (U.S. Coast Guard, Federal 

Highway Administration, Office of Pipeline Safety), the Critical 

Infrastructure Assurance Office (CIAO), and the nuclear power, 

chemical manufacturing, public utilities, firefighter, and health 

care industries. 

The Airline Bottom Line 

The airline industry realized immediate benefits in operations and 

maintenance. More long-term accidents will be prevented. 

Sharing safety information “not only improves safety, it saves 

money.” Mr. Hart pointed to United Airlines where flap overspeed 

events were reduced by 90% in less than a year. He said the 

industry “has changed from pushing a safety rock up a hill to being

a profit center.” 

“Sharing safety

information not only

improves safety, it

saves money” 

GAIN in the Future 

Mr. Hart quoted from the Institute of Medicine’s Committee on 

Quality of Health Care; “the focus must shift from blaming

individuals for past errors to a focus on preventing future errors by

designing safety into the system.” 

He concluded by saying since September 11, GAIN has a future

role in the area of security.

For more information, refer to the GAIN website found at 

HTTP://GAINWEB.ORG/ . 

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United Airlines Safety Culture: an Evolution of Learning 

and Cooperation - Hank Krakowski 

Vice President for Corporate Safety, Security and Quality 

Assurance, United Airlines 

Mr. Krakowski is the Vice President for Corporate Safety, Security 

and Quality Assurance at United Airlines. His responsibilities 

cover worldwide flight, operational, computer and maintenance 

functions, including emergency response. He was in charge of 

Flight Operations at United's Operations Control Center on 

September 11, 2001. 

His presentation focused on safety programs at United Airlines. 

Update on United

Mr. Krakowski began his presentation with a Chapter 11 update. 

The airline is running well with excellent operational and safety

performance, was the number one airline with on-time flights, is 

not experiencing any safety or reliability issues, and has negotiated 

agreements with labor. 

Hank Krakowski, 

United Airlines 

Continuous Improvement Program 

The mission of the Safety Department at United is to “find truth 

and facilitate change.” Mechanisms include self-disclosure,

partnerships between stakeholders, systems auditing, and 

continuous improvement. 

“The mission of the

Safety Department at

United is to find truth

and facilitate change” Mr. Krakowski said safety is a natural evolution and that “candid, 

open communication and Memorandums of Understanding

between unions, regulators and managers is key.”

United uses the Continuous Improvement Safety Program to 

implement change and re-evaluate safety. At the ground level, 

weekly meetings between representatives from management, 

unions, and the FAA identify safety issues. At the airline 

operations level, safety data is generated and analyzed, and safety

reports are written. In addition, United uses several internal and 

external auditing techniques to ensure all aspects of safety are

evaluated. There are internal quality control audits within a

department in addition to independent quality assurance audits. 

There are also external audits by the FAA, EPA, TSA, and OSHA. 

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The end result is that within United’s Safety Department, 

management, regulators, employees, and the union all see the same 

current safety status updates. 

Communication – Key to Safety

United’s last crew fatality was in 1978 when a DC-8 ran out of fuel 

and crashed near the Portland airport. The NTSB determined that

the probable cause of the accident was the failure of the captain to

properly monitor the aircraft's fuel state and to properly respond to 

the low fuel reading. 

“Candid, open 

communication and

MOUs between 

unions/regulators/ 

managers are key” Also contributing to the accident was the failure of the other two 

flight crew either to fully comprehend the criticality of the fuel

state or to successfully communicate their concern to the captain. 

At that time, flight culture was that the “Captain is King;” and if a

captain had a strong personality this made it difficult for other

members of the flight crew to intervene.

Mr. Krakowski said United brought in the FAA to find out how to 

assess crew performance and how the captain could delegate 

certain tasks and use the knowledge of the crew. 

Using crew resource management (CRM) tools, all United 

crewmembers are now trained to discuss safety issues with the 

captain. Mr. Krakowski said the captain’s authority is 

strengthened, not undermined, through CRM. In addition, pilot 

simulator checks equally evaluate Command/Leadership/Resource

(CLR), CRM, and flight skills. 

Flight Operations Quality Assurance (FOQA) 

United is now using data driven analysis to improve safety by

tracking if safety changes work. Mr. Krakowski said data 

collection is very important. Sixty percent of United’s aircraft are 

equipped with FOQA recorders for downloading data at the end of

the day. 

“Crews can request

routine real time...

data to predict

problems before 

major events occur” 

Data 

The FAA and industry are working together to aggregate 

deidentified data and identify trend data, such as unstable

approaches, Terminal Control Area Resolution Advisory (TCAS 

RAs) and exceeding flap/speed. Flight management and the 

Airline Pilots Association (ALPA) then analyze changes required 

to procedures and training. 

The ALPA Exceedence Guidance Team reviews identified data. If

there is gross exceedence or data is significantly over limits, the 

union contacts the crew. This approach develops a trusting

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relationship between management and the union in a learning

environment. 

Reporting Events

Using FOQA, crews can request routine real time trending engine 

and system data to predict problems before major events occur,

such as an engine shutdown. In the event there is a non-routine 

event, such as an engine surge or flap overspeed, the crew can 

request data to be downloaded. 

FOQA trends aircraft performance; this prevents flights taking off 

if there is a manufacturing and engineering issue.

Quality Assurance Auditing – Case Study 

At United, QA auditing in an independent internal process. Mr. 

Krakowski said there has been a shift in philosophies from the 

traditional “compliance police” to the Joint Quality Review Team, 

based on the systems and processes of ISO 9000. This approach 

looks at how the system sets up the crew for success and failure. 

“There has been a

shift in philosophies

from the traditional

‘compliance police’ 

to the Joint Quality

Review Team” QA auditing identifies non-compliance (direct violations), nonconformance (written procedures different from practices), and 

significant concerns (oversight and systems are weak). 

Mr. Krakowski gave an example of a QA audit based on the 

following near-accident: 

• An engine fails shortly after takeoff 

• Instrument flight rule (IFR) conditions were in effect 

• The first officer was the pilot

• The crew was late in identifying engine failure

• The first officer reacted improperly

• The plane came within 100 feet of a hill 

A joint QA review team consisting of the FAA and the union 

found full FAA/United compliance at takeoff but identified the 

feeling there were proficiency problems. The Chief Safety Officer 

decided on a systems evaluation. The end results were 263 

findings; eight of which were critical, which surprised pilots and 

United. Findings related to proficiency, safety, and the 

inexperience of some long-range relief pilots in making multiple

takeoffs and landings. United made the decision to handle the 

occurrence as an accident and to look more closely at taking a 

systems approach to evaluating incidents. 

Mr. Krakowski pointed out the strength of independent QA 

auditing is the ability to keep self-interests at bay.

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Safety Awareness Program 

Mr. Krakowski said United’s vision is to “create a total safety

analysis culture overall and traverse departmental barriers.” The 

“United mechanism for this vision is through three programs: ’s vision is to

create a total safety 

analysis culture

overall and traverse 

departmental 

barriers” 

• Flight Safety Awareness Program (FSAP)

• Dispatch Safety Awareness Program (DSAP)

• Maintenance Safety Awareness Program (MSAP)

Flight Safety Awareness Program (FSAP) 

FSAP provides the tools for open and honest discussions between 

management, unions, crews, and the FAA. If a crewmember sees 

or makes a mistake they receive immunity if they disclose the

information in a timely manner, unless the incident shows willful 

disregard or is intentional. 

“FSAP provides the

tools for open and

honest discussions

between

management, unions,

crews, and the FAA” 

The mechanism for self-disclosure is a memorandum of

understanding (MOU) between the unions the FAA. 

FSAP reports track altitude deviations, missed communications, 

and security issues. Pilots electronically submit these reports to the

United Safety Department, which then classifies the occurrence 

and ranks the risk level. 

FSAP reports are forwarded to Weekly Event Review Committee

meetings for review by FAA, union, and United managers. Action 

taken depends on whether the incident is significant or ambiguous. 

The committee closes the issue outright or makes 

recommendations, generates a letter of “no action”, or issues a 

Notice of Violation (this is a rare event). 

Dispatch Safety Awareness Program (DSAP) 

DSAP evolved from the success of the FSAP. It is used by United 

pilots, maintenance workers, and ground crew to “paint a full 

disclosure picture” of the safety environment related to flight 

dispatch. The program began in October 2002 and is already

effective. 

“All groups need to

communicate with

each other to

resolve safety

issues quickly” 

Maintenance Safety Awareness Program (MSAP)

United is currently revisiting the concept of maintenance safety

with the new union leadership. 

Safety Awareness Case Study 

United successfully followed FSAP procedures after recent 

problems with ice damage to engines of 14 Boeing 737s. 

Information was not readily available from ground maintenance 

personnel who may have thought they would be blamed. 

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United used backchannel communication between ramp and 

maintenance staff, assuring them there would be no culpability.

The review team found that ground personnel properly maintained 

engines, however, improvements were needed in engine operating

procedures established by the company to be used by pilots. 

United subsequently worked with the engine manufacturer to

develop improved procedures. 

“The FOQA program

has saved engines, 

aircraft, and lives” 

Saving Engines, Aircraft, and Lives 

According to Mr. Krakowski, the FOQA program has “saved 

engines, aircraft, and lives." He pointed to cooperation, 

confidentiality, and communication as key to these successes. The 

lesson learned was that all groups need to communicate with each 

other to resolve safety issues quickly. He concluded that it is 

important for all groups to be able to talk to each other and that 

communication must be “robust, open, and honest.” 

Safety Programs that Increase the Safety Margin and 

Reduce the Accident Risk - Don McClure

Air Safety Coordinator, Airline Pilots Association (ALPA) 

Mr. McClure is the ALPA Safety Coordinator and is responsible 

for developing and implementing FOQA (Flight Operations 

Quality Assurance) and ASAP (Aviation Safety Action Program). 

He previously was a Captain with Eastern Air Lines for 26 years 

and has participated in air safety and accident investigations for 

the past 36 years. 

Mr. McClure’s presentation focused on using FOQA and ASAP to 

increase the flight safety margin and reduce accident risk. 

FOQA Overview

Don McClure, Airline 

Pilots Association 

Mr. McClure began his presentation by defining FOQA as a 

program designed to enhance safety through the controlled, 

automated recording and analysis of flight data generated during

routine line operations. 

He pointed out the success of FOQA by European and Asian 

carriers for over 30 years. Even though the litigious environment 

is different compared to the U.S., data is respected. There is no 

concern over misuse by government agencies, and there is a long

recognized need for anonymity in reporting. Mature international 

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FOQA programs have improved hull loss prevention statistics 

“FOQA... enhances compared to European and U.S. carriers not using FOQA. 

safety through the

controlled, automated

recording and analysis

of flight data 

generated during

routine line 

operations”

Safety Trends 

An assessment of worldwide commercial jet hull loss accidents 

between 1959 and 1996 shows a high percentage of accidents 

occurred when aircraft were descending from cruising altitude to 

landing. 

Mr. McClure pointed to several safety trends in the U.S. In 1997 

the two top safety events by far were: 

• High descent rate below 2,000 feet 

• Low power on approach 

Examining these data in greater detail, the location with the highest 

rate of descent was also the most frequent user of low power 

approaches. This location was Myrtle Beach, South Carolina. In

both cases, the percentage difference between the Myrtle Beach 

data and the next highest airport data was extremely high. 

“Mature international 

FOQA programs 

have proven hull loss 

prevention statistics”

Using FOQA to analyze the Myrtle Beach statistics, ALPA

determined the standard flight plan with a higher altitude was 

designed to optimize fuel efficiency. Essentially, flight crews had 

to climb to 23,000 feet and then descend rapidly on flights lasting

only 17 minutes. Reducing the flight plan to an altitude of 15,000 

feet reduced the required decent and consequently resulted in a 

measurable reduction in flap damage (previously caused by pilots 

deploying flaps at higher speeds to cope with the need for rapid 

descents). 

FOQA and Unstabilized Approaches 

Flight Operations has taken a pro-active approach to reducing

unstabilized approaches by communicating safety information to 

the flight crews. Between 1998 and 1999 there were articles in 

various flight operations publications, postings on the FOQA 

Bulletin Board (postings for several were dedicated to stabilization 

issues), and briefings by check airmen. 

“Crew feedback is

essential to the 

success of FOQA” 

Mr. McClure gave several examples of briefings, safety bulletins, 

and bulletin board postings. He said that these communication 

tools have been very effective in reducing the percentage of 

unstabilized approaches resulting from low power on approach and 

high descent rate. 

Mr. McClure highlighted several initiatives with detailed graphs 

for US Airways flights approaching runway 23 at Charlotte, North 

Carolina airport. 

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Following installation of an Instrument Landing System (ILS) 

approach to runway 23 to replace the non-precision approach, six

months later there was an 84% reduction in unstabilized

approaches. This also increased the safety margin for other 

carriers. FOQA data not only was the incentive to install the ILS

but also allowed ALPA to determine the safety impact of the

installation. 

“FOQA is the highest

level of safety 

management” 

“(ASAP)...is a cost

effective approach to

flight safety for the 

airlines, pilots, and the 

FAA” 

Communication is Key to FOQA 

Mr. McClure stressed that crew feedback is essential to the success 

of FOQA, pointing to the various communication tools to get the 

message across: 

• FOQA Bulletin Board 

• Event of the Month 

• Crew contact by ALPA gatekeeper 

• Monthly data sent to the Fleet Manager 

• Company safety publications 

• Airport analysis page on the FOQA Alert 

Ultimately, the industry will recognize that FOQA is the highest 

level of safety management. 

ASAP Overview 

Next, Mr. McClure highlighted ASAP, calling the program a cost 

effective approach to flight safety for the airlines, pilots, and the

FAA. He stressed that for ASAP to work; there must be a

corporate commitment to air safety at the highest level and a

corporate non-reprisal policy, as prerequisites. Flight crew 

feedback of safety information is also key to a successful program. 

Using ASAP at US Airways, Mr. McClure described the benefits 

to having a safety action program in place. 

Airline Commitment 

• Airline management at all levels must commit to the

corporate safety mandate and support personnel and 

staff. 

• Air Safety staff must provide corporate safety

information. “For ASAP to work, 

there must be a

corporate

commitment to air

safety and a

corporate nonreprisal policy”

ASAP Defined 

Mr. McClure identified the key features of ASAP: 

• Identifies and resolves safety problems proactively

• Encourages airline and employee commitment, 

response, and accountability

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• Provides strong reporting incentives 

• Associated with NASA’s ASRS program 

• Provides safety benefits to airlines, pilots, the FAA, and 

the traveling public

• Addresses all ground and flight operations and 

procedures, Air Traffic Control, dispatch and aircraft 

performance, charting and instrument procedures, 

maintenance and minimum equipment lists (MEL), 

human factors, and technology and aircraft equipment. 

ASAP Reports 

Mr. McClure called the ASAP report “the backbone of an air 

carrier ASAP program.” “The ASAP report is

the backbone of an 

air carrier ASAP

program”

US Airways has based their ASAP reports on the British Airways 

equivalent reporting system. There are 58 mandatory reports 

relating to flight safety concerns or FAR deviations in three 

categories: Air Safety, Cabin Safety, and Disruptive Passenger 

Incident. Crews must file a report within 24 hours. 

The airline offers several incentives for reporting incidents: 

• Sole source protection 

• A non-punitive approach to corrective action (FAA also) 

• Confidentiality “[ASAP] maximizes

the input of 

employees as an

airline’s most

valuable safety 

resource” 

• Anonymity after corrective action 

ASAP’s Value to the Airline 

Mr. McClure said the bottom line is that ASAP: 

• Maximizes the input of employees as an airline’s most 

valuable safety resource. 

• Offers a corrective action approach to resolve safety

problems, and prevent incidents and accidents. 

• Is cost-effective since investigative expenses (such as 

$30K to defend US Airways, and $60K for the FAA to 

prosecute) can be applied to corrective and safety

initiatives. 

• Shows mutual trust and a cross-disciplined approach to 

problem solving is key to the success of the program. 

ASAP’s Value to the Airline Industry 

Once ASAP is implemented and operating, the potential value is 

that since safety problems are more readily identified and resolved, 

the result is improved accident and incident prevention strategies. 

Mr. McClure said this in turn leads to: 

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• Sharing strategies industry-wide

• Promoting FAA compliance through corrective actions 

• NTSB assistance through proactive accident prevention 

recommendations 

• Improvements in NAS (National Airspace System) 

operations 

Sharing Information Improves Safety 

US Airways communicates ASAP findings through several 

publications. Mr. McClure gave examples of lessons learned, an 

altitude awareness alert, and a pilot safety bulletin (joint 

publication with ALPA). He pointed to the impact of these 

publications in reducing the number of altitude deviations at US 

Airways. 

“ASAP is not an

immunity program” 

He concluded by saying an ASAP program is not an immunity

program and it does not apply to deliberate acts or criminal

activities. Rather it is a pro-active, corrective action safety program 

that requires a commitment from all stakeholders. 

Panel Discussion 

After concluding their presentations, the speakers formed a panel

and answered questions from the audience. Questions are 

identified by stakeholder group. 

Q: (Union participant to Hank Krakowski) What’s the difference 

between deliberate and non-deliberate actions? 

A: If a pilot overshoots a landing the incident is a judgment call, 

not a deliberate act. If a maintenance worker disregards a sign not 

to turn on an auxiliary power unit (APU), this is a deliberate act. 

The FAA/union/company representatives decide if an individual 

has crossed the threshold.

“They’re not 

interested in attacking

the individual but in 

finding out if it’s a 

system problem. Fix 

the system, not the

individual”

(Don McClure) – We worked on defining intentional and willful. 

Deliberate is when you know what your job duties are and don’t do 

them. The FAA relies on a three-person panel to decide if an 

incident is deliberate or not. 

(Christopher Hart) – Regulations are broad. We need three groups 

working together to decide and make sure everyone’s interests are 

represented. 

Q: (Union participant to Don McClure) How do you get around 

confidentiality in using event recorder information? 

A: We have stringent requirements in getting raw flight data. It’s

de-identified and the only person who knows the names is the 

ALPA representative. You can’t take a recorded event and use it

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for discipline. Part 13 of the Federal regulations say that the FAA 

can’t use data from FOQA against an employee. Companies are 

the same. They’re not interested in attacking the individual but in 

finding out if it’s a system problem. Fix the system, not the 

individual. Find out what’s causing the problem, educate the 

group, and see results. 

Q: (Union participant to Don McClure) How do you ensure 

recorded information won’t be used for prosecution? What is the 

recourse if it’s used? What are the consequences if data security is 

breached? How do you contact the crew? “If security is

breached we pull

the plug on the

program”

A: The ALPA gatekeeper can talk to the crew if needed. If

security is breached we pull the plug on the program. There have

been few, if any, breaches and the program hasn’t been shut down. 

