RAILWAY SAFETY ACT REVIEW. Safety Demands Attention to Human Factors. Third Submission of Canadian Pacific Railway Company July 5, 2007

Transcription

1 RAILWAY SAFETY ACT REVIEW Safety Demands Attention to Human Factors Third Submission of Canadian Pacific Railway Company July 5, 2007 I. Introduction Accidents are inevitable this is true in society at large and it is true in the railway industry. Transportation of freight by rail nonetheless remains the safest mode of freight transportation in North America. Of those accidents that do occur in the railway industry, some result from unavoidable or unforeseeable situations such as an avalanche or a mudslide and are simply out of rail companies hands. Many more still result from track or equipment failure. The leading cause of accidents in the railway industry, however, is human factors. These kinds of accidents are rooted in a plethora of causes, including fatigue, inattention, absent or vague communication, poor judgment, deliberate rule violations, technical or operational errors, actions based on assumptions, complacency, lack of teamwork and various other human behaviours, actions or inactions. Consequently, over the last number of years, CP has chosen to focus on understanding the human factor in developing its approach to safety. How and why people make mistakes, as well as possible systemic changes that can be made to avoid future errors assist CP to determine the vulnerable aspects of existing processes and to build better layers of defences. Moreover, CP believes that by attending to and managing human factors involved in train accidents and personal injuries, it can significantly improve the rates of such incidents.

2 - 2 - So far, the results have been very positive. As described in CP s opening submission, dated April 9, 2007, CP has achieved the lowest train accident rate in the North American railway industry in 6 out of the last eight years, including most recently again in A significant contributor to this achievement has been CP s consistently lowest rate of human factor caused train accidents. Consideration of and attention to human factors in relation to rail safety also requires some focus on technology. There is no limit to the amount that the railway industry could spend on new and emerging technologies. Even unlimited spending, however, does not assure improved safety. CP believes that a key consideration in evaluating where and how to invest in technology is the interface of the technology with CP employees. An important goal from a safety perspective when evaluating new technologies is to maximize the effectiveness of the defenses built into CP s systems and to assist in minimizing the impact of human error. This submission will focus on CP s efforts to manage safety from a human factor perspective. II. Background on Human Factor Caused Accidents The Federal Railroad Administration (FRA) keeps extensive data on the causes of accidents in the railway industry. While other causes of accidents have improved significantly over the last two decades, human factor causes have shown little change as illustrated by the FRA graph that follows:

3 - 3 - Background - HF Accidents Human Factors-Caused Accidents Per Million Train-Miles Accident Rate Trend Trend Nearly 50% reduction from No change from 1985 present While the decrease between 1980 and 1985 is significant (t(4) =-.910, p <.05), there is insufficient evidence to suggest the rate decreased between 1985 and 2005 (t(19) = -.115, p >.05) The FRA has concluded from its analysis of human factor caused accidents that this area needs to be its primary focus. Through this focus, the FRA has stated that it believes a 50% reduction in train accidents is possible within the next 5 years. During this same period, FRA estimates that approximately 80,000 new employees will join the railway industry and that therein lies an opportunity to drive improvements in human factor caused train accidents. For its part, and as mentioned above, CP has consistently achieved the lowest frequency of human factor caused train accidents in the industry during recent years through its focus in this area. More specifically, CP has achieved the lowest rate of human factor caused train accidents among North American class 1 freight railways in each of the last 4 complete years.

4 Human Factor Caused FRA Reportable Train Accidents Year U.S. Class 1 Average CP Rate of Human Factor Causes Lowest Other Class * In 4 out of the 5 years shown, the lowest other Class 1 railway was Norfolk Southern. ** All numbers are the rate of FRA reportable train accidents with human factor causes per million train miles. III. Railway Culture and Human Error Fallibility is intrinsic to the human condition and CP understands that it cannot change such a fundamental aspect of human nature. However, CP does believe that it can reduce the potential for human error, and thus for accidents, by changing the system within which its employees work. Traditionally, railway culture has been built on rules and discipline. Rules are created. People are trained to follow the rules. When rules are broken, punishment is meted out to ensure that the rule breaker will not make the same mistake again and to convey the message that rule violations will not be tolerated. CP has considerable experience with this approach, however, not unlike the FRA has recently concluded, CP came to the realization that a culture such as the one just described has done little to improve the accident and injury statistics. For the last decade, CP has put significant effort into shifting its culture to one that places a primary focus on human factors and that builds these factors into corporate safety processes. Changes introduced to date include improved instructional material and train accident cause-finding tools; human factor investigation protocols and corrective action guidelines; peer-based job observations and on-the-job coaching and mentoring; and fatigue initiatives.

