Managing the Organizational Interface

Three case studies.

IRSC 9-13 October 2005

Managing the Organizational Interface

Three case studies.

IRSC 9-13 October 2005

Ian NaishDirector, Rail / Pipeline Investigations

Branch

Transportation Safety Board of Canada

Railway Industry in CanadaRailway Industry in Canada

• 47,000 km of track47,000 km of track

• 60 railway companies60 railway companies

• 1400 reported 1400 reported occurrences per yearoccurrences per year

Managing Inter-organizational

Interfaces

Managing Inter-organizational

Interfaces

• Issues:Issues:– risk management in a changing risk management in a changing

environmentenvironment– areas where safety defences have areas where safety defences have

failed.failed.

– involvement of all staff in involvement of all staff in management of safety.management of safety.

LIMEHOUSE, ONLIMEHOUSE, ON

MCBRIDE, BCMCBRIDE, BC

Managing the Inter-organizational Interface

Managing the Inter-organizational Interface

NOBEL, ONNOBEL, ON

Nobel, Ontario, 2003Nobel, Ontario, 2003• Broken rail derailment in First Broken rail derailment in First

Nations landNations land

• No command centre set up - No command centre set up -

communications problemscommunications problems

• Responder training, but not Responder training, but not

experienceexperience

Limehouse, ON, 2000Limehouse, ON, 2000

• No site safety briefing No site safety briefing

• Contractors setting up at crossingContractors setting up at crossing

• Truck blocking signalsTruck blocking signals

• No flagpersonNo flagperson

• Three persons killedThree persons killed

• No site safety briefing No site safety briefing

• Contractors setting up at crossingContractors setting up at crossing

• Truck blocking signalsTruck blocking signals

• No flagpersonNo flagperson

• Three persons killedThree persons killed

McBride, B.C.McBride, B.C.

• Bridge collapse and fireBridge collapse and fire

• Changes in roles and responsibilitiesChanges in roles and responsibilities

• No records of maintenance work No records of maintenance work

donedone

• No regulatory requirement to audit No regulatory requirement to audit

proceduresprocedures

ConclusionsConclusions

• Work sites are Work sites are complex complex

• They have to be They have to be managed effectivelymanaged effectively

• Assign rolesAssign roles

• Communicate clearly, Communicate clearly, early and oftenearly and often

• Good records must Good records must be keptbe kept

Some suggestionsSome suggestions

• Plan in advance Plan in advance

• Meet early and often Meet early and often

• Train and re-trainTrain and re-train

• Due diligence when Due diligence when record keepingrecord keeping