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FEBRUARY 2001 HOW THIS DOCUMENT IS STRUCTUREDSection 1 outlines the necessary background information on the Railway Safety Management System regulations and Section 2 details the specifics of each System component. Section 3 discusses the record-keeping requirements of the regulations, while initial submission requirements and annual submission requirements are addressed in Sections 4 and 5. The final section outlines the documentation requirements of the regulations. Appendix A provides the full text of the Safety Management System Regulations for ease of reference while using the Guide. Appendix B provides a list of relevant definitions. Appendix C contains a sample listing of rail safety regulations, rules and general orders as of January 8, 2001. A sample Emergency/Accident Contact List, using telephone numbers for Transport Canada’s Ontario region as an example, is provided in Appendix D. In addition, a list of references and information sources is included at the end of this document. Correspondence can be addressed to: Rail Safety The guide and related publications are available on the Rail Safety web site. 1. INTRODUCTIONThis Guide is a companion to the Railway Safety Management System Regulations (Appendix A) pursuant to section 37 and subsection 47.1(1) of the Railway Safety Act. The Guide is intended to assist railways in developing Safety Management Systems that meet the requirements of the regulations. The following sections provide practical advice and suggestions as well as specific examples of methods and approaches that have been adopted by various railways. The Railway Safety Act defines a Safety Management System to be "a formal framework for integrating safety into day-to-day railway operations and includes safety goals and performance targets, risk assessments, responsibilities and authorities, rules and procedures, and monitoring and evaluation processes." See Appendix B for additional definitions. The objectives of the Safety Management System Regulations are to ensure that safety is given management time and corporate resources and that it is subject to performance measurement and monitoring on par with corporate financial and production goals. A Safety Management System will provide a more directed and focused approach to safety. It is anticipated that both increased management attention to safety and an enhanced safety culture within the industry will reduce public and employee fatalities and injuries, reduce property damage resulting from railway accidents, and reduce the impact of accidents on the environment. In addition, a Safety Management System will enable railways to demonstrate – in a concrete and visible manner – their commitment to safety to employees, customers and the public, and will help railways ensure compliance to regulatory requirements. AN OVERVIEWThe Safety Management System Regulations do not replace any existing rules, regulations or standards. Rather, the requirement for a new systemic approach to managing safety is an addition to the current framework. An effective Safety Management System will include both management and employee participation. As a result, it is highly desirable to involve employees and their representatives in developing the Safety Management System, in ongoing risk management, audit, and evaluation, and in developing corrective action plans. Existing Health and Safety Committees, established for the purposes of the Canada Labour Code (Part II), could provide a forum for employee involvement, provided that these committees are not diverted from their intended purpose. Alternatively, customized consultation processes could be developed. The mandate of the Railway Safety Act includes "not only [ to] the safety of persons and property transported by railways but also [ to] the safety of other persons and other property". While this mandate is relatively broad in scope, typically Safety Management Systems are even broader. A comprehensive Safety Management System would normally include items in addition to those under the jurisdiction of the Railway Safety Act (e.g., programs to meet the requirements of environmental protection legislation, compliance with the Transportation of Dangerous Goods Act and regulations, and occupational safety and health programs under the Canada Labour Code (Part II)). The inclusion of programs to meet the requirements of other legislation in a Safety Management System should help railway companies avoid duplication, meet their regulatory obligations and improve safety. However, this should not be taken to mean that the jurisdiction of the Railway Safety Act extends into these areas or that compliance with the Safety Management System Regulations in any way lessens a railway company’s obligation to comply with other legislation. Compliance with the Safety Management System Regulations will be assessed through Transport Canada’s compliance monitoring program, which is designed to verify that
2. SAFETY MANAGEMENT SYSTEM COMPONENTSThis section of the Guide outlines the required components of a Safety Management System. The box at the beginning of each section contains the statement of the requirement from the regulations. The rest of the section contains suggestions on how to meet the requirement and examples of methods and approaches that have been adopted by various railway companies as well as excerpts from relevant standards and guidelines. Figure 1 shows the key components of a Safety Management System, the relationships between them and the corrective action feedback loops.
