Opening remarks at the TSB Transportation Safety Summit
Chair, Transportation Safety Board of Canada
Ottawa, Ontario, 22 April, 2016
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Good morning. I'd like to start by thanking you very much for taking time out of your busy schedules to be here with us today and tomorrow.
I look around this room and see an incredible opportunity! That's because I see a wealth of experience, ideas, and perspectives. Over the course of the next two days, I hope we can all take advantage of, and learn from, that experience.
But I also want to challenge some of those ideas and those perspectives. I want you to be pushed—and in some cases I am pretty sure you will be. Because that's how we advance transportation safety: by exchanging ideas. By seeing how others have implemented some of these ideas. And by discussing the opportunities and challenges these ideas present.
I will consider this summit to be a success if each of us leaves Friday with something concrete, something we can change that improves either the way safety information flows, or the way safety data is used to find out where the real safety risks lie.
But to get us started, I want to begin by telling you why we have chosen these themes for this safety summit.
The TSB recognizes that all organizations must strike a balance between safety and production.
The process of an organization finding that balance—between operating with no risk (which would only be achievable by not operating at all) and operating with significant risk—has been described as “navigating the safety space”.Footnote 1 And as you are no doubt aware, the people who are ultimately responsible for navigating that space and achieving that balance—by establishing the goals and the priorities, by assigning the resources, and by determining the rules for the operating environment—are those typically higher up in an organization. Management. And your decisions can have a huge impact. But with all of the risks that a business must face, with all of the “top priorities” that must be juggled every day, how can companies identify if they are drifting outside the bounds of safe operation, or where they should invest their safety dollars?
Over the past few years, TSB investigations have identified multiple examples where risks in the transportation system went unaddressed. In some cases this was because an issue was not identified—either the data was not available, or it was not being mined. In other cases, issues were identified, but weak or missing processes for managing safety contributed to an inability to take action.
In fact, most accidents, whether big or small, can be attributed to a breakdown in the way an organization identifies and mitigates hazards and manages risk.
Some companies, however, consider safety to be adequate as long as their companies are in compliance with the regulatory requirements—the bare minimum. But regulations alone cannot possibly foresee all risks. Just look at Lac-Mégantic. Prior to that accident, nothing in the regulations precluded a company from leaving a crude oil train parked unattended, overnight, on a descending main track. While that may have been considered “compliant,” it certainly wasn't free from risk. Yet no additional measures were put in place to prevent a runaway. In the aftermath, we've heard some people say, “The accident was caused by someone who did not follow the rules,” as if that were the end of it. Case closed. But it's not that simple. No accident is ever caused by one person, one factor.
Some companies are clearly better at navigating this safety space than others. But why? It's not just the existence of processes. A Safety Management System, on its own, for instance, is not enough. Instead, these processes must be supported—and sustained—by leadership. What leaders believe—their priorities, and above all how they behave—sets the culture, including the safety culture.
In addition, good risk management requires good data and effective information flow. Getting the right information to the right person at the right time. Even more important—how that information is received and addressed by the receiver, or more generally, by the company, will make a huge difference in what and how information will be transmitted in the future!
Over the next two days, we are going to talk about how information flow reflects a company's culture and how it affects decision-making. We will distinguish between personal accountability and culpability, and we are going to have, I hope, a very frank discussion about how a punitive approach limits the flow of safety information—and how that same punitive approach may not prevent the recurrence of normal human failings that are a part of any system.
For example, if a helmsman turns right instead of left when so directed by the ship's master, running the ship aground, and the investigation determines that both were in a fatigued state as a result of the shipboard schedules, should the helmsman be disciplined?
This all has very direct consequences for the potential use of voice and video recordings, as an additional data source, in the context of a pro-active, non-punitive safety management system.
So I invite you to fully engage in these topics over the next two days, so that we can develop a common understanding of these issues and a meaningful way forward to maximize the benefits of all data sources, and truly advance transportation safety.
- Footnote 1
Reason, J. (1997) Managing the Risks of Organizational Accidents. Ashgate Press.
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