The Rail Safety Summit 2015

MIKE MCLEANChairman, TES 2000

Workforce SafetyWe’ve got it cracked!

Mike McLeanChairman TES 2000 Ltd

Do we need confidentiality in Safety?

CIRAS and CHIRP

My topics for today

• Supplier Qualification

•Worker competence

• Learning from Incidents

Supplier Qualification - RISQS

“Managed by the Industry for the Industry”

The Vision:-“Universally recognised as the most effective and efficient method and route for suppliers to engage with GB rail industry”

Objectives:-“Provide appropriate assurance regarding management systems and corporate legitimacy”“Act as a feed back tool to improve performance”

Standard NR/L2/CPR/302

The core criteria that affect me as a Contractor/Sentinel Sponsor:-

• 25 Pages which require systems, processes, procedures to enable me to operate safely

• Plus, controls and a reporting framework to enable/demonstrate consistent compliance

The Core Audit Module

Contents:-1. Management Systems2. Insurance Arrangements3. Policies4. Organisation and responsibilities5. Individual qualifications and experience of staff in key roles6. Provision of HSE advice7. Competence Management8. PTS and the Sentinel Scheme requirements

The Core Audit Module

Contents cont. –9. Employment medicals10. Alcohol and drugs arrangements11. Managing refusals to work on grounds of safety12. Managing fatigue13. Selection of safety critical products and plant14. Selection and management of Supplier’s services15. Control of bribery16. Reviewing changes to customer and regulatory requirements

The Core Audit Module

Contents cont. –18. Document management19. Internal and external communication arrangements20. Workforce involvement21. Risk assessment22. Co-operation and co-ordination23. Health, welfare and wellbeing24. First aid at work arrangements25. Close call, Near miss and Accident reporting and investigation

The Core Audit Module

Contents cont. –26. Site inspections27. Audit of management systems28. Monitoring and corporate safety and environmental performance

Just How Effective?

RISQS Objective:-• Provide appropriate assurance regarding management systems!

The Practice - Just one more time:-QUALIFICATION TENDER

Competence Management 10 detailed sections Describe in 600 words

Fatigue Management 13 detailed sections Describe in 600 words

Fatalities

Findings:-• Lack of clarity in managing near-miss incidents

• No effective performance regime for managing competence

• No comment at all on RISQS

Performance

• Would performance management help?

• How measured/shared?

• Not New!

• A Key Development Objective

Sentinel – Workforce “Competence”

• Perhaps expectations more easily identified

• Terminology, qualifications, skills, tickets, competences, competent

• Code of Conduct gets it right, competence management elsewhere!

Learning from Incidents• 70,000 shifts – 17 irregularities/incidents• No injuries but……• 5 High Risk

The key themes from these:-• Lack of familiarity• Over familiarity• Complacency• Disorientation• Communication

EUROCONTROL SOAM

One we did earlier!

ACCIDENTAbsent or Failed Barriers

Human Involvement

Local Conditions

Organisational Factors

• Aircraft Overran runway after landing long

• No serious injuries (391 pax, 19 crew)

• Potential for more serious outcome

• Aircraft repair cost: $100,000,000 (?)

• Damage to company reputation

Landing procedure inappropriate

Absence of reverse thrust

during landing roll not notices,

reverse thrust not used

Crew Resource Management

deficient

Flight crew did not use an adequate risk management strategy for

approach and landing

Crew employed flaps 25/idle

reverse landing configuration

First Officer did not fly the

aircraft accurately during the

final approach

Captain did not order a go-

around earlier

Captain cancelled go-

around decision by retarding the

thrust levers

Very heavy rainfall, runway surface affected by water

Crew not aware of critical importance of reverse thrust as stopping force on

water-affected runways

Most pilots not fully aware about ‘aquaplaning’

Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways

New 1996 approach/landing procedure inappropriate

Normal practice to use flaps 25/idle reverse

Recent crew experience using full reverse thrust lacking

Reduced visibility & distraction: rain and windscreen wipers

Captain & FO quite low levels of flying prior 30 days

FO awake for 19 hours at the time of the accident

Captain awake 21 hours at time of accident

High workload situation

No appropriately documented info, procedures re operations on water-affected runways

“Landing on Slippery Runways” (Boeing doc) not distributed in Qantas since 1977

Contaminated runway issues not covered during crew endorsement, promotion or

recurrent training in recent years

Document unclear (eg., key terms not well defined)

OC Mgt decisions informal, “intuitive”, “personality-driven”

No formal risk assessment conducted when changed landing procedure researched

Introduction of new landing procedure poor

No formal review of new procedures after ‘trail’ period

Cost-benefit analysis of new landing procedure was biased

No policies or procedures for maintenance of recency for management pilots

No policies, procedures on duty or work limits for pilots with flying & non-flying duties

ACCIDENTAbsent or Failed Barriers

Human Involvement

Local Conditions

Organisational Factors

Protection placed on the Up line not Down line – TES 2000, PSS

Communication between PSS/PICOP poor-sub-standard

PSS changed the SSWoP –

accessed from a

convenient point

PSS read off SSWoP when

reporting completion

PSS had attended his

brother’s funeral that

day

PSS relatively inexperienced -

not a factor

PSS had blocked at

same locations

7 hours between first and second task

PSS employed on a Zero Hour contract –financial pressure to work

TES had not specific HR procedure for bereavement-reported or otherwise

Too much detail in SSWoP

Actions

•RISQS – Let’s achieve the Vision

•Rice Stadium Time!!!

• Incidents – Let’s welcome the lessons