5 - 5 - Together, the introduction of these tools evidence a shift from a blaming culture that places all responsibility for an incident on an individual employee or group of employees to a system-based culture that concentrates on how corporate systems themselves can be reinforced to prevent future accidents and injuries. This is not to suggest that there is no longer a place for discipline, but rather that using a systems approach allows CP to look beyond its employees and to better examine the process weaknesses that may have culminated in an incident. Put simply, a systems approach allows CP to identify and change elements of the processes that create the conditions that allow errors to become accidents. Given the dynamic nature of the railway operating environment, a systems approach makes sense. Situations can change quickly and there must be some flexibility to recognize changes, create new work plans, and communicate effectively. CP has built its approach using lessons learned from James Reason, a British academic who specializes in system error. Mr. Reason has met with senior management at CP on a couple of occasions in recent years to reinforce the message that it is easier to change practices than it to change values and beliefs. Eventually, however, changing practices will lead to culture change. Reason also provides what he refers to as a taxonomy of unsafe acts. Essentially, unsafe acts leading to accidents and incidents can be broken down into intended actions and unintended actions. Intended actions include both mistakes and violations, while unintended actions arise from slips or lapses (ie. failures of attention or memory). In each case, organizational issues rather than individual behaviour may be at the root of unsafe acts. Putting the focus on blaming individuals leads to a failure to discover those latent conditions in an organization that contribute to or result in accidents. Shifting the focus on to the operational systems in a workplace provides a better opportunity to identify the factors that contribute to accidents and incidents and does not need to compromise the ability to resort to discipline for intentional or otherwise culpable acts.

6 - 6 - Using the Reason lessons, as well as the pre-existing impetus for change, CP has developed a number of initiatives over the last decade to better address human factors in relation to railway safety, each of which is described below. 1. Fatigue Management One of the human factors that can compromise safety is fatigue. It is also a topic that has received considerable attention in this process to date, and one for which CP will therefore provide some history. a. The Canalert Study A ground-breaking study of fatigue was carried out in 1995, known as Canalert, and represented a joint effort between CP, VIA, CN, and the Brotherhood of Locomotive Engineers. This was the first major scientific effort to study crew fatigue in North America and it precipitated a number of changes across the railway industry. The Canalert study demonstrated through sophisticated monitoring devices that predictable work patterns improved both the quantity and quality of sleep. The work pattern established by the study split the day into three segments day, afternoon and evening. Accordingly, three separate pools were set up, one for each segment of the day. Each pool has a different window of time during which employees can be called to work. Some overlap occurs between these time windows to ensure continuous crew availability. The pool structure resulting from the Canalert study was implemented as a pilot at CP with the train crews that work between Calgary and Field. Subsequent attempts to expand the time pools pilot to other locations were rejected by running trades employees at those locations, due in part to their concern that they might result in reduced earnings. The pool structure remains in place and is popular with all three groups in Calgary, because it improves their quality of life. While quality of life and fatigue management initiatives may have some overlap, it is important to understand that they are not necessarily the same issue. CP learned many important lessons from the Canalert study

