Speech to Rail-Government Interface 2015
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Board member, Transportation Safety Board of Canada
Ottawa, Ontario, 26 February 2015
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Hello, and thank you for that introduction.
At the Transportation Safety Board of Canada (TSB), we investigate accidents. And, in the immediate aftermath of an accident, people on the street and in the media want to know quickly not just “what happened,” but who is to blame. And so they typically ask if the accident was due to a “mechanical failure” or to “human error”—as if each accident had just “one” cause. At the TSB, however, we don't assign blame. And we know from almost 25 years of experience that every investigation reveals multiple causes and contributing factors, some that stand on their own and some that interact with other factors.
Take, for example, the accident in Lac-Mégantic, Quebec, where a train carrying 7.7 million litres of petroleum crude oil derailed in 2013, leaving 47 people dead and ripping a hole in the centre of the town. The TSB's subsequent investigation identified a total of 18 causes and contributing factors. We also identified a further 16 factors which added risk to the operation.
In other words, there was no “one” single cause.
I'll come back to the example of Lac-Mégantic in a moment, and in particular to the issue of trains operating on the main line through towns and cities, past homes and businesses—many of them carrying flammable liquids. But first I'd like to look at another area where the public and railways interact: public railway crossings.
The issue of crossing accidents is on the TSB's 2014 Watchlist [Slide #2: Vehicle crossing accidents], which identifies those issues posing the greatest risk to Canada's transportation system. And, put simply, the risk of trains and vehicles colliding at crossings remains too high. Yes, there have been some improvements in the busy Quebec City-Windsor rail corridor, but the number of level crossing accidents in the rest of Canada has not decreased at all over the past 5 to 6 years. While Transport Canada has just implemented long-awaited new regulations on grade crossings, it will take some time for improvements stemming from those regulations to be manifested in lower accident rates. I know the industry, through Operation Lifesaver, is working hard on this public safety issue, but more must be done to reduce this risk.
This includes: enhanced standards or guidelines for certain types of crossing signs, consultation with provincial authorities, and further public driver education.
But as I said a moment ago, what about mainline train accidents? That's what so many people across Canada are worried about right now: the spectre of another accident like Lac-Mégantic, only this time in their backyard.
Here is a 10-year picture of mainline train accidents in Canada, normalized by the number of mainline train miles. [Slide #3: Mainline train accidents/MMTTM] In other words, this is the rate of mainline train accidents. In all, the rate has improved by 52 percent. The data is presented in 4 categories—with the “cause” for most accidents generally represented by the final failure in the chain of events.
You will see that the rates of accidents caused by failure of railway equipment, track components and the “catch-all” category of “other” have all fallen significantly over the years. There are many reasons for this. For instance, the railways have used improved manufacturing processes and introduced new technologies to monitor and find flaws in rail infrastructure and equipment and to remove these flaws before they result in accidents.
But over the past 10 years, the rate of accidents where “actions” is the final factor has not changed at all. Why is that? Why is it that railway personnel not responding appropriately to situations continue at the same rate? What—if anything—can be done to change it?
When examining this issue, we first need to understand that human performance is not a cause of failure. Rather, it is a symptom of deeper trouble. It is connected systematically to people's tools, to their tasks, their training, their supervision and to the environment in which they operate. When decisions or choices result in an accident, those decisions often have their origins in the nature or structure of the organization. The employee may be the final link in the chain of events, but he or she is seldom the only link. So … who is the organization? It's management—the people higher up who set priorities, who make policy, decide on issues such as what equipment to buy, how to provide training, how to assess performance and how to deal with mistakes. And so we ask: Do those people welcome new ideas? How is responsibility for incorrect actions handled? When incidents happen, is punishment the first and only response, or does the incident lead to soul-searching and to systemic changes?
All of this can be summed up by one question: What is the safety culture of the organization?
[Slide #4: Safety culture and safety management systems]
The question may be simple, but assessing the culture and making profound long-term changes to an organization's culture is not an easy task. Nor can culture change be achieved in the short term. And how does safety culture relate to safety management systems (SMS)—which are now mandated by regulation for the Canadian railway industry?
Let's explore both of these ideas.
The concept of Safety Management Systems was introduced by Transport Canada in part to recognize the complexity of all the factors that go into managing safety, and to ensure that those factors were systematically considered and acted upon by a railway operator. Merely telling employees to follow the rules or the regulations is not sufficient to ensure safe operations. SMS was perceived as an overlay on top of all the rules and regulations, an overlay that would bring the rail industry to the next level of safety. In other words, SMS was seen as a way for companies to draw together the complexities of rail operations and to formally and systematically assess and mitigate emerging risks.
