Lac Mégantic Report Out...

[mrlupin]

Interesting read. One has to wonder how differently regulated rail transport is compared to aviation. Both operate under SMS. TC is getting its share of the blame on this one...

http://www.cbc.ca/news/canada/montreal/lac-m%C3%A9gantic-tsb-says-no-one-factor-to-blame-1.2739921

[Lakelad]

.

Transport Canada's lax safety practices go beyond rail

Self-reporting rules for marine, rail and aviation contributing to 'weak safety culture'

Thu Aug 21, 2014 - CBC News
By Amber Hildebrandt

The deadly Lac-Mégantic train crash — and this week's safety board report into what happened — raises questions not only about government oversight of the rail industry but of other sectors like air, marine and food as well, engineers and transportation experts say.

On Tuesday, the Transportation Safety Board released its final report on the worst rail disaster in Canada's history. In it, the watchdog agency criticized how the federal government ensures regulated companies follow safety rules.

TSB called on Transport Canada, the "guardian of public safety," to audit railway companies more thoroughly and frequently, saying Montreal, Maine & Atlantic Railway ran "largely unchecked."

Pointedly, TSB chair Wendy Tadros said federal auditors weren't "pulling back the curtains" to see what was actually happening inside a company.

"It's a pretty sweeping set of findings from the Transportation Safety Board," said David Jeanes, founding president of Transport Action Canada, a non-profit group that monitors rail safety. "It isn't just the rail mode. It's really about the whole process of safety regulation."

At the heart of the TSB criticism is a sometimes controversial approach called safety management systems, or SMS for short.

Under SMS, companies create their own safety plans, which are then checked by government officials, and they monitor their own safety performance, with occasional inspections by the regulator.

The rail industry adopted the approach in 2001, while large ships followed suit the year after and airlines started using it in 2005.

Reading binder vs. in-field checks

Critics suggest the move to SMS was driven by government cost-cutting measures, and stressed that it can only be effective if done in conjunction with sufficient checks by regulators on the companies.

In the case of Lac-Mégantic, TSB says Transport Canada looked at MM&A's safety plan on paper, but didn't dig deep enough into whether they were following the rules.

'I think this is a game changer. It'll bring safety management systems to the forefront.'-Jean-Paul Lacoursière

"What [the TSB] said is [Transport Canada was] satisfied to look at the binder and didn't verify that this binder, or the content of that binder, implemented physically in the field.

"And that's a big difference," says Jean-Paul Lacoursière, a chemical engineer at the University of Sherbrooke who specializes in risk assessments.

"The basic problem is self-management doesn't work when the government's not holding up its end of the bargain,"

.

[DEFCON]

Personally speaking, I think the government has to get back in the oversight / enforcement business. I do appreciate any attempt by government to save money, but SMS probably wasn't a good way to go about it. I think a cost effective re-invention is in order, but to keep the newer TC 'lite', and more efficacious, I believe the TC Inspector needs to become a sworn peace officer. With real teeth these people would be able to circulate and take meaningful action against wrong doers. If a few bad egg were granted the privilege of sitting in a prison cell in return for their stunts, I think the ingrained attitude that trains people to look the other way would change quickly.

[J.O.]

That's an interesting take, but it does come with some problems.

Inspectors who are representing the Minister are given broad powers of inspection for regulatory compliance in the Aeronautics Act. An inspector can demand access to any document, facility, person, place or thing relevant to a certificate or certificate-related activity that is defined in their delegation of authority. An inspector can even stop an aircraft from departing if they believe there is an immediate threat to safety (i.e. an ice cube on it's way to the runway without having been de-iced). No warrants needed, no advanced notice required. That is because they are inspecting and only inspecting for compliance. Inspectors cannot lay a charge under the CARS or the Act. If they see a contravention that needs enforcement attention, they issue a detection notice with supporting evidence and send it to Enforcement Branch.

The minute you give someone the powers of enforcement (such as Enforcement Branch), our judicial system kicks in and with that comes the requisite restrictions on the powers of search and seizure that are in law and jurisprudence. Enforcement inspectors cannot do what inspectors do. They either need a warrant or sufficient evidence gathered by an Inspector during a compliance inspection that would support the laying of charges. This isn't unique to aviation, it applies to all aspects of federal laws where the government has established an oversight body such as TC.

