Audit of Safety Management Practices at CN (phase 2) (PDF)

Rail Safety (Transport Canada) Asr

Sujets

• management
• risk management

Informations

• Publié par: Ewlie
• Nombre de lectures: 27
• Langue: English

Extrait

Final Report: Audit of Safety Management Practices at CN (Phase 2 of Transport Canada Action Plan to Address CN Safety Issues)

Updated: June 12, 2006

Table of Contents

 Page

Executive Summary …………………………………………………………………… 1

1. Introduction ………………………………………………………………………… 4 1.1 Background..………………………………………………………………………….. 4 1.2 Objectives……………………………………………………………………………... 4 1.3 Scope………………………………………………………………………………….. 5 1.4 Audit Conduct…………………………………………………………………………. 6 1.5 Format of Report………………………………………………………………………. 8

2. Summary of Audit Findings ………………………………………………………… 9 2.1 Safety Management Practices………………………………………………………… 9 2.2 Status of CN Corrective Actions to Phase 1 Targeted Inspection Activity…………… 13

3. Findings by CN Process Examined ………………………………………………… 15

APPENDICES

A.

Railway Safety Management System Regulations

EXECUTIVE SUMMARY Following high-profile derailments in August 2005, Transport Canada’s (TC) Rail Safety Directorate developed a two- phased Action Plan to assess overall compliance and safety issues of Canadian National Railway (CN). Phase 1 of the Action Plan comprised an analysis of relevant data to examine safety trends and issues at CN, and, targeted safety inspections of CN operations between August 22 and September 16, 2005 to determine the railway’s level of compliance with applicable safety requirements. A Draft Phase 1 Report dated November 26, 2005 was prepared and submitted to CN. Comments from the company were received on December 16, 2005 and a Final Report dated January 5, 2006 was produced. Phase Two of the TC Action Plan involved an audit of CN’s Safety Management practices and is the subject of this report. The audit was conducted between November 14 and December 10, 2005. It focused on selected areas of risk identified in the Phase 1 targeted inspection activity and was conducted to: •safety management practices based on the implementation of theEvaluate company’s Safety Management System (SMS); and, •Assess CN’s progress in implementing its Corrective Actions to the Phase 1 findings. Evaluation of CN’s Safety Management Practices Overall, there were strengths identified in certain elements of safety management in the company, notably with respect to the progress CN has made in establishing its SMS throughout the organization, and the use of the Risk Management Group in developing company-wide safety management standards and providing support to all organizational levels through risk assessments and the provision of safety performance/trend analysis. The audit identified a need for CN to further strengthen safety management practices to address the following gaps: •Disconnect between senior management and front -line supervisors/employees in understanding management’s commi tment to safety:Senior Management interviewed indicated a strong commitment to safety and stated that the corporate safety policy reflects the company’s philosophy and actions towards safety – they see themselves as involved and pro active. However, this contrasts with the view of many employees and some front- line supervisors interviewed who report that they feel pressured – productivity, workload, fear of discipline - to get the job done, which could compromise safe railway operations.

