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Sao Paulo, Brazil: Attorney General orders improvements at multiple crossings

The federal Attorney General has ordered that improvements at multiple level crossings must be made so that they meet minimum standards. 14 of the level crossings deemed critical are located in the cities of Jaú, Dois Córregos, Torrinha and Brotas.

The civil action requires that that immediate action is taken to ensure the safety of drivers and pedestrians. The parties that are required to take action within 30 days at the 14 crossings with critical deficiencies are the municipalities and the railway concessionaires ALL América Latina Logística SA, and ALL América Latina Logística Malha Paulista SA. There are an additional 16 level crossings where a plan setting-out intended remedial action is required within 60 days. The need for action has been determined by the safety regulator, ANTT.

Measures that need to be taken include ensuring that train horns are sounded as required, clearing vegetation obstructing sight-lines, renewing and improving signage and in some cases installation of active controls.

Failure to take action as required can incur a penalty of BRL 30,000 per day in respect of the critical crossings and a like sum if the remedial plan for the other 16 crossings is not submitted as required.

(June 28th, 2011)

Washington, DC: FTA launches SMS guidance for transit systems

The Federal Transit Agency (FTA) has launched guidance for transit system operators which will facilitate the development and implementation of Safety Management Systems (SMS) and Safety Performance Measurement Systems (SPMS).

In recent years the public transportation fatality rate has levelled‐off. Therefore the statistical reality is that as the transit industry grows and the passenger‐miles increase, the total numbers of fatalities and serious accidents will also increase. While the current rates of fatalities and accidents are low compared to other modes of surface transportation, any appreciable increase in the number of fatalities would be detrimental to an industry that for years has prided itself on its safety record. To avoid this situation, the transit industry needs to reduce the current low accident and fatality rates even further.

It is widely accepted that most public transportation accidents result from a combination of human, technical and organizational factors. Recent research and in‐depth accident investigation reports suggest that most of the links in an accident chain are under the control of the organisation, and accidents can best be prevented when the underlying causal factors are addressed at the organisational or system level. Human errors and technical failures are symptoms of the lack of organisational focus, accountability and communications. Addressing the root causes of public transportation accidents has become especially urgent in light of the recent high‐profile rail transit accidents.

Although level crossing accidents have a significant road user and / or pedestrian component, including level crossings within a transit system’s SMS constitutes good practice.

This FTA guidance makes clear that SMS offer the most promising means of preventing public transportation accidents by integrating safety into all aspects of a transit system, from planning to design to construction to operations to maintenance. SMS build on the four elements identified in the ʺSystem Safety Program Requirementsʺ, which has its origins in the defence and space industries:

  • A planned approach to system safety programme tasks
  • Qualified personnel to accomplish the tasks
  • Authority to implement the tasks through all levels of management
  • Appropriate financial and personnel resources to accomplish the tasks.

Safety management is based on the fact that safety is not an absolute condition ‐‐ there will always be hazards and risks in public transportation. Therefore, systematic and pro-active management is needed to identify and control these risks before they lead to mishaps. Small problems should be fixed before they turn into major ones. Isolated incidents should be investigated to see if they are systemic. When accidents occur, the lessons learned should be documented and actions should be taken to prevent similar accidents from occurring. Safety should become a common theme permeating the organisation, and affecting all individuals working there.

In the most basic form, safety management involves:

  • Defining clear levels of responsibility and accountability for safety within the organisation
  • Setting safety performance goals and actively pursuing them
  • Reporting and analysing hazards, incidents and accidents and taking corrective actions to prevent their recurrence
  • Managing safety risks systematically and proactively, including learning and continuous improvement
  • Developing a workforce that is knowledgeable, flexible, dedicated, and efficient
  • Monitoring and evaluating safety performance towards established goals.

