Analysing Rail Safety
Accidents
Peter Foley
General Manager Surface
Safety Investigation
Australian Transport safety
Burea...
Independent, fair and objective, we work closely with
industry to improve safety by:
• conducting thorough and systemic in...
Accident Investigation
&
Research
• Aviation
• Marine
• Rail
Background / Function (cont’d)
AVIATION | MARINE | RAIL
Jurisdiction – Main Freight Routes
Melbourne
Adelaide
Perth
Brisbane
Sydney
Darwin
Melbourne
• Adelaide (South Australia)
– 1 x Adelaide Regional Manager (Rail Co-ordinator)
– 4 x Investigators
• Canberra Central Of...
Safety
investigation
process Safety
action
Transport safety
matter
Notification and
assessment
Investigation
management
An...
ATSB investigation analysis model
AVIATION | MARINE | RAIL
Analysis process
Preliminary
analysis
Safety factors
analysis
Analysis review
Risk analysis
(safety issues only)
Safety ac...
Levels of analysis
Organisational Influences
(What could have been in place to prevent problems
with the risk controls?)
R...
AVIATION | MARINE | RAIL
Risk controls
• Operator or track manager measures to
assure safe performance of the operational
components
• Prevent haza...
Risk controls
• Preventative: reduce undesirable local
conditions, individual actions, events
– Training, procedures, equi...
Risk controls
• Recovery: detect, correct or minimise effects
of adverse local conditions, individual
actions, events
– De...
Organisational influences
• Establish, maintain or otherwise influence
effectiveness of organisation’s risk controls
• Man...
Types of organisational influences
• Safety management processes
– Hazard identification, change management, process
revie...
Risk analysis
Safety issue
Review existing
risk controls
Describe worst
credible scenario
Determine
consequence level
Dete...
Risk acceptability
• Critical safety issue – risk is regarded as
unacceptable whatever the level of benefits
associated wi...
ATSB analysis policy
• All key findings supported by evidence table
• All verified safety issues to be subject to risk
ana...
Accident trends
Safeworking – collisions with track vehicles
Weather related events
Derailments
Level crossings
AVIATION |...
Accident trends - Safeworking
AVIATION | MARINE | RAIL
Accident trends – Weather related
AVIATION | MARINE | RAIL
Accident trends - Derailments
AVIATION | MARINE | RAIL
Accident trends- Level crossing
AVIATION | MARINE | RAIL
Aviation data
AVIATION | MARINE | RAIL
• ATSB is the one stop shop for civil aviation incident
reports
• TSI Act requires ...
Safety intelligence – ATSB aviation
AVIATION | MARINE | RAIL
• Quarterly trend monitoring of occurrence data by
occurrence...
Safety intelligence
AVIATION | MARINE | RAIL
• Use and analysis of safety factors, both for
investigated and non-investiga...
• Statistical series- aviation
• Targeted safety issue research - aviation
• “Avoidable accident series”- aviation
• Natio...
Questions?
AVIATION | MARINE | RAIL
Analysing rail safety accidents
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Analysing rail safety accidents

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Peter Foley, General Manager, Surface Safety, from the Australian Transport Safety Bureau delivered this presentation at Rail Safety 2012. For more information on the annual conference, please visit www.railsafetyconference.com.au/

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Analysing rail safety accidents

