Transcript irsc 2009 ppt presentation - International Rail Safety

TSB of Canada –Reflections on a
Career in Rail Safety at the TSB
Ian Naish
Director, Rail Investigations (retd.)
Transportation Safety Board of Canada
IRSC, Båstad, Sweden
29 September 2009
Naish Transportation Consulting Inc
Topics to be presented
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Background
TSB Canada
SMS issues
Four accidents with SMS issues identified
Conclusions
Canadian Railway Network & TSB
Offices
January 2009, British Columbia
TSB Canada
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Independent federal agency
Multi-modal
Chairperson and four Board Members
21 rail investigators
Total Board employment: 235
TSB Mandate
Advance transportation safety by:
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making findings
making recommendations
reporting publicly
Do not assign fault or liability
Shall not refrain from reporting fully
Board’s findings are not binding
How work is carried out
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1,000 reported rail accidents per year
40 deployments per year
15 Board investigations per year in rail
ISIM Integrated Safety Investigation
Methodology
• Around 5 recommendations per year
• 15-20 Safety Communications per year
TSB Recommendations
• Board recommendations if safety
deficiency is systemic
• Can make prior to final report released
• Non-prescriptive and not binding
• Normally made to Minister of Transport
Accident
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Occ. Assessment
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Occ. Events
Integrated Safety Investigation
Methodology (ISIM) Model
Data Collection
Accident
Sequence of Events
Integrated Investigation Process
Unsafe Acts/
Conditions
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Integrated Investigation Process
Underlying
Factors
Risk Assessment Process
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Assessed Risk
Defence (Barrier) Analysis Process
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Safety
Deficiencies
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Risk Control Options Analysis Process
Risk Control
Options
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Safety Communication
Key Components of an SMS
• 1. A Safety management plan
• 2. Training
• 3. Regulatory monitoring (reactive and
proactive)
• 4. Documentation
• 5. Quality assurance, and
• 6. Emergency response preparedness.
SMS
• Some Safety Management Systems issues:
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risk assessment and control processes
regulatory overview
organizational safety culture
under-reporting of accidents
• 1996 – QNS&L One person freight train operation
• 2003 – McBride bridge collapse: “Black Swan Event?”
• 2006 – White Pass &Yukon Route runaway and
derailment
• 2007 – Prince George non-main track derailment
• Accident under-reporting
QNS&L Collision, 1996
QNS&L Collision, 1996
McBride Bridge Collapse, 2003
McBride Bridge Collapse, 2003
WP&YR Runaway and Derailment,
2006
WP&YR Derailment, 2006
Prince George Yard Derailment,
2007
Prince George Derailment, 2007
Prince George Derailment, 2007
Reporting Issues
Non Main Track Train Derailments
250
200
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Others
150
100
50
0
1
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Cars derailed
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6-10
Figure 2. NMTDs by Cars Derailed, May 1, 2007 - Dec 31, 2008
11+
Some Conclusions
• SMS is not necessarily easy to implement
or manage
• SMS problems can occur during times of
change
• Industry has to be accountable for SMS to
work
• Regulators have to be accountable too
• Safety culture is critical
Something to think about...
When anyone asks me how I can best describe my
experience in nearly forty years at sea, I merely say,
uneventful. Of course there have been winter gales,
and storms and fog and the like, but in my experience,
I have never been in an accident of any sort worth
speaking about. I have never seen but one vessel
in distress in all my years at sea...I never saw a wreck
and never have been wrecked, nor was I ever in any
predicament that threatened to end in disaster of any
sort.
E.J. Smith, 1907
On April 14, 1912, RMS Titanic sank with the loss of
1500 lives - one of which was its captain - E.J. Smith
Thank you!
Naish Transportation Consulting Inc.
www.naishconsulting.ca