A) Safety Policy, Annual Safety Targets and Associated Safety Initiatives2. (a) the railway company safety policy and annual safety performance targets and the associated safety initiatives to achieve the targets, approved by a senior company officer and communicated to employees; A company’s safety policy should:
See below for an example of a company’s safety policy. Experience has shown that there is a strong correlation between companies with low accident rates and companies whose senior management are seen to be concerned with safety and who communicate this concern to employees. To maximize this effect, the safety policy should be approved at the highest possible level within the company. The safety policy should be communicated to all employees. In some circumstances, it may also be desirable to communicate the safety policy to other stakeholders such as customers, communities through which the railway operates and the general public. Example 1 – Safety Policy POLICY It is company policy to take all appropriate measures to ensure the protection of passengers, employees and the public in general while traveling in railway equipment or while on company property. In following this policy the company will comply with all existing legislative requirements and will strive to eliminate any foreseeable hazards that may result in fires, damage to property and the environment, security losses, and personal injuries/illnesses. It is also company policy to sustain continuing programs designed to promote the health and safety of all employees and to co-operate with organizations and associations devoted to safety research and education. Safety shall be regarded by everyone as a prime consideration in the successful performance of their duties. Management is specifically responsible for the development and implementation of safe practices and procedures. Managers at all levels will continually monitor situations to identify any sub-standard practices and conditions that may exist so as to provide prompt and adequate corrective action. Health and Safety/Loss Control will be one of the criteria used in assessing management effectiveness. Employees have the responsibility to perform their duties in a manner that will not jeopardize the safety of customers or adversely affect their own health, safety or physical well-being or that of their fellow workers. Reasonable precaution is also expected from each employee to protect the property and equipment of the company that is under their care. The company firmly believes that health and safety in the workplace can only be achieved through total commitment on the part of everyone. It is therefore company policy to establish well-organized joint health and safety committees where required throughout the system. This applied philosophy of sharing safety responsibilities will further the foregoing objectives and contribute to a safer work environment. In addition to a safety policy, the regulations require railways to establish annual safety performance targets and identify initiatives that will be undertaken to achieve those targets. While the ultimate goal is to eliminate accidents, it is useful to have intermediate targets – set annually – against which continual progress toward the ultimate goal can be measured. Annual targets should be associated with planned safety initiatives designed to ensure that the company can meet its safety performance targets. See Example 2 below for safety performance targets. Annual safety performance targets should:
The target-setting process should:
Example 2 – Safety Performance Targets
* Federal Railroad Administration B) Safety Authorities, Responsibilities and Accountabilities2. (b) clear authorities, responsibilities and accountabilities for safety at all levels in the railway company; The Safety Management System should include the following:
Typically, clear authorities, responsibilities and accountabilities for safety can be demonstrated through
Example 3 on the following page illustrates some of the circumstances that may contribute to the decreased effectiveness of a Safety Department. Example 3 – "How Not to Treat Your Safety Department" A review of safety and operational issues at an American rail transit system was recently conducted by the safety oversight authority subsequent to a series of fatal accidents. The review found that the organization had not kept abreast with recent developments in system safety. The review also observed that the organization’s safety efforts had been weakened by
The Safety Department was moved from place to place in the organization, making its work difficult, its priorities uncertain and its status in the organization marginal. The review found little evidence of the Department’s participation in decision making (as required by the organization’s own System Safety Program Plan), in the conduct of safety audits and reviews, or in the implementation of public and employee safety awareness programs. From 1992 to 1996, the Safety Department staff was reduced from 17 to 12 positions. However, at the time of the review, only 8 of the 12 positions were filled. Furthermore, as a result of the Department’s movement through the organization, it became responsible for other functions, further reducing its ability to meet its safety responsibilities. These limitations are reflected in, among other things, the absence