1. Use of Collected Data in Accident Investigations
Photo: alarabiya.com
Ian Naish
Naish Transportation Consulting, Inc.
IRSC Vancouver
October 2013

2. This presentation describes
What is meant by “data”
Why it is collected
The various kinds of data collected
The uses of the data
Some examples and case studies
Conclusions and lessons learned
This presentation is given from the perspective of a government investigation organization
NB: most pictures and diagrams taken from TSB website; the rest from the web

3. What is data? factual information (as measurements or statistics)
information output by a sensing device
information in numerical form that can be digitally transmitted or processed
Source: Merriam-Webster online Dictionary
In investigations it is synonymous with evidence
All of the above have to be analysed to be useful
Evidence has judicial and police connotations; data is more neutral

4. Why Collect Data? It is fundamental to the scientific method
To establish chain of events
To confirm investigative hypotheses
To determine accident causality
To identify safety deficiencies
To make recommendations to improve safety

5. Some Types of Data Operational Technical Environmental Human factors
Organization
Perishable / non-perishable
Good data / bad data / limited data
Regulatory requirements, standards, instructions
Infrastructure, signals, equipment
Weather, time of day
Fatigue, medical, training, supervision
Safety culture, policies, philosophy

6. Data Collected at Accident Site
Verbal information
Operational
Photographic
Site measurements
Environmental
Material (components, documentation)
Electronic (loco event recorder; digital video recordings)
Witness interviews and records
Verbal from on-site personnel; emergency responders
crew information, operating bulletin, train consist
Overall scene, point of derailment, failed components, debris field
Fuel spills, dangerous goods, fires
Actual components and written records
Download of data from event recorder, digital video recordings
Photographs and measurement records
Photos: TSB

7. One example:Level Crossing Profile
Not to scale. 5% grade on the crossing and not enough for a low-boy trailer to cross. Source: TSB report R08T0158

8. Level Crossing, Plan View
Plan view of the crossing showing geometric alignment of roadway and the direction of vehicles involved in the accident. Source: TSB Report R08T0158

9. Site Diagram and Schematic
This particular diagram uses data from several different sources (signalling, track, timetable, accident site survey, witnesses). Source: TSB report R12T0038.
This investigation has many useful depictions of how data can be used (photographs, tables, diagrams, maps…)

10. Data Collected Off-site
Event recorder downloads
Railway company documentation
Materials examination – failure analysis
Historical accident, audit and inspection data
Police reports/Witness statements
Media records
Railway accident
reports
N.B. Investigators have to have legal authority
Examples of documentation based on locomotive event recorder data and an excerpt from a railway company time table (Source: TSB Canada)

11. What will the data be used for?
Advancing transportation safety
By (inter alia):
Establishing the chain of events
Confirming investigative hypotheses
Identifying systemic deficiencies
Identifying trends
Comparing performance
Identifying false information
Refuting incorrect statements
Assisting in legal issues (finding fault?)

12. When to Collect Data Whenever a reportable accident occurs
Whenever an accident is investigated
Whenever a reportable incident occurs
Whenever safety regulations require it
Whenever investigators research an issue
Photos: TSB

13. What to do with the Data Analyse it in order to make conclusions
Record it in a database
Review the data periodically for trend analysis
Analyse fields which relate to issues in a specific investigation
Formalize laboratory examinations in a report
Communicate to safety professionals, public & media
Discard any bad data when it is identified

14. Some Case Studies Organizational data
Equipment (Derailment – Whitby, Ontario)
Perishable data (Level Crossing - Sarnia)
Limited data (Level Crossing – Al Kharj, Kingdom of Saudi Arabia)
Bad data (first 24 hours) and noisy communications records – Al Khurais, KSA

