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![Page 1: IRSC 2009 Båstad Learning from failure: Research initiatives towards improving safety and reliability of the Swedish railway system Alexander Wilhelmsson.](https://reader036.fdocuments.us/reader036/viewer/2022062423/56649de65503460f94adf43c/html5/thumbnails/1.jpg)
IRSC 2009 Båstad
Learning from failure: Research initiatives towards improving safety and reliability of the Swedish railway system
Alexander Wilhelmsson
LUCRAM, Lund University, Sweden
Kurt Petersen LUCRAM, Lund University, Sweden
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IRSC 2009 Båstad, Sweden
Introduction
• Overview of ongoing research activities aiming at improving safety and reliability of the Swedish railway system
• 3 case studies will be briefly presented
• Research question forming the starting point for all of the research activities:
– What can we learn from failures in the railway system?
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IRSC 2009 Båstad, Sweden
Case study 1: Introduction
• The first of the three research activities is concerned with the ability to recover from failures affecting the railway system
• Two important aspects for describing a system’s resilience (i.e. ability to “bounce back” after failures) are its
– Robustness
– Rapidity
• Focus of this case study is on the system’s ability to return to normal operation after (large) failures, i.e. the rapidity aspect
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IRSC 2009 Båstad, Sweden
Case study 1: Response curves
• Particular focus on large failures where knowledge regarding available capacity is limited
• Previous failures (incidents and accidents) are used as a starting point
• By using so-called counterfactual scenarios in table-top exercises the aim is to gain knowledge of the capacity for handling (large) failures
• A workshop with employees from the Swedish Rail Administration has resulted in so-called response curves illustrating the recovery time with respect to the severity of strain
• The shape of the response curve reveal a number ofinteresting characteristics
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IRSC 2009 Båstad, Sweden
Case study 1: Vulnerability analysis
• The results from the present study are used as a starting point for vulnerability studies of the technical systems
• In this type of study, the use of recovery times are important in order to achieve realistic measure of the system’s overall vulnerability
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IRSC 2009 Båstad, Sweden
Case study 1: Discussion
• This case study contribute to improved knowledge regarding the capacity to restore the railway system after failures
• In particular, increased knowledge regarding the maximum capacity for handling failures can be gained
• The results are valuable for the assessment of the railway system’s overall vulnerability, e.g. for vulnerability analyses
• This information can be used as a basis for decision making regarding adequate resources in the face of future failures
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IRSC 2009 Båstad, Sweden
Case study 2: Introduction
• Case study 2 also use previous failures as a starting point
• However, in this study emphasis is on why these incidents and accidents happen
• The aim is to study how learning from previous failures can be used for avoiding failures in the future
• We should not only aim at avoiding the exact same accident, but to generally improve safety
• Accident investigations constitute an important tool for learning from accidents and incidents
• Case study 2 includes a comparison between the approach for investigating accidents and incidents in Sweden, Norway and Denmark
• Although the societies in general have a number of similarities, the investigation boards differ in some aspects between these countries
• What obstacles to learning from accidents can be identified, stemming from these differences?