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•Need for a comprehensive view of safety performance by senior management – one that is not primarily based on FRA Reportables:The audit team verified the implementation of different practices to monitor and report safety performance including safety data analysis, trend analysis, root/cause analysis, frequent and regular communications at management levels, and the link to management performance evaluations. However, it was found that the evaluation of safety performance at the senior mana gement levels is heavily focused on accidents that meet the United States Federal Railway Administration (FRA) reportable accident criteria 1 . The FRA accident numbers only represent a small portion of the actual number of CN accidents in Canada. •Data from day-to-day operational monitoring systems could be used more frequently to trigger formal Risk Assessments:Various processes are in place allowing the company to identify safety issues including CN’s Performance Monitoring and Rules Compliance (PMRC) System, Safety Audits/Blitzes, and Functional Safety Inspection/Defect Logs and Reports. The audit team did not find evidence indicating that data from these processes is used on a regular basis to trigger documented Risk Assessments. This practice would facilitate a more comprehensive, inclusive Risk Assessment process. •More thorough recording and tracking of details is necessary to improve the management of risk mitigation strategies (corrective actions):In examining completed Risk Assessment reports and safety measures stemming from the accident/injury reporting and analysis process, the audit team could not find documented details describing the risk mitigation controls – including responsibilities, key implementation activities and dates, and status – in all cases. This is co ntrary to the intent of CN’s Corrective Action/Safety Measure Management Standard. •The effectiveness of CN’s safety culture improvement initiatives needs to be reviewed:In interviews with employees, the Safety Culture improvement initiatives included in the 2005 CN SMS submission to Transport Canada – which indicated a focus on training, involvement, communications, coaching and recognition – were reported as not being effectively implemented. This was raised most predominantly in the Mechanical Services department.

1  operations of on-track equipment that involvingCollisions, derailments, fire, explosions, or other events results in total damages that is greater than the current reporting level of $7,700 (US)

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•Current field-level practices were identified as contributing to the high rate of defects/deficiencies:was evidence, through employee and front- lineThere supervisor interviews, that current field processes have contributed to the high- number of defects: - It was reported that Bad-Ordered (BO) Car count is a driving factor in the Mechanical Supervisor assessments of cars to be bad-ordered for repair disposition; - In the Engineering Department, there was evidence of incomplete defect repair records, missing entries in the Rail Defect Tracking System data- base, and required crossing tests not being completed; and, - There are gaps in CN’s processes for securing handbrakes, which may lead to continued non-compliance with Canadian Railway Operating Rule (CROR) 112 requirements. •CN’s safety management documentation can be improved:Documentation describing the functional processes and procedures examined in the audit did not include a clear description of the oversight roles and responsibilities of management above the front-line supervisor level. This can hinder the effectiveness of safety management oversight by causing confusion amongst the different organizational components and levels in large, decentralized organizations such as CN. Evaluation of Status of CN’s Corrective Actions to the Phase 1 Inspection Findings The audit team assessed CN’s progress with the implementation of selected corrective actions submitted on October 11, 2005 in response to the TC findings of the Phase 1 Targeted Ins pection activity. Evidence was provided to demonstrate that CN had implemented 8 of the 11 corrective actions selected for verification at the time of the audit conduct. It was noted that other corrective actions requiring longer-term development (e.g., Canadian Rail Operating Rule revisions to include Transfer Movements and Remote Control Locomotive Operations) were underway. TC will continue to monitor the implementation and effectiveness of CN corrective actions to the Phase 1 targeted inspection activity. CN fully co- operated in all aspects of the Phase 2 audit and the overall TC Action Plan. Through the establishment of the Safety Management System, CN has developed and maintains a number of safety management practices which include pockets of strengths as well as areas that require improvement. CN management has demonstrated a commitment to review and improve its safety management practices; however, actions to successfully move further in that direction still need to be established and implemented.

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1. Introduction 1.1 Background On August 3, 2005, 45 cars from a Canadian National (CN) train jumped the tracks and caused “bunker-c” fuel oil and pole-treating oil to leak into nearby Lake Wabamun in Alberta. Two days later, another CN train derailed over the Cheakamus River canyon north of Vancouver. A ruptured tank car sent 40,000 litres of highly corrosive caustic soda into the river. The severity of these derailments, along with an overall increasing trend in the number of mainline track derailments, made it incumbent on the Rail Safety Directorate to undertake action specifically targeted at CN. The Directorate subsequently developed an Action Plan to assess overall compliance and safety of CN. This Action Plan comprised two Phases: Phase 1 – an analysis of safety trends and issues at CN and the conduct of targeted safety inspections of CN operations between August 22 and September 16, 2005. A Draft Report dated November 26, 2005 was prepared showing Transport Canada’s Phase 1 findings and CN’s proposed Corrective Actions. This report was forwarded to CN for review prior to finalizing. The company forwarded feedback to the department and the report was updated as appropriate and finalized on January 5, 2006. Phase 2 a risk-based audit of CN’s Safety Management System (SMS) with a - focus on assessing the company’s safety management processes. The Audit was conducted from November 14 to December 10, 2005 and is the subject of this report. 1.2 Objectives of the Audit There were two objectives to this audit: 1. To verify that adequate detailed action plans and internal audit processes have been defined, documented and implemented to reduce the high equipment defect rates, rules violations and non- compliance issues ident ified from Transport Canada’s targeted inspection activity conducted August 22 to Sept 16, 2005. 2. To evaluate CN’s safety management practices based on the implementation of the company’s Safety Management System (SMS).

