RAILWAY SAFETY ACTRailway Safety Management System Regulations, 2015P.C.2015-9120152
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His Excellency the Governor General in Council, on the recommendation of the Minister of Transport, pursuant to sections 37a, 47 and 47.1b of the Railway Safety Actc, makes the annexed Railway Safety Management System Regulations, 2015.S.C. 2012, c. 7, s. 30S.C. 2012, c. 7, s. 37R.S., c. 32 (4th Supp.)InterpretationDefinitionsThe following definitions apply in these Regulations.accountable executive means the executive referred to in subsection 8(1) or 43(1), as the case may be. (gestionnaire supérieur responsable)Act means the Railway Safety Act. (Loi)dangerous goods has the meaning assigned in section 2 of the Transportation of Dangerous Goods Act, 1992. (marchandises dangereuses)main track means a line of railway on which the movement of railway equipment is authorized by a railway company. (voie ferrée principale)non-main track means a line of railway other than a main track. (voie ferrée non principale)railway occurrence means a railway occurrence that is reportable under section 5 of the Transportation Safety Board Regulations. (accident ferroviaire)OverviewPurposeThese Regulations establish the minimum requirements with respect to the safety management system that a company must develop and implement for the purpose of achieving the highest level of safety in its railway operations.Organization — PartsThese Regulations are divided into three Parts:Part 1 sets out the requirements applicable to a railway company with respect to its safety management system and with respect to record-keeping, notification and filing of information;Part 2 sets outin Division 1, the requirements applicable to a local railway company that operates railway equipment on main track with respect to its safety management system and with respect to record-keeping, notification and filing of information, andin Division 2, the requirements applicable to a local railway company that operates railway equipment exclusively on non-main track with respect to its safety management system and with respect to record-keeping, notification and filing of information; andPart 3 makes consequential amendments to the Railway Operating Certificate Regulations, repeals the Railway Safety Management System Regulations and sets out the date on which these Regulations come into force.Organization — processesThe safety management system requirements set out in Parts 1 and 2 are organized into key processes that group together related requirements, including, in most instances, the requirement that a company develop and implementprocedures that establish a step-by-step sequence of activities for dealing with certain matters;methods that are not necessarily a step-by-step sequence of activities, but that establish the manner in which certain evaluation, verification or supervisory activities are to be carried out; orplans that establish the proposed time for carrying out certain activities with respect to the consultation and knowledge management requirements, and the proposed manner in which those activities are to be carried out.Railway CompaniesApplicationRailway companyThis Part applies to a railway company.Delayed applicationIn the case of a railway company that begins railway operations after the day on which these Regulations come into force, sections 21 to 23 do not apply until the day that is six months after the day on which the railway company begins railway operations.Safety Management SystemProcesses, Procedures, Plans and MethodsProcessesA railway company must develop and implement a safety management system that includesa process for accountability;a process with respect to a safety policy;a process for ensuring compliance with regulations, rules and other instruments;a process for managing railway occurrences;a process for identifying safety concerns;a risk assessment process;a process for implementing and evaluating remedial action;a process for establishing targets and developing initiatives;a process for reporting contraventions and safety hazards;a process for managing knowledge;a process with respect to scheduling; anda process for continual improvement of the safety management system.IndexA railway company must keep an up-to-date index of all the processes referred to in section 5 that it has implemented.Content of indexThe index must indicate the date of the last revision of the railway company’s safety policy and must indicate, for each process,the management position occupied by a person designated under subsection 8(4), if applicable;the procedures, plans and methods required by this Part that are associated with the process, and the date of their last revision; andthe position in the railway company that has responsibility for the development and implementation of the procedures, plans and methods.Procedures, plans and methodsEvery procedure, plan and method required by this Part must be in writing and must indicate the date of its last revision.Process for Accountability — Accountable ExecutiveDesignation of executiveA railway company must designate an executive who is responsible for the operations and activities of the railway company to be accountable for the extent to which the requirements of the safety management system are met, including its effectiveness in achieving the highest level of safety in its railway operations.Notice to MinisterThe railway company must provide the Minister with the name of the accountable executive as soon as possible after he or she has been designated.Declaration to the MinisterThe railway company must ensure