Transitioning to safety management will require a cultural transformation on the part of both the transit industry and FTA in adopting a pro-active management approach for delivering on safety objectives and continuously improving public transportation safety. Safety management requires developing and sustaining a strong safety culture where the following practices and behaviours become ʹthe way we do business around hereʹ at each transit property:

  • Management is accountable and responsible for safety
  • Everyone in the organisation takes an active role in safety
  • Open communications and discussions of safety hazards and risks are encouraged
  • Safety hazards and close‐calls are reported
  • Risk management continues despite everything looking safe
  • Human errors and unsafe acts are treated as symptoms of organisational problems
  • Safety redundancy is inbuilt to ensure resilience in the face of unplanned events
  • Investment in safety is made even in times of financial constraint
  • Industry, oversight agencies and FTA work together to make the system safer
  • Practices and procedures are regularly reviewed and improved
  • Activities and decisions are risk‐based
  • Safety data are analysed to identify systemic causes
  • Investment is made in pro-active initiatives
  • The safety office is a pro-active partner working with other departments
  • Safety performance is measured
  • Safe practices, continuous learning and improvement are the norm, even during times of financial problems and labour pressure
  • Safety information is shared
  • The safety management system is audited
  • Safety information is shared internally and externally

In addition to developing and sustaining a safety culture, SMS has the potential of bringing other benefits. Many organisations have already adopted SMS and realized benefits such as:

  • Increased direct and indirect cost savings due to accident/loss prevention and reduction in insurance premiums
  • Increased competitive business advantage through a marketable record of safe operations
  • Logical prioritisation of safety needs based on the level of risk involved
  • Continuous improvement of operational and maintenance processes
  • Demonstrated due diligence when accidents occur
  • Improved communications and employee morale
  • Enhanced relationships and partnerships with other transit properties as a result of collaboration and information sharing
  • Increased collaboration between stakeholders on safety initiatives to mitigate risk, especially in emergency preparedness activities.

Performance measurement is a key component of safety management. Measurement brings clarity to vague concepts, helps transit agencies identify gaps in safety performance, and forces management and governing boards to take action to improve performance. Measurement of performance in a systematic way facilitates targeted intervention by regulatory authorities as weaknesses are identified.
The process of building and sustaining a successful SPMS is iterative, and involves a sequence of ten steps:

  • Getting started ‐‐ conducting a readiness assessment
  • Agreeing on outcomes & activities to monitor
  • Selecting key metrics
  • Identifying data needs
  • Pilot testing and collecting baseline data on metrics
  • Setting targets
  • Monitoring performance and evaluating results
  • Reporting findings
  • Integrating findings into decision‐making
  • Sustaining the performance measurement system.
FTA’s safety management system guidance

Performance measures should be developed in consultation with the key stakeholders including transit agency’s management, staff, customers, governing body, service contractors, and oversight organisations. Acceptance by these stakeholders is critical to the long term viability and success of the performance measurement program. In so far as level crossing safety is concerned, it is important to engage highways authorities and law enforcement agencies. Likewise Operation Lifesaver and other third party initiatives to improve safety need to be engaged.

SPMS developers should be encouraged to shift their focus from output/process measures to outcome measures that focus on safety goals and long‐term impacts. Performance targets should be realistic but, wherever feasible, should encourage progress beyond historical performance levels.

Sustained support and commitment of senior management are essential for the SPMS effort to take hold and become a vehicle for continuous safety improvement. Senior managers should be actively engaged in creating a measurement‐friendly culture by promoting performance measurement as a means of continuous improvement and using the resources and other tools at their disposal to accomplish such culture change. In addition, senior managers should set a personal role model by utilising performance metrics in decision‐making. When top managers insist on receiving and using performance indicators, and when the word is spread throughout the organisation, attitudes change rapidly.

Investment in developing skilled human resources capacity is essential to sustaining the SPMS initiative. Both technical and managerial skills will be needed for data collection and analysis, and setting goals. Investment in modern data systems and analysis tools will also be required to ensure the long‐term success of SPMS. The governing board and senior management must commit the financial resources required for building organisational capacity and maintaining the SPMS on a continuous basis.

The SPMS should be able to produce and report the true story ‐‐ both good and bad news. Performance information should be transparent, made available to all stakeholders, and be subject to independent verification. Messengers should be protected to preserve the integrity of the measurement system. The focus should be on opportunities for improvement rather than allocating blame.