[DEFCON]

That's a great answer; thanks JO

[Vsplat]

This is one of those reports that is going to take a number of passes to fully comprehend. I will say that this point that it looks a lot like the rail equivalent of Dryden, only without the national enquiry.

Many here will remember Dryden. The systemic failures that occurred ahead of that event bear an eerie resemblance to what lies in this report. While SMS is the focal point for the findings, I'm not sure the issue truly lies with the concept of SMS per se. I'd cast my gaze toward the attitude of the executive branch of Transport and above. SMS did not have to be about cost cutting. How was that drift allowed to occur?

If you spend enough time in this silly aviation pursuit, it is inevitable that a number of TC inspectors become friends, indeed colleagues. The tone I have drawn from our conversations over the years hasn't so much been about whether or not there are enough delegated powers or laws, but whether or not an Inspector who acts in accordance with their delegation will be understood or supported by their masters. Indeed, this report describes a rail system, but the comments I read could just as easily have come from Civil Aviation.

Inspectors who are unlucky enough to observe something worrisome increasingly face two or more unpalatable choices - lower the bar and allow a questionable operation to proceed by feeding comments into a long, slow moving paper train to nowhere, or take the action they feel they must, and risk their own health and earning potential.

In the wake of Dryden there was, for a time at least, real change and a tangible shift in the level of understanding and engagement as the Regulator actually took an interest in regulating in a meaningful way. Will this report bring similar clarity? For the sake of those who paid such a cruel price, I hope so.

Vs

[conehead]

Jeff and Vsplat; great comments! From the Maintenance end of the operation, I must say though, there is no oversight. As in the report of Rail observations, they only look at paper. They do not come out and look at the real operation. It truly is a case of the fox guarding the henhouse.

[Don Hudson]

Very well said, Vsplat.

For reference, the Dryden Inquiry can be found here.

The TSB Report on the Lac Megantic accident may be found here.

Re, ...but whether or not an Inspector who acts in accordance with their delegation will be understood or supported by their masters.

A timely and crucial question. I wonder how it is going to be answered.

conehead;

Re, ...As in the report of Rail observations, they only look at paper. They do not come out and look at the real operation. It truly is a case of the fox guarding the henhouse.

And Rail said they`d been doing `SMS` longer than aviation.

[conehead]

Re, ...but whether or not an Inspector who acts in accordance with their delegation will be understood or supported by their masters.

A timely and crucial question. I wonder how it is going to be answered.

conehead;

Re, ...As in the report of Rail observations, they only look at paper. They do not come out and look at the real operation. It truly is a case of the fox guarding the henhouse.

And Rail said they`d been doing `SMS` longer than aviation.

A timely and crucial question indeed. I have little confidence in the answer.

[Don Hudson]

conehead, re, "I have little confidence in the answer."

Well, it is exceedingly disappointing after Dryden to be told through the deaths of more Canadians that things haven't ultimately changed. So in the immediate sense I think there is good reason for both skepticism and even cynicism. But I think the question as to what form any response may take is also complex and we need to wait for a response from our government and from Transport. I think the question of support from senior officials for those on the front lines doing the work and seeing the problems is a question to ask. Were people afraid of losing their position or even their job just for doing their job?

Why and how has such a state of affairs occurred? When were the early warning signals that things were not what they should be, who sounded them?

There had to be observers who knew that things were not well in terms of oversight of rail transportation in Canada. Did they speak out, and what was the response.

But it is even more complex; Just looking at the documents and not checking what's actually being done is a serious enough shortcoming. But the key factor behind such auditing work is having sufficient resources who have the experience and knowledge to adequately examine and monitor major transportation operations and smaller operations alike. They need to know when something isn't being done correctly even though the documentation is correct and up to standard.

(ed to add):

From the Report's Executive Summary:

[JL]

The SMS idea/theory is fine. The real issue is TC oversight. SMS plus a robust oversight system that evaluates the outputs as well as the processes would result in improvements.

[Specs]

I think it's more than that. Something like a simple corporate reorg moves people around and roles change. Most of the time there is no real transition plan. Every time it happens one or two of the undocumented steps in the oversight processes that provide the checks and balances get reorg'd out of existence. In due time, the whole corp oversight process is irrevocably eroded and there will be an accident simply because there was nobody there to say you can't do that - it's not safe.

