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10-Apr-18 Safety Culture Twinning conference 1 Welcome to the conference Network rail

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Page 1: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 1

Welcome to the conference

Network rail

Page 2: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 2

Agenda

10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30 Welcome (Lisbeth Fromling, Network Rail) 10:30 – 11:30 Group 1 presentation (Network Rail, CFR, Infrabel and HZ) 11:30 – 11:50 Break 11:50 – 12:40 Group 2 presentation (ProRail, Irish Rail and OBB) 12:40 – 13:15 Lunch 13:15 – 14:05 Group 3 presentation (Trafikverket, Adif and PLK) 14:05 – 14:35 Group 4 presentation (RFI and SNCF Reseau) 14:35 – 14:55 Learning activity based on safety culture evaluation 14:55 – 15:15 Opportunity for questions 15:15 – 15:30 Summary of event and closure

Page 3: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 3

Welcome from Keir Fitch

Head of Unit C4 "Rail Safety &

Interoperability”, European Commission

Page 4: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 4

Welcome from Lisbeth Fromling

Chief Health, Safety, Quality and

Environment Officer, Network Rail

Page 5: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

/ PRIME Safety Culture Sub-Group

10-Apr-18

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Safety Culture Twinning Programme

Welcome to the final conference

• Thank you for joining us

• Today is a good day!

• Purely pro-active project

• All information is good

• Lots to share

Page 6: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

/ PRIME Safety Culture Sub-Group

10-Apr-18

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Safety Culture Twinning Programme

Co-ordinator

Participant

Page 7: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

/ PRIME Safety Culture Sub-Group

10-Apr-18

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Safety Culture collaboration

Page 8: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 8

Group 1 Presentations

Network Rail, CFR, Infrabel and HZ

Page 9: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 9

Group 1 Presentations

Network Rail

Page 10: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety Culture Twinning programme Network Rail visiting CFR and Infrabel

• Lynn Chamberlain-Clark, Principal Health and Safety Change Specialist

• Louise Cox, Head of Route Health, Safety and Environment

• Jason Jordan, Business Change Manager (Business Critical Rules)

• Allan Spence, Head of Corporate Passenger & Public Safety 10-Apr-18 Safety Culture Twinning conference 10

Page 11: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

How national bodies and national culture impact on safety culture • There is a tendency for

organisations to focus on the regulatory priority - this can limit learning and improvement.

• Safety culture aligns with national

attitude to safety.

10-Apr-18 Safety Culture Twinning conference 11

Page 12: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

• The equality of relationship is important – organisations need to be more than just responsive.

• Regulators need to develop trust in the expertise of the organisation

• Perception of ‘we can’t do that- they won’t let us us’; ‘we haven’t got the money’

• Lots of what we need to do is free (eg. improving behaviour)

NSA

IM Organisation

IM organisations can’t wait for this to happen they must be proactive

How national bodies and national culture impact on safety culture

10-Apr-18 Safety Culture Twinning conference 12

Page 13: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Training and learning

• Direct link from learning about incidents into training

• Legislation as starting point for training rather than risk can be dangerous

• Training model- supported by strong supervision process

• Process in place to remove those who are not competent- re-deployment

10-Apr-18 Safety Culture Twinning conference 13

Page 14: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Training and learning

• Incidents analysed from multiple inputs to get root cause

• Huge commitment to training • Induction -safety training 1.5

days from safety team; handbooks; e-learning

• Training is planned in June for next year based on incidents this year

• Moving towards trainer who is coach-like 10-Apr-18 Safety Culture Twinning conference 14

Page 15: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 15

Group 1 Presentations

CFR

Page 16: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety Culture Twinning programme CFR SA visiting Network Rail and HZ Infrastruktura

• Victor ALEXANDRU, Deputy Director General for Investments

• Răzvan CONSTANTIN, Inspector, General Safety Department

• Radu URZICEANU, Head of Unit, Strategy and Regulations Directorate

• Marin VLĂDUŢ, Principal Trainer, Signalling Directorate

• Adrian LASLO, Project Manager, Permanent Ways Directorate

Page 17: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety culture

Both organisations have mature SMS in function, with key operational leaders making personal commitments for safety behaviours Drive for change – transform the behaviour of a railway organisation into a private like, commercial oriented an customer focused corporation. Key words: simpler safer more effective

Page 18: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety culture

A caring culture in which safety and performance are interlaced. A culture which goes beyond the railways themsleves, interactind with the line side neighbours, local communities and all stakeholders. Concerned on the way in which resources are used and the impact on the environement. A diverse and inclusive culture.