SMS implementation started in about 2002, but it has not been as successful as the architects originally hoped. I will not go into all the reasons why it has had only limited success thus far, but I do want to point out that part of the reason is the perception that SMS is a complicated process with an emphasis on documentation and bureaucratic procedures. Yes, it's important for companies to have sufficiently detailed documents, and yes, Transport Canada must audit those documents, but real change must also happen “on the ground.”
What, then, is the missing link between SMS and improving overall safety? In my view, it is the link to an organization's safety culture. SMS must exist as more than just documentation. Merely crafting a safety policy or a “commitment statement” that is then signed by senior executives does not change the way those executives think or act. It does not change their individual beliefs, or their reliance on outdated models of managing. It does not make them more credible safety leaders in the eyes of employees, because what they say may not be consistent with what they do. Yes, writing down and communicating a vision for safety excellence is important, but those efforts may be wasted if senior managers' decisions or actions are perceived as contrary to their stated vision. For instance, do leaders actively encourage worker participation in recognizing and resolving potential safety problems? How quickly do managers take action when there is a safety issue? How does accountability for safety work in an organization? How is feedback and recognition for safety excellence dealt with? What about feedback when people make mistakes?
One of the many aspects of safety culture described in the literature is the notion that beliefs are harder to change than behaviour. And one of the simplest definitions of safety culture is the “way we do things around here.” The solution, then, seems obvious: change behaviour first—and that will gradually lead to change in beliefs. It sounds easy, but it is hard to measure, and harder still to change.
So what does all this mean for the small railway with limited resources? Beyond the formal requirements for SMS, you need to ask yourself some simple questions, such as: Do I have a personal vision for safety that is actionable—in other words, something my employees can observe? Have I communicated that vision? Do my actions match my words? Do I take action quickly to reduce risk posed by unsafe conditions? By changing something here, have I created more risk somewhere else? What can I do to reduce risk in this aspect of my operation? Ask yourself these and similar questions all the time—particularly when making changes that affect the operation.
The term “safety culture” has only recently entered the vocabulary of the Canadian railways, and indeed of the Railway Association of Canada. The RAC has embarked on a culture-change journey. We know it is a long-term effort, and we know that change will take time.
[Slide #5: Watchlist: Rail issues]
The TSB will be watching with interest to see where these efforts lead, and which of the changes takes root over time. How, for example, will railway companies and unions handle the implementation of on-board video and voice recorders? This has been on the TSB Watchlist since 2010, and in fact we first recommended the implementation of voice recorders in 2003.Footnote 1 We recognize that the expanded use of the information generated from video and voice recorders can assist railways in improving safety on board trains. However, the century-old “disciplinary” policies crafted by management and the unions stand in the way. The old model—what used to be called “blame and punish,” or “blame and retrain”—needs to be updated. Reporting systems need to be implemented that are non-punitive, so that employees are not afraid to report safety concerns or unsafe conditions. Further, employees should be encouraged to recognize and report situations that may be hazardous, so that the whole organization can learn and change.
In the wake of Lac-Mégantic, we've heard people say, “The accident was caused by someone who did not follow the rules,” as if that were the end of it. But as I said earlier, no accident is ever caused by one single factor, and no one wakes up in the morning and says “I think I'll have an accident today.” Yet, it's also true that employees don't always carry out procedures exactly as written. And so we will also be watching to see whether railways implement additional defences to guard against this. In fact, wherever possible, an administrative procedure should not be the only line of defence to prevent an accident.
And that leads me to another rail issue on the 2014 Watchlist: that of following railway signal indications. Since 2004, there has been an average of 30 occurrences per year where a train crew did not respond appropriately to a signal indication displayed in the field. These signals convey information such as operating speed and the operating limits within which the train is permitted to travel. A number of TSB investigations have identified train signal misinterpretation/misperception as a cause or contributing factor to an accident, and the TSB has made two recommendations on this important issue. What's needed is the implementation of additional physical safety defences to ensure that railway signal indications governing operating speed or operating limits are consistently recognized and followed.
Next month, it will be 25 years since the creation of the TSB. For almost a quarter of a century we've investigated accidents, identified the causes and contributing factors, and then done our best to persuade the people and organizations best placed to effect change that more action needs to be taken. Our work has evolved a great deal over the years, as has the way people think about accidents in general. But we're not the only ones evolving—so is the industry. 25 years ago, SMS was not much of a thought, let alone a requirement, for many organizations. Now it's being implemented much more widely, though not all systems are as mature as they need to be. As we go forward into the next 25 years, the TSB will be watching closely. Hopefully, railway management and the unions will make the fundamental changes required to not only implement SMS, but to change their entire safety culture—and by doing so, reduce the number of accidents across the country.