Q: (Union participant to Hank Krakowski) How are decisions 

made by the three-member panel and how are decisions made? 

A: At United two out of three need to agree. 

(Don McClure) – Advisory circulars say it is a consensual process. 

The FAA has a final say if the panel is deadlocked. 

(Christopher Hart) – It’s rare that the FAA does this. 

Q: (Government participant to Don McClure) At what level is the 

FAA involved? 

A: The top level. 

(Hank Krakowski) – This gives the FAA insight into carrier operations. 

Q: (Union participant to Don McClure) What is the difference 

between mandatory reporting events and voluntary reporting? 

A: Mandatory events are the ones we want you to report. 

Voluntary is for participation by carriers. There are only a few 

carriers that don’t have a list of mandatory reporting events. 

Q: (Government participant to Hank Krakowski) If there was no 

safety program and an aircraft experienced an unstable approach 

at an airport, how much would safety be a factor and how much 

economics because the company took a productivity hit? 

“It’s not an

economic issue,

it’s about safety” A: From a moral point of view we don’t want crews to be put in 

this position. It’s not an economic issue, it’s about safety. 

Corporations are committed to safety. 

(Don McClure) – Flight crews do their best to assess risk, and then 

factor in economic and safety impacts. 

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4. LESSONS LEARNED FROM EXISTING RAIL 

INITIATIVES 

The second panel of speakers discussed lessons learned from close 

calls in the rail industry. 

• Aidan Nelson, Confidential Reporting: the U.K. Rail 

Experience. 

• Professor Helen Muir, Impact of CIRAS on the U.K. 

Rail Industry.

• John Grundmann, Burlington Northern/Santa Fe

(BNSF) Safety Hotline.

There was a question and answer session for all panelists at the end 

of the presentations. 

This section summarizes each speaker’s presentation. To view the 

full text of the PowerPoint presentation, see the appendices of 

these Proceedings. 

Confidential Reporting: the U.K. Rail Experience - Aidan 

Nelson 

Policy and Standards Director, Railway Safety and Standards 

Board, United Kingdom 

Mr. Nelson is the Policy and Standards Director of the Railway 

Safety and Standards Board (RSSB) in the United Kingdom. The 

not-for-profit industry board is owned by the rail safety industry 

and supported by the Safety Advisory Committee and the unions. 

Mr. Nelson’s presentation focused on confidential reporting of 

railway accidents. 

Responsibilities for Accidents 

Mr. Nelson quoted how engine drivers complain of the placement 

of signals and that only rarely, or after an accident occurs are 

improvements made. When a fatal accident occurs the railway

servants are liable for manslaughter, while the railway companies 

who are really to blame for providing defective equipment escape 

Aidan Nelson, RSSB 

(United Kingdom)

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“scott-free.” Mr. Nelson said his source was Safe Railway 

Working by Clement Stretton, published in 1893. He questioned if 

anything had changed between then and now relating to accident 

liability – the company or the individual. 

A Pilot Reporting System 

In June 1999 a pilot Confidential Incident Reporting and Analysis 

System (CIRAS) was established in Scotland at the University of 

Strathclyde. The railway industry supported CIRAS in principle 

but did not include program funding in their business plans. 

Developing a National CIRAS 

Mr. Nelson said a catastrophic railway accident at Ladbroke Grove 

generated parliamentary interest in CIRAS. Over 70 railway

companies have now committed to supporting CIRAS. 

CIRAS is operated by a broad-based industry steering group, 

chaired by Mr. Nelson. There is currently 77,000 railway staff 

enrolled, with 80,000 forecasted for 2003/2004. CIRAS operates 

across organizational boundaries. 

“CIRAS operates across 

organizational

boundaries” 

Mr. Nelson pointed out cost concerns over mailing out the CIRAS 

journal four times a year to all enrollees. He said a core service

provider is contracted nationally by the RSSB and that this is a

challenge because of the European Union. Regional centers are 

funded by a levy on the number or enrollees. 

CIRAS Challenges 

Mr. Nelson said the transition from an academic pilot program to a 

“Issues o national program was “not without pain.” f

confidentiality led to

the creation of a trust 

to own the data and

license the system” 

Confidentiality 

He cautioned the audience about intellectual property rights (IPR) 

in a commercial environment and how issues of confidentiality led 

to the creation of a trust to own the data and license the system. 

He also cautioned about the need to test CIRAS to ensure it is 

confidential. 

Cost

Cost reduction was still an issue and there was a need to creatively

count the number of CIRAS enrollees. One suggestion was not to 

fully count the people performing the work. 

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Commitment 

Mr. Nelson stressed the need to commit to CIRAS through a 

Railway Group Safety Plan. He said the Railway Group Standard 

is an industry standard mandating enrollment of safety critical staff 

employed by network and train operators (Railway Group) in 

CIRAS. The challenge is to handle the supply chain to Railway

Group members within a contractual framework. 

Mr. Nelson said some organizations still feel they don’t need 

CIRAS. Of the organizations that do subscribe, he said there is 

still a widely held management concern that “blame is alive and 

well.” He cautioned about local managers keeping the supply of 

CIRAS forms under surveillance. 

“There is still a widely

held management

concern that blame is

alive and well” 

Quality of Response

Depending on the safety climate, the managerial response to a 

CIRAS report can be defensive, rather than helping to address the

issue. This reflects the manager’s self-justification within the

organization. Mr. Nelson said an independent peer review of 

responses “raises the quality considerably.” 

Managing CIRAS

Mr. Nelson said the RSSB is the managing agent for the CIRAS 

Charitable Trust. Board members are members of CIRAS. An 

RSSB stakeholder chairs the Trust. RSSB facilitates the

independently chaired industry steering group and funds the 

independent neutral chair of that group (Professor Helen Muir; a 

fellow panelist at this workshop). Mr. Nelson stressed the 

importance of the governance of CIRAS being separate from the

management of CIRAS. 

Funding costs for the core CIRAS facility are ₤0.75 million 

($1.25M). Mr. Nelson said costs are recovered from the general 

funding of RSSB. 

RSSB takes an annual census of enrolled staff and researches the 

effectiveness of CIRAS. The Board also responds to issues 

relating to rulebook or standards ambiguity 

RSSB’s CIRAS Committee 

RSSB’s newly formed CIRAS committee focuses on RSSB’s

safety leadership role within the rail industry. Mr. Nelson said the 

committee represents all rail sectors. 

The committee works principally from CIRAS national report data, 

cross-referenced with industry safety performance data. 

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Additional analyses are requested from the CIRAS core facility as

needed. Mr. Nelson pointed out the risk of data overload. 

The committee determines and then monitors RSSB actions in 

response to safety issues by identifying key issues for research, 

influencing national initiatives and standards of the Railway Group 

Safety Plan, identifying sources of risk, and initiating topic-based 

workshops. 

“Don’t underestimate 

management

challenges – you’re

likely to fail if you do” 

Future Challenges 

Mr. Nelson stressed the need for all parties to accept that there are 

challenges. “Don’t underestimate management challenges – you’re

likely to fail if you do.” “For CIRAS to be

successful the

champion and lead 

development must

come from within the

industry” 

CIRAS is an “integral component of a wider human error 

management program rather than a bolt on attachment.” 

For CIRAS to be successful, the champion and lead development 

must come from within the industry. This creates ownership and 

minimizes skepticism. 

Mr. Nelson said the greatest skeptics are the U.K. regulators and 

junior and middle managers because RSSB hasn’t yet sold the 

system to them. “It’s about attitudes, beliefs, and behaviors.”

In conclusion, Mr. Nelson said “CIRAS is effective when everyone 

is in it together for a highly safe railroad.” 

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Impact of CIRAS on the U.K. Rail Industry - Helen Muir 

Professor of Aerospace Psychology, Cranfield University 

Professor Muir is Professor of Aerospace Psychology and Head of 

the Department of Human Factors and Air Transport at Cranfield 

University in the United Kingdom. 

Helen Muir,

Cranfield University

(United Kingdom)

Professor Muir was recruited by the rail industry to oversee the 

Railway industry’s Confidential Incident and Analysis Reporting 

System (CIRAS). She is currently Chair of the CIRAS National 

Steering Committee, which is developing tools for rail confidential

incident reporting. Professor Muir’s presentation focused on the 

impact of CIRAS on the rail industry. 

What is CIRAS 

Professor Muir described CIRAS as an independent facility that

rail industry employees can confidentially report safety-related 

concerns to, and expect a response. The expectation is that by

analyzing CIRAS reports, the end result will be a positive

contribution to a safer railway system in the U.K. 

“CIRAS is an

independent facility

that rail industry 

employees can 

confidentially report 

safety-related 

concerns to, and 

expect a response” 

Since November 1999, 77,000 rail industry staff have been 

enrolled and briefed in CIRAS, 2,500 reports have been submitted, 

and an independent audit has showed no breaches of 

confidentiality.

The Challenge 

After a serious rail accident at Ladbroke Grove the U.K. Rail 

Industry made the decision to develop a national reporting scheme. 

Professor Muir pointed out that although CIRAS sounded like a 

good idea theoretically, there was some initial reticence from parts 

of the industry. 

The challenge was to obtain buy-in from the various industry

groups that CIRAS would be entirely confidential, and then 

develop a CIRAS infrastructure. 

• Initially an Implementation Group representing all 

industry groups (unions, train operating companies, 

maintenance companies, rail authorities and independent 

technical consultants) developed the system. 

• A Steering Committee with representatives from all 

stakeholders then took over and is responsible for the 

overall management of the system. 

• An independent Charitable Trust was established to be 

the custodians of the CIRAS data. 

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National Database and Regional Centers 

Professor Muir said the U.K. National system was based on a 

successful pilot CIRAS scheme that had been developed in 

Scotland, using face-to-face interviews. She pointed out the human 

factors benefit of this approach had been that people were able to 

talk to each other face to face. 

The Implementation Group who developed the National Scheme 

divided the country into three regions to reflect the regional 

cultures. These were administered by different organizations: a 

university, a consultant, and a government agency. Regional 

liaison groups (representing the companies and unions) addressed 

safety issues reported. 

Professor Muir recommended assessing a system that would work 

well in the United States, based on regional differences, saying

“our plan is not necessarily your plan”. In the U.K., the regional 

administrators all followed the same standards but had different 

approaches to the business processes. Professor Muir pointed out 

there may be one regional center in the future. 

“Our plan is not 

necessarily your plan” 

Reporting Process

The CIRAS Journal is mailed to all railway staff enrolled in 

CIRAS. On the back of each journal is a form for reporting a safety

related incident or situation to CIRAS. Alternatively, individuals 

can use a toll free phone number to report the same information. 

The name, address, and phone number listed on these forms or 

reported by phone is confidential and is not input into CIRAS. 

Forms are returned to individuals after data is collected. Within a

month the report must be input into a National CIRAS database, 

managed by the CIRAS Charitable Trust. 

“[CIRAS] journals are

a way to keep the 

system alive” 

Professor Muir pointed out that “[CIRAS} journals are a way to

keep the system alive” and that people are reading them. 

Feedback

CIRAS generates several reports: 

• National Report. A semi-annual update on CIRAS 

database information and new safety concerns relevant 

to staff in other areas, sent to railway companies and the 

unions 

• Company reports 

• Sector topic reports 

In addition, responses to previously reported incidents are reported 

in the CIRAS Journal. 

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Who Enrolls in CIRAS? 

• Main contractors; drivers, signalers, safety-critical and 

safety-related staff. 

• Railway infrastructure contractors and subcontractors. 

• Infrastructure staff nationwide. Since this group of 

80,000 is highly mobile, a fourth center, in addition to 

the three regional centers, will be operational later in 

2003. 

National Standards 

Professor Muir said the CIRAS database is audited to ensure

confidentiality of reported information. Railway staff are also 

briefed about security using training videos and manuals, to 

reassure individuals that their personal data is secure. 

“The CIRAS database 

is audited to ensure

confidentiality of

reported information” 

CIRAS Principles

Professor Muir listed the principles governing CIRAS: 

• Accept reports from any rail industry employee. 

• Accept any safety related subject relating to employee

health and any human factors aspects of engineering and 

“C operations. IRAS is in addition

to company reporting 

systems” • CIRAS is in addition to company reporting systems. 

• Keep personal information of reporters confidential. 

• Make personal responses available to employees of

participating companies.

• Do not process real time reports. 

• Make information the property of the CIRAS National 

Trust. 

• The National Steering Group will determine how 

CIRAS will operate

Company Obligations 

Professor Muir listed the obligations of companies participating in 

CIRAS:

• Commit sufficient resources to prepare considered

responses to reports. 

• Nominate a point of contact from the company.

• Promote CIRAS through briefings and other means. 

• Pay subscriptions on time. 

• Support the National Steering Group. 

Deliverables 

Professor Muir listed CIRAS deliverables to stakeholders: 

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• Provide managers with safety insights and best 

practices. 

• Provide analyzed CIRAS reports. 

• Function as an outlet for responding to individual safetyrelated issues. Professor Muir said unions believe very

strongly in this service.

• Assist managers in prioritizing actions agreed to in 

safety plans, which contribute to the Railway Group 

Safety Plan. 

How is CIRAS Used?

Railway company managers and the unions use CIRAS 

information in different ways: 

• RSSB uses it to identify underlying deficiencies and 

trends at an industry level and as input into strategic 

planning. 

• Unions use it as a communication tool and to promote a 

positive safety culture. “Unions use [CIRAS} 

as a communication 

tool and to promote a

positive safety

culture” 

• Train operating companies use it to see if specific

concerns have been addressed after submitting reports to 

CIRAS, and to share information and best practices

among companies. 

• Track maintenance contractors and the London 

Underground use it to tackle cross-company issues. 

Professor Muir said the London Underground found this 

aspect of CIRAS “extremely useful.” 

How Effective is CIRAS? 

A recent independent review of CIRAS effectiveness by an 

independent market research company found a high level of 

awareness of CIRAS and its broad purpose. 

• Professor Muir said that “overall, CIRAS was seen as 

independent from the rail companies” and “the 

confidentiality of the CIRAS organization was never in 

doubt.” 

“Overall, CIRAS was

seen as independent

from the rail

companies and the 

confidentiality of the 

CIRAS organization

was never in doubt”

• CIRAS was generally seen as effective in raising the

awareness of safety issues, being a safety valve for staff, 

and shaming some companies into action. 

• There was strong support for the CIRAS Journal – it is 

viewed as very effective and worth the cost. 

However, CIRAS was not always found to be effective in 

generating an acceptable response from companies or in resolving

issues resulting in tangible improvements. 

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Achievements 

Professor Muir pointed to several major achievements: 

• Establishing a confidential national reporting system

used by thousands of railway staff and supported by

industry.

“The secret has been 

getting everyone

together at the

beginning” • Establishing trust among the stakeholders. 

Professor Muir said “the secret has been getting everyone together

at the beginning so they can build the system themselves” and 

added “this sends a clear message out to employees and industry

that the Railway industry cares about safety.”

She continued “the existence and support for a confidential 

reporting system enables the railway industry to provide a clear 

demonstration of its commitment to safety to both staff and to the

traveling public.”

“The challenge will be

to open CIRAS to 

more individuals and

organizations, at the 

same time as 

ensuring that at no 

stage, data

confidentiality is

breached ” 

Future Challenges 

Professor Muir noted that as the rail industry changes, so too must 

CIRAS. She gave the example of contract changes for train 

operating companies impacting the regional structure of CIRAS. 

Other challenges include operating costs; Professor Muir said 

CIRAS journals are being reviewed to determine if costs can be

reduced without any impact on quality. 

In conclusion, Professor Muir said that data collection is an ongoing process and that the challenge will be to open CIRAS to 

more individuals and organizations, at the same time as ensuring

that at no stage, data confidentiality is breached. 

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BNSF Safety Hotline: Near Miss Information to Create a 

Safety Working Environment - John Grundmann 

Assistant Vice President Systems Safety, Burlington Northern 

Santa Fe Railway

John Grundmann is Assistant Vice President for Safety and 

Operations Support at the Burlington Northern Santa Fe Railway 

(BNSF). Mr. Grundmann is responsible for setting safety 

improvement and program development strategy, and for the field 

safety strategy implementation group, the grade crossing safety 

group, and safety reporting to BNSF and FRA. He is also 

responsible for dispatcher manpower planning, scheduling, and 

workload balancing. 

Mr. Grundmann’s presentation highlighted the implementation of a 

BNSF call reporting system. John Grundmann, 

BNSF System Safety Hotline 

BNSF implemented a system safety hotline in the early 1990s to 

provide employees with a voice to improve the company’s safety

and working conditions. The hotline developed from a

periodically reviewed voice mailbox to a live person-staffed callanswering center. 

The hotline was designed to capture calls in several safety

categories; policy, contractors (for example, contractors at on-site 

track work not complying with safety rules), policy problem 

solving (for example, changing the reimbursement policy for

purchasing safety boots), environmental conditions, and quality of 

life (for example, lighting issues). These categories have since 

been expanded. 

“The original intention

of the hotline was not

to solely capture “near

misses” 

Our goal was to provide a communication channel between front 

line employees and senior management, to relay their concerns. 

Mr. Grundmann said the original intention of the hotline was not to 

solely capture “near misses.” However, they do get one “near 

miss” call every two to three months, such as a train being

switched to a track with another train on it, but which did not result 

in an accident. 

Each of the 13 divisions within BNSF has its own hotline.

Current procedures are unable to provide complete confidentiality,

since Federal regulations require the employer to decertify an 

employee once it becomes aware of an infraction. Some of the 

calls received could result in employees being ‘decertified’ 

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because of a violation. Mr. Grundmann said “we are trying to get 

groups to come up with alternative disciplinary actions.” 

800# Safety Hotline Protocol 

Hotline calls are handled as follows: 

1. An employee calls the hotline.

2. A third party receives the call and assigns a case number, 

so that the employee can call back later or can be contacted 

(by the third-party person). 

3. The third party classifies the call in one of five categories, 

and forwards the call to the responsible party within the 

railroad. 

4. The responsible party sends written confirmation to the 

third party once the issue is resolved. 

5. A report is generated weekly and sent to senior 

management. 

6. Audits on randomly selected cases ensure that corrections 

described in the confirmation were actually implemented. 

7. Safety-related calls are sifted out from the hotline calls. 

This system ensures a short turnaround. Parties responsible have 

only until the next Friday (up to six business days) to receive an 

answer. Unanswered calls are included in the weekly reports sent

to the senior management and may get “high visibility,” resulting

in a “Why wasn’t this answered?!” response. 

