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Accident Investigation and Learning to

Improve Safety Management in Complex

System: Remaining Challenges

Proceedings of the 55th ESReDA Seminar

Hosted by the

Romanian

Railway Investigation Agency

AGIFER, 9-10 October, 2018,

Bucarest, Romania

Paul, S., Marsden, E., Verschueren, F., Tulonen, T.,

Ferjencik, M., Dien, Y., Simola, K.,

Kopustinskas,

V. 2019

EUR 30013 EN

This publication is a

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EU Science Hub

https://ec.europa.eu/jrc

JRC118706

EUR 30013 EN

PDF ISBN 978-92-76-14172-3 ISSN 1831-9424 doi:10.2760/242130 Luxembourg: Publications Office of the European Union, 2019.

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How to cite this report:

Paul, S., Marsden, E., Verschueren, F., Tulonen, T., Ferjencik, M., Dien, Y., Simola, K., Kopustinskas, V. Accident

Investigation and Learning to Improve Safety Management in Complex System: Remaining Challenges. Proceedings of the 55th ESReDA

Seminar Hosted by

Romanian Railway Investigation Agency AGIFER, 9-10 October, 2018, Bucarest, Romania, EUR 30013 EN, Publications

Office of the European Union, Luxembourg, 2019, ISBN 978-92-76-14172-3, doi:10.2760/242130, JRC118706. XX

-NA-XXXXX-EN-N i European Safety, Reliability & Data Association (ESReDA) ii Table of Contents European, Safety, Reliability & Data Association (ESReDA)............................ i Table of Contents................................ ii

Preface....... 1

Welcome speech 5

Romanian Railway Investigation Agency AGIFER, past and future Abstract.. 7 Operational analysis and projections in the prevention and management of emergencies

Abstract.. 9

SEMINAR PAPERS.. 11

Session 1: Past, present, future.................. 13

On a possible approach for the multi criteria event analysis in complex systems events........... 15

1.Introduction.................................................................................................................. 16

2.Method description... 16

3.Results.. 28

4.Conclusions.. 32

5.References 33

Railway accident investigation in a globalising system.. 34

1.Introduction 35

2. Railways in the Netherlands increasingly international 35

3. Railway accident investigation still national. 36

4.Lessons learned 38

5.Globalisation of railway systems. 41

6.Follow the ICAO example?.......................................................................................... 42

7.Discussion. 42

8.Literature...... 43

From Sectorial to Multimodal Accident Investigation Boards Some Lessons from the

Development in the Nordic Countries 44

1.A global view basic patterns, some developments and trends 45

2.The developments of AIB in Nordic countries (Denmark, Finland, Iceland,

Norway, Sweden). 47

2.1. Denmark. 47

2.2. Finland 47

2.3. Iceland 48

2.4. Norway... 48

2.5 Sweden. 48

3. Some important trends . 48

4. Multimodal AIBs some problems 49

5. Proposals for improvements... 49

Session 2: Organizations and human aspects 51

Learning from organisational dysfunctionalities, a Work in Progress 53

1.Introduction: Learning from Organizational Dysfunctionalities a Work in

Progress 54

2.From Organizational constituents to Organizational Factors 54

3.Hidden latent causes and organizational Factors. 55

4.Failing Governance or Organizations becoming dysfunctional 58

5.Signs of failing Organizational Structure as illustration of the WiP 59

6.Texas City Refinery case as illustration of a failed structure 60

7.Conclusion 61

Effective Communication During and After an Aviation Accident. 62

1.What to expect in the days immediately following an aviation accident and how can

the communication team be better prepared for coping with the public pressure and

media requests?............................................................................................................ 62

iii

2. Massive pressure from both internal and external factors 63

3. What we did immediately and after the accident?........................................................ 63

4. How high was the public interest?............................................................................... 63

5. Lessons learned. The most important lesson learned, from the communication point

of view. 65
Issues with lessons learned, as seen by field experts and managers, and synergy between experience reporting and experience sharing 67