There is little value in even the best‐designed performance metrics unless they are used systematically to inform decision‐making and drive safety improvement. Once the SPMS is in place, performance results should be evaluated carefully to gain insight into the success of past efforts and develop ideas for improving future performance.

Visible commitment to using metrics even when targets are exceeded re-affirms the message that performance measurement is a long‐term initiative as opposed to an episodic effort for a short period. One way of demonstrating commitment to performance measurement is to institute a formal process of reporting performance results. Another useful strategy is to have safety performance as a standing item on the agenda of executive meetings and staff meetings.

Acknowledging and rewarding employees who use performance results to learn and improve safety is important to sustaining the SPMS effort. This can be done through a variety of cost‐effective methods.

Separating the impacts of the transit agency’s activities from those of external factors beyond the agency’s control can be complex and challenging. For example, collisions involving a bus are influenced by many factors besides the actions of the bus driver. The impacts of weather, risky behaviours of pedestrians and other vehicle drivers should be understood and accounted for in evaluating the agency’s safety performance. In reporting performance results, it is important to explain any limitations of the performance evaluation process and caution the audience about interpreting the results in ways that may not be valid. This cautionary note is clearly applicable when addressing issues arising at level crossings.

The FTA guidance contains the following recommendations with regard to SMS:

  • Ensure that transit properties develop and implement safety management systems
  • Develop and sustain a positive safety culture
  • Promote practicing risk management in all activities
  • Demonstrate the feasibility of a Confidential Close Call Reporting System.

Similarly the guidance makes recommendations regarding SPMS:

  • Promote the adoption of standard terminology and uniform safety performance metrics in the public transportation industry
  • Advocate the need for clearly articulated safety goals and accountability for safety performance
  • Ensure that transit properties consistently measure and analyse safety performance
  • Encourage transit properties to consistently analyse and report performance trends and gaps
  • Identify gaps and establish quality standards for safety data.

Recommendations are also made concerning future research:
Produce a synthesis of best practices in developing and implementing safety management systems and safety performance measurement systems in the transportation industries

Develop a central clearinghouse for public transportation safety risk mitigation techniques by mode.

(June 21st, 2011)

Frankfort, Kentucky: Appeal Court upholds judgment in favour of railway

Kentucky’s Appeal Court has upheld a judgment that the Illinois Central Railroad Company (ICRR), a component of Canadian National’s operations in the United States, is not liable for an accident in which a train collided with a road vehicle on a passive level crossing.

The Appeal Court hearing stems from a January 21st, 2010, Hickman Circuit Court judgment and verdict, which dismissed all claims against the ICRR in a level crossing accident in which an ICRR train collided with a pick-up truck.

The accident in question occurred on August 17th, 2003, at the Tommy Via Road level crossing, in rural Hickman County. The truck driver, who had used the crossing numerous times, said that typically he crossed the railway without stopping unless he heard a train horn.

When the accident occurred this practice was followed with the truck driver approaching the passive public crossing at between 25 and 30 mph before slowing down in order to navigate a right turn and incline at the crossing. The railroad crossing intersects the road at nearly a right angle.

While the motorist claimed he looked in both directions and didn’t hear a train horn. However, immediately before his truck was hit by the train, the motorist attempted to reverse clear of the railway. He was not successful.

The original trial had appropriately considered and concluded that the ICRR had satisfied its obligations under applicable laws.

(June 20th, 2011)

New Delhi, India: Prime Minister calls for improved safety at level crossings

India’s Prime Minister, Dr. Manmohan Singh, has called on the Minister of Railways to ensure that signage and the condition of the road surface at unmanned level crossings are improved to a level that is compliant with laid-down standards. The call for action from the highest level in government has been prompted by the recent spate of high-consequence accidents at unmanned level crossings.

(June 2nd, 2011)

Dr. Manmohan Singh, India’s Prime Minister
Dr. Manmohan Singh, India’s Prime Minister

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