Transcript Vandalism and Rail Operations in Canada

Transportation Safety Board of Canada
Managing the Organizational Interface
Three case studies.
IRSC
9-13 October 2005
Ian Naish
Director, Rail / Pipeline Investigations
Branch
Railway Industry in Canada
• 47,000 km of track
• 60 railway companies
• 1400 reported
occurrences per year
Managing Inter-organizational
Interfaces
• Issues:
– risk management in a changing
environment
– areas where safety defences have
failed.
– involvement of all staff in
management of safety.
Managing the Interorganizational Interface
MCBRIDE, BC
NOBEL, ON
LIMEHOUSE, ON
Nobel, Ontario, 2003
• Broken rail derailment in First
Nations land
• No command centre set up communications problems
• Responder training, but not
experience
Limehouse, ON, 2000
• No site safety briefing
• Contractors setting up at crossing
• Truck blocking signals
• No flagperson
• Three persons killed
McBride, B.C.
• Bridge collapse and fire
• Changes in roles and responsibilities
• No records of maintenance work
done
• No regulatory requirement to audit
procedures
Conclusions
• Work sites are
complex
• They have to be
managed effectively
• Assign roles
• Communicate clearly,
early and often
• Good records must
be kept
Some suggestions
• Plan in advance
• Meet early and often
• Train and re-train
• Due diligence when
record keeping