www.irishrail.ie

Managing the Risk of Organisational Accidents

Peter CuffeChief Safety & Security Officer

Irish Rail

peter.cuffe@irishrail.ie

International Railway Safety Conference 2007

Goa, India

Railway Organisation

Safety Professionals

Society

Individual Accidents– A specific persons– Agent and victim– Limited scope

Organisational Accidents– Multiple causes– Many people– Devastating consequences– Often a product of technological innovation

Organisational Accidents are the result of

highly complex coincidenceswhich are rarely foreseen

by those involved.They are unpredictable because of

the large number of causes and the spread of information

over all the participants

Cost of Protection greatly exceeds the dangers

Cost of Protection greatly exceeds the dangers

Protection falls far short

of required level

Better defences convert to improved

production

Better defences convert to improved

production

Post Accident response measures

Better defences convert to improved

production

Post Accident response measures

Relaxation with further improved

production

Better defences convert to improved

production

Post Accident response measures

Relaxation with further improved

production

Catastrophic Disaster

Examples of Improved Production

• Invention of the Davy Lamp– Extract coal from

more dangerous areasMine accidents increased

• Introduction of Marine Radar– Travel faster in fog or busy waters

Marine history littered with “radar assisted” collisions

Dangers of the Un-Rocked Boat

A lengthy accident-free periodSteady erosion of protection

Easy to “forget to fear” Increasing production,

without extended defences, will erode safety margins

Production v Protection

Partnership is rarely equal– Production creates the resources for protection

Process managers have production skillsProduction information is:

Direct, Continuous & Easily Understood

Production v Protection

Partnership is rarely equal– Successful Protection shown by

Absence of Negative Outcomes– Information is indirect or intermittent– Hard to interpret, often misleading– Awareness often driven by accident

or near-miss

Defences

Create Understanding & AwarenessGive Clear Guidance on Safe OperationAlarms & Warnings of imminent dangerRestore System to a Safe StateInterpose Barriers between Hazards & LossesContain & Eliminate HazardsProvide Means of Escape & Rescue

Defences

Create Understanding & AwarenessGive Clear Guidance on Safe OperationAlarms & Warnings of imminent dangerRestore System to a Safe StateInterpose Barriers between Hazards & LossesContain & Eliminate HazardsProvide Means of Escape & Rescue

Defences-in-depth, successive layers, specific sequence

Holes are continuously moving

Defences can be deliberately removed:-Maintenance-Testing-During Failures

Latent Conditions

Poor DesignGaps in SupervisionUndetected Manufacturing DefectsMaintenance FailuresUnworkable ProceduresClumsy AutomationPoor TrainingInadequate Tools & Equipment

Active Failures v Latent Failures

• Immediate Effect• Shortlived Effect• Committed at the

“sharp” end, at the human-system interface

• Lie Dormant• No Impact until

local interaction• Spawned in the

organisation• Pervasive

In aviation, there are foreseeable hazards:

Gravity,Weather, Mountains,

and Human Fallibility

Human Error v Non-Compliance

Error - an intrinsic part of the Human Condition

Error - distractionError – loss of situational awarenessError - deliberate

We all learn by “trial and error”– Necessary to push limits to establish

system characteristics

We cannot change the Human Condition, but we can change

the Conditions under which Humans work.

Investigations

• Who ?• What ?• Where ?• When ?

• Why ?

PRISMA

• Choose “Top Event” (Accident or Near-Miss)

• Determine Direct Causes• Determine Preceding Causes• Stop when the Facts Stop• Stop at limits of Organisational Control

PRISMA – 23 Categories

• 4 x Technical• 5 x Organisational• 3 x Staff, Knowledge based• 6 x Staff, Rule based• 2 x Staff, Skill based• 1 x Customers• 1 x Public• 1 x Unclassifiable

PRISMA – 23 Categories

• 4 x Technical• 5 x Organisational• 3 x Staff, Knowledge based• 6 x Staff, Rule based• 2 x Staff, Skill based• 1 x Customers• 1 x Public• 1 x Unclassifiable

Rasmussen’s SRK Model

Knowledge based Behaviour

• Unexpected or new situations• High attention level• Problem identification and solving• Situational awareness• Understanding of Process• Analytical ability

Rule based Behaviour

• Recognition of situation• Pattern identification• Medium attention demand• Training to ensure correct rule

application

Skill based Behaviour

• Reflex/automatic reactions• Long learning process• Low attention demand• Triggered by environmental signals• Unlearning very difficult• Stress resistant• Error prevention by environmental

change, not by altered behaviour

PRISMA – 23 Categories

• Technical– External– Design (Ergonomics)– Construction/Maint.– Material (further

research required)

• Organisational– External– Supervision– Rules/Procedures– Management Priorities– Culture

PRISMA – 23 Categories

• Knowledge Based– External– Process Status/

Characteristics (eg current permits to work)

– Improper Goals (eg making up for lost time by speeding)

• Rule Based– License/Certified

Competency– Incorrect Permits or

other Safeguards– Pre-work Status Check

not done– Work sequence

incorrect or incomplete– Failure to monitor other

system characteristics– Failure to use correct

resources

PRISMA – 23 Categories

• Skill Based– Intentional

(eg typing error)– Unintentional

(eg leaning against controls)

• Customer(eg Inebriated passenger)

• Public(eg Suicide)

• Unclassifiable(eg Act of God)

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

Poor staff instruction

Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

OS Incomplete supervision

Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

OS OS Culture of shortcuts

Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

OS OS OC Time pressure

Causal TreePassing train caught cable and dragged

along platform

Cable draped over platform

Train on adjacent track

- Context

Staff unaware thatcable should not

be placed on plat. Plan not followed

OS OS OC OM

PRISMA Applied to Chemical Industry, Healthcare and Railway (SPADs)

• Analysis 1: Historic investigation findings were re-classified into PRISMA terms.

• Analysis 2: The same incidents re-analysed with PRISMA, using existing Inspectorate files.

• Analysis 3: New incidents were analysed with PRISMA, using appropriate data gathering.

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Analysis1

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Chemical industry Health care Railways

Study

Technical factors Organisational factors Human factors Other

PRISMA Applied to Chemical Industry, Healthcare and Railway (SPADs)

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Analysis1

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Chemical industry Health care Railways

Study

Technical factors Organisational factors Human factors Other

PRISMA Applied to Chemical Industry, Healthcare and Railway (SPADs)

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Analysis1

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Chemical industry Health care Railways

Study

Technical factors Organisational factors Human factors Other

PRISMA Applied to Chemical Industry, Healthcare and Railway (SPADs)

Reliability is InvisibleReliable outcomes are constant

There is nothing to pay attention toWe see nothing so ‘nothing’ is

happeningAnd nothing will continue to happen.

This is a deceptive diagnosis –Dynamic inputs create stable outcomes

Safety is a Dynamic Non-Event

Accidents do not occur because we gamble and lose,

but because we do not believe that the accident about to occur

is at all possible

Accidents do not occur because we gamble and lose,

but because we do not believe that the accident about to

occur is at all possible