that, within 30 days after the day on which it designates an accountable executive, the accountable executive provides the Minister with a signed declaration accepting accountability for the extent to which the requirements of the safety management system have been met.Designation of managersThe railway company may, in its safety management system, permit the accountable executive to designate one or more persons to develop and implement one or more of the processes required by this Part. A designated person must occupy a management position within the railway company that includes responsibilities relevant to the process or processes and the authority to make decisions with respect to that process or those processes.Annual updateIf the accountable executive designates a person under subsection (4), the accountable executive must ensure that the person reports to him or her, on an annual basis, with respect toany problems following the procedures or implementing the plans and methods, and the manner in which those problems have been or are being resolved or, if applicable, the reasons why they have not been or are not being resolved; andthe effectiveness of the procedures, plans and methods in contributing to the improvement of the safety of the railway company’s operations.Process with Respect to a Safety PolicySafety policyA railway company must include, in its safety management system, a written safety policy that reflects the railway company’s commitment to promoting railway safety. The policy must be approved and signed by the accountable executive.Annual reviewThe railway company must ensure that its safety policy is reviewed annually.CommunicationThe railway company must communicate its safety policy, and any changes to the policy, to its employees.Process for Ensuring Compliance with Regulations, Rules and Other InstrumentsList of instrumentsA railway company must include, in its safety management system, a list of the following instruments relating to railway safety:any regulations made under the Act that apply to the railway company and that are in force;any engineering standards approved by the Minister under section 7 of the Act or established by the Minister under subsection 19(7) of the Act that apply to the railway company and that are in effect;any rules approved or established by the Minister under section 19 of the Act that apply to the railway company and that are in force;any exemptions granted under section 22 or 22.1 of the Act that apply to the railway company and that are in effect;any notices sent to the railway company under section 31 of the Act that contain an order and that are in effect; andany documents in effect by which the Minister has ordered the railway company to do or to not do something, including a ministerial order issued under section 32 of the Act and an emergency directive sent under section 33 of the Act.Date and subject matterThe list of instruments must includein the case of an engineering standard or a rule, the date on which it was approved or established; andin the case of an exemption, a notice, or a document referred to in paragraph (1)(f), the date and subject matter.UpdateThe railway company must keep the list of instruments up to date and must indicate the date of its last revision.ProcedureA railway company must include, in its safety management system, a procedure forreviewing and updating the list of instruments referred to in subsection 10(1); andverifying compliance withthe requirements of the regulations, engineering standards, rules, and notices and documents containing an order, that are referred to in the list of instruments, andthe terms of the exemptions referred to in the list of instruments.Process for Managing Railway OccurrencesProcedureA railway company must include, in its safety management system, a procedure forreporting a railway occurrence to the railway company’s management; andreviewing a railway occurrence.CommunicationThe railway company must communicate to its employees the procedure for reporting railway occurrences.Process for Identifying Safety ConcernsAnalysesA railway company must, on a continual basis, conduct analyses of its railway operations to identify safety concerns, including any trends, any emerging trends or any repetitive situations. The analyses must, at a minimum, be based onany reports of railway occurrences;any internal documentation relating to railway occurrences;any reports of injuries;the results of any inspections conducted by the railway company or by a railway safety inspector;any reports of contraventions or safety hazards that are received by the railway company from its employees;any complaints relating to safety that are received by the railway company;any data from safety monitoring technologies;the conclusions of the annual report referred to in subsection 29(3); andthe findings of any audit reports.ProcedureA railway company must include, in its safety management system, a procedure for conducting the analyses referred to in section 13.Risk Assessment ProcessRisk assessmentA railway company must conduct a risk assessment in the following circumstances:when it identifies a safety concern in its railway operations as a result of the analyses conducted under section 13;when it proposes to begin transporting dangerous goods, or to begin transporting dangerous goods different from those it already transports; orwhen a proposed change to its railway operations, including a change set out below, may affect the safety of the public or personnel or the protection of property or the environment:the introduction or elimination of a technology, or a change to a