November 10, 2003
SOFA
Audit on The KVR by The Revelstoke FOPS H & S
Committee
On the 6th & 7th
of November,’03 Bob Gardali And Paul Bede conducted
SOFA audits on The KVR in Nelson, Castlegar and
Trail. This was done as per The Safety Framework for 2004 on The BCISA.
On Thurs. morning we met with Bill Ross at the Nelson Station, prior to
the departure of the “ Hot Shot “ which makes a
Trail Turn daily. We explained to Bill how we saw our objectives in this
endeavor. We explained, that when conducting SOFA audits, anonymity was
of first importance. We feel the credibility of The SOFA Audit process depends
on this. We also would be observing conditions on the premises re walking
conditions, slip / trip hazards or any other potentially unsafe conditions.
We also intended to speak with as many RTEs as possible. These conversations
would be non confrontational and relate to safety in general with due emphasis
on safe habitual working behavior. In addition, after conducting SOFA audits
observing crews, we would speak with them and discuss any “At Risk “ behaviors observed. We gave a brief history of the efforts
of The Revelstoke Workplace Committee in the past two years to most of the
RTEs we had an opportunity to meet.
Thursday – We
started our day at 0715 in Nelson. We introduced ourselves to the crew called
for “ The Hotshot “ and explained to them our reason
for being there. We observed them during their Job Briefing, which was carried
out professionally. Most mornings this train is required to make a lift,
it was not the case this particular morning. We headed to Castlegar, where this crew would
be making a set off and lift. After the crew had completed their switching
at Castlegar we had a discussion with the conductor about our
observations. The engineer was quite a ways from our location and the conductor
said he would relay the highlights of our discussion. We remained in Castlegar awaiting the arrival of the ”
Kraft switcher “. A half hour later this crew arrived. Once again, after
introducing ourselves, we observed them switching for a brief period before
they went for lunch. We took the opportunity to spend some time with them
and had a lengthy conversation about the importance of safe habitual behavior
on the job. From Castlegar We headed to Trail
where we once again introduced ourselves to the Yardmaster on duty and the
Yard crew. This assignment is best described as industrial switching. The
Cominco facility has been modernized over the years but there
are still many strange clouds and smells. The Yard itself lies on a steep
grade and The Warfield hill is the steepest grade on The CPR – 3.8%. We
made some observations as the crew finished tearing apart the “
Hot Shot” and then weighed a string of cars before heading for the
Acid Plant. As we were not in possession of the required respirator, we
did not observe them during this switching. We spoke with the Yardmaster
for a while and then followed the crew up the hill to Warfield where we
watched them switch out the ammonia spur. Before they headed back down to
Trail We talked with the yard crew including the engineer. Several safety
concerns were brought to our attention. We made note of these and examined
in particular an area adjacent to the ammonia spur that had been a point
of contention and only recently cleaned up. That was the last move of the
day and we headed back to Nelson. We feel we had succeeded in observing
three different crews engaged in their daily assignments. We recorded a
substantial number of SOFA observations. Perhaps most importantly we had
the opportunity to engage the crews in serious discussion about safe work
behaviors. In general, we felt we were well received. At 15:45 we headed back to Nelson.
Friday – Once
again, we started our day in Nelson at 07:15. There was a different crew
on The “ Hot Shot “ this day. After introductions
we performed an audit while they made a lift before departure. We headed
straight to Trail to observe the yard crew. Upon arrival at Trail we were
in time to audit the crew while they finished building the “
Hot Shot” and scaled some cars. It was time for the crews lunch break.
We again took advantage of the opportunity to sit with them and discuss
safety in general terms and specifically in regard to SOFA and the auditing
process. Again, several issues related to safety were brought to our attention.
These were made note of for discussion with Bill Ross later. After lunch
we watched a few more switching moves, shook hands and were on our way to
the pulp mill in Castlegar. We found a different crew on The Kraft Switcher
Friday. After introductions we audited them while they switched the chemical
spur and the pulp shed. We recorded numerous behaviors and again spoke with
the crew before calling it a day. Weather conditions for both days were
sunny and quite cold. As on the first day, we felt we made a representative
number of observations and engaged the crews in worthwhile discussions about
safety and The SOFA process. Upon returning to Nelson we sat down with Bill
Ross and discussed our two days visit on The KVR.
This was a new procedure for The Revelstoke Workplace
H & S Committee. While we have done numerous SOFA audits since their
introduction, this was the initial visit to another Terminal. We were apprehensive
as to how our presence might be perceived. We took care to let the crews
being audited know that all our observations would be statistical in nature
and there would be no identification of any RTEs observed performing “at
risk “ behaviors.
The total observations recorded over two days
were 126 safe behaviors and 9 at risk. The one common “At Risk “ behavior recorded needs some clarification. We did not anticipate
finding nor did we find a terminal in complete denial with regard to Safety.
The one behavior, which stood out had to do with testing the effectiveness
of handbrakes. We feel it is more a matter of phrases used on the radio.