Page 19: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety organisation Dedicated structure for a joint approach for:

Public Safety Workforce Health, Safety & Environment Assurance and Project Management

Charged with:

Risks identification and risk assessments Involving the local communities and volunteers Raise awareness with public

Page 20: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety culture

Bottom-up engagement- talking safety willing compliance reporting and accountability responsibility

Page 21: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Training and learning

Professional training realized in-house in own training centers with real tools and equipment Training monitoring realized by own safety staff Outside support for non-railways specialities – communication skills, management, behaviour etc

Page 22: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Useful initiatives

Page 23: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Network Rail Close call system/Life saving rules

Page 24: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

HZI safety rules applied to contractors

Page 25: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 25

Group 1 Presentations

Infrabel

Page 26: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Key findings of the twinning visits performed by INFRABEL at Network Rail and at HZI Croatia

Infrabel team:

Helga Colpaert – Coordinator Safety culture programme

Yvan Smets – Investigations and monitoring

Sonja Van Waeyenberg – Safety culture/Project Behaviour

Bob Boogaerts – Risk management

Kristof Driessens – Incident investigations

Final conference twinning safety culture - 12/12/2017 - London

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Page 27: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ Network Rail Planning of the visit

• Monday 24.04.2017 – Friday 28.04.2017

• Programme organised by the twinning team NR: Lynn Chamberlain-Clark (Principal Health & Safety Change Specialist)

Sean Brierley (Communications Manager)

Lee Parlett (Corporate Investigation & Assurance Manager)

Louise Cox (Head of Route Health, Safety & Environment London North Eastern and East Midlands)

Jason Jordan (Programme Manager Change & Business critical rules)

• Discussions with several NR colleagues in various departments (Training centre maintenance Romford, DU Tottenham, RSSB, St-Pancras station)

Final conference twinning safety culture - 12/12/2017 - London

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Page 28: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ Network Rail: key findings (1)

Notification of incidents, accidents, hazards and unsafe acts (close calls):

• Consider the necessary time to control the growth of the system and monitor the quality of the data

• 124.000 calls/year -> find the appropriate KPI’ s (f.i. % of closure within 90 days)

• Feedback loop to be developed

Investigation of incidents and accidents:

• Stable and mature process

• Linked with fair culture idea through a decision matrix

• 4 issues: Intention - Procedures & Rules - Substitution test – Training

Safer trackside working programme:

• Long term strategy: new, high reliability protection and warning systems for people working in the tracks -> engagement of future users throughout the product development cycle

• Pragmatic approach to implement short term improvements (f.i. using available technology, even without highest SIL level)

Final conference twinning safety culture -

12/12/2017 - London 28

Page 29: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ Network Rail: key findings (2)

Safety culture = package of complementary components:

• “Everyone home safe, every day”, in order to enhance the relationship between safety at the work place and safety at home

• 10 life saving rules, visible everywhere in the company

• “Take 5 for safety”

• Fair culture charter supports and defines the mutual commitment between the company and the employees and the 3 main unions

• Practical use of fair culture, through the decision matrix for incident investigations

• Close call system is functioning and delivers quality data; this requires the participation of all levels within the organisation

• Visualisation boards discussed in standing meetings enhance the involvement of the personnel and stimulate the feeling of ‘belonging’

Simple and direct approach at all the company levels

Final conference twinning safety culture - 12/12/2017 - London

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Page 30: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ HZI Croatia

Planning of the visit

• Monday 22.05.2017 – Wednesday 24.05.2017

• Programme organised by the twinning team HZI: Goran Nujić (Head of Safety)