You can gloss over SMS with FDA data and all the risk analyses and SMS audits you want - the bottom line is that there are huge blind spots in the whole process and a tragedy is inevitable.

TC and the Minister are incredibly naive in believing corporations have an interest in a safety culture. The entire enterprise is geared to making a profit. Safety oversight is most often intangible and not quantified. Something needs to be a pretty blatant risk before the corporation will consider the safety impact.

[Vsplat]

Specs, the issue of handover management is a good one to raise here, as it has a well documented role in poor outcomes.

The gap that sometimes develops when a shift change occurs while an active issue is on the go has been a factor in events from aviation, to heavy industry, to power generation and on to health care. As you point out, within regulatory and corporate oversight structures, this gap development has become a chronic, endemic component in the recurring accident cycle.

To your comment about data and SMS - Any data, FDA included, is forensic and, in many cases, a sample. It's like trying to appreciate a masterwork through a pinhole. The gold standard includes open and engaged communication with those who have first hand experience with a risk event.

The rub is at the interface. Who is capable of having that conversation with an operating crew? How far up the ladder does the message go before a manager decides that it is too personally risky for them to provide an accurate account of what they learned? How often is the senior manager hearing the event report also responsible for the policy at fault? Who tracks their response to safety events to ensure troublesome reports don't get squelched? Are the corporate rewards tied to proactive responses to safety threats or instead, for 'getting 'er done'? How often have we heard some variant of 'do it now, complain later'? applied to a safety concern?

We could apply this test to any company, regulatory agency, or sitting government in the land. Why is it so? Many reasons perhaps, but I can't help but notice how the public responds to safety decisions, purportedly taken in their interest.

A great example is the GTAA managing the extreme weather that ultimately forced a standstill. It was like watching a tennis match from hell. The GTAA would defend their actions as putting safety first and the volley back was meteoric. The passengers, press and, in many cases, airlines simply did not want to hear it. In this case, we can argue in hindsight about the many things that could have gone differently, but that itself points up a second aspect - this astounding expectation from humans that agencies run by other humans make perfect decisions - and increasingly, 'risk management' models that rely on such assumptions of perfection. Makes for pretty cost numbers on a page, but is it really effective?

Anyway, all that to say, I agree with you. It is more than that.

Cheers

Vs

[Don Hudson]

The following is a short list of available resources and historical documents associated with TC oversight matters as examined by the OAG, (Office of the Auditor-General of Canada) or reported elsewhere by media. It is necessarily limited and others will find other sources. However, the attempt here is to gather in one place, some of the more salient and relevant documentation associated with this matter.

It is certainly "more than that", as mentioned. In fact it goes to the heart of what has come to be known (since Perrow, in 1985), as the "organizational accident", a sense of which emerges in numerous documents focussed on processes and not just one event. If so, and I think it is so, then regardless of scale, size, role, priorities or economic, social or structural importance, the same principles apply when examining and dealing with an organizational accident.

We will be familiar with some of these documents or their being reported in the media. The 2008 OAG's Report on Air Safety in Canada is referenced here because the issues appear to be relevant to Rail Safety in Canada. The OAG Report on Rail Safety issued in November, 2013, (post-Lac-Megantic), is referenced below. Several media stories are referenced. The intention is to provide resources to examine this series of events in the context of the accident and the historical documentation available, some prior to the accident.

The dangers of "cherry-picking", hindsight-bias and confirmation bias are understood. As well, the danger of politicizing this event is understood. However, such processes and events are inevitably political in terms of how resources that are limited or at least perceived and characterized as limited, are allocated, supported and reinforced by the governments of the day.

There is likely no reason to re-introduce the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario, (1992). Most here are familiar or have even studied some or all of the documents available, (link above). As Specs & Vsplat have described however, "It's more than that"... In fact there is a pattern or at least a common thread over time running through the following links that indicates well-known problems (and responses, and assessments of those responses) with transportation safety and SMS in Canada. This is a first attempt at finding the "pattern that connects". The caveat as always, is politics and given the time involved and a repetition of cautions and causes, some skepticism is justified.

