Railway Safety Regulator

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(No Transcript)
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IRSC 2007GOA, INDIA

• SUB-THEME
• TRENDS AND PRACTICES ON SAFETY REGULATION AND
• ACCIDENT INVESTIGATION
• TITLE
• ACCIDENT INVESTIGATIONS
• PURPOSE DRIVEN RECOMMDENDATIONS
• PRESENTED BY
• HERMAN BRUWER
• RAILWAY SAFETY REGULATOR
• SOUTH AFRICA

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OVERVIEW OF PRESENTATION

• AN INTRODUCTION TO THE RSR
• WHAT WE HAVE ACHIEVED
• CHALLENGES FACING THE RSR
• THE RAILWAY INDUSTRY
• PURPOSE DRIVEN RECOMMENDATIONS
• DESCRIPTIVE VERSUS NON-DESCRIPTIVE
  RECOMMENDATIONS
• SELECTION OF RECOMMENDATIONS
• FOCUSSING OF RECOMMENDATIONS
• FORMULATING OF RECOMMENDATIONS
• CONCLUSION

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THE RSRAN INTRODUCTION

• The RSR is a relative newly established
  organization created by the National Railway
  Safety Regulator Act, 2002 and became operational
  in June 2005. We have a staff compliment of 60
  employees.
• The RSR is an independent juristic body or agency
  of the NDoT and report through its Board directly
  to the Minister of Transport.

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THE RSRAN INTRODUCTION (cont.)
The primary objects of the RSR are to - Oversee
safety in the railway transport
industry - Develop any regulations that are
required in terms of the act - Monitor and
ensure compliance with the act - Give effect to
the objects of the act and - Promote the use of
rail as a mode of transportation through
improved safety performance in the industry.
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THE RSRWHAT WE HAVE ACHIEVED

• MONITORING COMPLIANCE
• 224 SMS Audits
• 20 Targeted Safety Inspections
• 9 Independent Boards of Inquiry
• State of Safety Report (2005/06 2006/07)
• SAFETY REGULATION
• Draft MOUs with other Organs of State
• Draft Construction Regulations
• Draft Technical Standards
• Draft Human Factors Framework

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THE RSRMAJOR CHALLENGES

• Investigation of alternative funding strategies
  to ensure appropriate funding in support of
  strategic initiatives.
• Prioritizing of the emerging issues for
  development of Standards and Regulations.
• Development of a National Information and
  Monitoring System.
• Amendment Bill.
• Promote the use of rail as a mode of
  transportation through improved safety
  performance in the industry (a general
  turn-around strategy is required).

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THE RAILWAY INDUSTRYBACKGROUND

• 253 Registered Railway Operators representative
  of the following Railway Sectors
• Class 1 railways,
• Mining,
• Manufacturing
• Ports
• Agriculture
• Petrochemical
• Sidings terminals,
• Tourism heritage
• The operators are geographically spread
  throughout South Africa at 550 operational sites.

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THE RAILWAY INDUSTRYBACKGROUND

• For the purposes of background and as it has a
  direct bearing on occurrence investigations it
  should be mentioned that the South African
  national railway infrastructure has been severely
  neglected through years of under investment in
  the areas of commuter rail services and general
  rail freight. It goes without saying that there
  is a direct correlation between safety
  performance and investment. The underinvestment
  have resulted in the following unwanted situation
  
• Deterioration of safety performance in the
  reportable railway occurrence categories,
• Loss of rail market share in both the passenger
  and general freight markets,
• Ageing rolling stock and technology, and
• Unacceptable high costs of risk for operators
  with a subsequent high cost of transport to the
  economy.

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THE ROLE OF THE RSR IN OCCURRENCE INVESTIGATIONS

• The Railway Safety Regulator is confronted with a
  major challenge
• in order to bring about the desired change as it
  relates to driving
• down the cost of risk and to ensure appropriate
  levels of investment
• in infrastructure and rolling stock in order to
  promote the use of rail
• as a mode of transportation through improved
  safety performance
• in the industry.
• One of the tools used to bring about the change
  is Occurrence
• Investigations and Purpose driven
  recommendations.

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ACCCIDENT INVESTIGATIONPRINCIPLES

• I wish to quote from the Australian Code of
  Practice (Rail Safety
• Investigation) the following guiding principles
  for railway accident
• investigation
• A systems approach to investigation,
• The adoption of a just culture philosophy,
• A commitment to learning from failure
• The adoption of a structured, systematic and
  iterative process for gathering and analyzing
  data,
• Development of non-prescriptive recommendations,
  and
• Management commitment to fair and independent
  investigation.

