Major Rail Occurrence Forum Occurrence Trends in Derailments & Lac Megantic Case Study David Edwards Executive Director, ATRS Pty Ltd 29 April 2014 Sydney

How Safe is the Rail Industry ?

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

Edith River NT 27/12/11

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?

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

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

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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  

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

Sir Winston Churchill…

“No matter how beautiful the strategy, occasionally you should check the results”

Case Study

Lac-Mégantic, Canada

6 July 2013 Train Run-away and Derailment

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

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

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

Community Impact

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

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

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)

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

Thank You & Questions

“If you think safety is expensive, than try having an accident”

Remember Lac-Mégantic