Sluttrapport Deregulering og transportsikkerhet

Transkript

1 Sluttrapport Deregulering og transportsikkerhet S. O. Johnsen, L.Fjerdingen, J.Vatn RISIT Forskerkonferanse hos Veritas på Høvik den 1. og 2. oktober

2 Deregulering og transportsikkerhet Et samarbeidsprosjekt med bred involvering SINTEF/Sikkerhet og pålitelighet, NTNU/HF-fakultetet Prof Per Østby, TØI (Transport Økonomisk Institutt), Prof. Andrew Evans/UK, Prof. Andrew Hale/Nederland og Prof Ian Savage /Northwest University. Fokus på Innhenting og analysere empiri Gjennomgang og analyse av teori Publisering og forskningsformidling Utvikling av metoder for å redusere risiko ifbm større endringer 2

3 Tankekorset i prosjektet 3

4 Konklusjoner Området er komplekst og det er vanskelig å gi entydige konklusjoner. Vi har analysert mange dereguleringsprosesser, og finner ingen klare indikasjoner på at deregulering leder til økt risiko. Det er forhold som kan lede til økt risiko, men også forhold som kan gi lavere risiko. De dereguleringsprosessene vi har sett på har ikke ledet til økt antall ulykker. Vår forskning viser imidlertid at med gode prosesser* rundt dereguleringen, vil vi kunne gjennomføre endringen forsvarlig. Deregulering er derfor i seg selv ikke truende for sikkerheten. *Vårt forslag til metode for slike endringer beskriver gode prosesser 4

5 Resultater Vi har valgt å fokusere på seminarer og arbeidsmøter, for å diskutere og spre resultatene våre men også forskningsformidling publisering. I sluttfasen av prosjektet har vi fokusert på metodeutvikling for å få en konstruktiv og samlende vinkling på arbeidet vårt, med Mål/Goal: "How to improve safety during changes More detailed - suggest an approach (method) to improve safety during a major change process Overview is presented 5

6 Background Changes has been explored in Aviation (Deregulation USA Deregulation act 1978 ) Railways (Deregulation USA, EU example from Great Britain from 1994 to 2007) Road transport (1980- in America, Europe..) Of later interest (could results be explored?) The oil and gas industry (Integrated Operations at the Norwegian Continental shelf) 6

7 A major change process in this context A network of organizations in flux Service firm Service firm One Operator Service firm Change due to deregulation, outsourcing, or.. Operator Operator Operator 7

8 Theoretical perspectives Organizational issues The challenge of interactive and tightly coupled technologies: Perrow s theory of Normal Accidents The theory of High Reliability Organisations Information Accidents as a breakdown in the flow of information: Turner s theory of Man-made disasters Safety Goals/Safety Regime Rasmussen conflicting objectives migration Resilience engineering to support the ability to adapt or absorb disturbance, disruption and change (Hollnagel, et al..) 8

9 What has actually happened Change processes in aviation (Deregulation USA) Extensive literature reviews - no increase of accidents Recent results - Low cost airlines has less serious accidents than old establish operators in the 10 years period in USA (Ref HRO conference 2007) Change processes in railway industry (Deregulation EU) Extensive literature reviews - No increase of accidents in GB Interviews performed of RSSB and EuroStar, workshops Empirical data from these changes has been gathered, structured and discussed with the industry 9

10 Issues from literature review (example) Relationship between safety and profitability in railways and aviation Savage (1999) The Economics of Commercial Transportation Safety Brooking Institution Press 1999 Rose (1989) Financial influences on airline safety. White (2001) An independent review of rail privatisation in Britain 2001 Industry - the cause of increased safety is the deregulation, increased profits and increased investment The regulatory authorities say that the causes are new rules and more strict enforcement of rules 10

11 Simulations Complex changes such as deregulation of railways in GB (BR fragmented into 100 companies), the effect of Safety Case regime Learning from incidents both SPAD (Signal Passed at danger) and documented accidents up to 2006 Increased profits in the industry Using system dynamics and statistics to explore the development of safety when performing: proactive analysis of changes (scenario analysis) reactive learning from accidents and incidents 11

12 In a complex change a Safety case scenario analysis is an important mitigating action prior to the change Scenario analysis based on STEP 12

13 Key challenges identified Organizational issues (HRO) Mitigate complex and tight-coupled interactions (Perrow Normal accident scenario) Explore HRO and proactive indicators to support resilience Changes (deregulation or outsourcing) can imply decentralization and feedback control (change of fundamental principles) Increased focus on contract management 13

14 Key challenges identified (Requisite) Information (or Imagination) Safety case should be explored before change is implemented Communication challenges after major reorganizations Sharing common goals of safety in a network of firms 14

15 Key challenges identified Safety Goals/Safety Regime Increased regulatory action needed during the change process Safety research budgets should be sustained New entrants can be less safe than established operators Relationship between safety and size of operators should be explored Relationship between safety and profitability 15

16 Key stakeholders influencing safety Authorities Safety Goals Media (Requisite) Information Operators and service firms HRO Supplier Customers 16

17 How to assess the proposed change Identify key stakeholders Authorities, Operators,.. Establish arena to explore the proposed change, such as Community of practice Authorities Operator Perform assessment of key challenges [on a 5 point Likert scale, Strongly agree to Strongly disagree] Prior to change After/During the change 17

18 Assessment of change Key safety issues prior to the change Key safety issues during and after the change Increased regulatory action needed during the change process 18

19 Assessment Increased regulatory action Prior to the change Authorities: Question: Are sufficient resources allocated at the authorities to work with regulatory actions prior to the change? Assessment 5: Strongly agree, 1: Strongly disagree 19

20 Assessment Increased regulatory action Prior to the change Authorities: Question: Have necessary knowledge and understanding of the change been established? 5: Strongly agree, 1: Strongly disagree Question: Has key safety performance indicators been defined? 5: Strongly agree, 1: Strongly disagree 20

21 Next steps to be done Using and calibrating the method based on review of several large scale changes Integrated Operations in the Oil and gas industry (Master thesis, workshops, ) Further research in aviation and railway focusing on resilience engineering 21