technology,the addition or elimination of a railway work, or a change to a railway work,an increase in the volume of dangerous goods it transports,a change to the route on which dangerous goods are transported, ora change affecting personnel, including an increase or decrease in the number of employees or a change in their responsibilities or duties.ComponentsThe risk assessment mustdescribe the circumstances that triggered the requirement to conduct the risk assessment;identify and describe the risks associated with those circumstances;identify the factors taken into account in the risk assessment, including the persons who may be affected and whether property or the environment is affected;indicate, for each risk, the likelihood that the risk will occur and the severity of its consequences;identify the risks that require remedial action; andidentify the remedial action for each of those risks.ConsultationWhen identifying the risks that require remedial action and the remedial action to be implemented, a railway company must consult with the bargaining agents representing the employees of the railway company who are affected by any of those risks or, if there is no bargaining agent, withthe employees of the railway company who are affected by any of those risks; ora representative selected by the employees of the railway company.CommunicationThe railway company must communicate the risks identified as requiring remedial action, and the remedial action to be implemented, to the employees of the railway company who are affected by any of the circumstances referred to in subsection 15(1).Procedure, plan and methodA railway company must include, in its safety management system,a procedure for identifying the risks that require remedial action, taking into account, for each risk, the likelihood that the risk will occur and the severity of its consequences;a plan for the consultation referred to in subsection 16(1); anda method for evaluating the level of risk, taking into account the likelihood that a risk will occur and the severity of its consequences.Process for Implementing and Evaluating Remedial ActionRemedial action — implementationA railway company must implement remedial action with respect to the risks that it has identified in its risk assessment as requiring remedial action.Remedial action — evaluationThe railway company must evaluate the effectiveness of the remedial action in reducing or eliminating the risks.ConsultationWhen evaluating the effectiveness of remedial action with respect to a risk, a railway company must consult with the bargaining agents representing the employees of the railway company who are affected by the risk or, if there is no bargaining agent, withthe employees of the railway company who are affected by the risk; ora representative selected by the employees of the railway company.Procedures and planA railway company must include, in its safety management system,a procedure for selecting the remedial action to be implemented;a procedure for implementing the remedial action and evaluating its effectiveness; anda plan for the consultation referred to in section 19.Process for Establishing Targets and Developing InitiativesTargets and initiativesA railway company must, for each calendar year,establish targets designed to improve the safety of its railway operations; anddevelop initiatives to achieve each target.Basis for establishing targetsThe targets must be based on the analyses conducted under section 13 and must take into account the results of any previous analyses.Details of initiativesA railway company must include, in its safety management system, a written description of each initiative to be implemented in order to achieve each target and a written explanation of how the initiative will contribute to achieving that target.CommunicationA railway company must communicate to its employees the targets established and the initiatives to be implemented.Process for Reporting Contraventions and Safety HazardsInternal reportingA railway company must include, in its safety management system, a procedure for enabling its employees to report to the railway company, without fear of reprisal, a contravention of the Act or of any regulations, rules, certificates, orders or emergency directives made under the Act in relation to safety, or a safety hazard.PolicyThe railway company must include, in its safety management system, a policy, in writing, for protecting its employees from reprisals for reporting a contravention or safety hazard.CollaborationThe railway company must develop the procedure and the policy in collaboration with the bargaining agents or, if there is no bargaining agent, with its employees or a representative selected by its employees.CommunicationThe railway company must communicate the procedure and the policy to its employees.Process for Managing KnowledgeListA railway company must establish a list setting outthe duties that are essential to safe railway operations;the positions in the railway company that have responsibility for the performance of each of those duties; andthe skills and qualifications required to perform each of those duties safely.Employees — skills and qualificationsThe railway company must ensure that an employee who performs any of the duties referred to in paragraph (1)(a) has the skills and qualifications referred to in paragraph (1)(c).Employees — knowledgeThe railway company must ensure that an employee who performs any of the duties referred to in paragraph (1)(a) has knowledge ofthe requirements of the instruments referred to in subsection 10(1) that the employee needs to know to carry out his or