of strong public and employee safety awareness programs. C) Employee and Representative Involvement2. (c) a system for involving employees and their representatives in the development and implementation of the railway company’s safety management system; Experience has shown that a railway company will be markedly more successful in developing a safety culture if employees and their representatives, where applicable, are involved in the development and implementation of the Safety Management System. Employee and representative participation in drafting the company safety policy is highly recommended. A collaborative approach will help ensure that significant employee concerns are addressed in the policy and will provide an additional vehicle for communicating the railway’s commitment to safety to employees. Existing Health and Safety Committees could assist in this process provided that they are not diverted from their intended purpose under the Canada Labour Code (Part II). Alternatively, a customized consultation process could be developed. Employees and their representatives should also be consulted in setting annual safety targets and identifying the associated safety initiatives. Consulting with employees and linking the target-setting process with the railway’s risk management process will help ensure that the most significant outstanding safety issues and concerns are addressed. Health and Safety Committees may be the most convenient forum for this process, although their purview would have to be expanded to include crossing and trespassing issues as well as the other operational safety concerns that form part of a complete Safety Management System. Employees and their representatives can make important contributions to each step of the risk management process (as required by component 2(e)). The risk management process should include mechanisms for employees to identify safety issues and concerns on a routine and ongoing basis. These mechanisms should have a high level of visibility and participation to ensure that all risks are captured. Experienced employees may also be a good source of expert judgment for evaluating the probability and severity of safety issues and concerns where quantitative, historical data are not available. Finally, employees and their representatives should be involved in the development of risk control strategies, particularly for risks that they have identified. Employees should be informed of actions that are being taken or that are planned to address the safety issues and concerns they have identified. Feedback is essential to ensure continued participation. D) Compliance with Applicable Regulations, Rules, Standards and Orders2. (d) systems for identifying applicable
None of the current railway safety framework of rules, regulations and standards is being replaced by the Safety Management System Regulations, and the existing railway safety requirements will continue to apply in their current form. The Safety Management System will provide a framework for identifying legal obligations, monitoring changes to them, and demonstrating and evaluating compliance. The Safety Management System should include
In addition to the legal obligations contained in rules, regulations, standards and orders, other standards that the railway company has developed or has voluntarily adopted, such as those issued by the Railway Association of Canada (RAC), American Association of Railroads (AAR) or the American Railway Engineering and Maintenance of Way Association (AREMA), should be documented. A list of currently applicable rail safety legislation, regulations, rules and standards as well as any exemptions that have been obtained by the company or orders that apply to its operations provides a starting point for meeting this requirement. Appendix C contains a sample listing of rail safety regulations, rules and general orders as of October 15, 1999. Information on new and amended regulations, rules and standards is available from:
E) Risk Management Process2. (e) a process for
Risk management does not mean taking risks, but rather it means identifying risks and working to mitigate or eliminate them. The Safety Management System should include a formal risk management process that includes the following steps: > Step 1 – Identification of Safety Issues and Concerns
Railways are expected to do a thorough analysis of both new operations and significant changes to existing operations (see Figure 2 on the following page). In the case of new equipment, systems, operations, practices and procedures where experience and a safety history are not available, formal analytical techniques should be applied. These techniques are more demanding in terms of data, time, effort and expertise; however, this extra effort is justified for new equipment, systems, operations, practices and procedures and should be considered a normal part of the process of implementing change. Examples of significant changes requiring a risk assessment process include
A complete analysis of existing operations is not required provided that current risk mitigation strategies are documented (see component 2(f)). Input from accident and incident investigation, safety performance data collection and analysis, and complaints, inspections and audits should be used to identify areas of existing operations that require a thorough analysis.