OAG Report on Air Transportation Safety - Transport Canada*
http://www.oag-bvg.gc.ca/internet/English/osh_20080605_e_30880.html
Opening Statement to the Standing Committee on Public Accounts
Oversight of Air Transportation Safety—Transport Canada
(Chapter 3 - May 2008 Report of the Auditor General) http://www.oag-bvg.gc.ca/internet/English/parl_oag_200805_03_e_30699.html
May 2008 Report
PDF http://www.oag-bvg.gc.ca/internet/docs/aud_ch_oag_200805_03_e.pdf
5 June 2008
Sheila Fraser, FCA
Auditor General of Canada
*This is a copy of an official work that is published by the Office of the Auditor General of Canada, and that the reproduction has not been produced in affiliation with, or with the endorsement of the Office of the Auditor General of Canada.

Danger overhead: Why Transport Canada cuts are a red flag for small commercial aviation safety | canada.com (Ottawa Citizen story is no longer available on the web):
Sarah Schmidt
Published: March 31, 2013, 12:00 pm
Updated: 8 months ago


2013 Fall Report of the Auditor General of Canada*
Michael Ferguson

Auditor General of Canada

Fall 2013 Report
PDF (892 KB) http://www.oag-bvg.gc.ca/internet/docs/parl_oag_201311_07_e.pdf
Audit at a Glance
Chapter 7—Oversight of Rail Safety—Transport Canada
*This is a copy of an official work that is published by the Office of the Auditor General of Canada, and that the reproduction has not been produced in affiliation with, or with the endorsement of the Office of the Auditor General of Canada.

Transport Canada keeps exemptions on rail safety secret - Politics - CBC News
CBC investigation finds railways given waivers on safety inspections, rules that regulator never makes public.
By John Nicol and Dave Seglins, CBC News Posted: Feb 07, 2014 5:00 AM ET Last Updated: Feb 07, 2014 5:59 AM ET
CBC News this week revealed that Canada’s rail regulator has waived a number of safety rules and orders for both CN Rail and CP Rail operations in recent years. But Transport Canada has refused to offer reasons. (Darryl Dyck/Canadian Press)

Railway Association of Canada
Safe, Secure and Getting Safer
"Canada's railways run an average of 1,100 passenger and goods trains every day, often over some of the world's most rugged terrain and in some of the world's worst weather conditions. Canada's railways have the best safety record in North America and provide by far the safest means of ground transportation in Canada."



2014 TSB Recommendations & TC Responses - Transport Canada
R13D0054 - TRANSPORT CANADA RESPONSE TO THE TSB INITIAL RAILWAY SAFETY RECOMMENDATIONS RESULTING FROM THE ONGOING INVESTIGATION INTO THE RAIL ACCIDENT IN LAC-MÉGANTIC, QUEBEC ON JULY 6, 2013.

Transportation Safety Board of Canada - Statistics on rail accidents and incidents
2014 monthly statistics
January
February
March
April
May
June
Annual statistics
2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007
Other statistics
Federally regulated rail accidents and incidents, by train operator, 2004-2013
Federally regulated occurrences and casualties, by train operator (A-M), 2004-2013
Federally regulated occurrences and casualties, by train operator (N-Z), 2004-2013
Statistical Summary – Railway Occurrences 2013

Date modified:
2014-08-19

[Vsplat]

Don, an excellent summation.

Why does this cycle recur? The short answer is because, for most senior decision makers, the consequences of a safety failure remain less than those of a financial one. While in theory the two are linked, the high rate of turnover (to Specs' post) factors in the Russian roulette that is executive risk management in our current era. Will I be gone, with my package intact, before the bullet hits the chamber? I have heard a variation of that very question asked by a CEO, during the discussion of an accident-capable risk.

After a while, so many reports of inappropriate risk surface that the recipients almost become numb to the stimulus - Is the sky still falling? OK, what's next on the agenda?

Enforcement in the traditional, pre SMS age became obsolete because all of the avenues involved the working level victims of corporate decisions. SMS was supposed to have real teeth to make the 'Accountable Executive' accountable, but we know the history of that provision. If there is to be more enforcement, as called for above, it will need to be a different tool than what we have seen so far.

A CEO who makes reckless safety decisions, or plays corporate structure games to give themselves plausible deniability for bad safety practices, will continue to do so until they recognise a real risk of ending up poor, shamed, and captive. That is the ultimate challenge for any regulator or society.

Vs

[J.O.]

