National Railway Day Conference

On the right track? An examination of rail safety

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Kathy Fox
Chair, Transportation Safety Board of Canada
Ottawa, Ontario
7 November2017

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Slide: Title

Good morning,

Thank you for the invitation to speak today. It's always a pleasure for me to meet with industry leaders and representatives.

As we all know, the rail sector has been changing considerably over the past years, implementing new technology and managing increased traffic, including a significant rise in the transportation of crude oil.  Canada has one of the largest railway networks in the world with over 48,000 kilometres of track. It's safe to say that rail transportation is very important to our country's economy. Because whether trains transport people, freight, or crude oil, they are connected to a business. Every year, Canadian railways move 70% of the country's surface goods, including 40% of its exports. Our job at the TSB is to point out areas where safety can be improved, and to call for action so that business is conducted in the safest way possible.

In my presentation today, I'm going to highlight the progress that has been made in rail safety over the last couple of years, and talk about the work that remains to be done. I will also discuss safety culture and its importance within an organization, and perhaps challenge your cultural values and beliefs as industry leaders.

Slide: TSB 101

For those in the audience who may not be familiar with the TSB, I will provide a very brief introduction.

The TSB is an independent federal government agency whose mandate is to advance safety in four federally regulated modes of transportation: marine, pipeline, rail, and air. We do this by carrying out investigations into transportation occurrences, to understand not only what happened, but more importantly why it happened, so that steps can be taken to prevent it from happening again.

We are not a regulator, nor do we assign fault or determine civil or criminal liability.

Slide: Watchlist

In 2010, the TSB introduced its first Watchlist. The goal was to focus the attention of industry and Transport Canada—the regulator—on those safety issues posing the greatest risk to Canada's transportation system, particularly where action to implement TSB recommendations was too slow or insufficient.

Since then, we've updated the Watchlist every two years, reflecting progress that has been made and new issues that have emerged.

The latest Watchlist was published in 2016. Two new issues were added to those that were carried over from the previous Watchlist: one pertaining to the rail sector, and one multimodal. Railway crossing safety was removed from the list given the progress accomplished.

Slide: Issue removed: Railway crossing safety

In 2014, Transport Canada brought in new Grade Crossings Regulations and Standards aimed at improving the safety of grade crossings. With these in place, the TSB has been carefully monitoring grade-crossing accidents. We noticed an initial reduction in the number of accidents following the introduction of the new regulations. It appears now that these numbers are plateauing.

An ongoing commitment by all parties, including  funding to improve existing crossings, is required to sustain the momentum.

Slide: Transportation of flammable liquids

One issue that is still on the Watchlist is the transportation of flammable liquids. The Lac-Mégantic accident in July 2013 served as a tragic reminder of the risks associated with transporting crude oil by rail across North America. It sparked numerous discussions among safety experts, industry representatives, and regulatory agencies. As long as crude oil is being moved by rail, the risks will remain. Which is why it's important for companies to conduct thorough route-planning and analysis, to perform risk assessments, and to ensure effective risk-control measures.

We also called for the use of more robust tank cars when large amounts of flammable liquids are transported by rail. Following the Lac-Mégantic accident, Transport Canada issued new tank car standards with enhanced safety features, and we've seen a significant decline in the use of the "legacy" Class 111 tank cars. Transport Canada has also indicated that by 2025, these cars will no longer be allowed to transport flammable liquids. Until then, the risks must be properly managed.

Slide: Following signal indications

Another persistent Watchlist issue has to do with signal indications. Railways signals are not consistently recognized and followed, which poses a risk of serious collisions or derailments. An average of 38 occurrences are reported each year to the TSB where a train crew did not respond to signal indications.

Slide: Burlington

One such accident was the VIA train derailment that took place near Burlington, Ontario, in 2012. Three locomotive engineers were killed and dozens of passengers were injured when VIA 92 derailed at a crossover en route from Niagara Falls to Toronto. It was determined within days that the train had been travelling at more than four times the allowable speed for the crossover, and that the locomotive crew had not properly responded to signals requiring a slowdown to 15 mph.