> Step 2 – Risk Estimation Assessment of the probability and severity of the safety issue/concern either qualitatively or quantitatively Severity is normally measured in terms of the number of deaths or injuries, the value of property damage, or the cleanup costs and environmental impact, either as an average based on the experience of the company or industry over a certain time period or as a range. Other types of losses associated with accidents and incidents that are less easily measurable, such as damage to the company’s reputation and degradation of the quality and timeliness of service to customers, should also be evaluated in assessing the severity of risks. Where quantitative probability and severity estimates cannot be derived due to a lack of relevant data, qualitative estimates based on expert judgment may be substituted. > Step 3 – Risk Evaluation Evaluate and determine whether the associated risk is tolerable, tolerable with mitigation or unacceptable using a predetermined company risk classification methodology Risk evaluation is the process of assessing the significance of risks and determining which risks are tolerable, tolerable with mitigation or unacceptable. These decisions should be made using a predetermined risk classification methodology/tool such as the risk resolution matrix (see Example 4), which is adapted from the Manual for the Development of System Safety Program Plans for Commuter Railroads, American Public Transit Association. Example 4 - Risk Resolution Matrix
SEVERITY CATEGORIES
PROBABILITY CATEGORIES
Risk resolution matrices may have varying numbers of probability and severity categories (rows and columns). The number of categories and the category definitions should be established based on company size and experience. Category definitions used by one Canadian railway are shown on the next page (see Example 5). In this case, severity categories have a number of different dimensions and safety issues are assigned the severity category associated with the "highest" severity rating over all dimensions. Example 5 - Risk Category Definitions
The Safety Management System should include
F) Risk Control Strategies2. (f) risk control strategies; Risk control strategies are required for risks that have been classified as unacceptable or tolerable with mitigation. In generic terms, these strategies can focus on
It is expected that railways will identify some or all of the risks included in the table on the following pages as unacceptable or tolerable with mitigation. This list is not exhaustive, but it is intended to exemplify common risks and typical control strategies and to indicate the process each railway company should undertake. For existing operations, many of the risks will have already been considered and risk control strategies will form part of the railway’s current rules, standards, procedures and operating practices. In this case, the risk assessment process would document this link and then focus on the results of accident and incident investigations, safety data analysis, complaint follow-up, inspections, and audits to ensure that the risk is being mitigated to an acceptable level. This analysis should point railway companies to areas where they could undertake initiatives beyond their current practices in an effort to improve their overall safety performance. For new operations, or for changes to technology, staffing levels, types of operation or other areas where a railway company lacks historical data and experience, a formal risk management process as described in component 2(e) should almost always be undertaken. The Safety Management System should include procedures for the development of the required strategies, approval at an appropriate management level and effective implementation. Employees and their organizations should be involved in the development of risk control strategies, particularly for risks that they have identified, and they should be informed of the actions that are being taken or that are planned. Risks and Risk Control Strategies
G) Accident and Incident Reporting, Investigation and Analysis2. (g) systems for accident and incident reporting, investigation, analysis and corrective action; The Safety Management System should include
See Example 6 below for a list of the elements to be included in a comprehensive railway accident investigation process. Example 7 (on the following page) details the role of accident cause finding and corrective actions in accident prevention. Appendix D provides a sample emergency/accident contact list, using telephone numbers for Transport Canada’s Ontario region as an example. This could be used as the basis for developing similar lists for other locations. Example 6 – Elements of a Comprehensive Railway Accident Investigation Process
Example 7 – The Role of Accident Cause Finding and Corrective The purpose of immediate protection is to the reduce the immediate risk of another similar train accident. Examples are a 10 mph temporary speed restriction at the site when the cause was a track geometry defect or a 40 mph speed restriction on a type of car that appears to be unstable at higher speeds. The immediate protective actions, when required, must be implemented by the Investigating Team before operations are resumed. Once the cause of an accident is known and all relevant conditions and failures have been identified, long-term corrections may be appropriate. The purpose of these actions is to reduce the likelihood of a similar train accident recurring in the future. Examples of long-term corrective actions would be the accelerated removal of straight plate wheels and the overhaul of trucks on a specific class of car.
Source: Train Accident Cause Finding Manual H) Skills, Training and Supervision2. (h) systems for ensuring that employees and any other persons to whom the railway company grants access to its property, have appropriate skills and training and adequate supervision to ensure that they comply with all safety requirements; The Safety Management System should include
Example 8 details the importance of supervision in preventing accidents due to "operational and human factors". Example 8 – The Role of Supervision in Preventing Accidents Due to Operational and Human Factors Inappropriate operating practices, judgment errors and failure to comply with rules may cause an accident. A rules violation, while serious, is not necessarily the cause of the accident. Similarly, compliance with rules or accepted operating practices does not automatically remove the cause from the "operational and human factors" group of train accident causes. The other two groups are "equipment" and "track".Supervisors and employees must accept the principle that most accidents can be prevented. Supervisors must properly manage their people in order to prevent these causes. The employee must be educated on how to do the job and clearly instructed on what to do. Formal rules examinations, efficiency tests and observations during daily contact must be used to verify job knowledge and compliance. The employee must be given additional education after a deficiency is detected.