her duties safely;any federal legislation that may affect railway safety and that the employee needs to know to carry out his or her duties safely; andany of the railway company’s procedures — including any procedure referred to in this Part — standards, instructions, bulletins or other internal documents that may affect railway safety and that the employee needs to know to carry out his or her duties safely.Other personsA railway company must ensure that any person, other than an employee, who is authorized by the railway company to access the railway and whose activities may affect the safety of railway operations has knowledge ofthe requirements of the instruments referred to in subsection 10(1) that the person needs to know to carry out his or her activities safely;any federal legislation that may affect railway safety and that the person needs to know to carry out his or her activities safely; andany of the railway company’s procedures — including any procedure referred to in this Part — standards, instructions, bulletins or other internal documents that may affect railway safety and that the person needs to know to carry out his or her activities safely.Plan and methodsA railway company must include, in its safety management system,a plan for ensuring that an employee who performs any of the duties referred to in paragraph 25(1)(a) has the skills and qualifications referred to in paragraph 25(1)(c) and the knowledge referred to in subsection 25(3);a method for verifying that an employee who performs any of the duties referred to in paragraph 25(1)(a) has the skills and qualifications referred to in paragraph 25(1)(c) and the knowledge referred to in subsection 25(3);a method for supervising an employee who performs any of the duties referred to in paragraph 25(1)(a); anda method for verifying that a person referred to in section 26 has the knowledge referred to in that section.Process with Respect to SchedulingPrinciples of fatigue scienceA railway company must apply the principles of fatigue science when scheduling the work of the employees referred to in subsection (2), including the principlesthat human fatigue is governed by physiology;that human alertness is affected by circadian rhythms;that human performance degrades in relation to hours of wakefulness and accumulated sleep debt; andthat humans have baseline minimum physiological sleep needs.MethodThe railway company must include, in its safety management system, a method for applying the principles of fatigue science when scheduling the work of an employee who is required to work according to a schedule thatis not communicated to the employee at least 72 hours in advance;requires the employee to work beyond his or her normal work schedule; orrequires the employee to work between midnight and 6:00 a.m.CommunicationThe railway company must communicate, to any employees who are required by the railway company to work according to a schedule referred to in subsection (2), how the principles of fatigue science have been taken into account when requiring them to work according to that schedule.ExceptionThis section does not apply when scheduling the work of employees during an emergency related to the safety of railway operations.Process for Continual Improvement of the Safety Management SystemInternal MonitoringMonitoringA railway company must, on a continual basis, monitor the implementation of its safety management system to verifywhether the bargaining agents, the employees or a representative selected by the employees are being involved in the processes as required by this Part;whether the targets established by the railway company under section 21 are being achieved; andwhether the procedures required by this Part are being followed, and whether the policy referred to in subsection 24(2) and the methods and plans required by this Part are being implemented.Deficiencies in implementationMonitoring must include, if applicable, inquiring intothe cause of any deficiencies in the implementation of the railway company’s safety management system and any actions being taken to remedy those deficiencies; andthe reasons why the targets are not being achieved.Annual reportThe railway company must prepare an annual report setting out the conclusions of its monitoring activities.Accountable executiveThe railway company must ensure that the conclusions of the annual report are brought to the attention of the accountable executive.Internal AuditScope and frequencyA railway company must conduct an audit of its safety management system every three years to evaluatethe extent to which the requirements related to each process have been implemented; andthe extent to which the policy referred to in subsection 24(2) and the procedures, plans and methods developed by the railway company are effective in improving the level of safety of its railway operations.Audit planThe railway company must include, in its safety management system, an audit plan thatdefines the scope of each audit;indicates the evaluation criteria to be applied;specifies the method to be used in conducting each evaluation; andsets out the schedule for evaluating each process.Audit reportA railway company must prepare an audit report that includes the findings of the audit.Accountable executiveThe accountable executive must sign the audit report to attest to his or her acceptance of the report.Action planA railway company must prepare an action plan setting out the action to be taken to address each finding in the audit report that it identifies as a deficiency in its safety management system.Approval of action planThe accountable executive must sign the action