Tomislav Petanović (Chief of Division for Regulations)

Josipa Jagatić Celinščak (Manager of the Professional Education and Safety Culture)

• Discussion with other HZI colleagues and visit of the signal box of Zagreb and a local infrastructure work site

Final conference twinning safety culture - 12/12/2017 - London

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Page 31: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ HZI Croatia: key findings (1)

Strong sense for legal compliance is the foundation for the safety management and safety culture:

• Monitoring of legislation

• Management of legal changes

Simplification of rules and harmonization of different and several existing rulebooks

Safety culture programme is integrated in the safety management system and subject to a yearly assessment

Notification of incidents, accidents, hazards and unsafe acts:

• Procedure is integrated in the rulebooks

• Close call system (tool) is subject to appropriate financial means

Final conference twinning safety culture - 12/12/2017 - London

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Page 32: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Visit Infrabel @ HZI Croatia: key findings (2)

Extended education and training network and programme:

• Strong network of internal training centres all over the country

• Monitoring of the training on quality and quantity

• Public school: preparatory basic education for railway operations

• 3-year certification with written and oral exam

• Language: mandatory knowledge of Croation language for (foreign) train drivers

Proactive monitoring process:

• Leading indicators linked to safety targets

• Annual programme of controls

Final conference twinning safety culture - 12/12/2017 - London

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Page 33: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Over all conclusions of the visits

Lots of laws, rules and regulations to be applied in the daily work

Lots of risks in the daily performance, so risk awareness and safe behaviour are fundamental

A solid safety culture within the organisation is very important, and is strongly linked with the safety management system

Implementing a safety culture programme takes several years, a dedicated team and a specific budget

Involvement is needed at all levels of the organisation

‘Let’s talk safety’ seems very normal and logic, but also very hard to realise in the daily work (we need to learn to take the time for it)

Well organised process of incident investigations is provided. But it takes time to get people to report dangerous situations and to consider them as learning opportunities

IM’s have a lot of common focus points and issues, everyone has some success stories and some difficulties

There is not ‘1 fit for all’ solution : always consider the specific working conditions, the legal context and the stakeholder wishes

Final conference twinning safety culture -

12/12/2017 - London 33

Page 34: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Thank you for sharing your experience with Infrabel! The twinning showed us some possibilities for improvement, thanks to ‘recycling’ of best practices of other IM’s. This mutual ‘personalised’ exchange of experience was a good self assessment exercise. It was also reassuring: everyone has some success stories and some difficulties. It laid the foundation for a continuing future exchange of information amongst IM’s and learning from each other’s experiences.

Final conference twinning safety culture - 12/12/2017 - London

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Page 35: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Some impressions of the four twinning visits

Final conference twinning safety culture - 12/12/2017 - London

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Page 36: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Final conference twinning safety culture - 12/12/2017 - London

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A news flash in our company magazine //MAG 08/2017 (NL)

Page 37: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Final conference twinning safety culture - 12/12/2017 - London

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A news flash in our company magazine //MAG 08/2017 (FR)

Page 38: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 38

Group 1 Presentations

HZ

Page 39: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Major Findings During the Twinning Visit of HŽ Infrastruktura in Infrabel and CFR

Goran Nujić, Head of Safety

Tomislav Petanović, Chief of Division for Regulations

Josipa Jagatić Celinščak, Manager of the Professional Education and Safety Culture

Page 40: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Signal Controlled Protection System for the Track Workers in Infrabel

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Page 41: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

While track workers are doing their job one or several lookouts using sense of hearing and seeing, radio, horn and red flag to look out for an approaching trains and warn the track workers who have to leave the tracks for a train passage

The Classical Approach to the Track Worker Protection

Page 42: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Signal Controlled Protection System

ZKL3000

Signal Controlled Protection System (zones

with track circuits)

The track workers are protected by red signals while doing their work through a (switchable) short circuit bar influencing the track circuits

When a train is announced by telephone to the safety responsible person:

• The track workers leave the track

• The safety responsible person confirms by switching of the short circuit that the track is available for the train