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1.3 Scope The scope of the aud it included: 1. The following functional specific processes and procedures identified in Transport Canada’s targeted inspection activity (Phase1) as having a high rate of deficiencies/defects: • Equipment: - Car/Locomotive inspection procedures by mechanical s taff • Operations: - CROR 112 (securing railway equipment) - Accuracy of consists - Brake tests by train crews • Engineering - Track Inspection and Maintenance - Rail Maintenance - Crossing sightline assessment process - Automatic Warning Systems 2. CN’s corporate systems to address the following Railway SMS Regulation Section 2 mandatory requirements: - Management of TC - issued Notices & Orders (RSMS Regulation sub-section 2d) - Risk Assessment Process (RSMS Regulation sub- section 2e) - Accident and incident reporting, investigation, analysis and corrective action (RSMS Regulation sub-section 2g) 3. The following Railway SMS Regulation Section 2 mandatory components in the above areas: - Authorities, responsibilities and accountabilities (RSMS Regulation sub- section 2b) - Skills, training and supervision (RSMS Regulation sub- section 2h) - Collection and analysis of data for assessing safety performance (RSMS Regulation sub -section 2i) - Monitoring management- approved corrective actions (RSMS Regulation sub- section 2k) 4. The adequacy of the documentation, implementation and effectiveness for each area included in the scope of the audit. The audit was restricted to an assessment of CN safety management practices conducted under the authority of theRailway Safety Act.Rail safety activities concerning contractors, other railways and third parties were not included in the scope of this study.

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1.4 Audit Conduct The audit was conducted over the period of November 14 – December 10, 2005 and represents a snapshot of the safety management practices in place at that time. The audit was conducted in accordance with TC’s SMS Compliance Program Policy and Procedures. Audit Team The Audit Team was comprised of four core audit-team members, representing the following functional a reas: - Corporate - Equipment - Operations - Engineering The core audit team included: David Iezzi (Audit and Quality Assurance, TC HQ): Audit Team Leader & Corporate Rick Magill (Safety Systems Overview – TC Pacific Region): Equipment Doug Palmerton (Safety S ystems Overview – TC Prairie & Northern Region): Op erations Brian Slager (Safety Systems Overview – TC Ontario): Engineering The audit team was augmented with additional functional Railway Safety Inspectors (RSI) from TC regional offices. Approach Pursuant to the amendedRailway Safety Act, which came into effect on June 1, 1999, TC developed regulations which require railway companies to implement and maintain Safety Management Systems. The regulations, which came into force on March 31, 2001, are attached to this report as Appendix A. TheRailway Safety Actdefines a Safety Management System (SMS) as: “a formal framework for integrating safety into day-to-day railway operations and includes safety goals and performan ce targets, risk assessments, responsibilities and authorities, rules and procedures, and monitoring and evaluation processes”.