plan to acknowledge that he or she approves it.RecordsReview, analysis and evaluationA railway company must keep a record of the factors taken into account in, and the results of,the annual review of its safety policy;each analysis conducted under section 13; andeach evaluation conducted under subsection 18(2).DateThe record referred to in subsection (1) must include the date on which the review, analysis or evaluation was undertaken.Consultation, communication or collaborationFor each instance in which a railway company, in accordance with this Part, consults, communicates or collaborates with bargaining agents, employees or a representative selected by employees, the railway company must keep a record of the date and subject matter of the consultation, communication or collaboration and the manner in which it was carried out.Specified documentsA railway company must keep the following records:the documentation relating to each risk assessment conducted under section 15;the written description and written explanation referred to in section 22;the annual report referred to in subsection 29(3);the audit plan referred to in subsection 30(2);the signed audit report referred to in section 31; andthe approved action plan referred to in section 32.DurationA railway company must keep the records referred to in sections 33 to 35 for six years after the day on which they are created.Filing and NotificationFiling with the MinisterA railway company must, at the request of the Minister, file with the Ministeran up-to-date copy of the index referred to in subsection 6(1);the targets and initiatives referred to in subsection 21(1) for the current calendar year;the written description and written explanation referred to in section 22;the latest annual report referred to in subsection 29(3); andthe latest signed audit report referred to in section 31.Notification and filingA railway company that proposes to make a change referred to in paragraph 15(1)(b) or (c) must, before making the change, notify the Minister of the change and must, at the request of the Minister, file with the Minister the documentation relating to the risk assessment that it conducted with respect to the change.Local Railway CompaniesMain Track OperationsApplicationLocal railway company — main trackThis Division applies to a local railway company that operates railway equipment on main track.Delayed applicationIn the case of a local railway company that begins operating railway equipment on a railway after the day on which these Regulations come into force, sections 54 to 56 do not apply until the day that is six months after the day on which the local railway company begins operating railway equipment on a railway.Safety Management SystemProcesses, Procedures and MethodsProcessesA local railway company must develop and implement a safety management system that includesa process for accountability;a process with respect to a safety policy;a process for ensuring compliance with regulations, rules and other instruments;a process for identifying safety concerns;a risk assessment process;a process for implementing and evaluating remedial action;a process for establishing targets and developing initiatives; anda process for continual improvement of the safety management system.IndexA local railway company must keep an up-to-date index of all the processes referred to in section 40 that it has implemented.Content of indexThe index must indicate the date of the last revision of the local railway company’s safety policy and must indicate, for each process,the management position occupied by a person designated under subsection 43(4), if applicable;the procedures and methods required by this Division that are associated with the process, and the date of their last revision; andthe position in the local railway company that has responsibility for the development and implementation of the procedures and methods.Procedures and methodsEvery procedure and method required by this Division must be in writing and must indicate the date of its last revision.Process for Accountability — Accountable ExecutiveDesignation of executiveA local railway company must designate an executive who is responsible for the operations and activities of the local railway company to be accountable for the extent to which the requirements of the safety management system are met, including its effectiveness in achieving the highest level of safety in its railway operations.Notice to MinisterThe local railway company must provide the Minister with the name of the accountable executive as soon as possible after he or she has been designated.Declaration to the MinisterThe local railway company must ensure that, within 30 days after the day on which it designates an accountable executive, the accountable executive provides the Minister with a signed declaration accepting accountability for the extent to which the requirements of the safety management system have been met.Designation of managersThe local railway company may, in its safety management system, permit the accountable executive to designate one or more persons to develop and implement one or more of the processes required by this Division. A designated person must occupy a management position within the local railway company that includes responsibilities relevant to the process or processes and the authority to make decisions with respect to that process or those processes.Annual updateIf the accountable executive designates a person under subsection (4), the accountable executive must ensure that the person reports to him or her, on an annual basis, with respect toany problems following