• The signal clears and the train can run

Page 43: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Signal Controlled Protection System ATW Tx - Signal Controlled Protection

System

The track workers are protected by red signals while doing their work

When a train is announced by sound and flashing light on the wireless mobile:

• The track workers leave the track

• The safety responsible person confirms on his mobile that the track is available for the train

• The signal clears and the train can run

Page 44: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety Analysis of Railway Traffic in CFR

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Page 45: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety Analysis Meetings

Quarterly meetings in which railway safety activity is analyzed

Analyzed circumstances of occurrence and cause of accidents and incidents

Measures taken to prevent similar accidents and incidents

Way of accident prevention

Page 46: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Participants of Safety Analysis Meetings

Permanent way and Signaling Direction – Director, Staff with a training and control duties

Safety Department – Safety manager, Safety experts

Permanent way and Signaling Division – Regional director, Head of exploitation divisions, Head of units, Regional staff with a training and control duties

Regional Safety Department – Head of Regional Safety Department

Permanent way and Signaling Depots – Head of units or subunits, Staff with safety responsibilities

Railway stations –Staff with safety responsibilities

Traffic coordination centers - Staff with safety responsibilities

HQ Level

Regional Level

Units Level

Page 47: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Safety Analysis Meetings Minutes

Writing the minutes that mention the documents presented and discussed during the meeting

Signature of the persons who participated

Page 48: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 48

Group 1

Useful initiatives

Page 49: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Infrabel - Lookout training/Trespass prevention

10-Apr-18 Safety Culture Twinning conference 49

Page 50: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

CFR -Monitoring, management and supervision

10-Apr-18 Safety Culture Twinning conference 50

Page 51: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

10-Apr-18 Safety Culture Twinning conference 51

Group 2 Presentations

Pro Rail, Irish Rail and OBB

Page 52: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Agenda

• About the twinning group Menno Rook

– Companies – Program – Models

• Lessons per company – ÖBB Infra: Ludwig Koschutnig

– Irish Rail: Neil Blakeley

– ProRail: Menno Rook

– Observations SBB: Lukas Matter

• Group learning Ludwig Koschutnig

• Questions

Page 53: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

About the twinning group

Lukas Matter

SBB Infra

Menno Rook

ProRail

Heidi van Spaandonk

ProRail

Ellen Klijn

ProRail

Kay Doyle

Irish Rail

Neil Blakely

Irish Rail

Ludwig Koschutnig ÖBB Infra

Page 54: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Companies

Page 55: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Characteristics

Aspect Irish Rail ÖBB Infra ProRail # employees

1.629 (IM) 18.000 4.000

# safety staff (central and regional/local)

52 (26/26) 132 (44 /88 ) 48 (36/12)

km’s track

2.400 4.826 7.021

# switches

756 13.677 7.071

# level crossings

1.240 3.269 2.589

# railway undertakings 4 42

45

# trains per day

750 6.400 9.000

# maintenance contractors

110 (Support services only)

400 4

% maintenance outsourced

0% 20% 100%

Page 56: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Program

• Three 4-day visits to Dublin, Vienna and Utrecht

• Interviews – Several levels: from directors (e.g. COO) to shunters, capacity

allocators, traffic controllers, track workers

– Looked into change management, standards, safety processes and systems, incident investigation

– Stakeholders: contractors, RU, investigation body, branch organization

• Site visits

• Cultural activities

Page 57: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Models used

Page 58: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Key learning points ProRail

• Near miss – we’re only at the start of it

• Our fragmented sector does not help safety conversations, RailAlert partly fills gap

• We lack a more operational safety meeting with stakeholders

• Post incident group sessions

• Step ahead by measuring safety culture with safety culture ladder

Page 59: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Key learning points Irish Rail

• Near misses

– If nothing negative actually happens and there is no evidence to suggest something untoward occurred, a close call or near miss will probably go unreported.

• Rules vs behavior

– In breaking a rule colleagues only think of the immediate impact of breaking the rule. Consideration is not given of the wider ‘system failure’ consequences.

– Having lots of rules does not necessarily make for a safer organization.