“There is less than 

one failure for every 

200 million possible 

incidents – this is

phenomenal!” Mr. Grundmann gave the following example of using the hotline 

protocol to resolve a call. After a crew van nearly backed over an 

employee, the issue was resolved by rearranging the employee

pick-up area so that the van no longer had to back up. Some other 

situations may not be so easily resolved, but Mr. Grundmann said 

progress is being made. 

Benefits 

Mr. Grundmann pointed out the following benefits since the 

hotline was implemented: 

• There are significantly fewer ‘adversarial’

confrontations between groups. 

• A measure of the ‘true failure rate’ is that there is less 

than one failure for every 200 million possible incidents 

– this is phenomenal! 

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• The number of calls has dropped from hundreds per 

week to dozens per week. 

• Supervision is more direct. 

Future Challenges 

Mr. Grundmann noted there are still challenges for the BNSF

hotline.

• With 13 hotlines for the 13 divisions, data can be lost 

since the system is decentralized. 

• There needs to be better agreement on what is a “near 

“There needs miss.” to be 

better agreement on 

what is a near miss” 

• “We often don’t get enough information to provide a 

real and true analysis on a situation to provide the best 

solution.” 

Next Steps 

Mr. Grundmann said that BNSF is looking at the following hotline 

improvements: 

• Request employees to report near miss events on the 

hotline.

• Capture near miss calls as a separate category or place 

them in a different database. 

• Problem solve near misses for “best practices” solutions. 

• Distribute reports to all affected locations and 

employees. 

BNSF is also looking at partnering with other railroads to pull 

together resources and identify trends from aggregated

information. 

Mr. Grundmann said even though event recorder downloads have 

been used more punitively in the past, they can also be used as a

diagnostic tool to determine equipment problems as well as 

procedures. 

Panel Discussion 

After concluding their presentations, the speakers formed a panel

and answered questions from the audience. Questions are 

“The investigators identified by stakeholder group. 

found out that no one

will give out names –

an effective wall!” 

Q: (Industry participant to Aidan Nelson) You said that 2,500 

reports were collected. Have you seen any trends, yet? Also, if a 

lawyer requests information, are you obligated to give it? 

A: We have done a basic analysis on the data. The two reports 

provided on the CD (for this workshop) provide our findings so 

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far. On the lawyer question, the issue has not come up in civil 

suits. There have been more legal investigations. The 

investigators found out that no one will give out names – an 

effective wall!

Q: (Union participant to John Grundmann) You mentioned that 

there was a maximum of 14 days before something could be taken 

care of? Can you explain? 

A: This is the maximum period of time that a call can go on the

report without being addressed by senior management, but not 

necessarily taken care of. However, I have never seen an item 

linger on a report. 

Q: (Industry participant to John Grundmann) Can you address 

whether your reporting system is adding to the complexity of the 

procedures in your railroad? 

A: There is a single rulebook that is getting more complex. This 

is an issue with us. We plan to do a poll with local engineers then 

consult with the FRA to stay in compliance.

Q: (Industry participant to Aidan Nelson) Is there one U.K. 

operations rulebook? “I wish that executives 

had to see people

telling families of

losses” 

Yes, but it is complex and over 250 pages. 

Q: (Government participant to Aidan Nelson) Since the 

privatization of British Rail, there have been well-publicized

accidents, but really no incidents have taken place. What do you 

attribute safety improvement to in the last decade? 

A: We had a major accident in the 1980’s. A lot of initiatives went 

into place in 1994. We have made progress in many areas. We are 

now a lot smarter with human factors in accidents. I wish that 

executives had to see people telling families of losses. 

(Helen Muir) Generally, we have understood more of how to 

make safer systems. Engineers have become better in 

understanding what makes a safe system. We’re now working on 

human factors. The data has helped a lot. 

Q: (Union participant to John Grundmann) I am interested in 

Aidan and Helen’s program because the response could be 

monitored and the program could be made better from those 

responses. Does BNSF’s system have this same level of 

monitoring? 

A: It has, but it is not as rigorous. There are no formal quality

checks. It is done through the third party. When the third party

was brought on, training was tight to get them up to speed on the 

knowledge of railroad terms, issues, and so forth. 

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(Helen Muir) – You must bring the third parties to the same

knowledge level for the system to work. “You must bring the 

third parties to the

same knowledge 

level for the system 

to work” 

Q: (Government participant to John Grundmann) To get ‘buy-ins’ 

from the railroad industry in developing their database, which is 

the driver that develops memorandums of understanding? 

A: The Safety department is the driver, separate from the

operations department. 

Q: (Industry participant to John Grundmann) You mentioned that 

the 3rd party sifted through calls to get safety related calls. With 

responsibility delegated out, how much control did you have? 

A: The first step is safety team meetings. The escalation process 

went to the hotline if the issue wasn’t resolved. 

Q: (Industry participant to John Grundmann) Most investigations 

are what type? 

A: Facility.

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5. DISCUSSION GROUPS 

Four discussion groups, each representing a cross section of all 

stakeholders, met separately to discuss a series of questions related 

to close calls. 

A facilitator from the Volpe Center led each group discussion and 

note takers, also from the Volpe Center, recorded the discussion. 

To help identify trends, the note takers also identified the

stakeholder group (government, industry, union, or academic) 

where appropriate, not the individual’s name. 

The four groups each discussed the following questions: 

• What lessons were learned from the workshop speakers?

• What are the benefits to understanding close calls?

• What are the barriers to understanding close calls?

• What are the next steps to understanding close calls?

Discussions were lively in all groups as facilitators encouraged all 

participants to share their points of view and concerns. 

This section summarizes the combined responses from each of the 

four discussion groups to these questions. Comments are grouped 

by theme. Quotation marks and bulleted comments are quotes 

from individuals in the discussion groups. They represent exact 

quotes, except where changes were made to improve clarity or 

protect the speaker’s anonymity. 

See the apprendices for the detailed responses to questions on 

which this summary is based. 

Overview

Speaker presentations generated a high level of audience interest in 

what could be accomplished with a close call system for the 

railroad industry. 

All groups agreed that an organized approach to sharing 

information about close calls will be useful, and the right thing to 

do. The benefits will transform a reactive system to a proactive 

system. There will be a culture change from an industry that 

blames individuals for close calls and incidents, to one that focuses 

on a system that learns from information on close calls and makes 

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improvements to address accident precursors and therefore 

improves safety. 

Common themes among all groups included: 

• Track problems and create a close calls database. “This 

is the right thing to do!”

• Obtain commitment and buy-in from “each leg of the

stool” (three stakeholder groups: labor, industry

management, regulatory). 

• Develop a pilot close calls program using new model or 

an existing working model. 

• Educate all stakeholders by disseminating lessons 

learned on an ongoing basis. 

The following comments are grouped into three main sections. 

• Benefits of Understanding Close Calls 

• Barriers to a Close Call System

• Implementation Issues 

Many issues (i.e., trust) were simultaneously identified as barriers 

to a new system, issues to address in implementation, and benefits 

to be gained, if a successful system is achieved. It is an 

incremental process. As the system is established and used in a 

pilot, small steps will be taken that build confidence that change is 

possible. With that added confidence, more growth and risk-taking

is possible. 

What follows are a series of brainstormed comments, grouped 

together for relevancy. They may not be fully clarified or 

elaborated. 

Benefits of Understanding Close Calls 

Improved Collection of Data on Close Calls 

There is currently no comprehensive way to capture close call

information. A close call system will uncover a higher percentage 

of incidents from all perspectives. It would gain data otherwise lost 

from cover-ups/forgetting. It is desirable to “debrief the crew to 

identify large and small issues.” There is a need to have a system

in place to talk about issues confidentially “to enable a cathartic 

change”. 

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Close Call Incident Analysis Will Provide 

More Information and Better Solutions 

According to participants, by collecting and analyzing close call 

data railroads will be able to “pay attention to problems and enable

better solutions.” Multiple reports on the related close calls will 

give a sense of the scope of the problem, “identify systemic 

issues/problems and identify patterns”. 

The system will enable the discovery of precursors and root causes 

of accidents and incidents. By providing accurate information it

will be “easier to identify true causes and reduce the pursuit of ‘red 

herrings’ under the present system. The punishment associated 

with reporting can result in the intentional misreporting of events.”

“We will benefit from identifying real problems and pursuing real

solutions, cost effectively, rather than red herrings wastefully.” 

Through better understanding of risks the industry will uncover 

better solutions, resulting in data-driven decision making. The 

industry then will be able to “target resources to biggest problem 

and help to set priorities.”

A close call system helps identify system deficiencies, and also 

what works well. With information on close calls, railroads “can 

identify why the close call did NOT become an accident.” 

Anecdotal evidence can provide lessons learned. Close calls 

“allow industry to identify best practices.” 

Improved Safety

Close call systems help improve safety in a variety of ways. It

helps directly -- studying precursors to accidents/incidents has the 

potential of saving lives and preventing catastrophic losses. 

Design engineers will learn how to design safer systems. 

Indirectly, it “demonstrates [the industry’s] commitment to safety. 

Having fewer accidents will “improve the image of railroad 

industry and “increase public trust in railroads.” 

Safety Culture Change

According to participants, in order to introduce a close call system, 

the industry will need to begin making a variety of changes that 

will in themselves provide a variety of benefits. 

• Close call systems “convert a safety program from being

a reactive system to a proactive system.” 

• Close call systems also “sets up positive professional 

atmosphere “ and “increases accountability on all 

levels.” 

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• Employees will feel more “empowered to make

suggestions for change.” 

• [The]“system should be built with everyone updating

the process and information.” 

Close call systems make it all right to tell the truth without the 

perception of negative repercussions. “This program can break 

the negative spiral of if you tell the truth, you get disciplined and 

maybe dismissed.” “The truth does NOT set you free. The truth is 

held against you, so it breeds liars who will break the law.” In

talking about an incident, one participant said, “If there was no 

penalty for telling the truth, would he have lied? Probably not.”

In the long run, these changes should improve working conditions 

and therefore, also work attitude and morale. 

Improved Collaboration and Trust 

Collaboration and trust are also hallmarks of a good close call 

system. To have a system requires increased trust among all 

parties. 

At the same time, the installation and use of a system over time is 

itself a “mechanism for culture change from adversary to a team.” 

• Increases employee/management trust. “If you don’t 

have the trust as a foundation, all of this isn’t going to 

happen in the first place.” 

• Changes the culture from FRA being an adversary to

being part of a team. 

• Enhances cooperation between labor, management, and 

FRA and builds consensus from top to bottom. 

• Results in increased level of trust. If people trust each 

other they’re more likely to report problems without fear

of reprisals. “People have to have faith and get into real 

issues.” 

• Results in “better use of manpower if part of a team”. 

• Allows stakeholders to focus on training time and

resources since they trust information (a key issue for 

one discussion group).

Better Communication and Sharing of 

Information 

There is a need for better communication that is only possible with 

more trust. More trust will subsequently bring more open and 

honest communication. 

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• There should be better communication among railroads. 

• There is an opportunity to tap knowledge, resources, and 

expertise in industry.

• “If we have an open work place with [shared] goals of 

improvements it would be a benefit.” 

There is also a strong and related desire to share lessons learned, in 

order to avoid repeating the same mistakes. Suggestions included: 

• Publish useful information, not just information in a 

database, using a formal process (i.e., lessons learned in 

CIRAS Journal). 

• Recognize that other countries have the same problems; 

discover best practice from international sources.

Improved Cost Savings and Use of 

Resources 

Additional benefits will appear as better business practices through 

better resource allocation.

• Safety contributes to the bottom line, not just as a cost - 

follow the U.K.’s example; once safety is realized, 

benefits follow. 

• Prevention means less time lost on job and saves money

(industry). 

• Avoids litigation. Cost savings in insurance/legal claims 

- fewer claims paid out; less loss of life and injury. 

• Operating efficiency and decreased repair costs. 

• Doing business better may lead to more autonomy.

• Industry and unions can see business benefits --“A proactive response to learning leads to less regulation.” 

Barriers to Introducing and Using a Close Call System 

This topic generated the most discussion among all groups. 

Although many concerns were expressed, the groups did not 

consider them to be insurmountable obstacles. 

Some of the barriers are translated into implementation strategies, 

such as need for top-level buy in and policies relates to defining

and handling close call information. Common barriers were the 

following. 

Need Rule Waivers 

There exist serious legal impediments to implementing a close call 

system in the current environment. Any progress will require a

change in regulations. 

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FELA is a fault-based system. There is a perception of the “blame 

game” with everyone blaming everyone else for accidents. 

One participant stated, “Right now, if I see that someone is 

speeding, then I have to decertify him. Are there other ways

around it?” FRA will need to “give relief on the punitive part of 

CFR240 – there needs to be a cooperative spirit.” 

One industry participant said, “[I would] prefer to talk to a jury

saying that I am aware of this situation [safety injury situations] 

and am trying to resolve them, than say we know nothing about it.” 

Need a Culture Change 

There is a need for new paradigm to balance substance and 

procedures. There is a long history of distrust among all parties. 

“There is a lack of trust, integrity, and patience.” 

The following table reflects comments made at the workshop 

regarding how the three stakeholder groups view each other. 

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Stakeholder Perception of Each Other: Sample Comments 

Stakeholder FRA Industry Labor

FRA perception 

of: 

Railroads don’t want 

anyone in their business.

There is a huge 

bureaucracy of railroads. 

I can’t see how a railroad

like ___ can implement 

things if they “lose things” 

as it is...

It is hard to move from an 

adversarial stance of a 

“them versus us” culture 

and a long term “code of

silence.”

Industry

management 

perception of:

Most transportation

people don’t trust the

FRA

There is a history of

inaction and a long line of

failed programs

Employees think

everything is to be

blamed on working 

conditions.

According to a manager

from industry, labor

leaders “take away [more] 

control” than the industry

would like.”

Labor perception

of: 

Most transportation

people don’t trust the

FRA.

There is a perceived 

self-interest of

regulators by unions. 

There is a fear of

regulations and 

increased audits. 

A current militaristic

disciplinary process.

Humans will err, but

industry thinks everything

is a human factor. Industry

says, “it’s the employee’s

fault”. 

Unions are concerned

about internal punitive

actions. 

First Line supervisors will

beat up on me. 

Management focus on 

statistics.

Workers fear litigation if

they report close call. 

Some of the other rifts are between employees and management in 

all groups. “Then there is also trouble between railroads (i.e., 

Short lines and Class lines).”

One participant said, “We need an independent third party [to 

facilitate] since it’s difficult to move away from the traditional 

adversarial stance.” 

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Risks to Confidentiality 

Everyone agreed that even though confidentiality would be hard to 

achieve it is very important. There were fears about breaches in

confidentiality and the resulting impact, especially since

confidentiality has been breached in the past. Participants said

they want to protect information from attorneys (as part of 

discovery), punitive use by railroads or Federal agencies, and the

media. 

“True confidentiality is hard to achieve, there would have to be 

quality control.” “The third party collecting data should be getting

data not specifically for one company, but for the different major 

carriers, so they don’t know where the incidents happened.” 

Safety Not Rewarded by Industry in Ways 

that Count 

Some believe that, “Safety is not on the decision maker’s 

scorecard; [performance evaluations is] measured on productivity

more than safety.” “The conflict is that performance is measured 

on productivity – the trainmaster is told to get that train out!” 

“Some CEOs want to reduce number of injuries to make statistics 

look better. The result is a cover up.” In some railroads, 

“managers are rewarded for reported safety statistics. This creates 

incentives for not reporting incidents.” 

Individual Resistance to Change 

There was concern that “most workers are unwilling to change.” 

Each person will want to know, “what’s in it for me?”

There was also concern that some resistance may be due to a belief 

that there will not be a long-term commitment to close calls. The

industry has a history of failed programs. “I don’t think the union 

would buy into the program, they would think it is the ‘flavor of

the month’.” 

Funding/Resources 

There were a variety of concerns about the resource implications of 

instituting a close call system. 

• Initial loss of productivity

• We need financial support - who will pay?

• Will we spend more money on safety? This may

displace other safety activities 

• Lack of technology to collect data

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Measuring Return on Investment

It seems important to be able to document the business benefits of 

other close call systems. We “need to build a different business 

plan for each of the stakeholders.” 

When running a pilot project, use it to prove the business benefits 

of a close call system for the railroad industry. “If you cannot 

make the business case (benefit) you cannot sell the system.” 

According to an industry representative, we “need OBJECTIVE 

info to “sell” to senior management -- ‘You are asking me to 

spend money and can’t tell me if the program is successful? -- You 

have to objectively prove that it will work!’ ” 

Some felt that “it may be difficult to apply lessons learned from 

airlines to railroads. Methods of operation are different and 

potential benefits to railroads less than airline benefits.” For

example, “in the airline industry, if something goes wrong, the rest 

of the system doesn’t shut down (for example, a hydraulic pump 

on a plane doesn’t shut down the hydraulic system in the plane – 

there is usually a ‘back up’ system that keeps the plane running). 

In the rail industry, if something goes wrong, the system shuts 

down in ‘safe-mode.’ This might affect implementation.” An 

academic rebutted these comments by saying “Pilots still break 

rules.” 

Implementation Issues

All groups, although concerned about the potential barriers to 

success, recommended that the industry should go forward and 

consider incorporating a plan to reduce and overcome barriers. 

Critical Success Measures for Close Call 

System

Even though discussion group remarks were very diverse, several 

key critical success measures were repeated across all groups. 

• Obtain stakeholder buy-in 

• Develop a model pilot program 

• Simplify rules and guidelines 

• Improve collaboration and trust 

• Improve ongoing communication and sharing of 

information 

The following issues related to the suggested next steps in creating

a system for understanding and analyzing close calls. 

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Obtain Stakeholder Buy-In 

All agreed that to move forward we “need buy in from 

EVERYONE.” The following suggestions were made: 

• Top management support from all stakeholder groups is 

critical; sell the idea to the CEO. 

• According to a union representative, there is a need to

“facilitate local worker involvement. We need people 

on the ground to buy in and feel trust and be part of the 

process.” 

• Also need top/middle/bottom buy-in. 

• First line management can help solve problems. In the 

U.K., middle management is a barrier to coordination 

between boardroom and shop floor. 

• “Get buy-in from the FRA from the get-go.”

• “We have someone governed by FTA. They [the FTA]

probably need to be represented here, as well.” 

