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6/16/2016 1 Managing SPADs, Managing Risk Dr Todd Bentley Director – Safety, Environment, and Risk Metro Trains Melbourne MTM and SPADs Managing SPADs, Managing Risk | June, 2016
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6/16/2016
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Managing SPADs, Managing Risk
Dr Todd BentleyDirector – Safety, Environment, and RiskMetro Trains Melbourne
MTM and SPADs
Managing SPADs, Managing Risk | June, 2016
6/16/2016
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Other Organisations
• Estimates for a ‘largish’ rail organisation:• Details removed until research completed.
Managing SPADs, Managing Risk | June, 2016
Fundamental Question…
• So why do we spend so much time and resources trying to manage SPADs?
• Simple answer: it’s about managing risk.
Managing SPADs, Managing Risk | June, 2016
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RISKSRISKS
No IncidentNo Incident
CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
DerailmentMainlineSidingDerailmentMainlineSiding
Controls / MitigationsControls / MitigationsSPADSPADControls / MitigationsControls / Mitigations
Cat A (Train / operating interface)Driver errorDriver distractionIncorrect authorisationRail adhesionBraking failure
Cat A (Train / operating interface)Driver errorDriver distractionIncorrect authorisationRail adhesionBraking failure
Cat B(Network integrity)Preceeding aspect at proceed
Signal returned to danger by signaller / train controllerRunaway train
Cat B(Network integrity)Preceeding aspect at proceed
Signal returned to danger by signaller / train controllerRunaway train
• Staff management (training, recruitment)• Infrastructure maintenance• Rollingstock maintenance• Audit / monitoring• Advance protection systems
• Train protection systems (e.g. TPWS, Trip Cock)• Incident response effectiveness• Cross organization response• Error tolerant engineering designs
Incident prevented (emergency SPAD)Incident prevented (emergency SPAD)
Risk and SPADs
Frequency
Consequence
SPAD leading to CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
SPAD leading to CollisionTrain to trainTrain to vehicleTrain to workerTrain to personSPAD leading to DerailmentMainlineSPAD leading to DerailmentMainline
SPAD leading to siding derailmentSPAD leading to siding derailment
SPAD
Slips, Trips, FallsSlips, Trips, Falls
Managing SPADs, Managing Risk | June, 2016
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Back to the Fundamental Question
• So why do we spend so much time and resources trying to manage SPADs?• Not so simple answer: it’s about managing risk at an organisational level.
Managing SPADs, Managing Risk | June, 2016
What Can SPADs tell us about risk…
• SPADs provide us with an insight into the overall effectiveness of our Safety Management System (SMS)• We need to take the opportunity to learn and understand what were the ‘holes in the cheese’ that led to SPADs
Managing SPADs, Managing Risk | June, 2016
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RISKSRISKS
No IncidentNo Incident
CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
DerailmentMainlineSidingDerailmentMainlineSiding
Controls / MitigationsControls / MitigationsSPADSPADControls / MitigationsControls / Mitigations
Cat A (Train / operating interface)Driver errorDriver distractionIncorrect authorisationRail adhesionBraking failure
Cat A (Train / operating interface)Driver errorDriver distractionIncorrect authorisationRail adhesionBraking failure
Cat B(Network integrity)Preceeding aspect at proceed
Signal returned to danger by signaller / train controllerRunaway train
Cat B(Network integrity)Preceeding aspect at proceed
Signal returned to danger by signaller / train controllerRunaway train
Incident prevented (emergency SPAD)Incident prevented (emergency SPAD)• Staff management (training, recruitment)• Infrastructure maintenance• Rollingstock maintenance• Audit / monitoring• Advance protection systems
• Train protection systems (e.g. TPWS, Trip Cock)• Incident response effectiveness• Cross organization response• Error tolerant engineering designs
SPADs and the Organisation System
• A single SPAD will not necessarily reveal systemic factors• Reviewing multiple SPADs together, may reveal hidden trends or issues
Managing SPADs, Managing Risk | June, 2016
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OHS Risk
ProfileOHS Risk
Profile
Catastrophic Risk ProfileCatastrophic Risk Profile
Organisational Risk
Frequency
Consequence
SPAD leading to CollisionTrain to trainTrain to vehicleTrain to workerTrain to person
SPAD leading to CollisionTrain to trainTrain to vehicleTrain to workerTrain to personSPAD leading to DerailmentMainlineSPAD leading to DerailmentMainline
SPAD leading to siding derailmentSPAD leading to siding derailment
Slips, Trips, FallsSlips, Trips, Falls
Managing SPADs, Managing Risk | June, 2016
Understanding the Organisational System
• Hypothetical scenario #1: • A series of SPAD events have occurred in a new area of track• It was revealed that in each of these events, the signal arrangement plan was sub-optimal, and the signals were poorly sighted• This can then lead to the conclusion that the signal design process may have been flawed• When we look at the signal design process, there was a lack of consultation and review• RESULT: address the signal design process, and ensure that there is appropriate consultation with stakeholders in future designs.
Managing SPADs, Managing Risk | June, 2016
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Understanding the Organisational System
• Hypothetical scenario #2: • There has been a spike in the number of SPADs involving experienced drivers.
• If it was a single SPAD, one would consider it as a ‘once off’• In reviewing these combined cases, and discussing broadly with experienced drivers, it is suggested that several minor modifications to the refresher training program over time decreased focus on train handling and SPADs.• RESULT: the refresher program was reviewed, and increased focus on train handling and SPADs was re-introduced. Controls on training modification enhanced.
Managing SPADs, Managing Risk | June, 2016
Understanding the Organisational System
• Did we go far enough? Did we challenge our system hard enough?• What if there was a lack of consultation on
• Location of signal maintenance access?• Emergency egress / access?• …
• What about other refresher programs? Could something similar have occurred in• Rollingstock maintenance?• Train control?• …
Managing SPADs, Managing Risk | June, 2016
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OrganisationalFactors
An organisation is a system of systems
Managing SPADs, Managing Risk | June, 2016
Summary
• Organisations devote considerable resources to managing SPADs.• Industry, at large, is united in working together to share and learn to manage SPADs.• SPAD management addresses several ‘layers’ of risk
• Immediate operational level• It looks at a safety management system level • It looks at a meta-level, at our overall management systems
Managing SPADs, Managing Risk | June, 2016
