On the right track? An examination of SMS in rail and other modes Kathy Fox Chair, Transportation Safety Board of Canada Halifax, NS 12 October 2017

TSB 101: who we are, what we do Mandate: To advance transportation safety in the marine, pipeline, rail, and air modes by: conducting independent investigations identifying safety deficiencies, causes, and contributing factors making recommendations to address systemic issues It is not the function of the Board to assign fault or determine civil or criminal liability TSB is not a regulator

The evolution of safety: yesterday’s thinking … and today’s Image: the same old thinking leads to the same old results. (Image removed as it was not property of TSB)

What is culture, and why is it so important? Simple definition: The way we do things around here Culture change Takes time Can be difficult to measure Key notions: Behavioural statement Leaders must find ways to change behaviours Behaviour changes lead to changes in beliefs which changes the culture

Over 100 years of history, pride … and inertia Images: Black and white photos of old trains; workers holding a ceremony after the last spike has been driven. (Images removed as it was not property of TSB)

Main track collisions and derailments

Assigned factors (derailments only)

R15H0013 (Gladwick)

R15H0021 (Gogama)

Getting the job done Image: workeers attending to rail track (Image removed as it was not property of TSB)

Food for thought Were the involved employees able to identify the systemic issues prior to the derailment? In other words, did they have the “requisite imagination” to identify the risks around them? If so, could they raise these issues through any available mechanism? What were the norms about raising safety concerns? And what values and beliefs underscored and perpetuated these norms?

R16C0012 (Alyth Yard) Image: Transportation Safety Board

Image: witness being interrogated (Image removed as it was not property of TSB)

Elements of a robust safety culture Doing what you say you’ll do Just culture Reporting culture Learning culture

The (potential) use of voice and video data Source: TSB investigation report R16H0002 Source: TSB investigation report R16H0002

Image: a just culture decision tree (Image removed as it was not property of TSB)

Conclusions Ask yourself why things happened, and don’t accept “rule-breaking” as an answer. What’s driving your safety culture? what assumptions? what values? what beliefs? There has got to be a better way of getting where we want to go.

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QUESTIONS?