Transcript Introduction to RSSB

How should industry make decisions
affecting safety?
Anson Jack, Deputy CEO and Director of Policy, Research and Risk
RSSB
29 September 2009
International Railway Safety Conference, Bastad, Sweden 2009
Context
EU Safety Directive requirement is to maintain
and, where reasonably practicable, improve
safety
National legislation
Decision-making audit trail
DATA
ANALYSIS
INFORMATION
Review
Data to Decision
Making Audit Trail
IMPLEMENT
INDUSTRY
DECISIONS
KNOWLEDGE
3
DATA
Safety Management Information System
• Collects data from individual events across sector
Accidents
Investigations and reports
R&D
• Explores – behaviour – engineering – operations
CIRAS
• Confidential Incident Reporting Analysis System
INFORMATION
•
•
•
•
Monthly statistics of key safety measures
Monthly reports on Signals Passed at Danger
Periodic Reports on special topics (level crossings etc)
Annual Report / compendium of safety data
ANALYSIS
• We look at 6 precursors of train accident risk
Precursor Indicator Model
140
120
PIM indicator
100
6 - Trains & rolling stock
5 - SPAD
4 - Objects on the line
3 - Level crossing misuse
2 - Irregular working
1 - Infrastructure failures
80
60
40
20
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Safety Risk Model
• 120 hazardous events - frequency and consequence
• Enables rail companies to benchmark their risks and
identify areas for action
• Enables government to set risk based rather than
performance based targets
• Covers 99% of residual risk on the railway
Fault and event trees
Precursors
(Consequence)
Escalation
factors
Pr obability of
der ailment/tr ain
mile tr avelled
N umber of tr ain
miles tr avelled/year
Does tr ain maintain
clear ances?
Y/N
Does tr ain obstr uct
an adjacent line?
N /Y
Is ther e a collision
with tr ain on the
adjacent line?
N /Y
N
1 - 4.3E-08
Example fault tree
(not fully developed)
Fault
Sequence
Fr equency
(Events/yr )
257E+06
Y
Consequences
(Eq fatalities/
Event)
Risk
(Equivalent
fatalities/
yr )
N o accident
8.25
0.05
0.41
1.375
0.5
0.69
1.24
0.5
0.62
0.138
10
1.38
0.75
257E+06
Fault Sequences
N umber of passenger
train miles travelled/
year
4.3E-08
257E+06
Y
257E+06 x 5.6E-08
= 11 derailments/yr
N
0.5
Hazardous event definition
0.25
Passenger train
derailment/train mile
travelled
N
N
4.3E-08/train mile
0.9
0.5
Derailment
due to rolling
stock faults
Derailment
due to track
faults
Derailment due
to running into
obstructions
Derailment
due to overspeeding
Y
0.1
Y
Broken rail
leading to
derailment
Buckled rail
leading to
derailment
Example event tree
(not fully developed)
Track twist
leading to
derailment
Precursors (Cause)
9
Collective Risk =
3
From the SRM we know
• Highest risk of train accidents is from level crossings
• Overall system risk has fallen over the years
• The industry understands its risks (and has effective
measures to address them)
• Risk to the public is greater than risk to workforce or
passengers
• Frequency and severity of accidents has been reducing
From the SRM we know
Risk to passengers in all train accidents has fallen by
more than 80% in less than ten years
Modelled risk of fatality in a train accident has reduced
from 0.26 per billion passenger kms per year in 2000
to 0.045 per billion passenger kms per year in 2008
Source: RSSB Safety Risk Models (Version 1 2000 and Version 6 2009)
Total risk on the railway
Reportable minor injuries
(0.7%)
Major injuries (9.6%)
Fatalities (20.8%)
Total risk = 141.3 FWI/yr
Major injuries (55.9%)
Fatalities (89.3%)
MEMBER OF
THE PUBLIC
40%
PASSENGER
39%
Reportable minor injuries
(12.8%)
WORKFORCE
21%
Non-reportable minor injuries
(9.0%)
Class 2 shock/ trauma (1.6%)
Class 2 shock/ trauma (3.9%)
Class 1 shock/ trauma (4.1%)
Non-reportable minor injuries
(17.1%)
Fatalities (15.7%)
Major injuries (48.0%)
Reportable minor injuries
(11.3%)
Decision-making audit trail
DATA
ANALYSIS
INFORMATION
Review
Data to Decision
Making Audit Trail
IMPLEMENT
INDUSTRY
DECISIONS
KNOWLEDGE
13
How does industry take decisions
‘Taking Safe Decisions’:
– Product of research and consultation
– Think Tank - industry experts, regulator and
government
– endorsed by industry through RSSB Board
– complementary to, and consistent with, safety
regulators guidance
Summary
• Operators decisions are taken for legal and commercial reasons
• Legal duty to deliver safety So Far As Is Reasonably Practicable
• Whether or not something ensures safety SFAIRP is a judgement
based on:
– Good practice,
– Risk Assessment and Cost Benefit Analysis (sometimes)
• The SFAIRP judgement is based on collective risk and net costs
• Other factors part of a wider business case but not the SFAIRP
judgement
Summary
– ‘Societal concern’ about accidents is for government
– What should and should not be included in cost benefit
– Decisions are always based on judgement – not decided by CBA
– Make decisions consciously and record them
– The Tolerability of Risk traingle described in HSE guidance is not
part of operators decision criteria
Taking Safe Decisions has examples
•
•
•
•
•
Removal of fire extinquishers from passenger vehicles
Removal of signal post telephones when GSM-R is fitted
Axle Counters or Track Circuits
Fit new sanders or improve driver training
Length of walking route for drivers
• New examples (not in the literature)
– Taking window hammers out of trains
– All non breakable windows
– Train Horns – reduction in sound levels and times of use
Taking Safe Decisions
• Taking Safe Decisions is on the RSSB website:
http://www.rssb.co.uk/safety/safety_strategies/sdmoukr.asp
• Safety Regulator (ORR) has published guidance for
their inspectors on how to undertake CBA in support of
safety related decisions. This is complementary to TSD,
although written for inspectors rather than the industry
• The ORR guidance is available on their website
http://www.rail-reg.gov.uk/server/show/nav.1118
Decision-making audit trail
DATA
ANALYSIS
INFORMATION
Review
Data to Decision
Making Audit Trail
IMPLEMENT
INDUSTRY
DECISIONS
KNOWLEDGE
19
What is RSSB?
• Set up in April 2003 as a not-for-profit company
• Owned and funded by major stakeholders in the rail
industry, independent of any one party
• Approximately 250 employees covering a range of
technical and business disciplines
RSSB’s Purpose
Working with our industry partners our purpose is to:
-
Where reasonably practicable, continuously improve safety
-
Drive out unnecessary cost
-
Improve business performance
21
Thank you
[email protected]