7 - 7 - and continues to seek improved methods of fatigue management. Given the results of more recent studies and the general reluctance of employees to adopt the Canalert time pool structure, the company has gone on to explore alternative approaches to fatigue management. b. Current CP Fatigue Management Initiative While the pace of change slowed between 2002 and 2005 due to a number of other areas competing for attention, such as a significant overhaul to the Work Rest Rules, CP has since been actively exploring a fatigue risk management approach based on the most current research and modeling in this area. This framework has been developed by Dr. Drew Dawson, the Director of the Centre for Sleep Research at the University of South Australia, based on his work with the Australian railway authorities. Dr. Dawson has also been working with Union Pacific Railroad (UP), since 2004, to adapt this approach to the U.S. railroad industry. An Australian company, InterDynamics, has developed two software programs based on Dr. Dawson s models: the first program, FAID, derives a risk assessment of an individual s work pattern based on looking back at his work schedule. The second program, the Board Game, allows the use of what if scenarios looking at actual train/assignment histories and the impact of proposed pool/assignment adjustments to reduce the risk of fatigue. The fatigue risk management framework uses a hierarchy of 5 inter-related layers of mitigation processes: Level 1 employs the FAID software to assess fatigue risk based on employee schedules, and the Board Game software to test proposed pool/assignment adjustments to improve schedules, along with other possible mitigating measures. Level 2 requires a method for individuals with non-work induced fatigue, to declare themselves too tired to work without abusing the system.

8 - 8 - Level 3 requires methods to identify individuals who may have systemic issues such as sleep disorders that require treatment. Level 4 requires a way of finding fatigue related errors before they result in accidents. Level 5 requires thorough investigative techniques to identify those accidents where fatigue was a contributing factor in order to implement further corrective actions. In November 2005, UP held a conference with leading fatigue experts to critique the fatigue risk management framework they were developing. The panel found the approach to be a practical, innovative, evidence-based one that sets the standard for fatigue risk management systems in the railroad industry. Dr. Dawson has given presentations to CP on his approach, and CP has since been working with UP and InterDynamics to test and adapt the software tools and their approach to CP s operations. Earlier this year, CP initiated a pilot on its U.S. operations with a view to expanding the use of these tools to the Canadian operations as experience with this approach grows. c. Challenges in Fatigue Management As has been evident through the RSA Review process to date, the issue of fatigue management is complex. Even with CP striving to provide a work schedule for employees that minimizes the risk of fatigue, CP cannot control how effectively the employees utilize their time away from work to address this issue. CP provides education to employees on this, but it is the employees themselves who have more control over critical aspects such as quantity/quality of sleep, diet, health and other activities. And, as diligent as the

9 - 9 - employees themselves may be, events can occur, such as illness or family crisis that impact their ability to be rested. Running trades employees rely on line-up information to assist them in determining when they may be going to work and planning their sleep accordingly. CP has implemented several measures over the last few years to improve accuracy and communication of lineups. However, there is an aspect to this that is difficult for CP to control. To determine when they may be going to work, employees look at both the train line-up and the crew line-up. Given all the different operational issues that can come into play such as weather and equipment failure, it can be very difficult to maintain the accuracy of the train lineup. The additional dimension added to crew line-up accuracy is employee availability. CP has limited control over events such as employees missing calls, booking rest and booking sick on short notice - but those occurrences can have a significant impact on changing the time when other employees will have to go to work without much forewarning. There is also a complex interaction in fatigue management between the collective agreement and the regulatory environment. There are provisions in the collective agreement that govern the operation of pools and spare boards on the basis of first in / first out, subject to regulatory restrictions. The collective agreement also gives employees the right to book rest for different periods of time depending on the circumstances when they go off duty. In addition to using this right to manage the risk of fatigue, employees also book rest to line up time off work with other activities in their lives. There can also be a competing interest with some employees not booking rest, or doing so in a particular manner, to maximize their earnings. It is inevitable that many of these issues make their way into collective bargaining and the balance between pay, time off and fatigue management is not always easy to strike. The union leadership is also faced with competing interests. They understand the importance of fatigue management, and supporting such initiatives, but they also have pressure from some members to prioritize opportunity for earnings, provide scheduled