Source: Train Accident Cause Finding Manual I) Safety Performance Data Collection and Analysis2. (i) Procedures for the collection and analysis of data for assessing the safety performance of the railway company; The Safety Management System should include
Safety performance should be measured through a range of indicators designed to ensure accurate reporting (see Example 9 on the following page for a sample listing of activity measures). Safety performance indicators should be
Safety performance data can be captured by automated techniques or through inspection activities and reporting systems. Modern technology such as test cars, impact detectors and crossing systems has greatly expanded the type and quantity of safety data that can be captured at a reasonable cost. Example 9 - Activity Measures for Rail Safety Analysis
J) Safety Audit and Evaluation2. (j) procedures for periodic internal safety audits, reviews by management, monitoring and evaluations of the safety management system; Safety audits and evaluations of the Safety Management System are important mechanisms for ensuring that all of the organizational elements, functions and procedures in the Safety Management System are working well. Internal audits and evaluations are one of the key feedback loops for identifying required changes to the system. The Safety Management System should include
Audit and evaluation frequencies are expected to vary depending on the size and complexity of the railway, the risks involved, and the railway’s safety performance history. One major Canadian railway audits every component annually and conducts ongoing safety assessment activities through Health and Safety Committees. Larger railway companies will likely have the staff and expertise necessary to establish auditing processes and teams, although they may choose to hire external resources to obtain specific skills or assistance. Smaller companies that may not have the resources to conduct an audit program internally may be able to obtain assistance from a variety of sources, including senior railways with which they interchange, consultants and professional auditors. K) Corrective Action Development, Approval and Monitoring2. (k) systems for monitoring management-approved corrective actions resulting from the systems and processes required under paragraphs (d) to (j); The key to the effectiveness of a Safety Management System is the feedback loops that ensure that corrective action is taken. The need for corrective action may be identified through the following:
The Safety Management System should include
L) Documentation2. (l) consolidated documentation describing the systems for each component of the safety management system. The Safety Management System should be documented and the applicable sections readily available to those with defined responsibilities in the System. Procedures for updating and distributing the documentation should be specified. The documentation should show how each of the requirements is being met, including references to process and procedure documents, standards, guidelines, manuals, job descriptions, organization charts, etc., the current edition number or date, and the locations where these documents can be found. For a large company, the Safety Management System document may be a summary document that describes how the company is meeting its obligations in each area, while referencing other documents that describe the specific process and procedures that form the System. 3. RECORD-KEEPING REQUIREMENTS3. (1) A railway company shall maintain records of the following information for the purposes of assessing its safety performance:
(2) At the request of the Minister, a railway company shall collect, maintain and submit to the Minister specified performance or safety data for the purpose of monitoring the effectiveness of its safety management system and its safety performance. In addition to maintaining information on "reportable" accidents/incidents, railway companies are encouraged to maintain records of investigations along with descriptions of the corrective actions taken for "non-reportable" accidents and incidents. Indeed, to accurately assess safety performance, railway companies should maintain information on all accidents and incidents. Annual safety performance targets and the associated safety initiatives to achieve the targets should be linked to this data. 4. INITIAL SUBMISSION REQUIREMENTS4. (1) A railway company shall submit to the Minister the following information in respect of its safety management system:
(2) The information shall be submitted
A railway company shall not operate unless it has a Safety Management System in place that meets the requirements of these regulations. It is understood that the information listed above in subsection 4(1) of the regulations will be made available to employee representatives. The initial Safety Management System submission required by the regulations is intended to provide preliminary assurance to the Department that the railway company has developed and implemented a Safety Management System that meets regulatory requirements. The Safety Management System documentation required by component 2(l) should be much more comprehensive. Transport Canada audits will scrutinize the system and its documentation in detail to verify adequacy and effectiveness. The description of the company’s actual or projected network (owned or leased) and operations (item 4(1)(b)) should include