Page 60: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Key learning points ŐBB Infra

• Investigation / reporting tool

• Random checks

• Safety ID-card

• Learning movies

• Generation smart phone

• Check of RU and RU’s staff

Page 61: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Group learning (1)

Main finding: we’re different and difficult to compare. National culture is dominant.

• ŐBB rule based, strong influence of government and prosecutors

• ProRail less rule based, complex situation with fragmentation of sector, transparent

• Irish Rail smaller, less complex organization, short communication lines, rule based

Page 62: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Group learning (2)

Role of safety staff is important and differs:

• At ŐBB the responsibility for safety is put with the safety manager by law.

• ProRail made the line management responsible for safety (e.g. every board member is responsible for one or more safety risks) with the safety staff mainly advising and supporting.

• Irish Rail is somewhere between those situations, with a safety staff strongly focused on monitoring and controlling safety.

Page 63: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Group learning (3)

• Near misses: – No shared definition

– How to get them reported? How to lower the threshold?

– To report or to discuss?

• Safety culture improved over the years in all countries

• Use of smartphones introduces risks

• Do external assessments/certification help safety culture?

Page 64: Welcome to the conference Network rail · 10-Apr-18 Safety Culture Twinning conference 2 Agenda 10:00 - 10:15 The value of twinning (Keir Fitch, European Commission) 10:15 – 10:30

Group learning (4)

• Measuring of safety culture is possible to a certain level, within one company.

• Comparing infrastructure managers on safety culture within Europe has no added value.

• More valuable it is to exchange best practices, still knowing that no “one” solution will fit every company

• Stronger cooperation between EU and IM’s – to work together will improve the whole system

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10-Apr-18 Safety Culture Twinning conference 65

Lunch

12:40 – 13:15

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10-Apr-18 Safety Culture Twinning conference 66

Group 3 Presentations

Trafikverket, Adif and PLK

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Safety Culture Twinning programme Trafikverket visiting PKP PKL and ADIF

Susanne Kallman - Pelle Thoren - Pär Färnlöf - Jari Kokko - Anna Maria Östlund

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Scope of Twinning activities at Trafikverket

• Share and learn about; - methods to develop safety culture - ways to utilize existing safety systems,

processes etc. to improve safety culture

- blocking points for development of safety culture

• Develop the safety culture of Trafikverket

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Key findings – Top level management

• Involvement of top level management is essential to create conditions for an appropriate level of safety and development of sound safety culture

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Key findings – Organisation

• A centralised safety organization with clear delegation of responsibility from top level management provides potential to interact with all parts of the organisation

• Vertical integration of the rail sector creates opportunities to maintain a coherent SMS and good safety culture from top level to front line.

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Key findings – Tools

• Appropriate tools makes it easier for front line staff to understand and comply with safety regulations

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Key findings – Tools

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Key findings – Tools

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Key findings – Competence and education

• Competence and appropriate education are important drivers to improve safety and good safety culture

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Thank you for your kind attention

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Twinning programme – ADIF findings • PKP‐PLK (POLAND) • Trafikverket (SWEDEN) • Adif (SPAIN) • Speaker: Aitor Fajardo (Adif) ‐ [email protected]

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• What means safety culture? : – “The safety culture of an organization is the product of individual and

group values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs." (U.K. Health and Safety Commission).

• In other words: – “The way we typically do things around here”

• "Organizations with a positive safety culture are characterized by: – communications founded on mutual trust – shared perceptions of the importance of safety – confidence in the efficacy of preventive measures

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The Safety Culture Ladder – Vision Zero

THE FIVE INDICATORS OF A POSITIVE SAFETY CULTURE

1. Leadership/ Commitment management.

2. Two-way communication.

3. Employee involvement.

4. Learning culture.

5. Attitude towards blame.

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– Leaders

• Convincing leaders for commitment (time, money, people) • Delegating decisions to different levels of the organization (empowering staff) • Enabling both-directions for communication (Vertical and horizontal) • Writing safety communications (Safety Directive and Policy inside the organization) • Giving exemplary behavior (Attendance to Safety Committees)