10 time off work, and so on. These pressures present special challenges for unions and their ability to fully support fatigue management initiatives. 2. Communication Generally, a significant number of train accidents are caused by miscommunication and misunderstandings between employees. For example, one person may assume that another knows a particular task sequence and proceed without confirming the veracity of the assumption. Communications about the location of a critical control point may be misunderstood or simply not communicated. A necessary step in the process may be skipped over completely, while the choice to do so is not communicated between employees. Any of these kinds of situations can result in accidents and injuries on the railway. In an effort to lessen the potential for communication error, CP has implemented a number of communication programs, many of which borrow from the Crew Resource Management (CRM) training program widely used in the airline industry. The model is based on the reality that most accidents or incidents in the transportation arena are due to four clear factors: poor group decision making, inadequate leadership, ineffective communication, and poor task or resource management. To date, CP has applied CRM principles mainly to running trades employees, a group that includes locomotive engineers, conductors, and yard foremen/helpers. CP s objective in applying CRM principles to its running trades employees is to enhance situational awareness, to strengthen effective communication skills, and to promote teamwork. Ultimately, the hope is to further expand CRM to develop training and scenarios for Maintenance of Way and Mechanical Services employees as well. One of the clearest examples of how these objectives are achieved is through job briefings. Each employee involved in the front line operation of the railway, whether working in mechanical, engineering or on train operations, participates in a job briefing at

11 the start of their shift about the work to be performed. As work conditions and tasks change, employees are expected to conduct new job briefings to help ensure that all crew members are working with the same understanding and can perform the revised work tasks safely. More recently, CP has implemented a program for new running trades employees in the field. This group is provided with different coloured safety vests for the first year of their employment, which allows new employees to be easily identified. This program works in conjunction with the other communication protocols discussed above because the vests serve as a reminder to other crew members to pay extra attention to conducting thorough job briefings. It also hopefully reminds more experienced crew members of one of the five SOFA principles which is to mentor less experienced employees. a. SOFA and ORCA SOFA, Switching Operations Fatality Analysis Audits, was developed through a joint effort of the FRA and labour and management representatives and looked specifically at fatalities arising from switching operations. The project identified five common themes among fatalities during switching operations, which led to the establishment of five lifesavers job briefings, pre-departure checklists, proper communication, verification of tasks, and mentoring new employees. CP used the SOFA framework to develop a peer-driven observation process and this employee ownership of the process has been key to its function and success at CP. For further clarity, because SOFA focuses on switching operations, it is limited to yards. ORCA, On-Board Communication Audits, is a complementary program developed for train operations over the road (i.e. between terminals). One of the primary features of SOFA is that it requires employees to engage in conscious communication through verbal confirmations of switching actions and proper identification during radio communication. This requirement ensures a crew member on

12 the ground and the crew member in the cab of a locomotive communicate switch positions while at a switch, thus lessening the opportunity for leaving a switch in the wrong position. As well, the program allows health and safety committees to identify and address high-risk behaviours and to develop corrective action plans. Since the inception of SOFA, switching related incidents at CP have been on a consistent decline. The underlying theory of ORCA and SOFA is that effective communication will have a direct impact on lowering train accident and personal injury rates by increasing situational awareness, as well as understanding of and compliance to regulatory standards and corporate policies and procedures. It is also significant to note that neither ORCA nor SOFA is a disciplinary regime. Rather, employees are evaluated by their peers on various aspects of their communication and work processes, following which employees are debriefed on both safe and atrisk behaviours. Generally, peer auditors are members of local Health and Safety Committees and thus have a vested interest in ensuring that job duties are being performed safely. This audit process has allowed CP to detect behavioural trends that may increase the possibility of a train accident or personal injury. For example, to date ORCA has identified a number of trends that have allowed Health and Safety Committees to design specific action plans for improvement. These trends have included such significant factors as deficient communication between employees about permissible speed and other restrictions, signal indications, and clearances. In addition, however, an equal focus on positive behaviours allows employees and managers to celebrate what is being done well. Ideally, this approach increases employee motivation to perform work more safely. In short, both ORCA and SOFA illustrate the value of allowing railway organizations to design programs that address and improve particular safety concerns within their industry. Moreover, they demonstrate the ability to increase safety without regulation.

