Analysing rail safety accidents

Analysing Rail Safety

Accidents

Peter FoleyGeneral Manager Surface

Safety Investigation

Australian Transport safety

Bureau

Rail Safety 2012,

Sydney

29 March 2012

AVIATION | MARINE | RAIL

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


Accident Investigation

&

Research

• Aviation

• Marine

• Rail

Background / Function (cont’d)


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 Office (Australian Capital Territory)– General Manager, Surface Safety Investigation

– Canberra Regional Manager – Surface Safety


– 2 x Investigators/Technical Analysis (shared with Marine Team)

• Brisbane (Queensland)– Brisbane Regional Manager


– 1 x Human Performance investigator (shared with Marine Team)

• Perth (Western Australia)– Perth Regional Manager


Location of Rail Investigation Resources


Safety

investigation

processSafety

action

Transport safety

matter

Notification and

assessment

Investigation

management

Analysis

Report

preparation

Data

collection

Safety

enhancement

Investigation

oversight


ATSB investigation analysis model


Analysis process

Preliminary

analysis

Safety factors

analysis

Analysis review

Risk analysis

(safety issues only)

Safety action

development

sequence of events

analysis


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?)

Pro

du

ctio

n p

ath

Safety

issues

Safety

indicators

Inve

stig

atio

n p

ath

Occurrence Events(including technical problems)

(What events best describe the occurrence?)


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


Risk controls

• Preventative: reduce undesirable local

conditions, individual actions, events

– Training, procedures, equipment

– Work rosters, supervision, qualifications


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)


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


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


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


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


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


Accident trends

Safeworking – collisions with track vehicles

Weather related events

Derailments

Level crossings


Accident trends - Safeworking


Accident trends – Weather related


Accident trends - Derailments


Accident trends- Level crossing


Aviation data


• 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

Safety intelligence – ATSB aviation


• 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

Safety intelligence


• 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

• Statistical series- aviation

• Targeted safety issue research - aviation

• “Avoidable accident series”- aviation

• National Rail Occurrence Data publishing - rail

Safety research

Questions?


Analysing rail safety accidents

Technology

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