– Staff • Changing paradigms (Production is not at the expense of safety ) • Giving channels of communication to inform about hazards and to define solutions to the safety

problems • Increasing the knowledge, skills and competence • Rewarding good practices • Participating in safety contests

– Safety Departments • Providing good information (Books, magazines, bulletins, informative publicity campaigns). • Learning and reporting culture with equivalent tools and routines that supports organizational

learning. • Providing good practical training. • Promoting the creation of Safety Committees • Obtaining useful conclusions (lessons learnt) through the analysis of safety related information • Creating mailboxes for obtaining railway safety feedback experiences

– All through the company • Making conscious of the responsibility and the need to monitor the safety at all levels • Providing clear, and organized regulations, processes and procedures to follow

– Outside the company • Using the media (publicity campaigns, youtubers) Culture is to society what

memory is to individuals.

Is it possible to change our safety culture? How to influence and change people´s mind to improve Safety Culture

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Safety Culture Twinning programme PKP PLK visiting Trafikverket and ADIF

• Michał Zięcina, Head of Safety Management System Division, Safety Department

• Anna Jaworska, Chief Specialist on SMS monitoring and development, Safety Department

• Tomasz Osiak, Chief Specialist on SMS monitoring and development, Safety Department

• Krzysztof Zubilewicz, Senior Specialist on SMS monitoring and development, Safety Department

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Safety Culture is always a part of the organisational culture and national culture • Safety culture as a phenomenon exists in the context of

other cultures of – company’s organisational culture, national culture.

• Issue like distance of power, respect of authority or levels of individual trust influence the safety culture of the company as well as safety awareness of all the employees and must be taken into consideration when acting to facilitate cultural change.

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• Understanding of the safety culture in an organization requires understanding of: • national culture • company culture

• The cultural context can be seen in different areas – in the structure of the organisation, business procedures, management practicies, HR policies, even in.. office layouts

• The impact of the cultural background is complex and sometimes indirect – no obvious answers!

Safety Culture is alsway a part of the organisational culture and national culture

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The role and position of safety related issues in business processes

• Establishing a mature safety culture in an organisation must take into consideration the place of safety related tasks and responsibilities for safety issues

• First issue: how is safety included in the company activity • Second issue: how is that related in the company’s organisational

structure • The position of safety in business processes reflects the

company’s perception of safety and influence the way safety culture is shaped within the organisation

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• Examples: • Are the safety management processes included in the

business procedures or are there separate procedures? • Is there a dedicated safety department in the company or

are the safety activities part of various jobs in different areas of the organisation (traffic management, maintenance, planning, strategy, asset management)?

• Is there a person/body coordinating all safety related issues in the organisation? (a top level safety manager / safety commision)

The role and position of safety related issues in business processes

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• Subcontractors – Problems:

• Not used to work in the railway environment • Unknown regulations, procedures and

processes

– Possible solutions: • Establish bigger, wider and longer (in time)

contracts • Require acceptance and effective application

of IM regulations, procedures and processes • Require enabling titles for workers

Problems related with Safety Culture (I)

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• Many different actors and interfaces – Problems:

• Ensure a good safety culture in the railway sector with too many different actors and interfaces

– Possible solutions: • Improve the ability and capability to coordinate the sector • Establish common routines and working procedures • Act together in the sector across institutional borders • Improve and change contractual relationships between

clients • Encourage long-term partnerships • Reduce the number of interfaces and actors • Counterproductive to single market access and high mobility

within the sector

Problems related with Safety Culture (II)

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• All actors in the railway sector (IM, RU, Contractors, Suppliers, Manufacturers) should be able to:

– Propose safety actions

– Identify unsafe points

– Participate in the decisions

Participative System

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It´s necessary to analyse the influence of human factor in safety: – Relation accidents – age of the staff

– Relation accidents – years of experience of the staff

– Relation accidents - workload

Statistical analysis on Human Factor

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• How is it possible to ensure that personnel has correct education and competence to interact with safety critical applications in a sector with high mobility? – Competence related to safety

critical applications – Certificates with end of life to

ensure validity – Access related to certificate and

work orders – Common language for safety

critical applications

Control of competencies and enabling titles

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It´s an IT tool that it´s used to centralize all the information related with traffic safety: – Internal regulations – Operating rules – Orders and instructions – Information for Drivers Rule Book – Route Book That can be used by any potential

user of the national railway network.