Following its investigation, the TSB recommended the implementation of physical fail-safe train controls by major Canadian passenger and freight railways. This built on a previous TSB recommendation made in 2000 calling on Transport Canada and industry to implement additional backup safety defenses to help ensure that signal indications are consistently recognized and followed.

However, 12 years later, progress had been slow and safety defenses were still inadequate, which contributed to the Burlington derailment.

Slide: Slow progress on addressing TSB recommendations

Slow progress on addressing TSB recommendations is not unique to the rail sector. This multimodal issue was added to the Watchlist in 2016 because we determined that too often, it takes Transport Canada years to implement its planned actions in response to TSB recommendations.

 Whatever the cause may be for the delay, the end result is that we continue to find causal and contributory factors and underlying risks in recent accident investigations that are similar to those that gave rise to our long-standing recommendations. More timely safety actions are required to mitigate these risks, including, where appropriate, the adoption of short-term measures by industry pending the implementation of permanent solutions.

Slide: New issue:  Fatigue management systems for train crews

The other issue we added to the Watchlist in 2016 is fatigue-management systems for train crews. Since 1994, of all rail investigations involving human factors, 20% showed fatigue as a contributing or risk factor, and most of these involved operating crews on freight trains.

Sleep-related fatigue in the rail industry has been a recognized problem for over 20 years. But initiatives to date have been inadequate. By featuring this issue on our Watchlist, we are calling on Transport Canada to complete its review of fatigue-management systems. We are also urging the regulator, railway management, and employee representatives to work together to implement effective mitigation strategies.

Slide: On-board locomotive voice and video recorders

The final Watchlist issue I'd like to discuss is that of on-board locomotive voice and video recorders. The TSB called for the installation of voice recorders as far back as 2003, and it has been on the Watchlist since 2012. Voice and video recorders provide key information to understand safety risks and deficiencies following an accident and can assist with proactive safety management.

A number of you have also been calling for expanded use of recordings, and we support that—on the condition that the rights and obligations of all parties are balanced so that information is used in the context of a non-punitive, proactive safety management system. Safeguards must also be included to avoid inappropriate use of these recordings.

Last May, the Minister of Transport announced proposed amendments to the Railway Safety Act. If enacted, these amendments will require the installation of voice and video recorders on lead locomotives operating on main track. They will also allow Transport Canada and railway operators to access the recordings under specific conditions in the context of proactive safety management. The TSB believes this would enable your industry to enhance safety through an improved understanding of systemic risks in your operations.

To truly move toward a safer rail network, all of us also need to look at something that goes beyond legislation and recommendations. We need to look at safety culture.

Slide: What is culture, and why is it so important?

Most definitions state that culture is "a collection of values, beliefs and attitudes that determine how people behave in the workplace." Culture defines norms within a work group. Norms define what people are willing to accept, and therefore they determine the level of risk in a workplace.

The values and beliefs we hold about what will happen to the safety information we provide—and how safe it is to provide that information—will determine the extent to which people at all levels of the organization participate in a safety management system.

Therefore, a good safety culture is critical to an effective SMS!

The thing is, culture is hard to change. It has to come from within an organization, and the tone is set at the top. That means the leaders: their beliefs, their priorities, and above all how they behave. Because leaders' behaviour is emulated by others in an organization.

To help identify and challenge those values and beliefs, I am going to be a little provocative. Bear with me, keep an open mind, and try to accept what I am going to say in the spirit in which my remarks are provided. They come from a perspective of examining safety across a range of transportation modes, looking at strengths and challenges.

Slide: Over 100 years of history, pride… and inertia

One of the strengths of your industry is its history and the pride that comes from that history. Since the railway opened up this country, a can-do attitude and the supporting values and beliefs fostered a pride in being a railroader. That pride has allowed the railways to continue to be a backbone of our economy.

While being a strength, a deep history also makes cultural change more difficult. Like a freight train rolling down that track, values and beliefs have a lot of inertia!

And the rail industry has its own unique culture. Compared to other industries we deal with, it tends to be:

  • rules-based: with a long-standing focus on compliance;
  • punitive: having a demerit system tied to safety investigations; and
  • adversarial: which is generally the result of a rules-based and punitive work environment.