There was a difference of opinion about whether to solicit support 

from Congress to address liability issues. An industry

representative said, “we need to have Congress pass a mandate to 

drive this program. When someone said. “no, we don’t want 

Congress to mandate it to the FRA.” The response was “we three 

need to come together first, then go to Congress to get their 

support.“ 

Not only is there a need for participation by all stakeholders, there 

is a related hope for “equality/parity by all stakeholders.” Also, all 

stakeholders need to be involved from the beginning. 

• There was also support to identify individuals or a small 

team, including all stakeholders, to champion the 

system. We “need a champion within the industry, who 

will push it through ‘thick and thin’.”

• The participants also felt that, we need “mutually

beneficial solutions”. “Customize ‘what’s in it for me’

to each stakeholder.” 

• Encourage risk taking as first step. Next, help 

stakeholders become committed to change and 

participate actively in it. 

Develop a Model Pilot Program 

The following issues were identified as needing to be addressed in 

planning a close call pilot system. 

Establish pilot site(s) 

• “See if you get any takers for a pilot program.” 

Consider pilot programs in different venues/locations 

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(e.g. short lines, Class 1, passenger, switching). 

“Identify individual to “find” and broker a close call 

system and set up framework.” 

• Use aviation industry for benchmarks/case studies;

“Don’t reinvent the wheel - use FAA GAIN Program as 

guide.” “The U.K. CIRAS model is valuable for setting

up close calls across the railroad industry and share 

information.” 

• “Move away from passenger versus freight – every

program has failed when we try to split them up. We

have to do it, together,” said a union representative. 

Get commitment and agreement from all 

stakeholders 

• When developing a pilot test program, “obtain 

commitment/buy-in from top management of all 

stakeholder groups.” 

• “Get an agreement of the mission statement of the goals 

of the pilot program from all stakeholder groups.” 

Use other organizations as models

• Understand which government programs are successful

and pass on this information. 

• Look at NTSB as a model -- they don’t prevent, they

investigate using retrospective studies and safety teams. 

They have a different data collecting process, but their 

information is good 

Learn from our own experience in this area 

• “Coordinate with other efforts already underway. We

do have safety culture committees in the northern region 

of my railroad...they have employee evaluation forms 

done anonymously by other employees that try to 

uncover worker issues. We use it for testing,

programming and training.” 

• Form groups to look at existing data to identify

problems (e.g., SOFA (Switching Operations Fatality

Analysis), SACPs (Safety Assurance and Compliance 

Programs), RSAC (Railroad Safety Advisory

Committee) 

Set expectations up front 

• “Don’t look for too much right away. Start small; build 

from successes. If you start big, there will be too many

problems at the start. If we start small, we will be able

to gradually build on it.” 

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• What is an objective measure of success? Research

“how to measure success”; we need an objective way.

Keep stakeholders involved throughout pilot 

• “We need a summit meeting of stakeholders to keep this 

going. FRA is the governor.” 

• Identify the process and resources required. “The 

government pays for initial phase.” “Develop a

Memorandum of Understanding between unions, 

management, and FRA.” 

 Collect lessons learned 

• Compile lessons learned study across and within 

industry to show value of the system. “Best practices 

are out there but not nationwide”. 

• Include cultural problems in lessons learned. 

Determine Data Collection Mechanism

There were many suggestions related to data collection issuers. 

Information to collect

“Systematically collect data about close calls so it can be seen that 

certain situations would help other systems having the same types 

of issues.” Determine data needed and how it will be used. There

needs to be specifics on what type of data needs to be collected, an 

objective way to show the information collected. Collect

information on: 

• Why the close call occurred 

• Why is it acceptable to co-workers and managers

• Frequency of occurrence

• Where and when does this occur 

• Type of equipment 

• Worker profile 

How to collect data

Develop standardized operating rules and procedures (template)

for capturing all relevant information on incidents and train people 

in utilizing these procedures. 

Address confidentiality issue 

• Address data liability and confidentiality issues – 

“truthful reporting is not a numbers game.” Data should 

be administered by third party outside the industry to 

“push beyond the barriers”. This could be either an 

outside academic consultant, such as Aidan Nelson, or 

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government agencies, such as USCG, 

FHWA/FTA/Volpe. The third party should be nonregulatory and non-enforcing, and have some railroad 

knowledge. 

• Get reporters of close calls to do it truthfully [by good 

forms and training]. “I don’t think that these guys are 

‘liars.’ It [incorrect information] is often due to 

ignorance of how to fill out forms, confusing fields, 

non-uniform filling out of things”. 

Use a third party to collect data

• Have third party document best practices. “There are 

places that you can identify by the type of situations -- 

everyone will know which facility the incident occurred 

at.” 

• “How do you know if data is legitimate?” There was 

concern expressed for legitimacy of data reported,

quality control - people might turn others in if they are 

mad at them. Anticipate how to test the system. 

Need Close Call Definitions 

Participants had questions about what fits the close call definition. 

• A “close call” is subjective in eyes of person – what is a 

close call? People have options in defining it. They

have to decide whether it is more beneficial is to call an 

incident a “close call” or “injury.” 

• An industry representative asked, “How do I know if 

info applies to my railroad” “If the information gets to a

national level; how do I know if it applies to my

company?” Another responded, “set process to see if it 

will apply to your company; ask people on the ground if 

it’s a problem in their company and will this information 

help them.” 

• “Set up operating rules nationwide.” There is a lack of 

policy specifics relating to close call information. 

Another said, “One size does not fit all.” There are 

many technical differences between companies; this

means some companies have a data advantage over 

others. 

Adapt or Improve Rules, and Policies and

Guidelines 

There were many comments related to this area throughout the 

workshop. 

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• Get rid of autocratic regulations. Agencies need to take a 

look at the rules that are really successful. We need a 

“no reprisal” system for employees; for example, work 

with FRA about making 49CFR 240 more flexible. 

• “There is tension between the pursuit of safety and 

production objectives,” said by an industry

representative. [Reassess Human Resources programs 

and] reward managers for improvements in safety.

• Need better operating procedures/processes. Rules need 

to cover each close call scenario. Evaluate problems 

with policy and procedure. Need to simplify practices. 

Rules are complex and operators have information 

overload. Make it easier to understand written rules. 

Improve Training

A number of training issues were raised, many related to recent 

changes in the industry.

• Promote training for continuity and follow-through. 

• Training is more of a challenge now than it has ever 

been. With a smaller number of crews there are fewer 

resources for new employees. Industry is also changing

from “old heads”, with a history of generations of 

families working for the railroad, being replaced by

those with no family railroad employment history with 

people with whom they could learn and discuss issues. 

• According to an industry representative, “Twenty years 

ago the FRA published investigative accidents but they

no longer do this. This needs to be reactivated so 

everyone knows what’s going on and can use 

information as training tool on railroad safety. These 

reports identified the railroads by name; in the future

name should not be included.” 

• Don’t assume all operators have the same knowledge 

base. Include operational instructions or job briefing. 

• There is a need for team building to help build 

consensus and foster two-way communication. 

Provide Ongoing Communication

Disseminate safety diagnostic information faster and to lower

levels within organization. Communication tools that were 

suggested include the following.

• Web site

• Newsletter

• Regular meetings

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Themes by Stakeholder Group

Participants represented their own interests in their discussions, yet 

opinions tended to be shared across stakeholder groups. All groups 

talked about conflicts and lack of trust, needing mutually beneficial 

solutions, individual’s resistance to change, and the need for 

keeping data confidential. 

However some clear differences were apparent, most of which are 

quite predictable and reflect the current state of distrust and 

resentment. 

• Labor and industry management participants talked 

equally about wanting a cooperative spirit and fewer 

regulations, disliking FELA, and needing a third party to 

manage a close call system

• Labor participants talked extensively about being

punished for telling the truth and wishing they didn’t 

have to falsify reports out of fear of reprisal. They

talked more about the conflicting rules and disliking

their complexity. 

• Of all the groups, labor was most concerned with the 

lack of trust between management and employees, and 

the need for team building, consensus throughout the 

organization on decisions, and better two-way

communication. 

• Labor participants disliked the punitive discipline

process that leads to a fear of punishment and litigation, 

talked the most about loss of lives, and were concerned 

about the difficulty of transferring lessons learned from 

other industries. 

• Industry management participants wanted more

professionalism and efficiency -- saving time and 

money. They were frustrated with the difficulty of

“selling” ideas to senior management, and saw a history

of failed programs. They saw rules as generally helpful. 

• The only concern that stood out for regulators was not 

wanting to waste time studying the wrong thing, 

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6. RECOMMENDATIONS 

Workshop Observations 

The number of participants attending the workshop surpassed the 

Planning Committee’s expectations; they expected one third fewer

participants. Based on participants’ reactions and comments, the

Committee called it “a successful close calls workshop.” They had 

expected more resistance from workshop participants to the use of 

a close call system. 

While the different stakeholder groups expressed concerns, all 

stakeholder groups expressed an interest in moving forward. The 

Planning Committee noted the strong support across the board. 

Participants made several suggestions, for example, overcoming

regulatory hurdles such as CFR 49 Part 240; a prerequisite to 

reporting events associated with rule violations. 

“This is the 

opportunity to move 

forward”

The Planning Committee announced their commitment to continue 

to help the railroad industry study close calls and stressed, “this is 

the opportunity to move forward.” 

 Key Recommendations 

The Planning Committee made three key recommendations. 

Obtain Buy-In from Stakeholders Managers 

Just as the Planning Committee briefed their managers in the fall 

of 2002 to obtain buy-in for this Close Calls Workshop, workshop 

attendees must brief their senior managers on what they learned at 

“Workshop the workshop and “sell” the close calls concept. 

participants...need to

be champions in their 

own organization if 

this approach is to

successfully move 

forward”

Workshop participants have all become part of a process. They

need to act as champions in their own organization if this approach 

is to successfully move forward. 

Prepare an Executive Briefing for 

Stakeholder Leaders 

The Planning Committee will prepare an executive briefing to 

inform leaders in the railroads, regulatory agencies, and labor 

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unions about close calls and obtain their commitment to the 

process. 

Some of the topics suggested for the briefing were: 

• Addressing the “Catch 22” nature of willful violations 

specified in federal regulations, where people who 

report information are punished for reporting their close 

call. 

• Explaining how safety-related decisions are often driven 

by erroneous data, due to the punitive nature with which 

the information is also used, and the subsequent failure 

of reporters to give accurate information. 

• Discussing the impact of the expected retirement of a 

significant percentage of the experienced workforce 

within the next seven to 10 years. System safety will be

adversely affected without the knowledge of those 

experienced workers. Close call reporting offers an

opportunity to begin to capture that knowledge. 

The executive briefing will include a candid discussion about what 

can and cannot be achieved within a given period of time. 

Initiate a Pilot Close Calls Project 

The Planning Committee stated that workshop speakers made a 

strong case for a close call system and there were models from

which the railroad industry could follow and learn.

“There was support 

from all breakout

groups to move ahead

slowly with a pilot 

project”

There was support from all discussion groups to move ahead 

slowly with a pilot project on an experimental basis. 

• Scope. Although the scope of the pilot project was not 

defined, the committee agreed that it was a good next

step, giving the railroad industry the opportunity to try

out a close call system on a small scale. 

• Testing. Users will be able to test whether or not a 

confidential, non-punitive system is possible and can 

improve safety in the railroad industry. All committee 

members hoped that a pilot would be the beginning of a 

larger process. 

• Location. The Planning Committee will find a pilot 

location to pilot test the model. 

• Regulatory Concerns. There are certain regulatory

hurdles that need to be addressed through a waiver

process before the pilot can move forward. The 

Planning Committee will work with the FRA’s Office of

Safety in supporting non-punitive reporting of safetyrelated information by railroad employees. This would 

include addressing locomotive engineer concerns about 

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decertification when reporting, so that engineers are not

liable when they talk about close calls that would 

otherwise not be reported. This will build trust and 

confidence in the pilot reporting system. 

Continue Planning Committee Meetings 

The Planning Committee will continue to hold meetings to plan

and oversee the rollout and management of the pilot. They will 

also be responsible for periodic updates and progress reports. 

Conclusion

The FRA’s Tom Raslear concluded the workshop with the 

following comments: 

“Get the message out

to stakeholders at all 

levels” 

“The workshop far exceeded my expectations for what the 

outcome would be.” 

“Get the message out to stakeholders at all levels. Build 

momentum, otherwise it ultimately will not succeed.”

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APPENDICES

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APPENDIX A. FRA WORKSHOP INVITATION 

U.S. Department of Transportation 

Federal Railroad Administration Administrator 

1120 Vermont Ave NW

Washington, DC 20590 

Dear Colleague: 

A strategic goal of the Federal Railroad Administration (FRA) is to promote safety by working 

toward the elimination of rail-related fatalities, injuries and incidents. Railroads can reduce risk

before an accident by systematically studying "close calls." Accidents are often preceded by

close calls that provide a warning of an impending accident. A close call is "an opportunity to

improve safety practices in a situation or incident that has a potential for more serious 

consequences." When individual close calls are analyzed collectively, railroads can identify

safety hazards and develop solutions to these hazards before an accident happens. Analyzing

close calls is a proactive way to manage safety. Because FRA believes that this proactive safety

technique has significant potential for enhancing safety in the railroad industry, I invite you to a 

workshop entitled, Improving Safety through Understanding Close Calls.

Members of the Close Call Planning Committee, composed of railroad labor crafts and industry

management, have worked together during the last seven months to design this workshop. The

purpose of the workshop is to engage all the stakeholders in the railroad industry in a dialogue

on the benefits and challenges in developing and operating a close call database. The FRA's

Human Factors Research Program is sponsoring this workshop with support from the Office of

Safety and the Volpe National Transportation Systems Center. The workshop will take place 

Wednesday, April 23 and Thursday, April 24, 2003, at the Baltimore Hyatt Regency.

A close call system is not intended to be a regulatory program. The Workshop will provide an 

opportunity for senior industry stakeholders to learn the value of studying close calls and the 

challenges posed in setting up and using this information. This workshop will focus on the 

voluntary and confidential use of close calls within a railroad to pro actively identify factors that 

contribute to unsafe events.

The enclosed brochure and White Paper provide additional information. I look forward to a 

productive dialogue and meeting with you at the workshop.

Sincerely, 

Allan Rutter 

Administrator 

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APPENDIX B. WORKSHOP AGENDA 

Wednesday, April 23 

12:00 P.M. Registration and Refreshments 

1:00 P.M. Welcome 

Tom Raslear, FRA, Office of R&D 

Jo Strang, FRA Deputy Administrator for Railroad Development

John Goglia, NTSB Board member 

1:45 P.M. Panel 1 -- Lessons Learned from Close Call Systems 

Keynote Speaker: Christopher Hart, Assistant Administrator for System Safety, 

FAA 

(Break at 2:35) 

2:50 P.M. Captain Hank Krakowski, Vice President for Corporate Safety, Security & 

Quality Assurance, United Airlines

Don McClure, Air Safety Coordinator, Air Line Pilots Association 

(Break at 4:05) 

4:20 P.M. Panel 2 -- Lessons Learned from Existing Rail Initiatives 

Aidan Nelson, Director, Policy & Standards, Rail Safety Standards Board, UK 

Helen Muir, Professor Aerospace Psychology, Cranfield University, UK 

John Grundmann, Asst. Vice President Systems Safety, Burlington Northern 

Santa Fe

6:00 P.M. Wrap-up and Close followed by Reception 

Thursday, April 24 

7:30 A.M. Continental Breakfast 

8:30 AM Welcome to Day 2 

8:40 A.M. Breakout Group Dialog among Railroad Industry Stakeholders: 

Benefits and Challenges of Understanding Close Calls 

(Break at 10:15) 

11:45 A.M. Breakout Groups Report Out in Large Group 

12:25 P.M. Lunch

1:15 P.M. Planning Committee Panel

2:00 P.M. Wrap-up and Close 

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APPENDIX C. SPEAKER PRESENTATIONS

• John Goglia 

• Christopher Hart 

• Hank Krakowski 

• Don McClure 

• Aidan Nelson 

• Helen Muir

• John Grundmann 

Note: for full page presentations, go to WWW.CLOSECALLSRAIL.ORG.

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John Goglia – Understanding Close Calls 

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John Goglia – Understanding Close Calls 

...continued 

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Christopher Hart – Global Aviation Information Network 

(GAIN) 

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Christopher Hart – Global Aviation Information Network 

(GAIN) 

...continued 

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Christopher Hart – Global Aviation Information Network 

(GAIN) 

...continued 

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Christopher Hart – Global Aviation Information Network 

(GAIN) 

...continued 

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Hank Krakowski – United Airlines Safety Culture 

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Hank Krakowski – United Airlines Safety Culture 

...continued 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

...continued 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

...continued 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

...continued 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

...continued 

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Don McClure - Safety Programs that Increase the Safety 

Margin and Reduce the Accident Risk 

...continued 

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Aidan Nelson - Confidential Reporting; the UK Rail 

Experience 

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Aidan Nelson - Confidential Reporting; the UK Rail 

Experience 

...continued 

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Aidan Nelson - Confidential Reporting; the UK Rail 

Experience 

...continued 

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Helen Muir – Impact of CIRAS 

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Helen Muir – Impact of CIRAS 

...continued 

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John Grundman – BNSF Hotline Process 

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APPENDIX D. BREAKOUT GROUP 

DISCUSSIONS 

Four breakout groups, representing all stakeholders, met separately

to discuss a series of pre-determined close call questions. 

• What lessons were learned from the workshop speakers?

• What are the benefits to understanding close calls?

• What are the barriers to understanding close calls?

• What are the next steps to understanding close calls?

This section contains the detailed responses from each of the four 

breakout groups to the questions above. Most are direct 

quotations, but some responses have been changed to improve 

clarity or protect the speaker’s anonymity. If the speaker’s 

stakeholder affiliation is important, it is included in parentheses. 

For a summary of breakout group comments, refer to Section 6. 

What Lessons Were Learned from the Speakers? 

Speaker presentations generated a high level of audience interest in 

what could be accomplished with a close call system for the 

railroad industry. Even though breakout group remarks were very

diverse, several key critical success measures were repeated across 

all groups: 

• Stakeholder buy-in 

• Improved collaboration and trust 

• Better communication and sharing of information 

• Simplified rules and guidelines

The following comments are grouped by theme. 

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Improved Collection of Data on Close Calls 

• Track problems and create a close calls database. 

• There is no comprehensive way to capture experiences. 

• Collect information on: 

− Why close call occurred 

− Why is it acceptable to co-workers and managers

− Frequency of occurrence

− Where and when does this occur 

− Type of equipment 

− Worker profile 

• Need system in place to talk about issues confidentially,

to enable a cathartic change. 

• Gain data otherwise lost from cover-ups/forgetting.

• UK CIRAS model is valuable for setting up close calls 

across the railroad industry and share information 

(union). 

