1. International Railway Safety Conference - 2012 Paul Thomas CB FREng FCGI Chairman RSSB

2. HMS VANGUARD

3. Safety – why bother? Moral Legal Direct cost Reputation Poor Safety = Bad Business

4. THORP leak -2005 British Nuclear Group has released its board of inquiry report into the leak at Sellafield’s Thorp plant. A design error led to a leak of highly radioactive liquor while defective culture at the plant delayed detection for nine months. The exceptionally frank report lists the following management systems as having shortcomings which contributed to the event: safety case; procedures and systems of work; hazard reporting systems; training; supervision; design; maintenance; and plant modification. The report states that a ‘new plant’ culture existed and Thorp was simply not expected to leak. Nuclear Engineering International

5. Leadership & Responsibility “Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.” Admiral Hyman G Rickover USN

6. People Competence/Training & Assessment Supervision/Management Just Culture/Near Hit & Incident reporting Standards & Expectations

7. Windscale - 1957 Programme pressures Competence Appropriate procedures

8. Three Mile Island - 1979 Inadequate training Lack of OE feedback Consequences INPO

9. Chernobyl - 1986 Bad design Operational pressures Lack of safety culture WANO

10. Fukushima - 2011 Plant shut down successfully UNTIL Tsunami hit Periodic review

11. Peer Review Expert Peers 3 week visit POs & Cs Evidence – White Cards Feedback meeting Strengths AFIs Follow up visit Formal report

12. Final thoughts “It is necessary for you to learn from others' mistakes. You will not live long enough to make them all yourself” “I have a son. I love my son. I want everything that I do to be so safe that I would be happy to have my son operating it. That‘s my fundamental rule.”