5. ANNUAL SUBMISSION REQUIREMENTS5. (1) Not later than March 1 of each year following the year in which a railway company submits the information required pursuant to subsection 4(l), the railway company shall submit to the Minister the following information in respect of the preceding calendar year:
(2) The railway company shall include in the information its safety targets for the calendar year in which the submission is made. The annual Safety Management System submissions required by the regulations are intended to provide assurance to the Department that the railway company is maintaining an up-to-date Safety Management System that meets regulatory requirements. The record keeping and annual reporting of safety performance relative to safety targets and accident rates allow the railway company to assess the results/effectiveness of its Safety Management System. In addition, the annual submissions will better enable Transport Canada to provide assurance on the continuing state of railway safety in Canada. 6. PRODUCTION OF DOCUMENTSTo enable a railway safety inspector to monitor compliance with these Regulations, a railway company shall keep readily available all documents that are mentioned in its safety management system. At any time after the initial submission, and with reasonable notification, a Railway Safety Inspector may require a railway company to produce for inspection any of the documentation referenced in the Safety Management System for the purpose of compliance monitoring. APPENDIX A: RAILWAY SAFETY MANAGEMENT SYSTEM REGULATIONShttp://www.tc.gc.ca/railway/SMS_Regulations.htm APPENDIX B - DEFINITIONS Disabling Injury – has the meaning assigned in section 15.1 of the Canada Occupational Safety and Health Regulations and section 11.1 of the On-Board Trains Occupational Safety and Health Regulations (Blessure invalidante) Employee Representative – refers to an employee who does not exercise managerial functions and who has been selected from among those employees; where employees are represented by a trade union, it refers to the person selected by the trade union (Représentant des employés) Human Reliability Analysis – identifying likely occurrences of human errors in system components (e.g., matching machine to human capability) (Analyse de fiabilité humaine) Human Factor Analysis – applying human psychological, social, physical and biological characteristics in the design, operation or use of products or systems (Analyse du facteur humain) Minor Injury – has the meaning assigned in section 15.1 of the Canada Occupational Safety and Health Regulations and section 11.1 of the On-Board Trains Occupational Safety and Health Regulations (Blessure légère) Railway Safety Inspector – any person designated by the Minister as such under section 27(1) of the RSA (Inspecteur de la sécurité ferroviaire) Reporting Criteria – (a) in respect of an accident, the criteria set out in the definition "reportable railway accident" in subsection 2(1) of the Transportation Safety Board Regulations; and (b) in respect of an incident, the criteria set out in the definition "reportable railway incident" in subsection 2(1) of the Transportation Safety Board Regulations (Critères à signaler) Resources – the means to achieve an end or fulfill a function (e.g., people, money, material, tools, equipment) (Ressources) Risk – the chance of injury or loss measured as the probability and severity of an adverse effect on health, property, the environment, or other things of value (Risque) Risk Control Strategy – a course of action intended to reduce the frequency or severity of injury or loss, including a decision not to pursue the activity (Stratégie de contrôle du risque) Safety Initiative – a proposed plan, project or course of action designed to achieve a specific safety target (Initiative de sécurité) Safety Management System – a formal framework for integrating safety into day-to-day railway operations and includes safety goals and performance targets, risk assessments, responsibilities and authorities, rules and procedures, and monitoring and evaluation processes (Système de gestion de la sécurité) Safety Targets – quantitative or qualitative safety improvements to be achieved (Objectifs de sécurité)
APPENDIX C
* Railway Safety Handbook, Transport Canada - Revised October 15, 1999
APPENDIX D This matrix was developed for use in Ontario to assist railways in understanding the role and reporting requirements of government agencies that may be involved in train accidents. There will be differences in roles and reporting numbers in other provinces, but this list should provide a guide as to who to contact.
REFERENCES AND INFORMATION SOURCES
LIST OF TRANSPORT CANADA - SURFACE OFFICESNational Capital Region:
Transport Canada
Email: railsafety@tc.gc.ca Regional officeshttp://www.tc.gc.ca/rail/offices.htm
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