• Identify individual to “find” and broker a close call 

system and set up framework. 

• Implement a pilot program in new territory. 

• Near miss is subjective in eyes of person – what is a 

close call? Employee bumps self on rail/bumped by

passing equipment while leaning out/failure to be told of 

passing train. 

Close Call Incident Analysis 

• Pay attention to problems; enable solutions. 

• Close calls allow industry to identify best practices

(industry). 

• Use pilot studies to quantify benefits. 

• Generate manpower and equipment cost savings from 

more close calls awareness. 

Stakeholder Buy In 

• Need cooperation from all stakeholders and “mutually

beneficial solutions” (Said by union representative). 

• Upper management support is critical. 

• First line management can solve problems. 

• In the UK, middle management is a barrier to 

coordination between boardroom and shop floor. Need 

top/middle/bottom buy-in (union agreed, despite 

different interests). 

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Changed Rules and Guidelines 

• Get rid of autocratic regulation; agencies take a look at

the rules that are really successful. 

• Need a “no reprisal” system for employees. 

• There is tension between the pursuit of safety and 

production objectives (industry). 

• Need better operating procedures/processes. 

• Rules are complex and operators have information 

overload. 

• Need to simplify practices (industry). 

• Rules need to cover each close call scenario (union). 

• Evaluate problems with policy and procedures. 

• Understand written rules.

• Rules must be complied with (but management 

encourages procedural violations to keep traffic moving). 

• Make quality improvements in the contractor selection 

and rules compliance process. 

Improved Collaboration/Trust

• Need for increased trust among all parties. 

• “Most transportation people don’t trust the FRA.” 

• Change the culture from FRA being an adversary to

being part of a team. If people trust each other they’re

more likely to report problems without fear of reprisals. 

“People have to have faith and get into real issues.”

• If stakeholders trust information they can better focus 

training time and resources (key issue for one breakout 

group). 

• Union rep reported cover up of a close call by railroad 

management. 

Better Communication/Sharing of 

Information 

• “There should be inter-communication amongst 

railroads.” 

• Need for better communication. 

• Debrief the crew to identify large and small issues. 

• “System should be built with everyone updating the 

process and information.” 

• Publish information, not just information in a database, 

using a formal process. 

• Disseminate lessons learned. 

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Improved Training

• Improve training.

• Promote training for continuity and follow-through. 

• Industry is changing -“old heads” with a history of

generations of families working for the railroad being

replaced by those with no family railroad employment 

history to discuss issues with. 

• With a smaller number of crew members there are fewer

resources for new employees. 

• Twenty years ago the FRA published investigative

accidents but no longer do this – needs to be reactivated 

so everyone knows what’s going on and can use 

information as training tool on railroad safety. These 

reports identified the railroads by name. In the future

name should not be included. (industry). 

• Don’t assume all operators have the same knowledge 

base – include operational instructions or job briefing. 

Human Factors Issues 

• Humans will err (mentioned by many groups). 

• Several groups identified communication failures in 

close calls. Humans process information differently and 

must be accommodated. 

• Avoid complacency. 

• Fatigue is a factor – employees become complacent. 

• Stay focused and watch out for routines. 

Learning from Experiences Before Close 

Calls Become Accidents 

• Clearing snow at interlocking plant and train came

unexpectedly – lesson is before fouling track, obtain 

“foul time” from dispatcher and implement more formal

rules with railway workers. 

• Inexperienced operator at swing bridge did not know 

about need to swing bridge to equalize temperature; end 

result was difficulty in aligning and higher potential for 

injury and train delays. Solution is to use key factor 

analysis to formalize. 

• Train operators anticipate signals and pass signals at

Stop, overriding safety device. This remains a problem 

for the railroad. Other railroads use signal awareness 

forms with success and call out signal aspects. 

• Block limit granted and confirmed; dispatcher erred with 

wrong control point. 

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• Signal bridge visibility problem reported through “tribal 

knowledge” – happens at times, no report generated, just 

discussions between parties and managers lose data. 

• More false train stops occur than are reported, there is 

poor communication with no follow up, no procedures, 

and no responsibility or accountability.

• Know where signals are located in the dark and call in

information on the radio.

• Ensure all communications are on the same radio 

frequency.

• Inspect switches for quality prior to operational release. 

• Produce a checklist and flowchart guides. 

• Review job briefings prior to a trip. 

• Ensure there are multiple signals and yearbooks. 

• Identify equipment failure or lack of equipment, react to 

it, and fix it right away. 

• Use technology and engineering controls to prevent 

problems. 

• Never place yourself in danger zone. 

What are the Benefits of Understanding Close Calls? 

All groups agreed that this organized approach to sharing 

information about close calls would be useful, and the right thing

to do. The benefits will transform a reactive system to a proactive 

system. There will be a culture change from an industry that 

blames individuals for close calls/incidents to one that focuses on a 

system that learns from information on close calls and makes 

improvements. 

The following comments are grouped by theme. 

Safety Culture Change

• “Converts a safety program from being a reactive

system to a proactive system” (member of the Planning

Committee). 

• Results in data-driven decision making. 

• Increases public trust in railroads. 

• Increases accountability on all levels. 

• Increases employee/management trust - (Union) “Trust 

is the caviar in this list. I don’t see if you don’t have the 

trust as a foundation, all of this isn’t going to happen in 

the first place.” 

• Starts breaking negative spiral; makes it OK to tell the

truth without repercussions; sets up positive professional 

atmosphere: 

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− This program can break the negative spiral of “Tell the 

truth > discipline > dismissal”... The truth does NOT 

set you free. ...Truth is held against you, so it breeds 

liars who will break the law (union). 

− This program will bring about a setting of

professionalism (industry). [Comment from audience – 

Good luck!]

− A person may set up a fake explanation in order to save 

his job (union). 

− If someone ended up killing him, would that person

have said the same thing? (industry). 

− Yes, possibly (union). 

− If there were no penalty for telling the truth, would he

have lied? (union). 

− Probably not (industry). 

• Employees empowered to make suggestions for change. 

• Improved working conditions/attitude/morale. 

Better Understanding of Risks and Better 

Solutions 

• Multiple reports give scope to problem – target

resources to biggest problem and help to set priorities. 

• Identifies systemic issues/problems and identify

patterns. 

• Enables discovery of root causes. 

• Identifies true causes and reduces ‘red herrings;’ 

provides accurate information: 

− We end up pursuing ‘red herrings’ under the present 

system. This wastes time (government). 

− [Under the present system] we end up falsifying FRA 

reports, which is far more serious (union). 

• Can focus on why close call did not become an accident. 

• Identifies what industry is NOT doing right. 

Increased Collaborative Information 

Sharing 

• Uncovers higher percentage of incidents. 

• Enhances cooperation between labor, management, and 

FRA (industry) and builds consensus from top to bottom 

(union). 

• Recognition that problem is shared by others, including

other countries. 

• Discover best practice from international sources.

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• Team building - help build consensus and foster twoway communication (union). 

• “Better use of manpower if part of a product team” 

(Planning Committee member).

• Mechanism for culture change from adversary to team. 

• Improved training (union – stressed by several) (key 

issue for one breakout group). 

• Opportunity to tap knowledge, resources, and expertise 

in industry.

• “If we have an open work place with goals of 

improvements it would be a benefit.” 

Improved Safety

• Demonstrates commitment to safety. 

• Helps design engineers design safer systems. 

• Non-punitive way to improve safety. 

• Anecdotal evidence can provide lessons learned. 

• Prevents catastrophic losses. 

• Human cost savings “I think that it will be easy to show 

cost savings so we don’t have to tell their [locomotive’ 

engineers and railroad workers’] wives their husbands 

aren’t coming home” (union). 

• “Dead men don’t tell good stories.” 

• “Takes profit motive out of safety,” even though costs 

may be saved intact (union). 

Improved Cost Savings and Use of 

Resources 

• Allows safety to be shown as contributing to bottom 

line, not just as a cost. Follow the UK’s example; once 

safety is realized, benefits follow. Industry and unions 

see business benefits, “a pro-active response to learning

leads to less regulation” (industry). 

• Prevention means less time lost on job and saves money

(industry). 

• Information sharing is cost saving to company.

• Cost savings in insurance/legal claims - fewer claims 

paid out; less loss of life and injury (union). 

• Avoids litigation. 

• Operating efficiency and decreased repair costs 

(industry). 

• Benefit is from obtaining real problems and pursuing

real solutions, cost effectively, rather than red herrings

wastefully (government). 

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Miscellaneous 

• Can identify new technologies to reduce human 

error/expand on existing technologies. 

• Prevent unneeded regulations (industry) but also 

improve rules, regulations, operating procedures. 

• We are talking about creating accurate information. 

• We must get rid of the concept of “misdemeanor 

charges, life sentences” (union). 

What are the Barriers to Understanding Close Calls? 

This topic generated the most discussion among all groups. 

Although many concerns were expressed, the groups did not 

consider them to be insurmountable obstacles. Common themes 

included: 

• “Them versus us” culture

• Lack of policy specifics relating to close call 

information 

• Legal impediments 

• No top level buy-in 

• Need changes in regulations 

The following comments are grouped by theme. 

Need a Culture Change/Rulemaking 

Waivers 

• Failure to consider benefits of safety culture. 

• Need for new paradigm; balance substance/procedure. 

• Long history of distrust (key issue for one breakout

group).

• Hard to move from adversarial stance (union). 

• “Us versus Them” and a long term “code of silence”:

− Employee/management 

− Railroads/FRA 

− FRA/employees

− Between and within carriers 

− Short lines/class lines

− Field distrusts FRA and its culture, for example the 240 

Rule. Need independent third party since it’s difficult 

to move away from the traditional adversarial stance.

Labor especially sensitive to mandated discipline under 

these rules. 

• Will FRA give relief on the punitive part of CFR240 – 

“there needs to be a cooperative spirit” (industry).

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• FELA is fault-based system - “Right now, if I see that 

someone is speeding, then I have to decertify him. Are

there other ways around it?” (industry). 

• Perception of the “Blame Game” with everyone blaming

everyone else for accidents:

− Industry thinks everything is human factor, employees 

think everything is working conditions 

− Industry says “it’s still the individuals’ fault, 

management says it is the employee’s fault, employees 

think it is the working conditions”

• Fear of regulations. 

• Increased audits. 

• Self interest of regulators (union). 

• Complexity of rules “Three step slowed railroad down – 

there has to be a better way” (union). 

• Differing view; rules help people remember and help 

focus on safety (union). 

• Lack of trust, integrity, and patience – history of 

inaction and a long line of failed programs (industry). 

• “Railroads don’t want anyone in their business.” 

• Railroads are decentralized (contrasting view below). 

• Huge bureaucracy of railroads. 

• Current militaristic disciplinary process (union). 

• Internal punitive actions – union concern: 

− 1st Line supervisors “will beat up on me” 

− Inspectors have “no ability to write violations”

− Management focus on statistics, worker fear of

litigation if report close call 

• Labor leaders “take away control” (industry). 

Lack of Buy-In/Commitment 

• “Need buy-in from EVERYONE” – varying levels of 

commitment among stakeholders. 

• Concern there will not be a long-term commitment to 

close calls. 

• Barrier is a lack of high status leadership within ALL

stakeholder hierarchies (government). 

• “I don’t think the union would buy into the program, 

they would think it is the flavor of the month.” 

• Participation by all stakeholders. 

• Equality/parity by all stakeholders. 

• No equality of people involved in the planning process. 

• All stakeholders are not involved from the beginning. 

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• Varied levels of commitment within and among

stakeholder groups: 

− Safety is not on the decision-maker’s scorecard; 

[performance evaluations is] measured on productivity

more than safety. Managers rewarded for reported

safety statistics, creates incentives for not reporting

incidents (in some railroads, not all). Conflict is that

performance is measured on productivity (ex.

Trainmaster is told to get that train out! 

− Managers rewarded for safety statistics (Another Labor 

person offered this word as first was forming

thoughts)... problem is that if a bonus is not rewarded, 

manager ‘punishes’ those under him (union). 

− Totally disagrees with above statement...if managers 

don’t do specific things listed in their job description 

they will be evaluated accordingly (at least in the

northern region of U. Pac.) (industry). 

− Performance should be based on activities, not on 

statistics (industry). 

− I say, look at the incidents, some may disagree. If a 

manager is found to have falsified information he will 

be fired! (industry). 

− It seems to be a localized problem by carrier (several 

others). 

• Need buy in from FRA. 

• Need a champion within the industry. 

• History of failed programs. 

Individual Resistance to Change 

• Most workers unwilling to change; attitudes may be due

to generational change; need to work overtime. 

• New people are not coming up from the ranks to replace 

retiring Boomers and don’t have practical experience. 

Generation X work ethic is different - unwilling to work

weekends. Gung-ho on program changes then interest 

fades. 

• “What’s in it for me?”

Risks to Confidentiality 

• Primary concern for one breakout group. Everyone

agreed that it would be the hardest to achieve but also 

the most important. There was fear about breach in

confidentiality and what that would entail: 

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− Confidentiality of data collected (Government - “if we 

can address confidentiality we can move down the

road”). 

− Keep carrier confidential, too. “The third party

collecting data should be getting data not specifically

for your company, but for the four different major

carriers, so you don’t know where the incidents 

happened.” 

− Fear reflects badly on own performance. “Labor is

concerned about punitive part of confidentiality. If I

report, will it come down on me? (union). 

− Protect info from attorneys (discovery). 

− Punitive use by RR or Fed agencies or lawyers. 

− Don’t want to see name in the newspaper. 

− Confidentiality has been breached in the past. 

− Avoid “one brother ratting on another.”

− “True confidentiality is hard, there would have to be 

quality control.” 

• Ability to shield information from legal processes 

(industry). Would prefer to talk to a jury saying that they

are aware of this situation [safety injury situations] and 

are trying to resolve them, than say we know nothing

about it. 

• Talked about trying to implement “Red Block” [An 

alcohol and drug use prevention program – see web site 

HTTP://REDBLOCK.COM/] -- those who resisted 

implementing that program will probably resist 

implementing this program (union and industry). 

Implementation Issues 

• There needs to be specifics on what type of data needs to 

be collected; an objective way to show the information 

collected that will show the program is a success and 

encourage its use across the board. 

• How do you know if data is legitimate. 

• Concern for legitimacy of data reported, quality control -

people might turn others in if they are mad at them. 

(Anticipate how to test system) “There needs to be 

certain things they want people to report as opposed to 

anything” (industry). 

Need Close Call Definitions and Policies 

• Hard to translate knowledge into safety policy.

• What is an objective measure of success?

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• How do you define success? “National system will look 

at patterns, inaccurate reports are less likely to have a 

pattern.” 

• Person has to decide whether there is more of a benefit 

is to call an incident a “close call” or an “injury.” 

• “How to know if info applies to my railroad” - “If the 

info gets to a national level; how do I know if it applies 

to my company?” (industry). 

• “Set process to see if it will apply to your company; ask 

the people on the ground if it is a problem in their 

company and will this info help them.”

• One size does not fit all. 

• Many technical differences between companies; this

means some companies have a data advantage over 

others (government). 

• Set up operating rules nationwide (union). 

• Best practices are out there but not nationwide (all

stakeholders). 

Funding/Resources 

• Initial loss of productivity.

• “We need financial support.” 

• Who will pay?

• This may displace other safety activities (need resources

for this). 

• Will we spend more money on safety?

• “Federal Government should fund it because they fund 

FAA.”

• Lack of technology to collect data.

Measuring Return on Investment

• Need a business case quantifying return on investment. 

• If you cannot make the business case (benefit) you 

cannot sell the system...Railroads are getting bigger – 

getting harder to implement a system across a railroad. 

• Need OBJECTIVE info to “sell” to SR. Management -

“You are asking me to spend money and can’t tell me if

the program is successful. You have to objectively

prove that it will work” (industry). 

• I can’t see how a railroad like CSX can implement 

things if they “lose things” as it is...then there is trouble 

between railroads (union). 

• Talked about how high-speed rail in Illinois as a case in 

how business case was not clearly made [business,

politics] (several people). 

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• Also cited Operation Lifesaver as a program that has not 

reached its potential (union). 

• It may be difficult to apply learnings from airlines to 

railroads. Method of operation different - has to be

incorporated; potential benefits to railroads less than

airline benefits: 

− In airline industry, if something goes wrong, the rest of 

the system doesn’t shut down (example, hydraulic 

pump on a plane doesn’t shut down the hydraulic 

system in the plane – there is usually a ‘back up’ 

system that keeps the plane running). In rail industry, if 

something goes wrong, the system shuts down in ‘safemode.’ Point is, this might result in affecting

implementation (union). 

− Plane – once flying, gravity always in effect. Rail – 

once moving – momentum always in effect. 

Consequences are different, emphasis is different 

(industry). 

− Air is more black/white, but there are still ‘gray areas’

that are similar in rails. Pilots still break rules 

(academic). 

• Need to build a business plan for each of the 

stakeholders (government). 

What Are the Next Steps in Understanding Close Calls? 

Common themes amongst all groups included: 

• “This is the Right Thing to Do!”

• Obtain commitment and buy-in from “each leg of the

stool” (stakeholder group). 

• Develop a pilot close calls program using new model or 

existing working model. 

• Educate all stakeholders by disseminating lessons 

learned. 

The following comments are grouped by theme. 

Obtain Stakeholder Buy-In 

• Coordinate stakeholders.

• Sell to CEO; get top people on board - not present here 

but they should be (government).

• Get commitment/buy-in from top management of all 

stakeholder groups. 

• Be committed to change.

• Encourage risk taking for first step. 

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• Facilitate local worker involvement - “need people on 

the ground to buy in and feel trust and be part of the 

process” (union). 

• “Buy-in from the FRA from the get-go.”

• Remove fear of reprisal (union). 

• [Solicit] support from Congress to address liability

issues: 

− We need to have Congress to pass a mandate to drive 

this program (industry). 

− No, we don’t want Congress to mandate it to the FRA 

(several in all sectors). 

− We three need to come together, first, then go to 

Congress to get their support (union). 

• We have someone governed by FTA. They [the FTA]

probably need to be represented here, as well. 

• Identify individuals/small team to champion system 

(industry). 

• Form small team, including all stakeholders, to 

champion program. 

• Need a champion who will push it through “thick and 

thin.” 

Develop a Model Pilot Program 

• Need a summit meeting of stakeholders to keep this 

going. FRA is the governor (government). 

• Obtain commitment/buy-in from top management of all 

stakeholder groups. 

• Move away from passenger vs. freight – every program 

has failed when we try to split them up. We have to do 

it, together (union). 

