October 2008 International Rail Safety Conference 2008 Denver, Colorado, USA

October 2008 Safety Performance & Data Analysis - what do companies use for leading indicators?

October 2008 Alan Ross - A&K Ross Associates Pty Ltd Kangaroo Ground, Victoria, Australia

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 Example 2 - track worker(s) killed by trains - Singleton New South Wales

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

October 2008 Thank you! The occasion of the 70th anniversary of the World speed record for steam - 126mph, York UK, July 2008