Rail Safety 2017Brisbane – 4-5 April 2017

Tony SimesManager - Rail

ATSB

Rail Accident Investigations –The ATSB Approach

• Accident Investigations– Aviation– Marine– Rail

• Research – Aviation / Marine / Rail

Australian Transport Safety Bureau (ATSB)

• ATSB Investigators– Brisbane– Adelaide– Canberra– Perth

• Agreements with– OTSI (Sydney)– CITS (Melbourne)

• ATSB Rail jurisdiction– Australia wide– QLD

• Interstate line south of Brisbane

• Entire QLD after 30 June 2017

• Punitive (breaches of law)– Criminal / Civil– Regulatory (in some cases)

• Just Cause (recognises that errors occur)– Coronial (mostly)– Internal organisation (preferably)

• No Blame– ATSB

Investigation Types

• Not only ‘What’ happened, but ‘Why’

– Why did it occur

– Why did people behave the way they did

– Why did the environment/system allow it

• What factors and issues contributed to the accident

• How can the system be made more error tolerant

ATSB Investigation Analysis Model

Risk Controls (Recovery)

Risk Controls (Recovery)

Risk Controls(Preventive)

Local Conditions

Individual Actions

Technical Events

Production Goals

Accident

Organisational Influences

Incident

• Described in terms of production goals and risk controls• An accidents and incidents are deviations from the normal production path• Preventative risk controls

– Minimise the likelihood of deviations from the normal path• Recovery risk controls

– Minimise the severity of incidents and aim to prevent accidentswhen deviations occur

• An accident occurs where there is a failure or lack of risk controls

ATSB Investigation Analysis Model

• Safety factor:– an event or condition that

increases safety risk.• Safety issue:

– a safety factor that is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

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

duct

ion

path

Safetyissues

Safety indicators

Investigation path

Occurrence Events(including technical problems)

(What events best describe the occurrence?)

Safety Issues

• Notification• Site examination, collection/protection of evidence

• Sequence of Events– What happened– When did it happen

Investigation process

Derailment – Julia Creek, QLD

• Late December - Intense weather system across the tropical north of Australia

• Bureau of Meteorology had issued a series of localised severe thunderstorm warnings

• 27 December 2015 - Network Control was monitoring BoM website and information from rail traffic crews

• Track inspections arranged for sections of track west of Julia Creek

• Train 9T92 travelling toward Julia Creek from the east

• Train 9T92 observed and reported areas that had ‘plenty of water everywhere’, but appeared to be receding

• Track inspections arranged for sections of track east of Julia Creek (following train 9T92)

• Train 9T92 had passed the areas known to be flood ‘Hot spots’

• At about 0933, travelling at about 51 km/h, train 9T92 encountered a washout

• Train derailed and tipped onto side• Dangerous goods spill (sulphuric acid)• Minor injuries

Sequence

• Contributing factorsvs. causal factors

• Determine which events and conditions were safety factors, with an emphasis on determining the contributing safety factors and safety issues.

Safety factor analysis

• Standard of proof– Probably or likely– Do not want to limit learning

potential by requiring beyondreasonable doubt.

• Standard of evidence– Quantity and quality

• is it:– a contributing safety factor (existence plus influence), – another safety factor of interest (existence plus importance)– or of no consequence to the investigation.

Testing possible safety factors

What the ATSB found

• Scouring of the ballast and formation by floodwaters

• Track could not support Train 9T92

• Derailment

Safety factors• Procedures state that the NCO must stop

trains if aware of ‘Flood affected track’, but in this case trains were not stopped.

• Procedures state that train crew must not drive through water, but in this case the train didn’t stop

• Infrastructure unable to manage the amount of water

Question Why• Area not known as a flood ‘Hot spot’

• BOM radar limitations

• Track drainage

• Individual actions• Local conditions

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

duct

ion

path

Safetyissues

Safety indicators

Investigation path

Occurrence Events(including technical problems)

(What events best describe the occurrence?)

Safety Issues• Contributing safety issues

– Insufficient guidance for rail traffic crews to identify and manage potential weather related hazards

• Other safety issues– Inadequate information to define the designed

flood immunity of rail infrastructure.

– Insufficient guidance on the limitations of the BOM information

– Ineffective emergency egress from the 2800 class locomotive

– Availability of personal protective equipment

– Some reference documentation not included within the safety management system

• Organisational influences

• Risk Controls

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

duct

ion

path

Safetyissues

Safety indicators

Investigation path

Occurrence Events(including technical problems)

(What events best describe the occurrence?)

• How do we addressthe safety issues

– Determine the risk level associated with any verified safety issues.

– Prioritise actions based on risk profile • ATSB : communicating safety issues to relevant organisations.

Safety actions

• Identify gaps orweaknesses.

• Reality check

• Make sure all of thefindings make sense.

– Can be conducted progressively throughout the investigation

Review

What has been done• Safety alerts issued to improve the effectiveness of the network

rules managing hazards associated with extreme weather– stopping of rail traffic

– reporting weather related information

– additional guidance for Network Control on weather related decision making

– To be trialled over the 2016/17 tropical season and, if found successful, implemented into network rules

• Review of available weather monitoring services

• Upskilling knowledge relating to use and interpretation of meteorological information.

What has been done• Respiratory protection masks have been introduced on trains

transporting acid

• Reassess emergency evacuation procedures, locomotive windscreens, and secondary communication opportunities/options.

• Review the feasibility of adopting the Australian Standard AS7637 ‘Railway Infrastructure - Hydrology and Hydraulics’

Conclusion• Identify ‘What’ happened, but also ask

the question ‘Why’ did it happen.– Why did people behaved the way they did

– Why did the environment allow it to occur

• Adopt a framework designed to encourage quality analysis techniques

• What factors contributed to the incident

• Aim is to enhance safety, not to apportion blame or liability.

• Look for:– Organisational influences

– Risk control measures

Thankyou