1. Study 67

1.1. Introduction... 67

1.2. Methodology... 68

1.3. Results... 68

1.4. Verbatim 69

1.4.1. Field experts only. 69

1.4.2. Managers only... 69

1.4.3. Managers and field experts... 69

2. Discussion.. 70

2.1. Competition between experience reporting and experience sharing or synergy?. 70

2.2. Risk estimation of safety events 72

2.3. Judgmental feedback. 73

2.4. Self-centred vision. 75

2.5. The perceived uselessness of experience report 76

3. Conclusion. 78

4. Acknowledgements 78

References. 78

Session 3: Methodological aspects 81

Method and Mindset: Two Basic Elements for Accident Investigation. 83

1. Introduction.. 83

2. Organisational Analysis of Safety 84

3. Mindset 92

4. Conclusion 95

Acknowledgements 96

References. 96

Events groups' importance ranking with consistent preferences consideration. 99

1. Introduction. 100

2. Method. 100

2.1. Implementation - OPERATE Tool 100

3. Results.. 102

3.1. Other results.. 103

4. Conclusions.. 103

References.. 104

Reasonable recommendations 105

1. Background 106

2. The ESReDA Cube model. 106

3. Examples of ESReDA Cube applications.. 109

3.1. Derailing in Romania in 2017... 109

3.2. Explosion at BP Texas in 2005. 112

3.3. Explosion in Finland in 2018 113

3.4. A large set of recommendations in aviation.. 114

4. Results and discussion. 115

5. Conclusions.. 116

5.1. Acknowledgements... 116

6. References. 117

Session 4: Lessons learned and historical perspectives.. 119 Learning from incidents the interactive way.. 121

Introduction 121

1. How hindsight bias can impact learning?..................................................................... 122

2. How the case studies work... 122

2.1. The case studies. 123

2.2. Application of the case studies.. 124

iv

Conclusion.. 125

References.. 125

Using the owledge Operation: A Case Study on the Framing of

Organisational Diagnosis of Safety Management..

126

1. Introduction.. 126

2. Learning from Accidents, Knowledge, Normal Operations and Organisational

Diagnosis..

128

2.1. Learning from events and accidents research tradition. 128

2.2. From failures to learn accides lessons to the knowledge of accidents.. 128

2.3. Organisational analysis and diagnosis, pathogenic organisational factors 130

2.4. Some limits of the approach relying on lessons from accidents... 131

2.5. Normal operations research tradition 131

2.6. Research gap: the challenge of using knowledge of accidents in normal

operations 132

3. Approach.. 132

3.1. The context of the research case 132

3.1.1. Assessing management of safety by experts at IRSN: generic principles 132

3.1.2. Assessing management of safety and radiation protection during outages:

building a specific analysis framework... 134

3.2. Methodology, data collection and analysis... 135

4. The case study on the use in practice of the knowledge of accidents in

organisational diagnosis of safety management... 136

4.1. The use of the generic accident model and the dynamic of risk management.. 136

4.2. The use of lessons from accidents to address management of change.. 138

4.3. The use of lessons from accidents to address organisational complexity. 140

4.4. 141

4.5. The use of lessons from accidents to address human resources management.. 141

4.6. The use of lessons from accidents to address learning process from outages... 142

5. Conclusion 143

Acknowledgements 144

References. 144

Are structural weaknesses limiting the capacity to learn from incidents?................................... 150

1. Introduction.. 150

2. Good practice: what is meant by the term?.................................................................. 153

2.1. 'Good. 153

2.2. . 154

2.3. The ove 154

2.4. Context and the objectification of practice 155

2.5. 'Good' practice: a cliché?....................................................................................... 156

3. Practices in investigating and learning from incidents 156

3.1. Examples of 'good' practices of investigating incidents 157

3.2. Examples of 'good' practices of learning from incidents 157

3.3. Examples of 'good' practices that overlap investigating and learning from

incidents.. 158

3.4. 158

3.5. Instrumental use of t. 159

4. Social Structures and 'good' practice 159

5. Lifelong learning and the capacity to investigate and learn from incidents. 160

5.1. Education and training structures aimed at competence in incident

investigation.. 161

5.2. Structures, learning-to-learn and the development of practice. 163

5.3. Lifelong Learning Structures: Summary.. 166

6. Empiricism as a determinant of the capacity to investigate and learn from incidents. 166

6.1. Empiricism and the individual practitioner.. 167

6.1.1. Reflection and the practitioner. 167

6.1.2. Reflection through review and debrief. 169

6.2. The Case for Case Studies. 170

6.3. Continuous improvement and learning from incidents. 173

6.4. Mentoring and coaching practitioners... 174

6.5. Post-investigation critical review of investigation practice.. 175

v

6.6. Systematic study of 'good' practice... 177

6.7. Structures that support empiricism: Summary. 179

7. Cooperation between practitioners and academics as a factor of the capacity to

investigate and learn from incidents 180

7.1. 180

7.2. tations of cooperation with academics.. 180

7.3. What might academics expect from cooperating with practitioners?................... 183

7.4. Technical rationality, and the risks created by limited cooperation.. 184

7.5. The divide between academics and practitioners.. 185

7.6. Models for cooperation between academics and practitioners. 186

7.6.1. Collaborative evaluation research. 186

7.6.2. Participatory Action ResearchPAR.. 187

7.7. Cooperation in lifelong learning 188

8. Conclusions... 189

9. Acknowledgements.. 190

10. References. 191

Session 5: Methods.. 195

Do not repeat old mistakes in learning from accidents: It`s better to prevent a runaway than be ready for it 197

1. The incident. 198

2. Application of methods for incident investigation 199

3. Lessons learned 202

4. Comparison of lessons learned. 205

5. Twenty-three years after 207

6. Conclusions. 208

References.. 209

Analysing the depth of railway accident investigation reports on over-speeding incidents,

AFRAN..