In our current environment, I simpy can't envision a situation whereby the DOJ would be allowed to prosecute any CEO / AE to the extent defined in our current rules, never mind leaving them poor, shamed and captive. There is simply no political will for it, and that's not just because of the party that's currently in power.

[Vsplat]

J.O. agreed. All we can ask is 'what is it going to take?'.

Vs

[DEFCON]

Police organizations such as the Mounties generally don't like getting involved in too many specialty themed crimes; commercial aviation and medicine are two such areas of avoidance. Perhaps the Mounties could expand their scope of expertise in enforcement to include commercial aviation as they did many years back when they created their commercial fraud division for instance?

Personally, I am aware that aviation enforcement personal will often look the other way for the reasons JO mentioned above, but in cases such as with the AT 330 glider, when TC fails to act, the Mounties should have stepped in and laid criminal charges against the maintenance personnel that made the very conscious decision to switch fuel system parts and place all those lives at risk.

If a legislative demand on the part of the Government of Canada required TC to involve the Mounties in a collaborative investigation whenever a purposefully designed sniff test determines some degree of criminality exists as a component of an incident etc., the system may begin to unload whatever machinery it has that tends to favour politically correct choices in enforcement.

[Vsplat]

Interesting comment, Defcon - further underscores that this is a case of willpower to use the law, vice the law itself.

The Aeronautics Act already includes summary and indictable offences, charges that would be laid and investigated by the RCMP. But to your point, when was the last time we saw this used in a meaningful way?

[Lakelad]

.
A couple of interesting nuggets re safety and other areas contained in today's release of 'Air Canada’s Corporate Sustainability Report'

SAFETY PROGRAMS

During the year Air Canada also undertook a number of initiatives related to safety in specific
areas of the company. One such program was the Line Operations Safety Audit (LOSA), the second
time Air Canada has participated in this study.

It entailed placing trained LOSA observers on the flight deck during 350 scheduled flights to monitor
the operation from a safety perspective and collect data about errors and potential threats, which are
otherwise difficult to identify. The information is shared with the LOSA Collaborative, an international
network of more than 80 airlines, and the findings can be used in enhancing airline SOPs.

The information is collected and reported in a non-identifying fashion to encourage participation
and the program is supported by the Air Canada Pilots Association (ACPA).

.

[DEFCON]

Thanks Vsplat.

I've attempted to respond twice now, but lost both posts to gremlins of one sort, or another.

I don't know for certain, but the system does seem to recognize three distinct classes of aviation personnel; the owners / management, employees and the corporation itself.

The lowest rung employee can be held criminally liable as with the Winnipeg Navajo street crash. In that case, the pilot was charged criminally and I believe, most reasonable people would find his conviction appropriate under the circumstances. Yet, there seems to be another group that enjoys a special form of protectionism from criminal prosecution that masquerades as if it were a benefit of employment that arises consequent to employment with a corporation that itself is watched over in an unhealthy politically correct manner.

[DEFCON]

I don't know anything about the Transport Minister, nor do I want to, but I doubt she's any more qualified for the position than Dolton McDummy's past Minister of a number of portfolios, Sandra Pupatello, who's working career as a shelf stocker and cashier at A&P apparently qualified her as a world class executive. Oh yea, she also has a BA of some sort and was recently handed the Chairmanship of Hydro 1 by the female genius now heading Ontario, who also appears to be completely unqualified at little in life but politics.

Is there any wonder why government doesn't work?

[J.O.]

We don't have enough police to enforce the speed limits on every road either, but that doesn't stop them from placing radar checks at key points to encourage compliance. The quoted statement is, dare I say, disappointing.

[Don Hudson]

The response from the Minister insults the intelligence of the travelling public and disrespects those who know their stuff and who actually do safety work in Canada. In fact, I think the remarks create a false impression for the Canadian public that all is well when clearly it is not.

What is more disturbing is the sense of denial and perhaps even complacency at very high levels in government one gets from the Minister's comments, and from all that has transpired since 2008 with regard to the Auditor General's work.

Based upon history and now of present actions, I do not believe Canada can legitimately claim itself as a world leader in doing SMS, as it has so often done in the past. In fct I think the United States (FAA) may reasonably claim that they have learnt their lessons from the Southwest and American Airlines debacles, (lack of oversight issues) and have changed.