1. TSB of Canada –Reflections on a Career in Rail Safety at the TSB Ian Naish Director, Rail Investigations (retd.) Transportation Safety Board of Canada IRSC, Båstad, Sweden 29 September 2009 Naish Transportation Consulting Inc

2. Topics to be presented Background TSB Canada SMS issues Four accidents with SMS issues identified Conclusions

3. Canadian Railway Network & TSB Offices

4. January 2009, British Columbia

5. TSB Canada Independent federal agency Multi-modal Chairperson and four Board Members 21 rail investigators Total Board employment: 235

6. TSB Mandate Advance transportation safety by: making findings making recommendations reporting publicly Do not assign fault or liability Shall not refrain from reporting fully Board’s findings are not binding

7. How work is carried out 1,000 reported rail accidents per year 40 deployments per year 15 Board investigations per year in rail ISIM Integrated Safety Investigation Methodology Around 5 recommendations per year 15-20 Safety Communications per year

8. TSB Recommendations Board recommendations if safety deficiency is systemic Can make prior to final report released Non-prescriptive and not binding Normally made to Minister of Transport

9. Integrated Safety Investigation Methodology (ISIM) Model Occ. Assessment Data Collection Occ. Events Unsafe Acts/ Conditions Unsafe Acts/ Conditions Safety Communication Accident Underlying Factors Underlying Factors Assessed Risk Safety Deficiencies Safety Deficiencies Risk Control Options Risk Control Options Sequence of Events Integrated Investigation Process Risk Assessment Process Defence (Barrier) Analysis Process Risk Control Options Analysis Process 1 2 3 4 5 6 7 8 Accident

10. Key Components of an SMS 1. A Safety management plan 2. Training 3. Regulatory monitoring (reactive and proactive) 4. Documentation 5. Quality assurance, and 6. Emergency response preparedness.

11. SMS Some Safety Management Systems issues: – risk assessment and control processes – regulatory overview – organizational safety culture – under-reporting of accidents 1996 – QNS&L One person freight train operation 2003 – McBride bridge collapse: “Black Swan Event?” 2006 – White Pass &Yukon Route runaway and derailment 2007 – Prince George non-main track derailment Accident under-reporting

12. QNS&L Collision, 1996

14. McBride Bridge Collapse, 2003

16. WP&YR Runaway and Derailment, 2006

17. WP&YR Derailment, 2006

18. Prince George Yard Derailment, 2007

19. Prince George Derailment, 2007

21. Reporting Issues Figure 2. NMTDs by Cars Derailed, May 1, 2007 - Dec 31, 2008 0 50 100 150 200 250 123456-1011+ Cars derailed Non Main Track Train Derailments XYOthers

22. Some Conclusions SMS is not necessarily easy to implement or manage SMS problems can occur during times of change Industry has to be accountable for SMS to work Regulators have to be accountable too Safety culture is critical

23. Something to think about... When anyone asks me how I can best describe my experience in nearly forty years at sea, I merely say, uneventful. Of course there have been winter gales, and storms and fog and the like, but in my experience, I have never been in an accident of any sort worth speaking about. I have never seen but one vessel in distress in all my years at sea...I never saw a wreck and never have been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort. E.J. Smith, 1907 On April 14, 1912, RMS Titanic sank with the loss of 1500 lives - one of which was its captain - E.J. Smith

24. Thank you! Naish Transportation Consulting Inc. www.naishconsulting.ca