• See if you get any takers for a pilot program. 

• Consider pilot programs in different venues/locations 

(e.g. short lines, Class 1, passenger, switching). 

• Don’t reinvent the wheel - use FAA GAIN Program as 

guide (industry). 

• Get an agreement of the mission statement of the goals 

of the pilot program from all stakeholder groups. 

• Identify the process and resources required 

(government). 

• Have government pay for initial phase. 

• Develop MOU between unions, management, and FRA. 

• Present data so there is consensus and buy-in from all 

stakeholders: 

− Research “how to measure success” - need objective 

way.

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− Compile lessons learned study of lessons across and 

from industry to show value of system. 

− Understand which government programs are successful 

and pass on this information (government). 

− Understand the truth of the problems. 

− Cultural problems are lessons learned 

• Don’t look for too much right away - start small. 

• Start small, build from successes. If you start big, there

will be too many problems at the start. If we start small, 

we will be able to gradually build on it (union). 

• Work with FRA about making 49CFR 240 more 

flexible. 

Determine Data Collection Mechanism

• Determine data needed and how it will be used. 

• Address data liability and confidentiality issues – 

“truthful reporting - not a numbers game.” 

• Data should be administered by third party outside the 

industry - outside academic consultants [Aidan Nelson]

to “push beyond the barriers” or government agencies - 

USCG, FHWA/FTA/Volpe. Third party should be nonregulatory, non-enforcing, with some railroad 

knowledge (union). 

• Have third party put together best practices studies

“There are places that you can identify by the type of 

situations knowing and will know which facility the 

incident occurred at.” 

• “Systematically collect data about close calls so it can 

be seen that certain situations would help other systems 

having the same types of issues.” 

• A template would be useful (union). 

• Develop standardized operating rules and procedures 

(template) for capturing all relevant information on 

incidents and train people in utilizing these procedures

(industry). 

• Coordinate with other efforts already underway:

− We do have safety culture committees in the northern 

region of my railroad...they have employee evaluation 

forms done anonymously by other employees that try to 

uncover worker issues. We use it for testing,

programming and training (industry). 

− Use aviation industry for benchmarks/case studies.

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Address Data Issues 

• Report close calls truthfully - it’s not a numbers game. 

Some CEOs want to reduce number of injuries to make 

statistics look better. Result is a cover up (union).

• “I don’t think that these guys are ‘liars.’ It [incorrect 

information] is often due to ignorance of how to fill out 

forms, confusing fields, non-uniform filling out of

things” (union). 

• NTSB is different [probably a different focus on 

activities from railroad safety boards]...they don’t 

prevent, they investigate...safety teams try to prevent 

first...NTSB is proud that they are not proactive, they

are reactive...I think that they should be that 

way...different collecting process, but their information 

is good (union). 

• “I’m not sure that ‘consistent investigation’ is best way. 

It tends to narrow the investigation [in what they will 

look for, finding possible solutions, etc.]” (industry). 

• Look at existing data to identify problems (e.g. SOFA, 

SACPs, RSAC):

− SOFA – Switching Operations Fatality Analysis 

− SAP – Safety Action Plan

− SACP - Safety Assurance and Compliance Program 

− RSAC – Railroad Safety Advisory Committee

Provide Ongoing Communication

• Develop web site (industry). 

• Produced close calls newsletter. 

• Continue ongoing dialog – regular meetings

(government). 

• Disseminate safety diagnostic information faster and to 

lower levels within organization: 

• We have grade crossings set-up with diagnostic sensors 

(example, light is out) that is sent to a central spot that 

will get it fixed (union). 

• Standardize signal system/signs across nation (union). 

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APPENDIX E. WORKSHOP ATTENDEES 

Last Name First Name Organization 

Category – Union 

Aycock Robert Brotherhood of Locomotive Engineers

Boyles Dan United Transportation Union

Brickey David United Transportation Union

Carlton Jack Brotherhood of Locomotive Engineers

DePaepe Tim Brotherhood of Railroad Signalmen 

Dunlevy Donald PA State Legislative Board

Fields Carl Brotherhood of Locomotive Engineers

Foster Roy United Transportation Union

Fritter Steve United Transportation Union

Haley Kelly Brotherhood of Railroad Signalmen

Harvey Robert Brotherhood of Locomotive Engineers

Inclima Richard Brotherhood of Maintenance of Way Employees

Keebler William Brotherhood of Railroad Signalmen

Kertesz Kenneth Brotherhood of Locomotive Engineers

Koonce John Brotherhood of Locomotive Engineers

Last George Brotherhood of Locomotive Engineers

Mundy C. ATDD

O'Brien Thomas Brotherhood of Locomotive Engineers

Perkovich Thomas Brotherhood of Locomotive Engineers

Ramsey Jack United Transportation Union

Smullen John United Transportation Union

Sorg Robert Brotherhood of Locomotive Engineers

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Last Name Nickname Organization 

Stem, Jr. James United Transportation Union

Svob, Jr. Robert AZ Legislative Board

Szabo Joseph United Transportation Union

Todd Terry Brotherhood of Locomotive Engineers 

Verna Vincent AZ BLE Legislative Board

Way C. Edward IL State Legislative Board – BLE 

Category - Industry

Aumend Lee RailAmerica Inc.

Browning Don Norfolk Southern Corporation

Capobianco Anthony Long Island Railroad

Donlen James NJ Transit

Ferrone Neil CONRAIL

Gelder Royal Belt Railway Co. of Chicago

Gibbons William Long Island Railroad

Goodine Fred WMATA

Grizard William APTA

Hall Peter AMTRAK 

Hull John APTA

Jackson Fred Metrolink SCRRA

Karambir Cheema Santa Clara Valley Transportation Authority

Keane Robert Canadian National Railway

Kenyon Robert Union Pacific Railroad Co.

Kienzler James Canadian Pacific Railway

Klejst Stephen NJ Transit Rail Operations

Leopold Thomas Kansas City Southern Railway

Lindsey Alan BNSF Railway

Mayden Louis Indiana Harbor Belt Railroad

Meana Mark AMTRAK

Mogan Dennis METRA

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Last Name Nickname Organization 

Moller Jeffrey Association of American Railroads

Roark James Union Pacific Railroad (Northern Region)

Roberts Rick CSX Transportation

Snyder David Virginia Railway Express

Category - Government

Bridges Bernadette MD Transit Administration 

Cacini Richard TSI

Coplen Michael Federal Railroad Administration 

Ditmeyer Steven Federal Railroad Administration 

Elston Ralph Federal Railroad Administration 

Kaye Albert Federal Railroad Administration 

Kloeppel Miriam National Transportation Safety Board 

Lozeau David Chicago Transit Authority

Mao David Federal Railroad Administration 

Markos Stephanie US DOT Volpe Center - DTS-75 

McCown Robert Federal Railroad Administration 

Morgan Curtis Texas Transportation Institute

Multer Jordan US DOT Volpe Center 

Popkin Stephen US DOT Volpe Center 

Pulciana Don Transport Canada-Rail Safety

Raslear Thomas Federal Railroad Administration 

Remines James National Transportation Safety Boar

Rhodes Linda Chicago Transit Authority

Sposato Suzanne US DOT Volpe Center

Stemple Mark Charlotte Area Transit System

Sussman Don US DOT Volpe Center

Taylor Simon Marc Train Service

Thompson Phyllis Chemical Safety Board

Tsai Thomas Federal Asian Pacific American Council

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Last Name Nickname Organization 

Weeks Gerald National Transportation Safety Board

Category - Research

Gertler Judith Foster-Miller, Inc.

Kohli K. Vijay Fulcrum Corporation 

Laveson Jack Fulcrum Corporation

Philbrick Karen University of Denver

Reinach Stephen Foster-Miller, Inc.

Stentz Terry University of Nebraska-Lincoln

Category – Speaker 

Goglia John National Transportation Safety Board

Grundmann John BNSF Railroad

Hart Christopher Federal Aviation Administration

Krakowski Henry United Airlines

McClure Don Air Line Pilots Association

Muir Helen Cranfield University

Nelson Aidan Rail Safety & Standards Board

Strang Jo Federal Railroad Administration

Category – Vendor 

Dzinski Donald Egis Semaly

Keppen William Keppen & Associates

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APPENDIX F. SPEAKER BIOGRAPHIES 

John Goglia 

John Goglia has served as a Member of the NTSB since August 

1995. With more than 30 years experience in the aviation industry,

he is the first Board Member to hold an FAA aircraft mechanic's

certificate. 

As a Board Member, he has been instrumental in raising awareness 

of airport safety issues, including the importance of airport crash 

fire and rescue operations, and the dangers of wildlife at airports. 

He recently hosted a joint government-industry conference to 

highlight airport safety trends and facilitate improvements. He has 

been an outspoken advocate for greater compassion and sensitivity

in dealing with surviving family members of victims of

transportation accidents. In recognition of his dedication to helping

grieving families, the National Air Disaster Alliance awarded him 

its 2001 Aviation Safety Award. 

Mr. Goglia has participated in numerous air, rail and bus accident

investigations. He chaired the Board's public hearings on the 

ValuJet crash into the Florida Everglades. He has been the onscene member at the Fox River Grove, IL grade-crossing accident 

that killed seven high school students in a school bus, the Silver 

Spring, MD commuter rail collision, and the Bourbonnais, IL fatal 

train crash involving Amtrak's City of New Orleans. 

Prior to becoming a Board Member, Mr. Goglia held numerous 

positions in the airline industry and was involved for more than 20 

years as a union flight safety representative on accident 

investigation teams. For 12 years, he operated his own aircraft 

service company.

John Grundmann 

John Grundmann is Assistant Vice President Safety and Operations 

Support at the Burlington Northern Santa Fe Railway (BNSF). 

He leads the team responsible for setting strategy for safety

improvement and program development, the field safety strategy

implementation group, the grade crossing safety group, and safety

reporting to BNSF and FRA. His operations support 

responsibilities include dispatcher manpower planning, scheduling

and workload balancing. He previously held the positions of 

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General Director of Transportation, where he was responsible for 

implementing and monitoring the operations and scheduling of

dispatchers for BNSF's state-of-the-art Network Operations Center 

(NOC). 

Throughout his career with the railroad, Mr. Grundmann has had 

extensive operations experience both in the field 

(switchman/brakeman, trainmaster) and at the headquarters level 

(superintendent of operations, terminal superintendent). He holds a 

degree in Business Administration from the American University

in Washington D.C. 

Christopher Hart 

Chris Hart is the Assistant Administrator for System Safety at the

FAA. Reporting directly to the Administrator, the Office of System

Safety provides data, analytical tools and processes, safety risk 

assessments and other assistance to numerous FAA and worldwide 

aviation safety programs; spearheads industry-wide safety

activities, such as the Global Aviation Information Network 

(GAIN); and helps to identify key safety issues and emerging

trends affecting safety. 

Mr. Hart's previous positions have included: Deputy Administrator 

of the National Highway Traffic Safety Administration (NHTSA),

member of the NTSB where he had specialized interests in human

factors and the impact of automation on transportation systems, 

Deputy Assistant General Counsel to the Department of 

Transportation, managing partner of Hart & Chavers, a 

Washington D.C. law firm, and attorney with the Air Transport 

Association. 

Mr. Hart has a law degree from Harvard Law School, and he 

earned a Master's degree (magna cum laude) in Aerospace 

Engineering from Princeton University. He is a pilot with 

commercial multi-engine and instrument ratings. 

Hank Krakowski 

Hank Krakowski is Vice President for Corporate Safety, Security

and Quality Assurance at United Airlines. His responsibilities 

cover worldwide flight, operational, computer and maintenance 

functions, including emergency response. 

He joined United as a pilot in 1978 and has served as Director of

Flight Crew Planning and most recently as Director of Flight

Operations Control. He was in charge of Flight Operations at 

United's Operations Control Center on September 11th 2001. 

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In addition to his officer duties, Captain Krakowski also flies the 

Boeing 737 out of O'Hare. He is a rated Flight Dispatcher, a 

practicing Aircraft Mechanic and an air show pilot with the

Chicago-based Lima aerobatic demonstration flight team. He has 

served as chairman of communications and national spokesman for 

the Air Line Pilots Association. He holds a master's degree in 

Business & Management and a bachelor's degree in mechanical 

engineering from St. Louis University. 

Don McClure

Don McClure is Air Safety Coordinator, Airline Pilots Association. 

He is responsible for Development and implementation of Flight 

Operational Quality Assurance (FOQA) and Aviation Safety

Action Programs (ASAP). He was also a Captain with Eastern Air 

Lines, Inc., from 1964 to 1990. 

Captain McClure has participated in Air Safety and Accident 

Investigation activities for ALPA from 1967 to the present. 

Positions held include: Central Air Safety Chairman, EAL; Chief 

Accident Investigator, EAL; Chairman, ALPA National Accident 

Investigation Board; Chairman, ALPA Flight Recorder 

Committee; and Instructor, ALPA Basic Accident Investigation 

Course. He has flown 40 different types of General Aviation 

Aircraft, with a total flight time of more than 14,000 hours and has 

participated in more than 20 major aircraft accident investigations. 

Helen Muir 

Helen Muir is Professor of Aerospace Psychology, Cranfield 

University and Head of the Department of Human Factors and Air 

Transport. The work that she and her team have implemented has 

been used to support changes to a series of airworthiness 

regulations in the UK, in countries within the EEC community, 

USA and Canada. While research initially focused on the aviation 

environment, the team has supported projects in other safety

critical industries including rail, shipping and offshore. 

Professor Muir was recruited by the railway industry to oversee the 

development of the Rail Industry Confidential Incident and 

Analysis Reporting System (CIRAS). She currently is Chair of the 

National Steering Committee. Her team is assisting the industry in 

developing tools for rail accident reporting.

She is also a consultant and serves on a range of committees

associated with Human Performance in safety critical industries. 

She is a member of the CAA Airworthiness Requirements Board 

and is an independent advisor to the Health and Safety

Laboratories. She is also a Fellow of the Royal Aeronautical

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Society and helped to establish their Human Factors Group (acting

as Chair for the first five years). 

Personal recognition includes being the first psychologist to 

receive an award from the Royal Aeronautical Society (the 

B.W.O.Townsend Award) and being awarded the Order of the 

British Empire in 1993. In 1998 the Royal Aeronautical Society

awarded her the Roger Green Medal and the Southern California 

Safety Institute also presented her with the Award of Excellence in 

Cabin Safety. In 1999 she was awarded the Whittle Safety Award 

by the International Federation of Airworthiness. Professor Muir 

holds an MA in Psychology, a PhD from the University of London, 

and is a Chartered Psychologist. 

Aidan Nelson 

Aidan Nelson is Executive Director of Railway Safety for the 

United Kingdom. He is responsible for policy, standards and 

industry leadership projects. 

Mr. Nelson began his career in the railway industry in front line 

operating roles. He moved into freight and passenger business 

management then became Director of Regional Railways North 

East. With the restructuring of the railway industry, Mr. Nelson 

moved to Railtrack as Director of the North East and London 

North Eastern zones. He developed Railtrack's Line Safety

Directorate before moving to its Safety and Standards Directorate 

(S&SD) as Deputy Director, where he was responsible for industry

safety strategy and planning

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APPENDIX G. CLOSE CALLS WHITE PAPER 

Improving Railroad Safety through 

Understanding Close Calls

Summary 

Railroads can reduce risk before an accident by systematically

studying close calls. Analyzing close calls is a proactive way to 

manage safety. A close call is "an opportunity to improve safety

practices in a situation or incident that has a potential for more 

serious consequences." When individual events are analyzed 

collectively, railroads can identify safety hazards and develop 

solutions to these threats. 

The development of successful close call systems share several

common features that involve building trust to encourage 

disclosure of close call information. These features include using a 

third party to collect and store the information, confidential 

reporting, and limited protection for sources from liability or

enforcement.

The Federal Railroad Administration’s Office of Research and 

Development is sponsoring a workshop for the railroad industry to 

learn more about the safety benefits of studying close calls. The 

workshop will also provide a forum for participants to discuss 

issues and build trust. 

Introduction

Accidents may be

preceded by “close

calls” that warn us of a

safety problem

During the last 23 years, the Concorde jet suffered a series of tire 

blowouts on the landing gear. The blowouts ruptured fuel tanks, 

damaged hydraulic lines, electrical wires, and engines. Except for 

the damage to the aircraft, there were no fatalities.

On July 26, 2000, an Air France Concorde jet blew a tire, rupturing

a fuel tank and catching fire. The plane crashed shortly after 

takeoff killing 109 passengers and crew. A tragic accident like the 

Concorde may be preceded by several close calls similar to the

accident, that do not result in catastrophe or harm to people, 

equipment, or the environment. These close call events provide an 

opportunity to proactively manage safety. Instead of waiting for an 

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accident to occur, these events provide valuable information on 

which the railroad can act to reduce risk. 

Railroads can target the 

greatest risks to safety

Over the last decade, the railroad industry achieved significant 

progress in improving the safety of railroad operations. However, 

as the number of reportable events declines, additional reductions 

become more difficult to obtain. When the number of reportable 

accidents decreases, accident data becomes less valuable in

determining the sources of risk. Also, when safe outcomes do 

occur, there is nothing to capture the organizations' attention; 

safety is invisible1 . 

Railroads maximize safety by addressing areas that pose the

greatest safety risk. Close calls can provide information to monitor 

risk and manage safety. 

The aviation industry uses close calls as part of its safety

management process. In the United States, the aviation industry

created the Aviation Safety Reporting System (ASRS) and the 

Global Aviation Information Network (GAIN). The success of

these industry-wide systems led to the creation of companyspecific systems for evaluating close calls. The analysis of close 

calls within airlines enables them to identify safety concerns 

specific to their organization. 

Other modes and

industries successfully

use close call

information to manage 

safety

ScotRail, a passenger railroad in Scotland, created the Confidential 

Incident Reporting and Analysis System (CIRAS). After a trial 

period, other railroads in the United Kingdom adopted this system 

to improve their safety management processes. 

Evaluating close calls is also part of the safety management 

process in other industries like the chemical process and nuclear

power industries. In those industries the probability of an accident 

is relatively low, but the adverse consequences are high. 

This paper discusses the safety benefits of analyzing close calls

and the lessons learned by organizations that successfully use those 

events as part of their safety management process.

What Is a Close Call?

A commonly used definition of a "close call" refers to an event that 

could have resulted in personal injury, property damage, or 

environmental damage, but did not. However, this definition is too 

narrow. For example, events that cause injuries, or property

damage, but do not reach the threshold for reporting can still 

provide information about system safety. When these events are 

used to evaluate system safety, they signal a weakness that, if left

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alone, could result in more serious consequences. Small accidents 

may be predictive of larger accidents to come. 

