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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 …

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

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  • 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. 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. Accident Investigation & Research • Aviation • Marine • Rail Background / Function (cont’d) AVIATION | MARINE | RAIL
  • 4. Jurisdiction – Main Freight Routes Melbourne Adelaide Perth Brisbane Sydney Darwin Melbourne
  • 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. 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. ATSB investigation analysis model AVIATION | MARINE | RAIL
  • 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. 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
  • 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. Risk controls • Preventative: reduce undesirable local conditions, individual actions, events – Training, procedures, equipment – Work rosters, supervision, qualifications AVIATION | MARINE | RAIL
  • 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. 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. 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. 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. 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. 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. Accident trends Safeworking – collisions with track vehicles Weather related events Derailments Level crossings AVIATION | MARINE | RAIL
  • 20. Accident trends - Safeworking AVIATION | MARINE | RAIL
  • 21. Accident trends – Weather related AVIATION | MARINE | RAIL
  • 22. Accident trends - Derailments AVIATION | MARINE | RAIL
  • 23. Accident trends- Level crossing AVIATION | MARINE | RAIL
  • 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. 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. 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. • Statistical series- aviation • Targeted safety issue research - aviation • “Avoidable accident series”- aviation • National Rail Occurrence Data publishing - rail Safety research
  • 28. Questions? AVIATION | MARINE | RAIL