1. 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

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

3. 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.

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

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

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

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

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

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