General Register of Documentation

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Group 4 Presentations

RFI and SNCF Reseau

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Safety Culture Twinning programme

Vito Donato Raimondi Salvatore Castello

Rete Ferroviaria Italiana (RFI SpA) Sicurezza di Rete e Qualità

(Railway Network Safety and Quality)

Birmingham, 12 December 2017

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Rete Ferroviaria Italiana is the national railway

Infrastucture Manager of Italy Sicurezza di Rete e Qualità

is the Direction of RFI responsible for the

Safety Management System

93

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94

Rete Ferroviaria Italiana twinned with SNCF Réseau

the national railway Infrastucture Manager of France

The visit was hosted by Direction Sécurité, Sûreté, Risques (DSSR) Safety, Security and Risk Management Direction

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Rete Ferroviaria Italiana twinned with SNCF Réseau

95

• RFI visited SNCF Réseau in Paris from 13 to 17 March 2017

• SNCF Réseau visited RFI in Rome from 27 to 31 March 2017

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To explore the safety culture we proceeded with a systematic

approach, viewing the following SMS’s processes:

Safety performance monitoring Hazard identification and risk assessment Investigations in case of accidents or incidents Improvement management

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Those topics are implemented in the “PRISME project”

Safety performance monitoring Hazard identification and risk assessment Investigations in case of accidents or incidents Improvement management

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The “PRISME project” allows SNCF Réseau to develop safety

awareness, culture and commitment

It is possible to identify in the Organization benefits of safety

management

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99

Interesting tools used in SNCF Réseau for safety culture:

• Feedback from experience • Human Factor and Organization

(FOH)

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Interesting tools used in SNCF Réseau for safety culture:

• Feedback from experience • Human Factor

Two types of periodical journals, where a selection of incident

and accident are discussed and analyzed, are available:

- Monthly for the management

- Two-monthly for all the operator

This represents an effective way to disseminate the safety

informations to all the staff

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Interesting tools used in SNCF Réseau for safety culture:

• Experience returns • Human Factor and Organization (FOH)

It’s not a «real tool» but it is a structured approach:

Developing non-technical skills of operators

Analysis of the "deep" causes of events

Integrating FOH into safety management processes

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Interesting tools used in SNCF Réseau for safety culture:

• Feedback from experience • Human Factor and Organization (FOH)

We consider those as useful actions for the Organization

Managed by the Direction Sécurité, Sûreté, Risques (DSSR)

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SNCF Réseau findings at RFI

Thierry Saule, Safety Department (DSSR)

Jean-Marc Pourchier, Europe Department

103

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SNCF Réseau twinned with RFI

The visit was hosted by Sicurezza di Rete e Qualità (Railway Network Safety and Quality),

27-31 March 2017, following the RFI visit to SNCF Réseau.

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A great many findings, amonsgt wich 4 major: – on SMS, – on management & control of existing risks, – on the IT tools: « Cruisenet », – on enquiry process.

All of these elements: – are a strong basis for effective risk control, – also directly contribute to staff awareness and a shared safety

culture.

Safety «fundamentals» control is a prerequisite to any innovative approach.

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Finding 1: SMS = shared living tool

– part of SIGS (Sistema Integrato di Gestione della Sicurezza) • SIGS = common part between SGS, SGL and SGA , • Integration => shared « system » processes effectiveness.

– started in 2001, before ANSF creation:

Voluntary decision, thus not experienced as an external requirement driven from outside

– known throughout the organisation:

• «referents» at each level & in each geographical zone, • training for employees.

SMS contributes to the global staff awareness

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Finding 2 : Management & control of existing risks

– Technical & procedural « safety fundamentals » are systematically explicited & formalised:

• Each procedure is linked to a process, • Each process is linked to a danger, • Each existing danger is in the « Registro dei Pericoli ».

