industry collaboration bowties - cge risk · 2018. 10. 5. · industry collaboration bowties 05...
TRANSCRIPT
Industry collaboration bowties
Presented by David Griffin28 September 2018
Industry collaboration bowties 05 June 2018
What RSSB does…
2
“Through research, standards, analysis and insight, RSSB supports our members and stakeholders in driving improvements in health and wellbeing and delivering a safer, more efficient and sustainable rail system.”
Products and services:
▪Tools and models
▪Risk modelling
▪Guidance, expertise, advice
▪Training
▪Good practice and tools
▪ Industry systems
▪Standards
▪Networking and industry groups
▪Research
Focus on those issues which one company can't solve on its own efficiently
Organisations have a legal duty to cooperate with one another on safety
Industry collaboration bowties 05 June 2018
What RSSB does not do….
3
Determine overall transport strategyAward franchises
Manage the track, infrastructure and stations
Operate passenger or freight trains
Investigate accidents
Enforce compliance against safety standards
etc
Industry collaboration bowties 05 June 2018
Introduction
4
Industry collaboration bowties
▪ Collaboration
‒ Processes
‒ Information
‒ Tools
‒ Focus
▪ Collaboration bowties
‒ Understanding risk
‒ Prioritisation
‒ Monitoring
▪ Generic hazards
▪ Standards
▪ Reporting systems
▪ The vision
Industry collaboration bowties 05 June 2018
Safety risk management: legal duties
Single duty holder
• Ensure safety so far as is reasonably practicable
• Carry out suitable and sufficient risk assessments
• Have in place a Safety Management System
Industry collaboration bowties 05 June 2018
Safety risk management: co-operation
• ROGS regulation 22: duty of co-operation
Single duty holder
Co-operation
Industry collaboration bowties 05 June 2018
Safety risk management: collaboration
Single duty holder
Co-operation
Collaboration
• Working together to tackle:
− Shared risks
− Common interface issues
− System-wide problems
Industry collaboration bowties 05 June 2018
Enablers of safety collaboration
Common processes
Common information
Common tools
Common focus
Industry collaboration bowties 05 June 2018
Enablers of safety collaboration
Common processes
Common information
Common tools
Common focus
Industry collaboration bowties 05 June 2018
Common processes
Taking Safe Decisions
• Principles applied by GB railway in making decisions that impact on safety
• Published following extensive programme of research and consultation
• Industry consensus endorsed by regulator
Industry collaboration bowties 05 June 2018
Common processes
Taking Safe Decisions
• Principles applied by GB railway in making decisions that impact on safety
• Published following extensive programme of research and consultation
• Industry consensus endorsed by regulator
Industry collaboration bowties 05 June 2018
Commercial and other drivers
Common processes: Taking Safe Decisions
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
ReviewAnalyse
Yes
No
Yes
Select options
Analyse options
Scope problem
Make change?No
Monitor
MonitoringMaking a change
Safety concern?
