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International Railway Safety Conference - 2012

Paul Thomas CB FREng FCGI Chairman RSSB. International Railway Safety Conference - 2012. HMS VANGUARD. Moral Legal Direct cost Reputation Poor Safety = Bad Business. Safety – why bother?. THORP leak -2005.

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International Railway Safety Conference - 2012

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  1. Paul Thomas CB FREng FCGI Chairman RSSB International Railway Safety Conference - 2012

  2. HMS VANGUARD

  3. Moral Legal Direct cost Reputation Poor Safety = Bad Business Safety – why bother?

  4. THORP leak -2005 British Nuclear Group has released its board of inquiry report into the leak at Sellafield’s Thorp plant. A design errorled to a leak of highly radioactive liquor whiledefective cultureat the plant delayed detection for nine months. Theexceptionally frankreport lists the following management systems as having shortcomings which contributed to the event:safety case; procedures and systems of work; hazard reporting systems; training; supervision; design; maintenance; and plant modification. The report states that a ‘new plant’ cultureexisted and Thorp was simply not expected to leak. Nuclear Engineering International

  5. “Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.” Leadership & Responsibility Admiral Hyman G Rickover USN

  6. Competence/Training & Assessment Supervision/Management Just Culture/Near Hit & Incident reporting Standards & Expectations People

  7. Programme pressures Competence Appropriate procedures Windscale - 1957

  8. Inadequate training Lack of OE feedback Consequences INPO Three Mile Island - 1979

  9. Bad design Operational pressures Lack of safety culture WANO Chernobyl - 1986

  10. Plant shut down successfully UNTIL Tsunami hit Periodic review Fukushima - 2011

  11. Expert Peers 3 week visit POs & Cs Evidence – White Cards Feedback meeting Strengths AFIs Follow up visit Formal report Peer Review

  12. “It is necessary for you to learn from others' mistakes. You will not live long enough to make them all yourself” “I have a son. I love my son. I want everything that I do to be so safe that I would be happy to have my son operating it. That‘s my fundamental rule.” Final thoughts

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