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IRSC 2009 Båstad, Sweden
Case study 2: Initial studies
An initial comparison between the accident investigation boards in Sweden, Norway and Denmark show some differences in terms of structure and responsibility
2002: Permanent AIB also includes railway accidents
2005: Permanent AIB also includes road traffic accents
1978: Permanent AIB for civil and military aviation accidents established
1989: Permanent AIB for civil aviation accidents established
2008: Permanent AIB includes aviation, sea, road traffic and railway accidents
2004: Permanent AIB for civil aviation and railway
2001: Permanent but separate AIB for road traffic accidents
1990: AIB includes 'all types of accidents'
1970 1980 1990 20102000
(AIB = Accident Investi-gation Board)
1979: Permanent AIB for aviation accidents established
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IRSC 2009 Båstad, Sweden
Case study 2: Preliminary results
• The preliminary results from this study indicate that some of the factors that influence the ability to learn from accidents include:
– The structure of the accident investigation board, i.e. the number of investigators, their level and span of skills and competences
– The mandate of the investigation board, i.e. ability to influence the implementation of recommendations and follow-up activities
– The investigation method used by the investigators, i.e. what causes that are emphasized, the formulation of recommendations
– The processing of information between involved actors, i.e. the way that findings in the investigation is conveyed
• Future work include analysis of a number of accident investigation reports issued by the accident investigation boards
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IRSC 2009 Båstad, Sweden
Case study 3: Introduction
• Case study 3 is focusing on safety investments in railway tunnel projects
• Several sets of guidelines and legislations are applicable for the safety design of railway tunnels in Sweden
• This has resulted in disagreements between different actors involved in the process, due to incompatibility of these legislations
• Attempts to solve disagreements and different views among authorities involved in tunnel projects have not been successful
• The aim of this study is to investigate;
– how the decision making process and the outcome regarding safety investments is affected by these incompatible legislations, and
– what bases for decision making that are used in practice
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IRSC 2009 Båstad, Sweden
Case study 3: Method and results
• The study is based on interviews and document studies including six railway tunnel projects in Sweden, consisting of a total of 28 tunnels
• 11 interviews have been carried out with a total of 18 persons
• The results from the interviews show that there has been a substantial focus on safety considerations from an early stage in all studied projects
• Disagreements become evident during the approval of building permit, which is required in order to build tunnels in Sweden
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IRSC 2009 Båstad, Sweden
Project C
Final safety design
Project B
Final safety design
Building permit Yes/No
Decision making regarding safety design
Revision of safety design
No
Final safety design
Yes
Employees from Swedish Rail Admin.
Consultants
Building proprietor
§
Rescue service
Local building committee
Municipality
§ § Project A
Final safety design
• Several applicable legislations
• Decentralised decision making involving local building committee and local rescue service
• The role of the rescue service
• Comparisons with the outcome from other projects (“precedents”)
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IRSC 2009 Båstad, Sweden
Case study 3: Discussion
• Decentralised decision making in questions that are considered to be of national interest put a lot of pressure on local decision makers
• A detailed comparison of the different safety measures in each project shows that no major differences can be identified
• This can be explained by a substantial influence from comparisons with other projects (“precedents”)
• Suggestions on different ways of solving the identified problems have been put forward, e.g.:
– excluding tunnels from the requirement for building permit
– new attempts for achieving consensus or coordination between authorities
– clarifying the role of the rescue service
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IRSC 2009 Båstad, Sweden
Conclusions
• Several processes that together influence the ability to improve safety and reliability of the Swedish railway system have been identified
• Learning from previous failures is a valuable starting point, both in order to gain knowledge of existing capacity and to make improvements
• The ability for generalization of the results needs to be further addressed
• Although further and more detailed studies are necessary, the different case studies provide valuable input in order to improve the safety and reliability of the Swedish railway system
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IRSC 2009 Båstad, Sweden
Finally…
Thank you for your attention!
Questions or comments?
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IRSC 2009 Båstad, Sweden
Case study 3: Description of studied projects
Length of the tunnels included in the study
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
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A A A A A A A A A A A A A A A A B C D E F F F F F F F F
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IRSC 2009 Båstad, Sweden
Case study 3: Description of studied projects
Project Trafic flow per day Tunnel type Geographic posistion
A 28 passenger trains and 20 freight trains Single-track tunnel Rural area
B 420 passenger trains Tw o single-track tunnels City area
C 104 passenger trains and 35 freight trains Tw o single-track tunnels Rural area
D 8 passenger trains and 24 freight trains Single-track tunnel Rural area
E 120 passenger trains and 50 freight trains Double-track tunnel Rural area
F 31 passenger trains and 21 freight trains Single-track tunnel Rural area
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IRSC 2009 Båstad, Sweden©
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IRSC 2009 Båstad, Sweden
Case study 1: Empirical study
Blue shadowed field: estimated minimum andmaximum recovery time
Black line: estimated most likely recovery time