Industry collaboration bowties 05 June 2018
Common processes
VPF2017=£1,897,000
Industry collaboration bowties 05 June 2018
Enablers of safety collaboration
Common processes
Common information
Common tools
Common focus
Industry collaboration bowties 05 June 2018
Common information
Safety Management Intelligence System (SMIS)
Industry collaboration bowties 05 June 2018
Common information
1988 - Clapham Junction
BR Incident Management System
Industry collaboration bowties 05 June 2018
Common information
1988 - Clapham Junction
BR Incident Management System
1994 - Privatisation
Safety Management Information System
Industry collaboration bowties 05 June 2018
Common information
1988 - Clapham Junction
BR Incident Management System
1994 - Privatisation
Safety Management Information System1999 – Ladbroke Grove2000 – HatfieldSafety Risk ModelAgreement: open sharing of safety data
Industry collaboration bowties 05 June 2018
Common information
1988 - Clapham Junction
BR Incident Management System
1994 - Privatisation
Safety Management Information System1999 – Ladbroke Grove2000 – HatfieldSafety Risk ModelAgreement: open sharing of safety dataPrecursor Indicator Model
Close Call System
Safety Management Intelligence System
Industry collaboration bowties 05 June 2018
Common information
Safety Management Intelligence System
Industry collaboration bowties 05 June 2018
Common information
1988 - Clapham Junction
BR Incident Management System
1994 - Privatisation
Safety Management Information System1999 – Ladbroke Grove2000 – HatfieldSafety Risk ModelAgreement: open sharing of safety dataPrecursor Indicator Model
Close Call System
Safety Management Intelligence System
Industry collaboration bowties 05 June 2018
Enablers of safety collaboration
Common processes
Common information
Common tools
Common focus
Industry collaboration bowties 05 June 2018
Common tools: Safety Risk Model (SRM)
• A structured representation of safety risk on the mainline railway
• Mature and well-used
• Basis for almost all safety-related QRA
• Disaggregates risk into >100 hazardous events and ~3,000 precursors
• Risk Profiling Tool allows localisation
Industry collaboration bowties 05 June 2018
Common tools: bowties
▪Not widely used at cross-industry level (yet)
– Freight derailments
– Road risk
– Trespass
▪More widely used within individual companies
▪Complements quantitative approach (SRM)
24
Industry collaboration bowties 05 June 2018
Enablers of safety collaboration
Common processes
Common information
Common tools
Common focus
Industry collaboration bowties 05 June 2018
Common focus: industry strategy
• Commitment from Industry leaders
• Priority initiatives to reduce health and safety risk
• A reference point for industry collaboration
Industry collaboration bowties 05 June 2018
Common focus: 12 priority areas
1. Workforce health and wellbeing
2. Public behaviour
3. Station operations
4. Road risk
5. Level crossings
6. Fatigue
7. Workforce safety
8. Infrastructure asset integrity
9. Workforce assaults and trauma
10.Train operations
11.Freight
12.Rolling stock asset integrity
Industry collaboration bowties 05 June 2018
Next generation reporting
systems and risk models
More effective
assuranceImprove learning,
sharing and horizon
scanning
Next generation rules and controls
Improved Health and
safety cooperation
Smart supplier
capability assessment
& information
Develop our people
Exploit new technology
Design for health &
safety and change
management
Common focus: improving our capability
Industry collaboration bowties 05 June 2018
Common focus: Industry safety, health and wellbeing groups
System Safety Risk Group
People on Trains and in Stations Risk Group
Train Accident Risk Group
Level Crossings Strategy Group
Road Risk Group
Trespass Risk Group
Suicide Prevention Duty Holders Group
Infrastructure Safety Leadership Group
National Freight Safety Group
Heritage Trains Safety Group (TBC)
TARG Editorial Board
Cross Industry Freight Derailment WG
SPAD Risk Reduction Strategy Working Group
Platform Train Interface Strategy Working Group
Health & Wellbeing Policy Group
Health Economics Group
Health & Wellbeing Professions Committee
Risk Management Capability Group
High Integrity Systems Group
SMIS Advisory Group
Risk and Safety Intelligence PAG
Industry collaboration bowties 05 June 2018
What do the risk groups do?
30
Monitor industry safety performance
Highlight emerging safety issues
Champion cross industry initiatives
Identify safety priorities and share
with industry
Advise RSSB on its products, services
and work programmes
Support RSSB’s engagement and communications
Share relevant learning and good
practice
Horizon scanning
Advisory only - a platform for cross-industry collaboration and exchange of informationNo safety management responsibilities - management of company safety obligations remains with DHs
Industry collaboration bowties 05 June 2018
The Taking Safe Decisions framework
31
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Monitor industry safety performance
Highlight emerging safety issues
Horizon scanning
Champion cross industry initiatives
Identify safety priorities and share with industry
Advise RSSB on its products, services and
work programmes
Support RSSB’s engagement and communications
Share relevant learning and good practice
Collaboration bowties
32
Industry collaboration bowties 05 June 2018
Collaboration bowties
▪ Inform a common cross-industry understanding of risk and how this risk is controlled
▪Highlight weak risk controls and identify what improvements can be made
▪ Identify where additional monitoring could improve understanding of the effectiveness of risk controls
▪Be overlaid with the various industry requirements and thus showing a clear link to industry standards
▪ Inform the future development of standards, guidance, tools and training.