The values and beliefs that come from and perpetuate these characteristics are the ones that need to be challenged if the rail industry is to successfully transform its culture.

An accident is never caused by a single factor or a single individual. It's important to look at the big picture, especially at systemic factors that may have contributed to an accident. Blaming a worker for an accident only serves to foster a rules-based, punitive culture. In that type of culture, safety information will not flow—and safety will not improve.

In a recent investigation involving a derailment in a rail yard, the TSB identified employee fatigue as a contributing factor. Such a finding raises important questions about values and beliefs, for instance:

  • What would lead an employee to report to work when he or she is unfit due to fatigue?
  • Why would this employee report to an internal accident investigation that he or she was fit and rested? And,
  • Why would internal investigators accept this statement without questioning it?

If such questions are not addressed, then efforts to improve rail safety remain incomplete. Which is why the TSB is sometimes forced to conclude our investigation reports with the statement that we are "not aware of any safety action taken following the occurrence."

In other investigations, the TSB has identified gaps in training, supervision and inadequate procedures that contributed to occurrences—instead of just pointing the finger at an employee for not following the rules. Without taking a hard look at the values and beliefs contributing to this situation, the rail industry will not be able to move forward on improving safety and safety culture.

So, what elements make up a robust safety culture? Well, it starts with doing what you say you will do, particularly with respect to…

Slide: Elements of a robust safety culture

Conducting risk assessments

Safety Management Systems (SMS) have been required in the railway industry since 2001, and regulations were updated to that effect in 2015. However, there are still railway companies that aren't conducting risk assessments before making operational changes.

Moreover, there still seems to be an attitude of trying to justify why a risk assessment is not required by the regulation.

A just culture

So, is there an alternative for a rules-based, punitive culture? What will happen if we take a different approach to looking at rules compliance and addressing behaviour following an occurrence? Other transportation industries provide a very effective model where "normal" error is treated as a learning opportunity and an opportunity to improve the system, while truly culpable or negligent behaviour will still result in disciplinary action.

These organizations have been able to enshrine their SMS processes within a "just culture." What's a just culture? It's an environment that draws a clear distinction between simple human mistakes and unacceptable behavior; one that does not immediately blame the worker, but seeks first to find systemic contributing factors.

Reporting culture

Another element of a good safety culture is a reporting culture—that is, one where people feel "safe" to report issues and incidents because they know they will be treated fairly, and they know that the underlying issues will be addressed. In companies without a strong reporting culture—where, for example, an employee fears retribution for speaking out—problems are less likely to be reported. The result? Those problems will remain unknown and unaddressed by the company.

Learning culture

The final element of a good safety culture is one that is also a learning culture.

Ideally, this is the natural outcome of an organization where employees trust that they can report problems. Because, once reported, management—and ideally the whole organization—asks, "what can be learned from this?" In other words, how do you use the data that's been reported in order for the company to learn and to grow?

Slide: Just culture decision tree

As I was talking about a just culture a few minutes ago, I mentioned the need to look for systemic contributing factors rather than immediately blaming the worker. Here is an example of a decision tree that can be used to look at the big picture before making a decision on next steps.

Slide: Conclusions

To wrap up, we at the TSB are aware of the impact of rail transportation on business operations. The efficiency—and safety—of the Canadian rail network are crucial for the country's economy.  Through our Watchlist, we identify those safety issues in Canada's transportation system that must be addressed, and we take proactive measures to encourage the industry and the regulator to address those issues.

Improving the safety of our transportation network benefits everyone —companies, employees, customers and the general public.

Your industry must and can do more to respond to safety issues as they are identified, rather than wait for the regulator to take action.

Then, there is culture. To move forward to a robust safety culture, steps must be taken.

First, When you investigate an occurrence, start asking why things happen—and don't accept "rule breaking" as an answer.

Then, think about what's driving your safety culture—the assumptions, values, and beliefs that underpin it. Are those values and beliefs punitive? Adversarial? Or are you willing to take a more systemic look, learn from experience, and embrace a more just culture?

I agree that it is seldom easy to change the way we do things. But it's important to question ourselves, to question the way we think, and to question the way we act if we wish to truly advance safety.

Thank you.