the procedures or implementing the methods, and the manner in which those problems have been or are being resolved or, if applicable, the reasons why they have not been or are not being resolved; andthe effectiveness of the procedures and methods in contributing to the improvement of the safety of the local railway company’s operations.Process with Respect to a Safety PolicySafety policyA local railway company must include, in its safety management system, a written safety policy that reflects the local railway company’s commitment to promoting railway safety. The policy must be approved and signed by the accountable executive.Annual reviewThe local railway company must ensure that its safety policy is reviewed annually.CommunicationThe local railway company must communicate its safety policy, and any changes to the policy, to its employees.Process for Ensuring Compliance with Regulations, Rules and Other InstrumentsList of instrumentsA local railway company must include, in its safety management system, a list of the following instruments relating to railway safety:any regulations made under the Act that apply to the local railway company and that are in force;any rules approved or established by the Minister under section 19 of the Act that apply to the local railway company and that are in force;any exemptions granted under section 22 or 22.1 of the Act that apply to the local railway company and that are in effect;any notices sent to the local railway company under section 31 of the Act that contain an order and that are in effect; andany documents in effect by which the Minister has ordered the local railway company to do or to not do something, including a ministerial order issued under section 32 of the Act and an emergency directive sent under section 33 of the Act.Date and subject matterThe list of instruments must includein the case of a rule, the date on which it was approved or established; andin the case of an exemption, a notice, or a document referred to in paragraph (1)(e), the date and subject matter.UpdateThe local railway company must keep the list of instruments up to date and must indicate the date of its last revision.ProceduresA local railway company must include, in its safety management system, a procedure forreviewing and updating the list of instruments referred to in subsection 45(1); andverifying compliance withthe requirements of the regulations, rules, and notices and documents containing an order, that are referred to in the list of instruments, andthe terms of the exemptions referred to in the list of instruments.Process for Identifying Safety ConcernsAnalysesA local railway company must, on a continual basis, conduct analyses of its railway operations to identify safety concerns, including any trends, any emerging trends or any repetitive situations. The analyses must, at a minimum, be based onany reports of accidents;any internal documentation relating to accidents;any reports of injuries;the results of any inspections conducted by the local railway company or by a railway safety inspector;any reports of contraventions or safety hazards that are received by the local railway company from its employees;any complaints relating to safety that are received by the local railway company;any data that is accessible to the local railway company from safety monitoring technologies;the conclusions of the annual report referred to in subsection 57(3); andthe findings of any audit reports.ProcedureA local railway company must include, in its safety management system, a procedure for conducting the analyses referred to in section 47.Risk Assessment ProcessRisk assessmentA local railway company must conduct a risk assessment in the following circumstances:when it identifies a safety concern in its railway operations as a result of the analyses conducted under section 47;when it proposes to begin transporting dangerous goods, or to begin transporting dangerous goods different from those it already transports; orwhen a proposed change to its railway operations, including a change set out below, may affect the safety of the public or personnel or the protection of property or the environment:the introduction or elimination of a technology, or a change to a technology,an increase in the volume of dangerous goods it transports,a change to the route on which dangerous goods are transported, ora change affecting personnel, including an increase or decrease in the number of employees or a change in their responsibilities or duties.ComponentsThe risk assessment mustdescribe the circumstances that triggered the requirement to conduct the risk assessment;identify and describe the risks associated with those circumstances;identify the factors taken into account in the risk assessment, including the persons who may be affected and whether property or the environment is affected;indicate, for each risk, the likelihood that the risk will occur and the severity of its consequences;identify the risks that require remedial action; andidentify the remedial action for each of those risks.CommunicationA local railway company must communicate the risks identified as requiring remedial action, and the remedial action to be implemented, to the employees of the local railway company who are affected by any of the circumstances referred to in subsection 49(1).Procedure and methodA local railway company must include, in its safety management system,a procedure for identifying the risks that require remedial action, taking into account, for each risk, the likelihood that the risk will occur and the severity of its consequences; anda method for evaluating the level of