33
Industry collaboration bowties 05 June 2018
What do collaboration bow ties look like?
▪High level – specified level of interface between DHs
▪Validated by cross-industry group
▪Barriers scored for effectiveness
– Publicly available (un-scored)
– Available to members (scored)
▪Chained where appropriate
▪Threat lines linked to SRM (where possible)
34
Industry collaboration bowties 05 June 2018
Scoring the effectiveness of controls
35
Existing and potential future risk controls scored according to an effectiveness scale, such as:
Scores are “national” average
Industry collaboration bowties 05 June 2018
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Using bowties to support monitoring
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Industry collaboration bowties 05 June 2018
Using bowties to support monitoring
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Effective monitoring allows the risk groups to understand:• The overall level of risk and temporal trends
in risk• The effectiveness of individual or groups of
controls• The effectiveness of any risk improvements
Industry collaboration bowties 05 June 2018
Monitoring residual risk – Safety Performance Indicators (SPIs)
• Measurements that reflect the effectiveness of the risk control arrangements.
• Used to determine whether (or not) any trends are appearing in safety performance.
• Two key types of SPI:
38
Activity Results
(outcome)
Precursors
(outcome) Accidents
(outcome)
Drugs and alcohol
testingTests
passedSPADs
Train
collisions
Activity
Outcome
A measure of whether a risk control system is in place
A measure of events after they have occurred
Industry collaboration bowties 05 June 2018
SPIs and BowTies
39
ActivityResults
(outcome)
Activities required to deliver the risk control
Measure of whether the risk control is in place
Measures the results of the activity indicatore.g. audit findings or inspection scores
Loss of
control
(outcome)
Precursors
(outcome) Accident
(outcome)
Industry collaboration bowties 05 June 2018
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Using bowties to prioritise improvements
Scope problem
Analyse options
Select options
Define change
Identify hazards
Determine risk acceptance principles
Demonstrate compliance
Determine safety requirements
Implement
Yes
Safety concern?
Monitor
ReviewAnalyse
Yes
No
Make change?
Commercial and other drivers
No
Industry collaboration bowties 05 June 2018
Using bowties to prioritise improvements: Scoring process
▪ Identify controls where control effectiveness could be improved
▪ Identify prospects or initiatives that are required to realise this improvement
– Improvement of existing control
– Implementation of new control
42
Criterion L M H
Cost pa <£100k £100k-£1M >£1M
Complexity Local, Single Duty Holder (SDH)
National SDH, or multi DHs in same country
Multi-modal, multi DHs internationally
Timescales 6 months 6m-2years >2 years
Criterion L M H
L L M H
M L M H
H L M H
Ease of Implementation of change
Novel solution / change process
Adaptation of known solution & change process
Known solution & change process
Ease of monitoring effectiveness of change
New monitoring
Adapted monitoring
Existing monitoring
Industry collaboration bowties 05 June 2018
Using bowties to prioritise improvements: Safety benefits
▪By how much would this project/initiative, in isolation, reduce this specific threat?