210

1. Introduction.. 211

2. Case study. 212

3. Conclusions.. 215

4. References 219

On some issues related to the railways events impact on other industries 221

1. Introduction.. 221

2. Method and case study results.. 222

3. Conclusions.. 228

References.. 229

Session 6: Case studies 231

Historical contradictions in railway sector work accidents in which workers are run-over by trains: analysis based on the Cultural Historical Activity Theory. 233

1. Introduction.. 234

2. Method. 236

3. The railway activity system 237

3.1. A dialectical, systemic and historical perspective for the understanding of work

accidents.. 238

4. Final Considerations. 241

Acknowledgements 242

References.. 243

An historical and organisational point of view on Bretigny 2013 railway accident.. 245

Warning.. 246

Introduction 246

1. Track maintenance and safety model in France 247

1.1. Preventive maintenance of tracks to keep them from deterioration. 248

1.2. Precautionary measures to manage occasional deteriorations.. 248

1.3. The assignment of a track sector to a dedicated team that is responsible for its

maintenance. 249

2. An aging network that is deteriorating due to a lack of investment 249

2.1. A structurally unprofitable system that is inadequate to maintain the substance

vi of the network 250

2.2. A specific local context that heavily penalises the Brétigny sector.. 252

2.2.1. The intense traffic on the Brétigny sector accelerates track aging.............. 252

2.2.2. An inadequate track design that exacerbates equipment fatigue.. 252

2.2.3. The combination of these mechanical stresses leads to accelerated track

deterioration 253

2.3. Budgetary pressure blocks the implementation of measures adapted to the

excessive track solicitation in Brétigny. 254

2.4. Due to a lack of ad level becomes critical

and impacts safety. 255

3. A structural crisis that puts the pressure on maintenance organisations and impacts

safety management. 256

3.1. Reorganisations with insidious consequences.. 256

3.1.1. A process of progressive adaptations with budgetary imperatives... 256

3.1.2. Reorganisations with an insidious and in-depth impact on the equilibrium

of the maintenance and safety model.. 257

3.2. Arbitrary cuts in personnel that heavily penalise the Brétigny sector... 258

3.3. The collapse of the track safety management system in Brétigny 260

4. Conclusions and perspectives.. 261

References.. 262

A freight train derailment analyses using Accident Investigation Board Norway method and

Safety Management System wheel tool.

264

1. Railway safety (Safety Management) and learning from experience.. 265

2. General terms about investigation methods, the method of the Investigation Body

r

Railways..

267

3. Information on the accident covered in the Investigation Report 269

4. Analysis of the accident using the methods of investigation described above. 272

5. Conclusions on strengths and weaknesses of the two methods 274

References.. 278

Session 7: Going across sectors 279

Independence and Interdependence in Safety Investigations.. 281

1. Romanian safety investigation authorities 281

2. How appropriate is to have a multimodal safety investigation authority in Romania?

What are the advantages and disadvantages of such an organization in Romania?..... 283

3. Present and possible future concerning the independence and interdependence in

safety investigations. 284
Some aspects of the probabilistic versus risk evaluations of railways events.. 286

1. Introduction.. 286

2. Method and results... 286

3. Conclusions.. 290

References.. 290

Key Factors of the National Emergency Management System 291

1. Introduction.. 291

2. The Model or Emergency Response Management 292

3. Results and conclusion. 297

4. Conclusion 300

References.. 300

Workshop 301

BIOGRAPHIES...................................................................................................................................... 309

ANNEXES............................................................................................................................................... 361

Annex A 55th ESReDA seminar program. 363

Annex B About the seminar 367

Scope of the Seminar. 367

Application domains.. 368

vii

Seminar organization. 368

Location... 368

Organization 368

Chairman of the seminar.. 368

The Technical Program Committee Chair... 368

The Technical Program Committee Members. 368

Opening of the seminar 369

Closing of the seminar. 369

Logistics.. 369

About Romanian Railway Investigation Agency AGIFER 369 About the European Safety, Reliability & Data Association (ESReDA).. 370 About ESReDA Project Groups connected with this seminar.. 370

The . 370

-up from accident 371

ESReDA Project Group on Foresight in Safety. 371

Participating Organisations... 371

Accident Investigation and Learning to Improve Safety Management in Complex System:

Remaining Challenges

1

Preface

a greater consideration of the historical dimension and of the cultural aspects in complex sociotechnical systems seems to be one of the recurring challenges Accident Investigation and Learning to Improve Safety Management in Complex System:

Remaining Challenges

2 s s ă s ܇ An incident with a freight train in the Port of Rotterdam that originated on the Black Sea could require the in

We should always keep in mind that the

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