We witnessed numerous situations when cars being set off or doubled over
were left with sufficient handbrakes to prevent uncontrolled movement. The
conductor or Foreman would then ask for the pin, causing the slack to adjust.
After seeing the slack adjust and ensuring the cars remained stationary,
the conductor/foreman would cut off. We feel it would be a good suggestion
to reinforce better radio procedures in this area. If a specific request
to “ test the Handbrakes” is not made, for one, the engineer can
never be certain that that is exactly would he is doing. In order to make
the entire crew involved in this requirement to test the efficiency of the
handbrakes we feel it should be worded over the radio specifically to include
three words: Test, Efficiency, Handbrakes. This makes for clear communication
and everyone is involved knowingly. We were pleased to find that “ Three Point protection “ appears to used whenever required.
We did note a few instances where it was not requested when reaching in
to shut angle cocks. It was explained that according to SOFA guidelines
Three Point should be used whenever a person places himself “
foul ‘ of equipment. These particular “at Risk “
behaviors were rare and did not appear to be standard procedure or
commonplace. One “at risk “ behavior we observed
was an RTE riding the end platform on a covered hopper. He contended this
was the safest place to ride on this particular type of car. We explained
that originally we had the same opinion. At the end of the discussion, it
was simply put that according to The Transportation F/Ops Safety Rules and
Work Procedures this practice would be regarded as a violation. We encouraged
the RTE to take a minute or two to find an alternate solution, for example,
taking a couple of minutes to switch out a more appropriate car to ride
the point.
At the end of our two day adventure to The KVR,
we feel that the number of “ At Risk “ behaviors
“ was no greater than we’ve come across in our own terminal. We do believe
there should be a change in radio procedure in the application of testing
Handbrakes. It might be in order to conduct a little blitz on Handbrakes
in general.
Part of our purpose in auditing The KVR was
to make note of conditions in the workplace as in slip/trip hazards and
other concerns. One item was brought to our attention quite emphatically.
It was not a specific hazard but a perception that Cominco
was not quick to respond to Hazards identified by RTEs. While we personally
did not come across any of these hazards we feel this is something KVR management
will have to keep track of and address when/if necessary with Cominco
management. It did not occur until we had left to inquire if the KVR and
Cominco conducted joint safety meetings with management and
union reps present. This might have merit a couple of times a year. There
was one area inspected on The KVR where we felt there was an abundance of
trip Hazards present. This was the yard in Castlegar.
At this location we encountered quite a lot of debris adjacent to the right
of way including tie ends and other track debris. With winter’s approach
much of this could soon be covered with snow increasing the hazards by making
them less readily apparent. This concern was addressed specifically to Bill
Ross. A concern was also brought to our attention regarding a crossing in
The Tadenac Yard. This would be the main crossing south of the
scales. It is felt that a mirror might well be appropriate at this location.
There seem to have been a number of incidents. We did not witness any but
the potential seemed very real. One common factor in Trail, which amplifies
the seriousness of any incident, is the number of dangerous commodities
being handled both by train crews and trucks moving about the refinery.
This, obviously, is also a factor when speaking about the serious potential
of uncontrolled movements. When we inquired about the apparent lack of windsocks
we were informed that the numerous smokestacks on the premises served this
purpose. While that seems to make sense we wonder if prevalent winds are
the same at ground level as they are at the height of the smokestacks. A
number of these smokestacks reach considerable height. With regard to the
number of dangerous chemicals and associated fumes in the workplace at Trail
the question of respirators came up. Indeed we came across one RTE who had
not been issued one or been fit tested. This was corrected while we were
there. We hope it will always be one of the first orders of priority for
any new RTEs in the future. We cannot overemphasize the potential for serious
injury in the Trail Yard. It is impressive that there has never been, to
the best of our knowledge, a serious or catastrophic incident in The Trail
Yard. This speaks greatly to the safe work habits and practices of train
and yard crews over the years. On the subject of respirators, another question
that occurred later was the chemical spur at the Pulp mill in Castlgar. We were not made aware of any problems concerning
respirators but feel a policy specific to the chemical spur should be in
place. This would be a good item for inclusion in a best practices guideline.
Another concern brought up had to do with Yardmasters. We won’t dwell on
it ,but it was mentioned that frequently the YM will be in
the yard lacking PPE whether this would be boots, glasses or vests. It would
be more than appropriate to remind all Yms that
when they are out in the yard full PPE is mandatory. One last item worthy
of attention would be a pre - departure checklist. This is a valuable safety
tool and is required as per the “Safe Practices “ manual.
We think one should be developed locally specific to the needs of the terminal.
In summation: Our visit to The KVR was more than interesting.
The operation is vastly different in many ways to what we experience on
the mainline. Railroading is still Railroading.
There are as many similarities as there are differences. The greatest common
factor might be the need for constant vigilance and application of safe
procedures. By no means did we find a complacent workforce. We spent a good
deal of time discussing various aspects of safety and safe practices with
the crews we met. The great majority of RTEs took this quite seriously and
willingly engaged us in conversation. By and large we found a group of dedicated
employees who appear to take Safety in all aspects quite seriously.