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

• Background

• TSB Canada

• SMS issues

• Four accidents with SMS issues identified

• Conclusions

Canadian Railway Network & TSB Offices

January 2009, British Columbia

TSB Canada

• Independent federal agency

• Multi-modal

• Chairperson and four Board Members

• 21 rail investigators

• Total Board employment: 235

TSB Mandate

Advance transportation safety by:

• 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

• 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

Integrated Safety Investigation Methodology (ISIM) Model

Occ. AssessmentOcc. Assessment

Data CollectionData Collection

Occ. EventsOcc. Events

Unsafe Acts/Conditions

Unsafe Acts/Conditions

Safety CommunicationSafety Communication

Accident

Underlying Factors

Underlying Factors

Assessed RiskAssessed Risk

Safety Deficiencies

Safety Deficiencies

Risk ControlOptions

Risk ControlOptions

Sequence of Events

Integrated Investigation Process

Integrated Investigation Process

Risk Assessment Process

Defence (Barrier) Analysis Process

Risk Control Options Analysis Process

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2

3

4

5

6

7

8

Accident

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:– 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

Figure 2. NMTDs by Cars Derailed, May 1, 2007 - Dec 31, 2008

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50

100

150

200

250

1 2 3 4 5 6-10 11+Cars derailed

No

n M

ain

Tra

ck

Tra

in D

era

ilm

en

ts

X Y Others

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 vesselin distress in all my years at sea...I never saw a wreckand never have been wrecked, nor was I ever in any predicament that threatened to end in disaster of anysort.

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