Managing the Organizational Interface Transportation Safety Board of Canada Managing the Organizational Interface Three case studies. IRSC 9-13 October 2005 Catalysts for this Briefing A few weeks warning and no staff to delegate to. Seriously, see next slide Ian Naish Director, Rail / Pipeline Investigations Branch

Railway Industry in Canada 47,000 km of track 60 railway companies 1400 reported occurrences per year

Managing Inter-organizational Interfaces Issues: risk management in a changing environment areas where safety defences have failed. involvement of all staff in management of safety.

Managing the Inter-organizational Interface MCBRIDE, BC NOBEL, ON LIMEHOUSE, ON

Nobel, Ontario, 2003 Broken rail derailment in First Nations land No command centre set up - communications problems Responder training, but not experience

Limehouse, ON, 2000 No site safety briefing Contractors setting up at crossing Truck blocking signals No flagperson Three persons killed

McBride, B.C. Bridge collapse and fire Changes in roles and responsibilities No records of maintenance work done No regulatory requirement to audit procedures

Conclusions Work sites are complex They have to be managed effectively Assign roles Communicate clearly, early and often Good records must be kept

Some suggestions Plan in advance Meet early and often Train and re-train Due diligence when record keeping