1. Managing the Organizational Interface Three case studies. IRSC 9-13 October 2005 Managing the Organizational Interface Three case studies. IRSC 9-13 October 2005 Ian Naish Director, Rail / Pipeline Investigations Branch Transportation Safety Board of Canada

2. Railway Industry in Canada 47,000 km of track47,000 km of track 60 railway companies60 railway companies 1400 reported occurrences per year1400 reported occurrences per year

3. Managing Inter-organizational Interfaces Managing Inter-organizational Interfaces Issues:Issues: –risk management in a changing environment –areas where safety defences have failed. –involvement of all staff in management of safety.

4. LIMEHOUSE, ON MCBRIDE, BC Managing the Inter- organizational Interface NOBEL, ON

5. Nobel, Ontario, 2003 Broken rail derailment in First Nations landBroken rail derailment in First Nations land No command centre set up - communications problemsNo command centre set up - communications problems Responder training, but not experienceResponder training, but not experience

6. Limehouse, ON, 2000 No site safety briefingNo site safety briefing Contractors setting up at crossingContractors setting up at crossing Truck blocking signalsTruck blocking signals No flagpersonNo flagperson Three persons killedThree persons killed No site safety briefingNo site safety briefing Contractors setting up at crossingContractors setting up at crossing Truck blocking signalsTruck blocking signals No flagpersonNo flagperson Three persons killedThree persons killed

7. McBride, B.C. Bridge collapse and fireBridge collapse and fire Changes in roles and responsibilitiesChanges in roles and responsibilities No records of maintenance work doneNo records of maintenance work done No regulatory requirement to audit proceduresNo regulatory requirement to audit procedures

8. Conclusions Work sites are complexWork sites are complex They have to be managed effectivelyThey have to be managed effectively Assign rolesAssign roles Communicate clearly, early and oftenCommunicate clearly, early and often Good records must be keptGood records must be kept

9. Some suggestions Plan in advancePlan in advance Meet early and oftenMeet early and often Train and re-trainTrain and re-train Due diligence when record keepingDue diligence when record keeping