risk, taking into account the likelihood that a risk will occur and the severity of its consequences.Process for Implementing and Evaluating Remedial ActionRemedial action — implementationA local railway company must implement remedial action with respect to the risks that it has identified in its risk assessment as requiring remedial action.Remedial action — evaluationThe local railway company must evaluate the effectiveness of the remedial action in reducing or eliminating the risks.ProceduresA local railway company must include, in its safety management system,a procedure for selecting the remedial action to be implemented; anda procedure for implementing the remedial action and evaluating its effectiveness.Process for Establishing Targets and Developing InitiativesTargets and initiativesA local railway company must, for each calendar year,establish targets designed to improve the safety of its railway operations; anddevelop initiatives to achieve each target.Basis for establishing targetsThe targets must be based on the analyses conducted under section 47 and must take into account the results of any previous analyses.Details of initiativeA local railway company must include, in its safety management system, a written description of each initiative to be implemented in order to achieve each target and a written explanation of how the initiative will contribute to achieving that target.CommunicationA local railway company must communicate to its employees the targets established and the initiatives to be implemented.Process for Continual Improvement of the Safety Management SystemInternal MonitoringMonitoringA local railway company must, on a continual basis, monitor the implementation of its safety management system to verifywhether the targets established by the local railway company under section 54 are being achieved; andwhether the procedures required by this Division are being followed, and whether the methods required by this Division are being implemented.Deficiencies in implementationMonitoring must include, if applicable, inquiring intothe cause of any deficiencies in the implementation of the local railway company’s safety management system and any actions being taken to remedy those deficiencies; andthe reasons why the targets are not being achieved.Annual reportThe local railway company must prepare an annual report setting out the conclusions of its monitoring activities.Accountable executiveThe local railway company must ensure that the conclusions of the annual report are brought to the attention of the accountable executive.Internal AuditScope and frequencyA local railway company must conduct an audit of its safety management system every three years to evaluatethe extent to which the requirements related to each process have been implemented; andthe extent to which the procedures and methods developed by the local railway company are effective in improving the level of safety of its railway operations.Audit planThe local railway company must include, in its safety management system, an audit plan thatdefines the scope of each audit;indicates the evaluation criteria to be applied;specifies the method to be used in conducting each evaluation; andsets out the schedule for evaluating each process.Audit reportA local railway company must prepare an audit report that includes the findings of the audit.Accountable executiveThe accountable executive must sign the audit report to attest to his or her acceptance of the report.Action planA local railway company must prepare an action plan setting out the action to be taken to address each finding in the audit report that it identifies as a deficiency in its safety management system.Approval of action planThe accountable executive must sign the action plan to acknowledge that he or she approves it.RecordsReview, analysis and evaluationA local railway company must keep a record of the factors taken into account in, and the results of,the annual review of its safety policy;each analysis conducted under section 47; andeach evaluation conducted under subsection 52(2).DateThe record referred to in subsection (1) must include the date on which the review, analysis or evaluation was undertaken.CommunicationFor each instance in which a local railway company communicates with its employees in accordance with this Division, the local railway company must keep a record of the date and subject matter of the communication and the manner in which it was carried out.Specified documentsA local railway company must keep the following records:the documentation relating to each risk assessment conducted under section 49;the written description and written explanation referred to in section 55;the annual report referred to in subsection 57(3);the audit plan referred to in subsection 58(2);the signed audit report referred to in section 59; andthe approved action plan referred to in section 60.DurationA local railway company must keep the records referred to in sections 61 to 63 for six years after the day on which they are created.Filing and NotificationFiling with the MinisterA local railway company must, at the request of the Minister, file with the Ministeran up-to-date copy of the index referred to in subsection 41(1);the targets and initiatives referred to in subsection 54(1) for the current calendar year;the written description and written explanation referred to in section 55;the latest annual report referred to in subsection 57(3); andthe latest signed audit report referred to in section 59.Notification and filingA local railway company that proposes to make a change referred to in paragraph 49(1)(b) or (c) must, before making