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PRESCRIPTIVE VERSUS NON-PRESCRIPTIVE
RECOMMENDATIONS

• Naturally any Regulator will be very cautious in
  making prescriptive recommendations. However,
  from time-to-time the hand of the Regulator will
  be forced to make prescriptive recommendations
  dependent on the presence of an immediate threat
  and the potential severity thereof.
• As a general statement it can be said that the
  prescriptive recommendations will specify the
  desired end state, but will refrain from the
  nuts-and-bolts or the How in achieving the
  end state.
• Examples of non-prescriptive recommendations may
  be
• Improved radio communication systems
• Improved signalling systems

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PRESCRIPTIVE VERSUS NON-PRESCRIPTIVE
RECOMMENDATIONS (cont.)

• Examples of prescriptive recommendations may be
• With immediate effect to change the trains
  working rule, or
• With immediate effect to institute a permanent
  speed restriction

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PURPOSE DRIVEN RECOMMENDATIONS

• Purpose driven recommendations are those
  recommendations which takes due cognizance of the
  limitations of the operator (whether self imposed
  or imposed by external factors), but which
  recommendations are continuously pushing the
  envelope to ensure an improved state of safety
  and taking cognizance of national imperatives,
• Purpose driven recommendations are aimed at
  improving the overall safety management system or
  state of safety.
• Purpose driven recommendations allows for
  thinking out of the box and allows for paradigm
  shifts to be made, especially so when an operator
  has never been challenged on his way of doing
  things.
• Purpose driven recommendations could be a mixture
  of prescriptive and non-prescriptive
  recommendations.

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SELECTING PURPOSE DRIVEN RECOMMENDATIONS

• As a general principle the test in the selection
  of recommendations lies within the remit or the
  terms of reference (TOR) of the formal
  investigation. The following critical question
  that needs to be answered is Do the
  recommendations meet the TOR?
• Thus, it illustrates the importance of ensuring
  that the remit is set correctly or that the remit
  is adjusted, if circumstances warrant it, during
  the investigation process to ensure that the
  investigation team always stays within their
  mandate.

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SELECTING PURPOSE DRIVEN RECOMMENDATIONS

• In determining whether the recommendations meet
  the TOR the investigator has to ask the
  following questions
• Does it address the identified immediate and
  underlying causes audit trail to evidence in
  hand
• Is it aimed at prevention and mitigation?
• Does it reduce the likelihood of recurrence?
• Does it reduce the consequences of future similar
  accidents?
• Does it deliver demonstrable safety benefits?

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SELECTING PURPOSE DRIVEN RECOMMENDATIONS

• Once it has been established that the
  recommendations meet the
• requirements of the remit the recommendations are
  selected on the
• basis of the integrity of the process followed
  which is
• Analysis of evidence and findings,
• Factors for consideration,
• Written Findings,
• Concerns identified and raised during the
  investigation, and
• The relevancy thereof to the investigation.

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SELECTING PURPOSE DRIVEN RECOMMENDATIONS

• Following the aforementioned process will thus
  ensure that the selection of the recommendations
  are backwards traceable to appropriate
  evidence.
• The final criteria to be addressed are the
  requirement that no recommendation should create
  an apportionment of blame or that it should be
  excluded on commercial grounds.

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HOW ARE RECOMMENDATIONS FOCUSSED?

• Focus the recommendations on the written findings
  and the identified concerns.
• Maintain a SYSTEMS approach/focus to overall
  safety improvement. This implies that the
  recommendation may not have a negative impact on
  other parts of the system which may impact on
  safety.

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FORMULATING THE RECOMMENDATIONS

• Apply the SMARTER principle in the formulation of
  
• recommendations
• Specific (Clear and Unambiguous)
• Measurable
• Attainable
• Results Orientated
• Time bound
• Economically Viable
• Review (Subject to review by inspection)

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CONCLUSION

• Chair, Ladies and Gentlemen,
• I wish to conclude my presentation on purpose
  driven
• recommendations. As a final statement I wish to
  state that the South
• African Railway Safety Regulator embrace, endorse
  and practice
• international best practices in our investigative
  processes.
• However, our recommendations are not only aimed
  at a functional
• safety improvement at operator level, but also
  taking cognizance of the
• national state of safety, national imperatives to
  be achieved and the
• desired end state. To us it is not only the
  principle of learning from
• failure which is applied, but also the principle
  of adapt or die.
• Thank you