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TC conducts audits of a railway company’s SMS as the primary tool in assessing compliance with Section 2 of the Railway SMS Regulations. The audits are conducted through a two- stage process: 1. Assessment of Documentation: In this first stage, TC examines and evaluates a railway company’s SMS to assess compliance with the documentation requirements of Section 2 of the RSMS Regulations, and to acquire a more in- depth understanding of the railway company’s SMS. 2. Assessment of Implementation and Effectiveness: In the second stage, TC examines and evaluates the extent to which the railway company has complied with the Section 2 requirement to implement and maintain its SMS. The TC auditors are guided by the company’s Safety Management Systems documentation and by professional judgment and knowledge of the railway’s organization, performance, and operations. The degree of implementation is determined by conducting interviews, reviewing records and observing facilities, equipment and operations. The audit team reviewed CN documentation related to the specific processes included in the audit scope from November 14 to 18, 2005 at CN Corporate Headquarters in Montreal. This documentation was previously requested to be made available for review by the audit team. Field verification and data- gathering was conducted from November 21 to December 10, 2005. In addition to CN’s Corporate Headquarters Office in Montreal, and Network Headquarters in Edmonton, six field locations were visited (three in each of CN’s Eastern and Western Regions): •CN Eastern Region • Moncton (Gordon Yard) • Montreal (Tashereau Yard) • Toronto (MacMillan Yard) •CN Western Region • Winnipeg (Symington Yard) • Edmonton (Walker Yard) • Prince George, B.C. These sites were selected with a view to gaining an appreciation of the national implementation of CN’s SMS and its safety management practices.

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Interviews were conducted with 305 staff representing: •Corporate/Senior Management (22 interviews) •Front-Line Supervisors (70 interviews) - Field site management •Employees (213 interviews) - Equipment Maintenance Employees - Locomotive and Freight Car Maintenance Employees - Operations Employees/Crews - Locomo tive Engineers - Yard crews - Engineering Employees - Track Maintainers Director – Safety and Occupational Health provided coordination forCN.  

On December 16, 2005, following field verification and data-gathering, the audit team briefed CN Senior Management at TC offices in Montreal. The purpose of this briefing was to discuss the audit team’s preliminary findings with a view to identifying areas requiring additional analysis and to facilitate the preparation of CN’s Corrective Action Plan. 1.5 Format of Report This report presents the results of the audit of CN’s safety management practices conducted as Phase 2 of TC’s Action Plan to address CN Safety Issues. Chapter 2 provides a summary of the audit results in two areas: i) Safety Mana gement Practices; and, ii) the status of the implementation of CN’s Corrective Actions to the Phase 1 targeted inspections. Findings by CN process examined are presented in Chapter 3.

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CHAPTER 2 – SUMMARY OF AUDIT FINDINGS A summary of the audit results is shown in this Chapter under: • Safety Management Practices. • Status of implementation of CN Corrective Actions to Phase 1 Targeted Inspection activity 2.1 Safety Management Practices This audit focused on checking processes, reviewing documents and conducting interviews to verify that the elements of CN’s Safety Management System as shown in the scope statement are developed and implemented. Following is a summary of the assessment of CN’s safety management practices under the RSMS Regulation (section 2) component examined: Safety Policy, Annual Safety Targets and Associated Initiatives (RSMS Regulation sub-section 2a) Senior Management interviewed indicated a strong commitment to safety and felt that the corporate safety policy statement reflects the company’s philosophy and actions towards safety. They see themselves as involved and proactive. This contrasts with views of many employees and some front- line supervisors interviewed who report that they feel pressured – productivity, workload, fear of discipline - to get the job done which could compromise safe railway operations. Safety Authorities, Responsibiliti es and Accountabilities (RSMS Regulation sub- section 2b) The audit team found that documentation describing the functional processes and procedures examined in the audit requires improvement. More specifically: • Management oversight Roles and Responsibilities are not clearly documented above the front-line supervisor level for the function/discipline processes examined; • These is no co nsolidated documentation describing the Certified Car Inspection (CCI) Process; and, • Management Performance Agreements (PMPs) do not show specific roles and responsibilities assigned for implementation of specific safety initiatives.

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