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David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
David Edwards - ATRS - ATRS views on occurrence trends
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David Edwards - ATRS - ATRS views on occurrence trends

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David Edwards delivered the presentation at 2014 Major Rail Occurrence Forum (Derailments). …

David Edwards delivered the presentation at 2014 Major Rail Occurrence Forum (Derailments).

The RISSB Major Rail Occurrence Forum (Derailments) has been designed to build on and continue the analysis of major occurrence reports and to seek Industry learning from them. By reviewing major occurrence reports, Rail Organisations have the opportunity to learn from the lessons without having to suffer the same occurrence.

For more information about the event, please visit: http://www.informa.com.au/derailments14

Published in: Business, Technology
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  • 1. Major Rail Occurrence Forum Occurrence Trends in Derailments & Lac Megantic Case Study David Edwards Executive Director, ATRS Pty Ltd 29 April 2014 Sydney
  • 2. How Safe is the Rail Industry ?
  • 3. And the Answer is… Ø  Generally, very safe by world standards Ø  Continued improvement is being achieved Ø  Less engineering or mechanical defect caused derailments Ø  Level crossings are still an issue, but improving trend Ø  Weather related derailments are a concern Ø  The key issues today appear to be organisational safety, just & learning cultures procedural compliance human factors Ø  What level of safety risk are you prepared to accept? Ø  Varied across organisations, but improving trend
  • 4. Edith River NT 27/12/11
  • 5. Workplace Safety Perception… Ø  our individual differences influence how we perceive our work environment, the tasks at hand, our skills & capabilities Ø  based on such perceptions, we make decisions on how we are going to behave Ø  what level of safety risk are you prepared to accept?
  • 6. Incident Trend Analysis - Improvement Ø  Decreasing level crossing collisions with road vehicles Ø  No fatalities to workforce/employees during 2013 Ø  Decrease in serious injuries to passengers & public Ø  Slight decrease in number of loading irregularities Ø  No increase in Infrastructure – Broken Rails (steady) Ø  Significant improvement in wheel, axle & bearing failures Ø  Slight improvement in rolling stock train partings
  • 7. Incident Trend Analysis – No Improvement Ø  Significant increase in running line derailments in 2013 when compared with the previous 5 years (ONRSR & TSV) Ø  Rate of freight train derailments is high when compared with UK railways (ONRSR) Ø  Increase in level crossing collisions with persons Ø  Slight increase in number of serious employee injuries Ø  Increase in the SPAD rate across most categories Ø  Increase in infrastructure buckled track Ø  Near miss incidents with trains entering work areas
  • 8. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Bird’s  Pyramid   600   Near  Misses   30 Property Damage 10 Minor Injuries 1 Death or Serious Injury Lag  Indicators   Lead  Indicator   The key area for the Rail Industry to manage Consider  greater  use  of   confiden1al  incident   repor1ng  
  • 9. Incident Trend Analysis – Key Issues Ø  Difficult to access normalised data Ø  Multiple incident data sources Ø  Need for industry wide incident data base (SISAR) Ø  RISSB Incident Data Guidelines Ø  ONRSR is committed to encouraging & assisting industry to develop a national safety risk model & safety incident data base Ø  It’s time industry took the lead & implemented a workable data strategy solution
  • 10. Sir Winston Churchill… “No matter how beautiful the strategy, occasionally you should check the results”
  • 11. Case Study Lac-Mégantic, Canada 6 July 2013 Train Run-away and Derailment
  • 12. Incident Background Ø  Train derailed on 6 July 2013 in town of Lac-Mégantic, Quebec Ø  Train ran-away un-manned with 5 Locomotives for 11 km Ø  74 DOT-111 tank cars - 7.2M litres of North Dakota crude oil Ø  Destined for refinery in St. John, New Brunswick Ø  Weight of train 10,287 tonnes & 1,433 metres long
  • 13. Contributing Factors Ø  Train not stabled correctly (Montreal, Maine & Atlantic Railroad) Ø  Minimal wagon handbrakes applied Ø  4 of 5 locomotives shut down Ø  Lead locomotive “running” with full service brake application Ø  Reported fire on lead locomotive & “shut down” by fire service
  • 14. Fallout Ø  54 people killed Ø  40 buildings destroyed in downtown Ø  5.6 million litres of crude oil spilled Ø  Chaudière River & sewage system contaminated Ø  31 hectares of land contaminated Ø  Oil carried by the river 120 km from the disaster site Ø  TSB, TC & Police investigations Ø  Extensive media coverage Ø  Inadequate insurance coverage
  • 15. Community Impact
  • 16. Up Stream Causes Ø  Ineffective Safety Regulation Ø  Rail Organisation culture Ø  Short Cuts & Secrecy Ø  Not licenced for dangerous goods Ø  Regulator did not know, but should have known Ø  Procedural weaknesses Ø  Network Manager failures Ø  Interface failures with rail groups & emergency services Ø  Emergency Shut Down Button
  • 17. Post-Lac Mégantic Issues Ø  Operations (including crewing levels) Ø  Regulatory Ø  Municipal Ø  Dangerous Goods Ø  Tank Car Design Standards Ø  Insurance & liability Ø  Cross-Border Harmonization Ø  Communications Ø  TSB Recommendations Ø  Training
  • 18. Tank Car Standards - Safety Concerns Ø  New AAR standards issued and implemented in October 2011 Ø  New standards reduce risk of spills and leaks Ø  Majority of tank car owners are leasing companies & shippers Ø  310,000 tank cars (pressure and non-pressure) in NA fleet Ø  240,000 tank cars are DOT 111 type (Lac Mégantic)
  • 19. Summary – Derailment Occurrence Trends Past Ø Steady progress, but could do better with greater effort Ø Traditionally very poor at incident trend analysis Ø Tend to focus on internal “lag” indicators only Ø No consideration of wider industry incident data base Future Ø Need to establish industry wide incident data base (SISAR) Ø Opportunity to provide greater focus on derailment “lead” indicators Ø Wider use of incident trend analysis Ø If so, a chance to predict the next major derailment before it occurs
  • 20. Thank You & Questions “If you think safety is expensive, than try having an accident” Remember Lac-Mégantic

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