Use of precursors for safety monitoring by NSAs/ERA

ERA-TRL workshop

20 February 2013, Lille

Vojtech EKSLER (ERA)

Introduction /1

0

1

2

3

4

5

6

Fata

l tra

in c

olli

sio

ns

and

de

railm

en

ts p

er

bill

ion

tr

ain

-km

(EU

-27

)

Accident risk 5-year moving average

Introduction /2

1. (Fatal) railway accidents became rare

Less than 10 fatal collisions and derailments per year at EU level.

2. Measures of safety performance become opaque

Our knowledge about railway safety performance and underlying problems

3. Our ability to manage risks is undermined

Complacency take ground easily

Introduction /3

Frank E. Bird 1969

A hippopotamus can be made invisible in dark water. African proverb

Ignorance can lead to potential danger.

Definitions

‘Precursors to accidents’ are indicators of incidents that under other circumstances could have led to an accident.

Precursors include for example near-misses, incidents, technical, human and organisational failures.

RSD introduced six precursor indicators to be monitored at EU level in 2004

Accident precursors (EU)

5563

1776

525

2749

56 43

4486

2213

433

2700

33 28 0

1 000

2 000

3 000

4 000

5 000

6 000

Signals passed atdanger

Broken rails Track buckles Wrong-sidesignalling failure

Broken wheels Broken axles

2010 2011

Accident precursors

Accident precursors p.a. (2010-2011)

Significant accidents p.a. (2000-2011)

Ratio

SPADs + Wrong-side signaling failures

Train collisions with a railway vehicle

6,407 29 1 / 221

Broken rails&wheels& axles + Truck buckles

Train derailments

14,198 192 1 / 74

Potential of accident precursors monitoring

… for safety data analysis + learning from accidents

Safety monitoring: state of the art

(HAZARDOUS) EVENTS

INCIDENTS

ACCIDENTS

SERIOUS

ACCIDENTS

RSD Art.19

SIGNIFICANT

ACCIDENTS

RSD Annex I

NON-SIGNIFICANT

ACCIDENTS

CSI REPORTING

(EU level)

NIB Investigations

Safety monitoring: roles of stakeholders

(HAZARDOUS) EVENTS

INCIDENTS

ACCIDENTS CSI REPORTING

(EU level)

EU (ERA, EC)

Member States (NSAs)

RUs / IMs / ECMs

Competence of different stakeholders

Major challenges

Accident/precursors reporting framework incomplete

Use of accident/precursors data by different stakeholders remains limited (unexploited)

Knowledge derived from accident/precursors data by authorities is limited

Right balance in defining roles and responsibilities

What the NSAs do in respect to precursors monitoring?

Use of precursors by NSAs

22 (out of 27) NSAs use precursors other than those defined in the RSD

Common purpose is general safety monitoring

Precursors indicators seldom used for planning supervision activities

Current practice at national level

Approaches vary among countries

Various indicators, reporting frequency, database keeper, purpose and use of data, etc…

Yes (AT,BE,BG,CZ,DK,EE,FR,LV,NL,NO,PT,SE,

UK); 13

No (CT,EL,ES,FI, HU,IE,IT,LT, LU,PL,RO,SI

,SK); 14

Availability of a database on accident precursors at country level

Most commonly used precursors by NSAs

Runaway train

Misrouting (train accepted on wrong track)

Departure without authorization

SPAD (other movement, track)

Malfunctioning of LC protection system

Impaired braking ability

Disconnection of train when running

Overspeeding

Broken arms at level crossings

Need for more harmonization?

View on use of precursors at EU level varies

Cautious approach advocated by NSAs

It would be a great challenge to get a common

understanding of new indicators

Extended monitoring of precursors under CSIs?

Yes; 8

Possibly; 3

No; 11

Guidance for NSA; 1

N/A; 4

Yes

Possibly

No

Guidance for NSA

N/A

Introducing TRL study

Introducing TRL study

Precursors historically used by RUs/IMs

Available experience with precursors limited worldwide

Lack of common understanding (definitions, purpose, roles)

Theoretical knowledge vs. empirical experience

Prospective study into harmonized train accident precursors analysis and management (September 2012 – March 2013)

OBJECTIVES

1. Establish a theoretical basis for precursor’s data management by defining a common set of causal trees and by identifying those precursor indicators with highest relevance to the safety management at EU/NSA/RUs, IMs levels.

2. Provide an overview on the precursors monitoring practice at the level of NSA and RU/IM in a sample of EU countries.

3. Determine a potential harmonized set of precursor indicators for different levels of safety management (RU/IM, NSA, ERA).