october 2008 international rail safety conference 2008 denver, colorado, usa
Post on 18-Dec-2015
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TRANSCRIPT
October 2008
Weather forecasting - why we need leading performance indicators
• To know with some certainty what is going on
• To provide an early warning of the potential for undesired events
• To allow for preparation and defence against the undesired events
• To promote a positive culture towards improving performance
October 2008
Characteristics of good indicators
• Objective and easy to measure
• Relevant to the organisation or work group whose performance is being measured
• Provide immediate and reliable indications of level of performance
• Understood and owned by the work group
October 2008
Example 1 - Hatfield, 2000
• Looking at a specific example of an undesired event - a train derailment due to a broken rail
• What leading performance indicators can provide the early warning?
• They will be based on the available control measures
October 2008
Hatfield, UK, October 2000
• Derailment of passenger train south of Hatfield
• Four passenger deaths
• 70+ injured, 4 seriously
• Speed 185km/h
Service car roof penetrated by
staunchion - all 4 deaths
occurred here
October 2008
Hatfield - final investigation
report
• Immediate causes - fracture & fragmentation of high rail on the curve
• Rail failure due to multiple & pre-existing fatigue cracks
October 2008
Hatfield - final investigation report
• Underlying cause (1) - failure of maintainer to manage inspection and maintenance effectively
October 2008
Hatfield - final investigation report
• Underlying cause (2) - failure of infrastructure manager to implement effective rail renewal
October 2008
The fractured rail
The high rail on the curve fractured into over 300 pieces and over a distance of 35m -
forensically reassembled
October 2008
What happened?
• The most southerly fracture - failed due to a combination of fatigue cracking in the rail head followed by brittle fracture of the web and foot
October 2008
Why did it happen?
• A fatigue crack through approximately 30% of the rail head
• Surface of the rail characterised by widespread surface cracking and spalling
October 2008
What knowledge was lacking?
• Fatigue crack through approximately 80% of the rail head
• Fracture had probably occurred some time prior to the accident
October 2008
Effective use of lead indicators
• Identify potential weaknesses
• What can be done to counter weakness
• Set performance standards for actions
• Monitor performance against standard
• Take corrective action
• Repeat process- continual improvement
• PLAN - DO - CHECK - ACT
October 2008
The basis for the lead indicator?
• Quality control at manufacture• Accurate database of installed rail• Predictive failure based on traffic conditions• Rail flaw detection process• Intervention standards• Currency of knowledge and standards• Follow up and close out of defects• Risk based approach - know higher risks• Maintenance standard & currency
October 2008
What are the early warning signs?
• What indicators will tell the organisation that, if they do not act, there is a potential for track worker deaths?
• What are the critical controls and how can their effectiveness be measured?
• In this case, what knowledge was missing or not acted on?
October 2008
Singleton, New South Wales
2 maintenance workers killed
when struck by a freight train
Very basic rudimentary protection
system
October 2008
• The two workers were providing their own protection, they acknowledged an up train but did not see or hear a down train that arrived a short while later
October 2008
Effective use of lead indicators
• Identify potential weaknesses
• What can be done to counter weakness
• Set performance standards for actions
• Monitor performance against standard
• Take corrective action
• Repeat process- continual improvement
• PLAN - DO - CHECK - ACT
October 2008
The basis for the lead indicator(s)?
• Absolute occupation of track - windows• Safe work protection systems currency• Network Rules - currency and ownership• Warning devices availability• Work planning - effective & thorough• Visibility & audibility of trains• Standard risk assessment• Near miss or irregularity incidence• Standard of auditing of the above
October 2008
The best measures?
• Average number of layers of protection (Singleton had only one & that was person) - set a minimum
• How does protection stack up against risk & ‘best practice’?
• What is the level of compliance with the protective measures & procedures?
• Accurate and in depth auditing & incident (near miss) investigation