Instead, the following definition is proposed: 

An opportunity to improve safety practices based on 

a condition or incident with a potential for more 

serious consequences2

This definition ties close calls to the safety management process. It

highlights the opportunity to reduce risk by understanding the 

factors that lead to an unsafe event.

Decide on a threshold

for what events count as 

close calls

Using this definition, a threshold must be set to decide what events 

count as close calls. This definition could be used broadly to 

include many cases, or narrowly to include only a few cases. 

Potential cases include: 

• Events that happen frequently, but have low 

consequences (e.g., lifting objects that put employees at 

risk for minor injuries such as sprains) 

• Events that happen infrequently but have the potential 

for high consequences (e.g., a train that proceeds past a 

red signal without proper authority) 

• Events that cause an accident that is below the Federal

Railroad Administration’s (FRA) reporting threshold 

(e.g., an event that causes an injury requiring first aid, 

such as a cut)

• Events that are above the FRA threshold where the 

potential exists for a far greater accident (e.g., a slow 

speed collision with only minor damage to the

equipment) 

Ultimately, what events are considered close calls depend on how 

these events are used in the safety management process. 

Safety Benefits of Analyzing Close Calls 

The benefits of using close calls lay in how they are systematically

used in the safety management process. A safety system is the 

combination of procedures, equipment, and training, used to 

manage safety. Close calls represent an opportunity to identify and 

correct weaknesses in the railroad’s safety system prior to an 

unsafe event.

After implementing changes in safety, managers can use close calls 

to monitor the effectiveness of these changes in railroad operations 

over time. Safety managers and labor organizations can use

information gathered from close call events in ways that range 

from reactive to proactive.

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Reactive Approach 

Reactively analyzing

close calls identifies

why unsafe events

occur after safety has

been compromised 

Reactively analyzing close calls identifies why unsafe events occur 

after safety has been compromised. 

In a reactive approach, close calls are analyzed like reportable 

accidents to understand the contributing factors. Analyzing

individual events makes it possible to identify where safety is 

compromised and develop solutions to these threats. 

Recommendations made by the Switching Operations and Fatality

Analysis (SOFA) working group illustrate how the analysis of 

accident and injury data can improve safety 3 . The SOFA working

group analyzed fatalities and injuries in switching operations and 

identified several contributing factors. Based upon this analysis, 

the group proposed five safety recommendations to the railroad 

industry.

Proactive Approach 

Proactively analyzing 

close calls looks at

several cases to find

trends or patterns 

before safety is

compromised 

In a proactive approach, close calls and reportable accidents are 

collectively analyzed to identify trends or patterns related to 

failures or weaknesses in the safety system.4 As the number of 

reportable events, like accidents have declined, the predictive

value of this information has decreased, since there are fewer 

outcomes to suggest trends.5 Close calls provide additional 

information to guide decisions related to safety management. 

Also, proactively using close call information in safety

management focuses attention on the future, so that the past does 

not repeat itself.2 There are many benefits to using close call events

proactively.

Close calls can show where current weaknesses exist in the safety

system. Close calls occur more frequently than reportable events, 

like accidents. Therefore, monitoring close calls can identify trends 

where protection is missing or could be improved, prior to an 

accident. 

For example, a train collision took place in 1999 at Paddington in 

the United Kingdom, when the locomotive engineer passed a red 

signal. Following the accident, investigators discovered that the red 

signal at this location had been violated on eight previous 

occasions due to problems with the signal system.

Close calls can be used to monitor changes in safety over time.

The higher frequency of events increases the sensitivity for 

detecting new failures as well as existing ones. Thus, the railroad 

can adapt to the conditions that change gradually over time as well 

as unexpected events. 

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Monitoring close calls can uncover hidden conditions previously

not exposed by looking at reportable accidents alone. Hidden 

conditions such as design defects, gaps in supervision, unworkable 

procedures, and inadequate training may be present for years 

before they combine with local circumstances to result in an 

accident.5 Where observable failures may be unique to an event, 

hidden conditions are more likely to be consistent across a range of

events. Close calls can identify patterns over time and across 

facilities. 

Who Benefits from Analyzing Close Calls 

Everyone benefits

from using close calls

to control safety 

When close call events are analyzed, everyone benefits:

• An effective program for collecting information about 

close call events shifts safety awareness to individuals at

all levels of the organization. Safety becomes a concern 

for everyone. 

• All groups see economic benefits in reducing costs 

associated with reductions in time lost from injuries, 

damage to railroad property, damage to the environment, 

and time required to move the customers goods. 

Productivity improves when the railroads can more

effectively schedule train and maintenance operations. 

Lessons Learned from Organizations that Analyze Close Calls 

Organizations that successfully analyze close calls share 

information well. They: 

• Encourage disclosure by building and maintaining trust 

between the railroad parties 

• Engage front-line staff in the design of the system to 

build the trust necessary to foster disclosure 

• Structure the system so that information can be easily

organized and analyzed 

• Provide continuous feedback to people at all levels of 

the railroad 

Encourage disclosure by building and maintaining 

trust 

Features that encourage the disclosure of close call events include:

using a third party to collect and store the information, screening

close calls for inclusion, confidential reporting, and limited 

protection for sources from liability or enforcement.6 

Third parties are neutral organizations that collect and store the 

close calls. In addition to collecting the information, they can

check the information for accuracy, appropriateness, and 

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completeness. With CIRAS, the reporting system developed by

ScotRail in the United Kingdom, individuals provide information 

about a close call by mail or telephone to an independent third 

party. After receiving the initial report, the source may receive a

call from the third party to acquire more detailed technical, 

environmental, and personal information and to verify the accuracy

of the information. 

It is important that only appropriate information is entered into the

system. Does the event meet the definition of a close call? When a 

close call is reported, someone must determine whether it should 

be included in the system. One positive way of filtering close calls 

is to include the stakeholders in the decision. For example, in the 

GAIN system, two representatives, one from the FAA and one 

from a labor organization, decide whether to include the 

information in the system, using a team approach to handling close 

call events that provides mutual protection.

Confidentiality in reporting encourages individuals to feel more 

comfortable disclosing close call information. CIRAS removes 

identifiers (e.g., name, location) and the information is stored in a

database, to protect the identity of the individual reporting the 

information. The original forms are returned to the individual and 

no copies are made.

Assuring 

confidentiality makes 

individuals more 

comfortable disclosing

information

Protecting people and organizations from liability and enforcement 

creates an environment where employees and managers feel

comfortable disclosing information. Successful close call systems, 

like the ASRS database also protect the person disclosing

information from disciplinary action. However, this protection 

does not provide immunity from all unsafe behavior. Behavior that 

willfully or recklessly places others in danger (i.e. sabotage or 

substance abuse) must be dealt with responsibly. 

Limited protection

from liability and 

enforcement allows

freer information 

exchanges 

Drawing the line between acceptable and unacceptable behavior 

and communicating that information throughout the organization 

poses a significant challenge to the successful use of close calls.

Engage Front-Line Staff in the Design of the System 

Successful implementation of a close call system requires 

acceptance by a broad segment of the railroad community. The 

best way to achieve this is to involve users from all stakeholder 

groups in the system definition and design. 

Structure Systems to Organize and Analyze 

Information

To facilitate the analysis of close calls, effective systems are

structured to easily obtain information for an accident model of 

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how the system should work. In CIRAS, information is grouped in 

terms of human factors and plant/technical failures. The model 

addresses factors at both the individual and organizational level. 

This includes errors made by the front-line staff such as detection 

failures and application of the wrong rule. It also includes errors 

associated with management such as resource allocation, staffing, 

procedural failures, and equipment design. 

Provide Feedback to All Levels of the Organization

Sharing information with individuals at other locations sensitizes

them to the potential hazards. Successful safety management

systems that use close call events provide feedback at all levels of 

the organization. There are several advantages. 

Feedback from close call systems enables people to track the 

threats to safety and weaknesses of the system over time. The 

railroad industry can better adapt to emerging threats to system 

safety as conditions change. Several close call systems (CIRAS 

and ASRS) produce reports for the industry that describe trends or 

patterns across an organization. 

Feedback, however, must be used properly to manage safety. 

While it is helpful to measure the effectiveness of a solution in 

resolving a problem using close calls, it is counterproductive to set 

a goal of simply reducing the total number of close calls. One 

nuclear power plant that set goal of reducing the total number of 

disclosed close calls achieved a 50% reduction in disclosures in the

first month followed by a greater reduction in subsequent months.7 

However, none of this had impact on the actual occurrence of the 

problem. 

Feedback allows people to monitor the success of specific 

solutions. It is important to determine the degree to which a 

solution corrected a failure. 

Timely feedback from the system can be given to the person who 

reported the close call. Giving timely feedback after someone

discloses a close call shows that the information is valued and 

encourages continued disclosure. 

Next Steps

Successful implementation of a close call system requires 

acceptance by a broad segment of the railroad community. 

Creating acceptance requires a dialog about how close calls will be 

used to build trust among the stakeholders. Any discussion will 

need to involve the participation of all stakeholders. While some 

members of the railroad community are familiar with the use of

close calls, many others are not. 

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The FRA's Office of Research and Development is sponsoring a 

workshop for railroad industry to learn more about the benefits of 

using close calls to manage safety within a railroad. Several 

speakers will: 

Learn more about

using close calls and 

discuss issues at a

workshop 

• Share how their organization or industry uses close calls 

to manage safety 

• Identify challenges to the development and use of close 

calls, and discuss solutions to those challenges 

The workshop will provide an opportunity for participants to raise 

issues that concern the railroad industry and propose solutions. 

References 

1 Weick, K. (1991). Organizational culture as a source of high reliability. California Management 

Review. 29: 112-127. 

2 Phimister, J.R. Oktem U., Kleindorfer P.R., and Kunreuther H. (2000). Near-Miss Management 

Systems in the Chemical Process Industry. http://opim.wharton.upenn.edu/risk/downloads/01-03-

JP.pdf. 

3 Switching Operations Fatality Analysis Working Group. (1999). Switching Operations Fatality

Analysis: Findings and Recommendations of the SOFA Working Group. 

4 van der Schaaf, T.W. (1991). A framework for designing near miss management systems. In

Near Miss Reporting as a Safety Tool (ed. Van der Schaaf, T.W., Lucas, D.A., and Hale, A.R). 

Boston: Butterworth Heinemann, 27-34. 

5 Reason, J. (1998). Safety culture: Some theoretical and practical issues. Work and Stress. 12 

(3): 293-310. 

6 (Davies, J.B., Wright, L., Courtney, E., and Reid H. (2000). Confidential incident reporting on 

the UK railways CIRAS System. Cognition, Technology, and Work. 2:117-125. 

7 Ives, G. (1991) "Near miss" reporting pitfalls for nuclear power plants in Near Miss Reporting

as a Safety Tool (ed. Van der Schaaf, T.W., Lucas, D.A., and Hale, A.R). Boston: Butterworth 

Heinemann, 51-56. 

 

To obtain additional copies of this paper or for more information about the workshop, contact: 

Jane Saks 

EG&G Services 

Volpe Center 

55 Broadway, DTS-920 

Cambridge, MA. 02142 

Email: SAKS@VOLPE.DOT.GOV 

Tel. 617.494.3861 

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APPENDIX H. SYNCRUDE CASE STUDY 

Although this case study is not from the transportation industry, it 

is included in this Appendix since it makes an excellent business 

case for studying close calls. 

CASE STUDY3

Organization – Syncrude Canada Ltd. 

Website URL - HTTP://WWW.SYNCRUDE.COM/

Program Name – Loss Management 

Program Launch – Early 1980’s

About Syncrude – 

Syncrude Canada Ltd. is the world's largest producer of crude oil from oil sands.4

 It also 

is the largest single source producer in Canada, currently supplying 13 percent of 

Canada’s petroleum requirements. Syncrude has been in existence since 1964, with 

production beginning in 1978. It manages and operates all oil sands activities on behalf 

of the numerous companies comprising the Syncrude Project joint venture. The Project’s 

operations consist of three principal stages: mining, extraction and upgrading. Through 

the use of water-based extraction technology, Syncrude separates oil from the sand that is 

surrounded by a water barrier. Since 1984, output of crude oil has more than doubled 

annually while unit-operating costs have been cut in half. But while Syncrude is 

recognized as a highly productive and profitable organization, it also is known and has 

 3 This case study was prepared by Dr. Phyllis G. Thompson of the U.S. Chemical Safety and Hazard Investigation

Board. The CSB is an independent, non-regulatory federal agency whose mission is to investigate and help prevent 

chemical-related incidents at commercial facilities. The case study is based on information identified through

Internet research, review of documents provided by Syncrude, and interviews conducted with company employees

and other knowledgeable individuals. No separate attempt has been made to independently assess this information

or Syncrude's near miss program and its results.

4 HTTP://WWW.ENERGY.GOV.AB.CA/COM/SANDS/INTRODUCTION/OIL+SANDS.HTM

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been formally acknowledged for its corporate social and environmental responsibility and 

commitment to sustainable development. 

Program Details –

General Concept and Administration

Syncrude’s emphasis on near miss reporting is an integral part of the company’s 

comprehensive loss management initiative, which embraces business practices related to 

safety of the people in the company, health of people outside of the company and overall

protection of the environment. At Syncrude, loss control management, defined by Bird 

as “the application of effective management skills to the control of loss from the risk of

business”5

, is the way of (profitably) doing business and safety is an operational strategy. 

The company subscribes to the philosophy that a safe, healthy, financially secure, and 

content worker is more productive. Its view is that safety is not a business expense. . .but 

lack of safety is. And lack of safety represents both a direct expense (e.g., investigation 

costs, production downtime, medical expenses, damage to equipment or product, sick 

pay, repairs, legal costs, court fines) and indirect expense (e.g., employers and public 

liability claims, business interruption, product liability, training of replacement staff, loss 

of goodwill, loss of corporate image) that Syncrude has determined it cannot and will not 

accept. Syncrude’s attitude toward loss management evidences itself even in contracts 

that Syncrude awards, which include loss management elements and take into 

consideration what prospective vendors offer their own employees in the way of, for 

example, safety programs and benefit packages. 

In explaining its comprehensive approach to safe operations, Syncrude’s Chairman and 

Chief Executive Officer (CEO) has emphasized that “putting people first” is the surest 

route to success in business. With that as a guiding philosophy, and with support starting

at the very top of the company and continuing down through the management structure, 

Syncrude has instituted a rigorous, proactive program focused on preventing trouble 

before it occurs as a means of furthering the cause of its bottom line objectives. 

Syncrude’s loss management program defines and is its way of doing business, and has 

led to inculcation of an effective safety-based culture throughout the company. 

Syncrude recognizes there may be easier, less expensive alternatives to its systematic, 

comprehensive effort program, but its position is that those ad hoc alternatives would 

prove more costly in the long term. Consistent with this position, it has elected not to 

address safety in isolation, making it, instead, a core element of its integrated approach to 

loss management. This macromanagement model of loss control permits Syncrude to 

rapidly realize the cost effectiveness and bottom line impact of its program. By

identifying actual losses, Syncrude is able to put contingencies in place to prevent future

losses. By identifying potential losses, it is able to put preventative measures in place 

before losses occur. 

Syncrude admits it is difficult for it to calculate how much effect any single part of the

tightly integrated program has had on the company’s overall performance. This includes 

near miss reporting, which started about the same time as Syncrude’s overall loss 

management program. Syncrude defines a near miss as an undesired event, which, under 

 5 Bird and Germain, Loss Control, 29.

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slightly different circumstances, could have resulted in harm to people, damage to 

property or loss to process. Like an actual incident, it might result from hazardous 

conditions, non-compliance behavior or inadequate operational documents (e.g., job 

standards; training materials). From its perspective, the only difference between an 

actual incident and a near miss incident is that the latter involves no perceivable loss. It

investigates both in the same manner, searching for root causes and corrective actions. 

Syncrude believes its integrated approach to loss management, and its objective of 

continuous improvement in every aspect of its operation, yield benefits that increase over 

time. It believes the safer it is, the more profitable it is. And it believes that its use of

near miss information is driving down the number of actual incidents. Significantly, it 

has tangible proof of the validity of those beliefs.

Operational Features and Procedures 

The effectiveness of Syncrude’s near miss reporting effort relies on worker training, 

information collection, information analysis, action planning, implementation 

assessment, and feedback and reward systems.6

 

Worker Training - New Syncrude and contract employees are given a site-wide 

orientation, a departmental orientation and an area-specific orientation. Contractors also 

take a Construction Safety Training System (CSTS) or equivalent course before coming

to any of Syncrude’s oil sands operations. All workers are trained in programs such as 

"New Worker Initiative," and “Field Level Risk Assessment” (FLRA). 

Syncrude believes FLRA probably is the way in which workers best learn about the 

importance of near miss reporting because it emphasizes, prior to workers beginning their 

jobs, the identification of hazardous conditions, substandard performance, and other 

factors about which Syncrude wants to be kept informed. Syncrude considers this 

training, and the worker’s acceptance of and commitment to the need to report near

misses, the last barrier and defense against incidents because it occurs just before work 

has begun and often long after job assessments, risk assessments, engineering, and other 

formalized processes have been completed. Following this initial phase of their training, 

Syncrude continues to support its new workers by requiring every new employee to have 

a mentor working with him or her. This mentoring is especially important when two 

factors converge, as they are now doing due to a major expansion effort at Syncrude: 

areas are under construction and workers assigned to those locations are new to the site. 

After being employed for a period of time, most mine employees take a specialized

course on “Loss Control Reporting”, which deals with why and how to effectively report 

problems, including near misses and actual incidents. The problems they are asked to 

report are not limited to injuries and property (facility/equipment) damage. Syncrude

also collects reports in the following categories: occupational illness, loss of

containment, fire/explosion, production, security, and environmental. Shortly it will 

begin asking for and analyzing reports on business/administrative problems. 

Information Collection – One way Syncrude captures information on near misses is 

through pocket cards that employees and contractors fill out, anonymously if they wish. 

 6 While mining has been used for many of the following examples, the other Departments also are actively engaged 

in near miss initiatives.

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(See Syncrude’s Near Miss Card on the last page of this case study.) The cards, which 

vary somewhat in format depending on the operation and department, are used to collect 

information on and classify reported errors as near misses, hazardous conditions and noncompliance (i.e., tasks or actions done contrary to established rules or procedures). They

also permit persons to report both compliance and situations warranting commendation, 

that is, observations of tasks or actions completed correctly and safely and observations 

of jobs well done. 