– Either directly
– As an enabler to further work
43
Industry collaboration bowties 05 June 2018
Using bowties to prioritise improvements: Prioritisation
▪Threat lines can be linked to SRM
– Robust estimate of the significance of the threat line (FWI/yr)
▪Controls may exist on more than one threat line
– Need to be combine safety benefits
▪Projects/initiatives can be plotted:
– Safety benefit score
vs
– Effort score
44
1
2
3
4 5
6
7
8 9
10
11
Effort ≈ Safety Benefit
Effort ≈ 2 x Safety Benefit
Effort ≈ 5 x Safety Benefit
Effort ≈ 10 x Safety Benefit
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
Safe
ty B
enef
it S
core
Effort
SAFETY BENEFIT / EFFORT: TOP 10
Generic hazards and standards
45
Industry collaboration bowties 05 June 2018
Generic hazards
Intended to be an input to risk assessment / hazard identification process
– Encourages a consistent approach to hazard naming and levels
– Reduces effort in hazard identification
– Reduces the likelihood of missing hazards
– Published for rolling stock in GEGN8642 issue 1
46
Railway System (not complete!)
Train
Track Station
Signalling
Structure Level Crossing
Electrification
Failure of train
wheelset
Cyclic top
Train detection failure (wrong side)
Structure collapse of overbridge Potential for
slip, trip or fall
Generic hazards generally on the boundary of the railway “subsystems”
Industry collaboration bowties 05 June 2018
Leve
l 2
cau
se
Leve
l 1ca
use
Rai
lway
sy
stem
ca
use
Rai
lway
sy
stem
haz
ard
Acc
iden
t
So how do generic hazards relate to collaboration bowties?
47
Derailment
Collaboration bowtieRailway system level
Sub-system level 1 bowtie
Sub-system level 2 bowtie
Loss of train
guidanceWheelset
failureAxle bearing
failure
Generic hazards
Manufacturing defect
Hot Axle Box Detection (Trackside)GERT8014 Axlebox condition monitoring
Generally more “causal” than collaboration bowties
Industry collaboration bowties 05 June 2018
Development of generic hazards
• Start with an initial set of hazards
• e.g. the list in GEGN8642 issue 1
• As standards NTRs/RISs are updated, undertaking a mapping exercise
• Mapping each requirement to one or more generic hazards based on which hazards the requirement is potentially a control for
• If hazard doesn’t exist then create it
• Publish mapping as appendix to NTR/RIS
• If the mapping is successful (and useful to the users) then complete for all standards
• As bowties are developed “causally” ensure that there is consistency between generic hazards and bowtie top events and threats
48
Industry collaboration bowties 05 June 2018
GIGN7619
49
Industry collaboration bowties 05 June 2018
Development of generic hazards
50
CSM RAHazards can be close out by “codes of practice”
Goal“to be able to select a hazard, and to query all the requirements than control that hazard from all standards”
The vision
51
Industry collaboration bowties 05 June 2018
Phase 1 – Industry Collaboration Groups
52
How is risk controlled?
What controls work well/badly?
What has happened in the past?
Industry reporting systems
Railway System Level Bow Ties
Industry Collaboration Group
Projects and initiatives
How could controls be improved?
Duty Holder data entry
Safety Reporting
Past event data
Safety Monitoring
Strategy
Duty Holders
Project Progress
Projects and initiatives
considered by Duty Holders
Control effectiveness
What does this really mean?
Industry collaboration bowties 05 June 201853
Industry reporting systems
Safety Risk
Model
Risk Profiling
Tool
Hazards aligned where possible
Duty Holder Bow Ties
Download and adapt
Bow Tie Server
Railway System Level BowTie
Level 1 BowTie
Duty Holder audit & incident
investigationData informs effectiveness
Duty Holder data entry
Data for risk estimates
Duty Holder data informs
understanding of effectiveness
Generic Hazards
Industry Safety Requirements
(RMDB)
Du
ty H
old
erIn
du
stry
Co
llab
ora
tio
n
Data informs effectiveness
Hazards aligned where possible
SRM risk + DH data = DH risk profile
Sharing Bow TiesEffectiveness scores
Aligned BowTietop event and
threats
Industry safety reqmtsmapped to hazards
Potential Bow Tie Server / RMDB link?
Quantitative Qualitative
Phase 2 – Integration
Thank you