13 Instructional Materials and Training A frequent source of error in the railway industry leading to accidents and injuries is a lack of clear understanding of a task, process, or rule. Such misunderstandings ultimately lead to misapplications of processes and rules. Further, these misunderstandings can occur at both the field employee level and the managerial level. As a result, CP incorporates educational opportunities for all levels of employees to ensure that everyone working in the organization has an optimal understanding of workplace rules and procedures. Instructional materials have been revamped to be more accessible. Written to target a grade 6 education level, the updated materials use action-oriented verbs rather than passive ones. Bullet points and information chunking replace traditional paragraphs to make the information easier to absorb. CP s Red Book for track maintenance is an example of revamped instructional materials that have improved clarity of instruction, which CP believes has resulted in direct improvements to track maintenance and safety. Classroom training is further supplemented by on-the-job coaching. New employees are paired with trained peer coaches who can help ensure that all new hires are better prepared for their daily job duties. In addition, managers and supervisors are also subjected to a mandatory training program where they receive hands-on training in key procedures. Such a program provides that supervisory employees clearly understand the rules and procedures to properly perform job tasks, the theory being that if employees at all levels understand how to perform tasks safely, there is a greater opportunity to lower accident and injury rates. Ongoing training at all levels of the organization accords with CP s guiding safety principles, which view training and involvement from all employees as essential for safety.

14 Workplace cues provide key information to employees and serve as a reminder of critical control points, events, or procedures. Initiatives have ranged from track maps and timetables to way-side signs that denote critical elements like grade changes to computer system enhancements. 4. Confidential Close-Call Reporting The FRA-led close-call program uses an independent 3 rd party the Bureau of Transportation Statistics (BTS). In this way, the program ensures confidentiality and protects the individual who makes the report of a close call incident from discipline. BTS can protect data even from Freedom of Information requests. The FRA is funding 4 pilot sites for up to 5 years. UP was the first pilot site, with the pilot commencing at their North Platte terminal in February In September 2006, CP was also accepted by the FRA to run a confidential close call reporting pilot. A Memorandum of Understanding was developed by labour and management with the assistance of the FRA. It was signed in June 2007 and it is expected that CP s pilot will commence later this year at its Portage, Wisconsin terminal. The intended purpose is to identify and assess safety risks in railroad operations that were previously unreported. Again, this initiative is not disciplinary in nature. Rather, it is designed to encourage employees who make certain types of errors to report them to CP management with a view to better understanding what actions led to the error and how to improve future performance. Quite simply, this initiative requires CP to move away from the blame, shame, and punish approach to safety and towards a more collaborative model in which employees can genuinely learn from their mistakes. Moreover, it is hoped that the Close Call Reporting initiative will allow CP management to better understand behavioural trends that may lead to reportable errors.

15 Investigation of Safety Related Occurrences Protocol (ISROP) The investigation of various accidents in the late 1990 s led to the development of a more comprehensive, human factor oriented accident investigation methodology. In 2002, CP introduced ISROP, a protocol that uses a variety of tools to determine what went wrong and what made a given action seem reasonable at the time. After some revisions, the protocol was implemented system-wide in Benefits of the protocol include standardization of CP s investigative systems, improvements in the quality of data and its analysis, an increased understanding of factors contributing to accidents, and the development of more effective corrective actions to help prevent future incidents. Four primary components characterize ISROP: the initial response, data collection, data analysis, and corrective actions. Specific procedures are in place that govern investigation team formation and notifications, as well as site preservation, to ensure that the initial response to an incident is quick and effective. Data collection and evidence preservation are key to a thorough and complete data analysis, the latter of which allows CP to identify safety concerns, assess risk, and prioritize concerns. Finally, the ability to identify what kind of error was made assists in developing and implementing appropriate corrective actions to minimize the risk of the same error occurring in the future. ISROP has improved the quality of CP s investigations and corrective action processes, but it took some time to gain acceptance. Strong resistance emerged from unions who feared disciplinary ramifications for their members, as well as from front-line managers already experienced in investigations. Over time, however, the momentum behind ISROP has grown, allowing its benefits to outweigh the concerns of those resistant to change. The protocol is now mandatory for accidents above a certain dollar threshold and for incidents involving serious personal injuries.