Information on the cards is entered into a central database that contains current and 

historical details about all near miss and actual incidents, as well as hazardous condition 

and compliance data. The database provides consistency in the treatment of data and is at 

the heart of the automated reporting system, giving Syncrude the ability to provide

instantaneous feedback, generate sophisticated analyses and track open and closed actions. 

People are more inclined to use the cards, as opposed to preparing the traditional, formal 

incident reports, since they make reporting easy and simple. In a single year, for 

example, one department received 9,270 card reports. Consistent with the overall 

corporate profile, the number of actual loss incidents has decreased as card reporting has 

increased. Other benefits noted by departments have been reduced injuries, increased 

damage reporting, and employees who today are better able to recognize hazards and atrisk behaviors and are not hesitant to report them. 

Card information is monitored and training is provided to help improve report quality. 

Syncrude takes some action on every report, even if it is only to notify the submitter that

it was received and that the company appreciates the person’s contribution. In order to 

break the incident chain, Syncrude works backward from the observed event through the 

sequence of steps that led to the near miss. This reverse engineering approach allows 

Syncrude to identify, link and understand the conditions existing prior to the near miss so 

appropriate actions can be designed to prevent recurrence. Everyone is kept informed of 

the status of efforts being taken to address reported events, such as near misses, through 

such means as notices on bulletin boards and information in the company’s internal

newsletter. Significant reports and actions are specially highlighted (e.g., installation of 

sidewalks in an area where pedestrians and vehicles were sharing the same street space, 

with the potential for occurrence of life-threatening actual events). As part of the

maintenance effort to keep program awareness high, individuals are publicly recognized 

and rewarded (e.g., through receipt of stickers, and entry of their reports into drawings

held for modest prizes) for submitting cards. 

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1 4

O perat ions – Injury

Incident Character – Su bstandard Actions 2 n d Quarter N ear M iss Analysis - 2002

7 4

3 4

1 5

7 5 3

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

In a t t e n t iv e t o J o b

H a z a r d s

Pro c e d u r a l

D e v ia t io n s

T r y in g t o G a in / S a v e

T im e

W o r k in g U n s a f e ly o n

M o v in g o r

D a n g e r o u s

E q u ip m e n t

U n s a f e P o s it io n Fa ilu r e t o W a r n o r

S e c u r e

Information Analysis – Every quarter, and then again annually, Syncrude’s Mine 

Department compiles statistics on near misses in mining. It derives the information from 

reports submitted by both its employees and contractors in the Department’s various 

divisions (e.g., Mine Operations, Mine Maintenance). Details contained within those 

reports are examined from a variety of perspectives, and translated into quantifiable,

objective terms consistent with Bird’s emphasis on what must be done in order to manage 

loss by measuring performance. Once the incident reports are categorized to show the 

organizational unit from which they were received, and by the general nature of 

consequences reflected in the reports (damage and injury), further analysis occurs. As 

the following examples indicate, this analysis involves breaking down information in the 

reports into ever finer detail, looking at that information in terms of incident character, 

basic causes, substandard actions, causal factors, equipment involved, and locations. 

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8

Operations – Damage

Incident Character – Basic Causes

2nd Quarter Near Miss Analysis- 2002

6 0

1 7 1 7

1 2

9

4 3

0

10

20

30

40

50

60

70

Low W ork

Sta nda rd

Low Maintenance

Standa rds

Ov e r looke d by

Inspe ct ion

Lack of

Knowle dge /Skill

W orn out from

Norma l Us e

Insufficent

Planning

Other

10

Operations – Damage

Driving and Operating Procedures – Causal Factors

2nd Quarter Near Miss Analysis - 2002

1 7

13 13 13

1 2

1 1 1 1

9

5

444

3 3

2 2

0

2

4

6

8

10

12

14

16

18

Missing/Defect ive E quipment

Passing Innap propriately

Failing to Yield

E ngine/T ransm issio n Failures

Imp ro per Parking

O bjects on R o ads/Dum ps

Shift C hange

Safety Berms no t Adeq uate

Proper Signage Missing /Dam ag ed

Ro ad C onditions

W rong Way/W rong R oad

C o mm unicat ion

Failing to Stop

Po wer C ables

Spo tt ing to o C lo se to Sho vel

T alking on C ell Phone 126
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Action Planning – Based on its analysis of information contained in near miss reports, 

Syncrude develops a strategy for addressing noted problems. This might involve, for 

example, identifying questions that must be answered, policies and standards that must be 

reviewed, equipment changes that must occur, or training that must be developed. 

Specific action items are developed, assigned to lead individuals along with due dates, 

and tracked to completion. The following action descriptions are taken from a list of 70 

action items prepared in the case of an initiative involving vehicle near misses on haul 

roads. 

 Study the visibility and road conditions 

categories on the LCR and recommend 

improvements. 

 Ensure that signal/clearance lights are being

upgraded to L.E.D. lighting. 

 Review and revise existing berm standards to 

ensure visibility at intersections. 

 Study training and orientation packages to 

ensure that people have learned material and 

that they are tested. 

 Find out worst-case scenario for hauler stopping

distance. 

Implementation Assessment – Program implementation involves two major steps: data 

management and corrective action evaluation. Syncrude has an extensive Loss 

Management information system that has evolved over 25 years and serves as the nerve 

center for the near miss program. It currently is undergoing revision to improve its “user 

friendliness” and to incorporate a standardized design for capturing near misses and 

hazardous conditions company-wide. The system is comprised of over 50 Oracle tables 

sitting on at least four different servers, with applications (including an automated 

Management of Change application) linked (or planned for linkage) to corporate budget, 

work order, medical and other related tables. 

With information in hand, Syncrude is able to study near miss events to design

appropriate corrective actions. Teams may be convened to work on a problem through 

development of an action plan, conduct of a continuing series of analytical meetings, 

execution of specific assignments and preparation of action reports. However, as the 

company is encouraging near miss reporting with the goal of driving up the number of 

reports, it cannot and does not measure its success in addressing near misses by whether 

the total number of near misses goes down. Instead, it focuses on measuring its success 

based on whether the number of actual incidents decline and whether the kind of near 

misses being reported changes. It believes it has succeeded in both cases, pointing out, as 

one example, the fact that the number of incidents between haulers and light vehicles has 

declined while the number of haulers on the roads has increased. 

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Feedback and Reward Systems - Those responsible for the Mine Department’s near miss 

reporting effort prepare a quarterly near miss study for mine management, team leaders 

and the Mine Safe Operating Committee. The information in the study is shared, through 

team meetings, with all mine workers. Some other Syncrude departments have similar

reporting and analytical initiatives specific to their own operations. 

Workers throughout the company have tangible incentives, in the form of quarterly

gainshare checks, to address productivity and safety goals. The formula for calculating

gainshare checks takes into account both production costs relative to targets, as well as 

the lost time injury (LTI) frequency rate. Being under budget and being safe translate

into being rewarded. Checks are distributed corporate-wide when quarterly performance 

on at least one of the performance indicators is better than the previous best record. 

Syncrude’s goal is to achieve a corporate culture in which employees are so careful that

injuries do not occur and, as a result, LTIs do not exist. The result of Syncrude’s 20-

year-history of working to reduce injury frequency rates (including both medical aid and 

lost time injuries) is reflected in the following graph of mine department employee

injuries. It serves as evidence that incentive programs, coupled with effective near miss 

programs, can drive both incidents and associated injuries downward. While the graph 

reflects only the mine department, the injury records for the entire corporation and for

Syncrude contractors mirror this downward trend.

Year End Recordable Injury Frequency Rate 

Syncrude Mining Employees

0

2

4

6

8

10

12

14

16

18

20

19791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001

Year

Frequency Rate

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Program Results and Evaluation 

Syncrude has been able to measurably document benefits in at least three areas that are

attributable to near miss information and its overall loss management programs: 

operational productivity, cost savings, and efficiency. 

Operational Productivity - Incidents rates have decreased even as near miss reporting has 

increased. Syncrude calculates frequency rates using the formula 

I*200,000

T 

where:

 I is the number of medical aid and lost time

incidents (while classifying an incident in the 

medical aid category might be problematic, (i.e., 

was medical aid actually required), an incident 

is classified in the lost time category if any

hours are missed over and above the day of an 

incident), 

 200,000 is the number of hours a “typical” small 

company’s employees would work in a year

(this is an industry standard of measurement 

applied in the mining, construction and oil 

industries), and 

 T is YTD exposure hours (i.e., the number of

hours actually worked). 

Less incidents and more hours worked translate into greater productivity. They also 

translate into tangible savings. One area of savings has been in insurance premiums. As 

Syncrude has demonstrated the effectiveness of its loss management program (e.g., 

through deceases in the frequency rates of incidents), insurance rates have dropped. 

Cost Savings - Improvements in Syncrude’s safety record have led to substantial, direct 

savings of at least one million dollars annually in insurance costs (for worker 

compensation for injuries and for coverage for property damage) and much more 

influence over the property insurance terms offered by its private sector carriers. It has 

one of the lowest insurance premiums for worker coverage in either the oil or mining

industries in Canada. Syncrude’s insurance premiums are set by the government 

chartered, independently operated Worker’s Compensation Board (Board), whose 

regulations encompass the majority of employers and employees in the province and 

whose funding comes exclusively from the regulated employers. 

The Board bases employers’ premium rates on the type of industry and the frequency and 

severity of injuries for the industry. Syncrude is the first company in the province to 

have the Board set its premium based on the company’s measured safety record instead 

of on the standard applied to its industry. This customized “savings for safety” incentive, 

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while not a standard underwriting approach, is viewed by the Board as a promising way

of encouraging appropriate organizations to initiate comprehensive efforts similar to 

Syncrude’s. Appropriate organizations are those meeting the criteria of corporate size, 

health and safety program sophistication, and disability management. 

Like all covered employers, Syncrude is only required to report an injury to the Board if

that injury results in the worker being off beyond the day of the injury. Although the 

Board does not require near miss reporting, the Alberta Provincial Government’s Dept. of 

Human Resources and Employment (HRE) does. In addition to fatalities and injuries

requiring hospitalization for more than 2 days, HRE requires three categories of near miss 

events to be reported to its Division of Workplace Health and Safety (equivalent to a U.S.

state’s OSHA): (1) unplanned or uncontrolled explosion, fire or flood that causes a 

serious injury or has the potential of causing a serious injury; (2) collapse or upset of a 

crane, derrick or hoist; (3) collapse or failure of any component of a building or structure 

necessary for the structural integrity of the building or structure. 

Syncrude estimates that, across the board, it annually saves between $150 - $200 million 

dollars... about ten percent of its annual crude oil production... as a result of improved 

operational reliability attributable to the success of its loss management programs across 

all operations (i.e., mining, extraction, utilities, refining). Safety translates into lower 

operating costs, and control over costs allows control over and improvement of margins. 

Early in its existence Syncrude realized it would pay a price, literally, if it failed to run a

safe company. Its property insurance and worker compensation rates would be higher. 

Production could suffer due to absence of injured employees from the job, the need for 

more frequent repair of equipment, and shortened useful life of capital assets. In short, 

over two decades ago Syncrude acknowledged that unsafe operations could place it at a 

competitive disadvantage, and it began to address that challenge. Its efforts have been

successful and everyone has benefited. As its employees and contractors work smarter 

and safer, the company saves money. It shares those savings with employees, providing

further incentive for them to improve safety. The statistics show that those incentives

and the emphasis on preventing incidents work. 

 Syncrude today has over ten times fewer

injuries than in earlier years. Its goal is to have

zero injuries on site that cause anyone to have to 

miss work. 

 According to Syncrude Corporate Loss 

Management, employees and contractors 

combined worked a total of approximately 21 

million hours in 2002. Through the end of 

2002 the lost time injury rate, again for both 

employees and contractors combined, was 0.10 

per 200,000 hours (which is approximately 100-

person years) worked. This translates into 10 

lost time injuries for the 21 million hours. 

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 In addressing the 0.10 injury rate for 2002, 

Syncrude’s year-end stewardship report states 

this was “. . .our lowest year end value ever 

recorded.” By comparison, for 2001 the injury

rate was 0.15. The 2002 year-end performance 

represents a 33% decrease in the lost time

frequency rate over 2001 even while workforce 

exposure hours increased by 35%. 

 The reduction in lost time injuries has occurred

despite the fact that, beginning in 2002, 

Syncrude has engaged in a major construction 

program to expand the entire plant (e.g., 

physical size, amount of equipment, production 

capability) by at least fifty percent. In addition, 

this expansion has been coupled with a major 

hiring initiative. 

Due to its focus on safety and near miss management, Syncrude has been able to 

effectively control for the risk of exposing employees. . .experienced as well as 

inexperienced. . . to new occurrences of potentially hazardous conditions. 

Efficiency - Studies done on reported near misses have resulted in operational changes. 

For example, a study done in 1997 and 1998 led to the realization that, given the number 

of near misses between heavy haulers and light vehicles, it was only a matter of time

before there would be an actual collision. A collision had the potential to cause severe 

consequences. In order to prevent those incidents, Syncrude examined factors that could 

contribute to a collision: road and intersection design, hauler design, lighting,

inattentiveness, sign standards, driving standards. A comprehensive action log was 

developed, and actions tracked to completion, in order to address noted deficiencies. To 

date, Syncrude has not experienced any collisions and attributes the lack of incidents to 

its proactive, systematic use of near miss information. 

Lessons Learned - 

As near miss reporting has increased, incidents have decreased, employees have received 

financial rewards, and Syncrude has realized increased productivity and decreased 

operating costs. The benefits have been significant and sustainable. In order to reach the 

point where it is today, the program has been modified over time in a number of areas 

and currently is under review to see 

where it might again be strengthened. 

One item agreed to by Syncrude’s 

Senior Loss Management Advisors is 

that the company needs and will 

construct a common data system for 

capturing near misses, hazardous 

conditions, and other associated 

information. 

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Syncrude’s proactive, results-oriented approach to identifying and correcting substandard 

conditions before an incident occurs takes energy, commitment and time. However, as

Syncrude has learned, it returns tangible benefits to the bottom line, as well as in the form

of situational awareness, attention to safety and to the environment in which employees 

work, management and worker accountability, and information on near misses (and 

incidents) that were reported and acted upon. By identifying and correcting near miss 

and hazardous conditions and unsafe behaviors, all of which have been proven to be 

leading indicators of actual incidents, the chain of events that ultimately results in loss is 

broken. Whether that loss comes in the form of equipment damage or human injury, it is 

a loss Syncrude will not accept. Syncrude’s efforts are designed to ensure it need not 

face such losses and its record proves those efforts have been highly effective. 

While Syncrude recognizes that any near miss reporting system must be industryspecific, it also has learned that certain principles apply regardless of the industry sector. 

Based on its experiences, Syncrude would advise those interested in establishing a similar

program to keep the following recommendations in mind: 

Structure 

 make the program a regular, not a separate, part 

of organizational operations. 

 keep all aspects of the system as simple to

understand, easy to use and convenient to 

operate as possible to facilitate reporting,

feedback, and action. 

 have a single, company-wide reporting, data

collection and management system, not separate 

systems for different operating units, since data 

needed in initial reports is the same regardless 

of the operating unit. 

Actions 

 use severity and potential impact of near misses 

as the criteria for deciding the priority to assign

to a near miss report, the general approach and 

specific actions to take, and the level of 

resources to devote to addressing the problem. 

 make a conscience decision about the need for 

action on every report and, if action is 

warranted, track it to completion. 

Involvement

 have key, if not total, management support 

before initiating the program. 

 empower employees to take actions on unsafe 

conditions and acts. 

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Improving Railroad Safety Through Understanding Close Calls

 accept anonymous reports, but educate workers 

on the need to submit at least enough

information to permit some type of action to 

occur. 

Feedback 

 have a standardized way of formally letting

submitters know their near miss report was 

received and is getting some level of attention. 

 have a standardized way of letting everyone

regularly know about ongoing as well as 

completed action(s) taken on at least major

reported near misses, minimally including in the

widely distributed status report the date each 

near miss was reported, a description of each 

near miss event and a description of the 

action(s) being taken on each reported event. 

 provide periodic update reports on actions 

underway when their completion spans an 

extended period of time. 

 provide public recognition and token rewards to 

those who report near misses, making it clear 

that reporting is a positive step. 

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SIDE 1 – Near Miss Reporting Card

 Work Observation

Department: Division: Team – Area:

Company: Location: Observer:

Date: Mode of Operation:  Shutdown  Normal

Activity Observed:

Personal Contact Made  YES  NO 

Item Safe At 

Risk

Personal Protective Equipment – appropriate for 

task, in good condition

Comment:

Line of Fire - safe positioning, pinch points 

Comment:

Balanced Grip, Position, Traction – not in danger

of overreaching, falling, sliding, etc.

Comment:

Focused on Job at Hand – eyes and mind on task,

good view of work. 

Comment:

Access and Egress – clear path to move to and

from area, easy access to equipment

Comment:

Screens/Guards in Place – required screens,

hoarding, flagging in place

Comment:

Housekeeping – area free of debris, material, 

tripping hazards 

Comment:

Use of Tools & Equipment – right tool/equip. for

job, safety devices and guards in place

Comment:

Use of Vehicles or Mobile Equipment – following 

rules and regulations, spotter required

Comment:

Codes, Practices, Procedures – e.g. permits, 

lockouts and isolations, tagging, excavations,

vessel entries 

Comment:

Rigging and Hoisting – following proper lifting 

practices, lifting devices in good condition, 

Comment:

ACTION TAKEN: Record on other side, with any more comments

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SIDE 2 – Near Miss Reporting Card

S e c u r i n g C a n a d a ' s E n e r g y F u t u r e

 SAFE ACTION

 

Department:

 

Division: Team – Area: Location

Date:

 

Observer: Company: Mode of Operation: Shutdown 

Normal

 Compliance/Commendation  Near Miss  Hazardous Condition  Non Compliance/At Risk

 Rules/Procedures 

Housekeeping



Tools/Equip./Bldg.

 Vehicles/Mobile

Equip./Road

 PPEs

What Did You Observe?

What Action Did You Take? 

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Improving Railroad Safety Through Understanding Close Calls

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Improving Railroad Safety Through Understanding Close Calls

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Close Call Systems

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Web Sites 

Federal Aviation Administration: 

WWW.ASY.FAA.GOV/SAFETY_DATA

WWW.ASY.FAA.GOV/GAIN 

WWW.GAINWEB.ORG

United Kingdom Confidential Incident Reporting System (CIRAS) 

HTTP://WWW.CIRAS.ORG.UK/ 

Bureau of Transportation Statistics Safety Data Action Plan

HTTP://WWW.BTS.GOV/SDI/SDAP000913.HTML

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