1. 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

2. 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

3. 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)

4. 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

5. 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)

6. Main track collisions and derailments

7. Assigned factors (derailments only)

8. R15H0013 (Gladwick)

9. R15H0021 (Gogama)

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

11. 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?

12. R16C0012 (Alyth Yard)
Image: Transportation Safety Board

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

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

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

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

17. 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.

18. WWW.TSB.GC.CA Contact us: Media relations: (819) 994-8053 @TSBCanada

19. QUESTIONS?