IRSC Vancouver 2013 Theme 1 - Components of a Robust Safety Management System

1. IRSC Vancouver 2013Theme 1 - Components of a Robust Safety Management System Why is Rail Safety Important to me? Lessons from Accident Investigation David Edwards Executive Director Australasian Transport Safety Solutions (ATRS) Pty Ltd Vancouver, Canada 8 October 2013

2. Presentation Overview • BackgroundThe importance of people, culture & perception in managing safety risk • Case Study Robertson Rail Accident • Conclusion Why is safety important to me? A personal experience !!!

3. Workplace Safety Perception • our individual differences influence how we perceive our work environment, the tasks at hand, our skills and capabilities • based on such perceptions, we make decisions on how we are going to behave • what level of safety risk are you prepared to accept?

4. Safety Risk Tolerance Factors that shape our perception & tolerance of risk • general work environment • company leadership • management & supervisor role models • home & family life • sporting lifestyle • organisational culture

5. Safety Risk Behaviour level of risk perception = level of safety behaviour

6. Human Risk Environment Factors A number of factors contribute to how we view the work environment in terms of safety risk: • Memory – ability to learn varies from person to person, our perception of an event impacts on what we remember – our memory is biased • Experience – our memory is based on previous experience • Knowledge – people who take risks may not be less knowledgeable • Mood – our disposition affects how we function • Work stress – time pressure & work load • Group pressure – perception also applies to groups • Risk exposure – if we believe a risk is controlled, we may lower our risk rating & increase our risk taking behaviour • Workplace safety performance – no safety incidents = safe workplace?

7. Safety Value The Importance of Values in Reducing Risk • The extent of risk taking ultimately depends on the values that prevail, not the safety technology available (Wilde – Target Risk 2 - 2001) • Both personal values & organisational values • What are your safety risk values?

8. Case Study Robertson Accident NSW Southern Highlands Australia19 May 1998 “my safety values”

9. Robertson Accident Site Moss Vale Rail Line From Wollongong Illawarra Hwy From Wollongong Old Road Bridge

10. Incident Background • Railway construction contractor laying concrete sleepers for track upgrade • Redundant 1928 road overbridge too low to accommodate added ballast • Bridge deck & piers removed • Formation adjacent to bridge abutments lowered to improve drainage • On 19 May 1998 a bridge abutment collapsed onto rail track after period of rain • In darkness and fog, freight train hit obstruction & locomotive rolled over hitting adjacent abutment of the new bridge • Train speed at time of collision = 34 kph • Two train drivers killed

11. The Train Locomotives 3 x NR Class (NR3/NR26/NR57) GE-9 4,000 hp 16 cyl 130 tonnes 22 metres in length 120 in class Two Driver Crew Train Train No.1BY4 Port Kembla to Whyalla Wagons = 26 x RCGX & RCGF Loading = Jumbo Coil Steel Total trailing load - 1,672 tonnes

12. Sequence of Events

13. Sequence of Events Bridge Superstructure Removed for Vertical Clearance

14. SeSequence of Events Drains Lowered Adjacent to Abutments

15. At 0400 Hours on 19/05/98 Undermined Abutment Collapses onto Track & Hit by Freight Train

16. Collapsed Abutment

17. Opposite Abutment Wall (before)

18. Opposite Abutment Wall (after)

19. A Tragic Accident Site

20. Locomotive Cab Condition

21. Why did Locomotive Roll Over?

22. What Crash Protection?

23. Other High Risk Locations

24. Contributing Factors • Previous vertically integrated NSW Government rail authority broken up with part privatisation in a new disaggregated rail environment • Stakeholders included: Network Manager (Rail Access Corporation)Network Maintenance (Rail Services Authority)Use of contractors for maintenance projectsMultiple Train Operating Companies • Little or no engineering design, control, supervision (cost driven) • No risk assessment conducted • No interface plans between stakeholders • No clear responsibility or accountability and no understanding of safety culture • information withheld from formal investigation

25. In Summary I believe there are four key elements that drive our personal perception of safety risk, they are our… • Attitudes – Values – Beliefs – Behaviours The Robertson derailment in 1998 was for me a life changing experience that altered my attitudes, values, beliefs, and behaviour, the cause of which I now share with you !!!

26. Why is Safety Important to Me? Incident Day 4 Unexpected family visit to crash site

27. Robertson – 19/05/98 Rest in Peace John Anderson&Wayne Dunstan

28. Thank You “If you think safety is expensive, try having an accident”