  1. 1. Analysing Rail Safety Accidents Peter Foley General Manager Surface Safety Investigation Australian Transport safety Bureau Rail Safety 2012, Sydney 29 March 2012 AVIATION | MARINE | RAIL
  2. 2. Independent, fair and objective, we work closely with industry to improve safety by: • conducting thorough and systemic investigations of transport accidents and other safety occurrences • identifying safety issues through investigations, research and analysis • promoting safety awareness and getting practical results. Background/Function AVIATION | MARINE | RAIL
  3. 3. Accident Investigation & Research • Aviation • Marine • Rail Background / Function (cont’d) AVIATION | MARINE | RAIL
  4. 4. Jurisdiction – Main Freight Routes Melbourne Adelaide Perth Brisbane Sydney Darwin Melbourne
  5. 5. • Adelaide (South Australia) – 1 x Adelaide Regional Manager (Rail Co-ordinator) – 4 x Investigators • Canberra Central Office (Australian Capital Territory) – General Manager, Surface Safety Investigation – Canberra Regional Manager – Surface Safety – 2 x Investigators – 2 x Investigators/Technical Analysis (shared with Marine Team) • Brisbane (Queensland) – Brisbane Regional Manager – 2 x Investigators – 1 x Human Performance investigator (shared with Marine Team) • Perth (Western Australia) – Perth Regional Manager – 2 x Investigators Location of Rail Investigation Resources AVIATION | MARINE | RAIL
  6. 6. Safety investigation process Safety action Transport safety matter Notification and assessment Investigation management Analysis Report preparation Data collection Safety enhancement Investigation oversight AVIATION | MARINE | RAIL
  7. 7. ATSB investigation analysis model AVIATION | MARINE | RAIL
  8. 8. Analysis process Preliminary analysis Safety factors analysis Analysis review Risk analysis (safety issues only) Safety action development sequence of events analysis AVIATION | MARINE | RAIL
  9. 9. Levels of analysis Organisational Influences (What could have been in place to prevent problems with the risk controls?) Risk Controls (What could have been in place at the operational level to reduce the likelihood or severity of problems?) Local Conditions (What aspects of the local environment may have influenced the individual actions / technical problems?) Individual Actions (What individual actions increased safety risk?) Productionpath Safety issues Safety indicators Investigationpath Occurrence Events (including technical problems) (What events best describe the occurrence?) AVIATION | MARINE | RAIL
  10. 10. AVIATION | MARINE | RAIL
  11. 11. Risk controls • Operator or track manager measures to assure safe performance of the operational components • Prevent hazards that result in losses • Parts of the management system • Often termed defences or barriers • If increase risk – termed safety issues • Part of the why AVIATION | MARINE | RAIL
  12. 12. Risk controls • Preventative: reduce undesirable local conditions, individual actions, events – Training, procedures, equipment – Work rosters, supervision, qualifications AVIATION | MARINE | RAIL
  13. 13. Risk controls • Recovery: detect, correct or minimise effects of adverse local conditions, individual actions, events – Detection / warning (level crossing equipment) – Restore or protect system (Automatic Train Protection, emergency procedures) – Protection / containment (crashworthiness, Personal Protective Equipment) – Escape / rescue (exits, emergency lights) AVIATION | MARINE | RAIL
  14. 14. Organisational influences • Establish, maintain or otherwise influence effectiveness of organisation’s risk controls • Management processes, not management outputs • If increase safety risk, termed safety issues • Part of the why AVIATION | MARINE | RAIL
  15. 15. Types of organisational influences • Safety management processes – Hazard identification, change management, process review • Organisational characteristics – Organisational structure, management skills, internal communication • Regulatory influences – Standards, audits • Other external influences – Industry organisations & standards, public opinion AVIATION | MARINE | RAIL
  16. 16. Risk analysis Safety issue Review existing risk controls Describe worst credible scenario Determine consequence level Determine likelihood level Safety risk level Describe worst possible scenario AVIATION | MARINE | RAIL
  17. 17. Risk acceptability • Critical safety issue – risk is regarded as unacceptable whatever the level of benefits associated with the activity • Significant safety issue – risk level is regarded as acceptable if it is kept as low as reasonably practicable (ALARP) • Minor safety issue – risk is generally regarded as very low and adequately controlled AVIATION | MARINE | RAIL
  18. 18. ATSB analysis policy • All key findings supported by evidence table • All verified safety issues to be subject to risk analysis • ATSB encourages safety action before completing report (action by industry, regulator) • ATSB recommendations focus on describing safety issue of concern AVIATION | MARINE | RAIL
  19. 19. Accident trends Safeworking – collisions with track vehicles Weather related events Derailments Level crossings AVIATION | MARINE | RAIL
  20. 20. Accident trends - Safeworking AVIATION | MARINE | RAIL
  21. 21. Accident trends – Weather related AVIATION | MARINE | RAIL
  22. 22. Accident trends - Derailments AVIATION | MARINE | RAIL
  23. 23. Accident trends- Level crossing AVIATION | MARINE | RAIL
  24. 24. Aviation data AVIATION | MARINE | RAIL • ATSB is the one stop shop for civil aviation incident reports • TSI Act requires IRMs and RRMs • 15000 events reported and categorised each year • 8000 discrete events make it into the database per year • Data is shared with CASA
  25. 25. Safety intelligence – ATSB aviation AVIATION | MARINE | RAIL • Quarterly trend monitoring of occurrence data by occurrence type • Development of event risk classification and its use in presenting data • Use of occurrence type specific fields to allow for easier analysis of occurrences
  26. 26. Safety intelligence AVIATION | MARINE | RAIL • Use and analysis of safety factors, both for investigated and non-investigated data • Analysis of safety issues by risk and associated safety actions • Tracking of how safety issues have been addressed
  27. 27. • Statistical series- aviation • Targeted safety issue research - aviation • “Avoidable accident series”- aviation • National Rail Occurrence Data publishing - rail Safety research
  28. 28. Questions? AVIATION | MARINE | RAIL
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