16 Technology The application of technology complements CP s human factor focused programs and forms an important component in CP s drive for increased safety in its operations. Through careful evaluation and testing of new technologies, CP has introduced a number of innovations in recent years. CP believes that the potential safety benefit of any new technology is maximized when the technology provides layers of defences in CP s systems and when they become part of a process that accounts for human factors. One of the better examples of such a technology innovation is the use of wheel impact load detectors (WILDs). These detector sites sense the impact from each wheel on the train as it rolls along the railhead and are strategically placed throughout CP s network. WILDs provide both reactive and proactive capability. The reactive capability is provided in the sense that a train can be stopped and have a car set off for repair if a wheel on that car is registering too high of an impact on the rail, and thereby running the risk of breaking a rail. The proactive capability is provided by the data that is collected on all the wheels that pass over the site. Railcars are often interchanged between railways so WILD data collected by each railway is also shared, meaning that an even more complete data set is available for predictive maintenance analysis as railcars move from one railway s network to another. The data is centrally stored and the readings from each car passing over different detector sites on different days provide the opportunity to do trend analysis and plan proactive maintenance on equipment. Ultimately, WILDs form part of a railroad industry project that uses data from wayside detectors to predict condition-required maintenance. Data from all wayside detectors are compiled in an industry database called InteRRIS and shared with both railroads and private car owners. While some technologies interface directly with CP employees (such as hot box detectors that use a talker system to provide immediate results to a train crew), the importance of WILDs from a human factors perspective is less direct. They provide an important

17 predictive capability that reduces the risk of a wheel defect being missed by human eyes or ears during train inspections. In other words, the WILD data provides increased opportunity to remove railcars from service before wheel problems become acute. Prior to WILDs, CP relied solely on employees performing visual inspections. These inspections are often performed at night with flashlights or in the midst of adverse weather conditions. Technology such as WILDs provides an additional layer of defence that can be particularly valuable in such circumstances. Another example of technology providing a further layer of defence is the automated joint-bar inspection system. In partnership with the FRA, CPR piloted and later implemented an automated joint-bar inspection system that uses high resolution line-scan cameras and computer-intelligent vision systems to see small cracks in joint bars that might not be picked up in visual inspections. As with all aspects of its operations, CP continues to plan for the future. The company has created a 5-year plan for advanced technology implementation, which will see a number of new technologies rolled out across the system. These include, for example, acoustic bearing detectors, new devices to monitor wheels, and truck hunting detectors, which are designed to measure lateral instability of trucks that can cause wheel climb derailments. More opportunities potentially exist to introduce significant technological innovations that could provide yet further layers of defences against human error. For instance, the FRA is actively funding and promoting the testing of electronically controlled pneumatic ( ECP ) brakes. These brakes use an electric signal, rather than air moving through the train brake pipe, to provide brake commands to train brakes. The two main benefits of ECP brakes are shorter stopping distance and improved train handling. To date, this particular technology has been well received in the U.S. CP hopes to test ECP-equipped trains in the coming year.

18 The introduction of technology has contributed greatly to the improved train accident record in the North American rail industry over the last four decades, but the human factor cannot be divorced from technological advances. Humans create the technology; write the software and failure prediction algorithms; install, test, and operate the equipment; monitor technological deficiencies and repair defective components; and create the procedures. Ultimately, then, the man-machine interface cannot be ignored. Instead, each must be appreciated for its active role in creating a safer railway system. IV. Conclusion For the last decade, CP s safety culture has evolved from one of individual blame to a systems approach model. The systems approach centers on a determination of why accidents and injuries occur. Most often, the answer involves human error, a finding that has led CP to implement some innovative programs designed to identify and address the elements that lead to human error. Since the inception of these programs, CP has enjoyed a steadily declining accident and injury rate, which is a true testament to their effectiveness. Technology goes hand-in-hand with CP s human factor initiatives and is used to complement and assist employee skills in order to achieve better overall safety. Cuttingedge equipment sees what the human eye cannot and warns of potential dangers. Together, CP s people oriented safety initiatives have allowed it to move ahead as the industry leader in creating a safer railway. Perhaps most significantly, these initiatives clearly demonstrate CP s move towards a just culture rather than a disciplinary one. Such a culture focuses on whether employees understand how and why their actions result in accidents, injuries, or incidents. Further, CP believes that a just safety culture and framework is the best way to improve railway safety. Those initiatives implemented to date herald clear support for this belief and pave the way forward. Continued education, working to understand causes of errors, building corrective actions that address systemic problems, and encouraging employee reporting form the cornerstones of the future path at CP.

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