– Risk control and documentation are deeply linked:

An enormous « retro-ingeneering » work has been carried out by RFI

CODICE RFI Autore Titolo Attività di Sicurezza

PROG./ Realizzazione

(SI/No)

Manutenzione

(Si/No) Ruolo

Contesto operativo

Codice Documento

II Livello Dettaglio

CRITERIO Reg. (UE)

1169/2010

SOTTO CRITERIO Reg. (UE)

1169/2010

Documento "prevalente" (SI=regola / NO= risultato applicazione regola)

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Finding 3 : Integrated web tool supports management in day to day tasks:

– «Cruisenet» integrated functions, amongst which: • Non conformity management process, • Return of experience:

– Human factors: use of the GEMS « SRK » model, – Accidents & incidents database, with many filtering & processing functions,

• Audit process: plan, results & workflow, • Action plans, according to the criticality of findings, etc.

– The tool traces all actions taken & results, – Whole information available at high level.

Contributes to: • Effective risk control, • Global management awareness & commitment:

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The RFI Cruisenet home page

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Finding 4: enquiry process; 2 different ways of anticipating use of reports by judicial authorities

– RFI process focuses on data control: • RFI Experts investigating are independent from local management,

– nomination of a Commission,

• Report formally validated at each level (Central or territorial).

– SNCF Reseau process insists on field « contradictory immediate constatations »:

• Importance of « minutes », approved by each involved party local management,

• These « minutes » to be used in the enquiry, later.

Different solutions for the same need

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Learning for the industry

Safety Culture Twinning programme

Group 4

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2 IMs involved in RFI – SNCF Réseau twinning (probably conclusion drawn from other groups) ► Differences in the way to manage safety, without questionning a level of safety considered as acceptable in each IM - Risk based/rule based approaches - Safety Culture - Big data ….

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Safety Culture Twinning programme Group 4

Learning for the industry

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► Question about the management of borders interfaces? no identification of difficulties in operationnal aspects up to now

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Safety Culture Twinning programme Group 4

Learning for the industry

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Observations from each other point of view : - Analysis of all the hazards of RFI system - RFI’s database where all the non-conformities are recorded - SNCF Réseau’s PRISME program

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Safety Culture Twinning programme Group 4

Learning for the industry

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Big opportunities to learn from the differences and gather the best practices from each other

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Safety Culture Twinning programme Group 4

Learning for the industry

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Twinning is the best learning and sharing knowledge for the industry because it can be a methodology to create synergy among IMs Twinning should be extended from safety culture to all SMS’s processes

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Safety Culture Twinning programme Group 4

Learning for the industry

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Twinning is the best learning and sharing knowledge for the industry because it can be a methodology to create synergy among IMs Twinning should be periodic and systematic to discuss a SMS’s process at a time

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Safety Culture Twinning programme Group 4

Learning for the industry

2017

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Twinning is the best learning and sharing knowledge for the industry because it can be a methodology to create synergy among IMs Twinning allows:

• to do a “real time benchmark”

• to exchange best practices

• to identify common principles

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Safety Culture Twinning programme Group 4

Learning for the industry

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Safety Culture Twinning programme Group 4

Thank you for your attention

“If you have an apple and I have an apple and we exchange these apples then you and me will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas,

then each of us will have two ideas.”

George Bernard Shaw

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Learning activity based on safety culture

evaluation

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Safety culture scoring

Difficulties- see example of one level at one time and

another at a different time- how do you score different safety culture levels for the business as a whole, range!

Looking at how leadership casts a shadow was a good indicator of and how proactive people are in seeking training and learning- correct questions even if difficult to score

Safety ownership and role modelling of leaders’ - authenticity of safety conversations key

Measuring and benchmarking safety culture within Europe is

very difficult, maybe impossible, because of the differences in

national cultures but also organizational settings

Measuring safety culture based on these 2 models (or other) possible to some extent – within one organization – in order to improve

Common “language” difficult:

• Near miss or close call, what is that?

• Safety conversation, how do you see it?

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Opportunity for questions

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Closing summary and farewell

ERA