15. TSB Statistical Highlights
2012 Statistical highlights: railway occurrences
A total of 1,011 rail accidents under federal jurisdiction were reported to the TSB in 2012, similar to the 2011 total of 1,022 and a 10% decrease from the average of 1,128.
Accidents involving dangerous goods totaled 118 in 2012, the same as in 2011 but down from the five-year average of 147.
In 2012, there were 48 accidents involving passenger trains, down from the 2011 total of 68 and down from the five-year….(contd)
Source: TSB Canada
This is one way of using data to communicate information on the level of rail safety in Canada
Source: TSB website

16. Rail Accidents Reported in 2004
Pictorial representations in reports are good ways to assess and compare between various types of accident, including frequency and severity
Source: TSB Canada

17. Broken Rim (part of trend) between 1998 and 2004
TSB report R04T0008: A systemic issue was identified during an investigation into a 2004 derailment in Whitby, Ontario. A shattered wheel rim resulted in intermittent broken rails, with a final derailment occurring on a bridge causing fatalities to occupants of a highway vehicle. Data was collected on historical broken rims and a specific manufacturer was found to have the biggest proportion of broken wheel failures, which was a significantly greater proportion than their overall proportion in the North American fleet. The 1995 production year’s one-wear wheels were withdrawn from service in North America. Canadian Pacific prohibited all of its wheel suppliers from re-using any Southern-marked wheels on wheel sets assembled and sold to CPR.
Photos: waymarking.com and TSB Canada

18. Data from Media Video Photo: TSB
TSB Report R99S0071: Two persons on wheelchairs were crossing a track when one got stuck in the planking/flange. The train crew applied the brakes in emergency and stopped just after striking the wheelchair and occupant. By the time the investigator arrived on site, the crossing planking had been replaced. He obtained the local media’s videotape of a wheelchair user demonstrating issues faced in negotiating the crossing. The Engineering Laboratory froze this frame from the video and it was used for the report.
Photo: TSB

19. Limited Data: Level Crossing Accident –Al Kharj, Aug. 2012
This accident occurred at 03:15. The crossing was about 450 km from the investigation office location. The accident was not reported immediately and the investigator inspected the site 12 days after the accident when much of the debris had been removed. This image and one other satellite images and and internet site helped identify specific safety issues at this crossing, including crossing geometrics, vehicle blocking-back / storage restrictions, trip generation, i.e. traffic volume generated from nearby factories and the exposure factor for the crossing. Environmental information was obtained from the weather underground website which yielded data from the Al Kharj air force base. Information on the phase of the moon was also discovered on the internet. Two broken windshields from transport trucks were found at the site: one north of the roadway and one to the south. Discussions with railway police revealed there had been several previous accidents at the crossing.

20. Incorrect Information and Communication Record Issues -Train 1 Derailment, KSA
Typical Saudi Railways Organization conventional passenger train equipment used in Train 1. EMD SDL50 locomotive and European/Korean passenger rolling stock.
Source: pnninews.com.pk.

21. Derailment Site, looking northwest
Train 1 derailment at Al Khurais Junction, Siding 10, June 27, Evacuation of train underway.
Three investigators immediately deployed from Dammam to the site, which was several hours travel time away. Whilst en route, information came from their colleagues that the derailment was sand related, as they had seen media photographs showing the rails were covered in sand.
Source: constructionweek.com

22. Sand on Rail? Source: Saudi Gazette
The apparent “rail” in the foreground was actually a cover on a communications cable duct. Sand on the rails was not an issue. The train had derailed at a turnout to a siding.
Radio communications records from the signaller at the traffic control centre just before the accident were poor in quality.
TSB Canada and RAIU Ireland provided assistance in cleaning up the voice records. All but one record were understandable after the RAIU enhancement.
Source: Saudi Gazette

23. Conclusions & Lessons Learned
Good data is a basic prerequisite for investigations analysis and to produce investigation reports
Data records allow trend monitoring
Investigation reports and statistical reports communicate safety issues
There are an increasing number of ways to obtain data
Data gaps must be identified and ways found to address them
Discard bad data whenever it is found!

24. Thank you!
Photo: VIA Rail Canada