the change, notify the Minister of the change and must, at the request of the Minister, file with the Minister the documentation relating to the risk assessment that it conducted with respect to the change.Non-Main Track OperationsApplicationLocal railway company — non-main trackThis Division applies to a local railway company that operates railway equipment exclusively on non-main track.Safety Management SystemProcesses, Procedures and MethodsProcessesA local railway company must develop and implement a safety management system that includesa process with respect to a safety policy;a process for ensuring compliance with regulations, rules and other instruments;a process for identifying safety concerns;a risk assessment process; anda process for implementing and evaluating remedial action.IndexA local railway company must keep an up-to-date index of all the processes referred to in section 68 that it has implemented.Content of indexThe index must indicate the date of the last revision of the local railway company’s safety policy and must indicate, for each process,the procedures and methods required by this Division that are associated with the process, and the date of their last revision; andthe position in the local railway company that has responsibility for the development and implementation of the process, procedures and methods.Procedures and methodsEvery procedure and method required by this Division must be in writing and must indicate the date of its last revision.Process with Respect to a Safety PolicySafety policyA local railway company must include, in its safety management system, a written safety policy that reflects the local railway company’s commitment to promoting railway safety. The policy must be approved and signed by an executive who is responsible for the operations and activities of the local railway company.Annual reviewThe local railway company must ensure that its safety policy is reviewed annually.CommunicationThe local railway company must communicate its safety policy, and any changes to the policy, to its employees.Process for Ensuring Compliance with Regulations, Rules and Other InstrumentsList of instrumentsA local railway company must include, in its safety management system, a list of the following instruments relating to railway safety:any regulations made under the Act that apply to the local railway company and that are in force;any rules approved or established by the Minister under section 19 of the Act that apply to the local railway company and that are in force;any exemptions granted under section 22 or 22.1 of the Act that apply to the local railway company and that are in effect;any notices sent to the local railway company under section 31 of the Act that contain an order and that are in effect; andany documents in effect by which the Minister has ordered the local railway company to do or to not do something, including a ministerial order issued under section 32 of the Act and an emergency directive sent under section 33 of the Act.Date and subject matterThe list of instruments must includein the case of a rule, the date on which it was approved or established; andin the case of an exemption, a notice, or a document referred to in paragraph (1)(e), the date and subject matter.UpdateThe local railway company must keep the list of instruments up to date and must indicate the date of its last revision.ProceduresA local railway company must include, in its safety management system, a procedure forreviewing and updating the list of instruments referred to in subsection 72(1); andverifying compliance withthe requirements of the regulations, rules, and notices and documents containing an order, that are referred to in the list of instruments, andthe terms of the exemptions referred to in the list of instruments.Process for Identifying Safety ConcernsAnalysesA local railway company must, on a continual basis, conduct analyses of its railway operations to identify safety concerns, including any trends, any emerging trends or any repetitive situations. The analyses must, at a minimum, be based onany reports of accidents;any internal documentation relating to accidents;any reports of injuries;the results of any inspections conducted by the local railway company or by a railway safety inspector;any reports of contraventions or safety hazards that are received by the local railway company from its employees;any complaints relating to safety that are received by the local railway company;any data that is accessible to the local railway company from safety monitoring technologies; andthe findings of any audit reports.ProcedureA local railway company must include, in its safety management system, a procedure for conducting the analyses referred to in section 74.Risk Assessment ProcessRisk assessmentA local railway company must conduct a risk assessment in the following circumstances:when it identifies a safety concern in its railway operations as a result of the analyses conducted under section 74;when it proposes to begin transporting dangerous goods, or to begin transporting dangerous goods different from those it already transports; orwhen a proposed change to its railway operations, including a change set out below, may affect the safety of the public or personnel or the protection of property or the environment:the introduction or elimination of a technology, or a change to a technology,an increase in the volume of dangerous goods it transports,a change to the route on which dangerous goods are transported, ora change affecting personnel, including an increase or decrease in the number of employees or a change in their responsibilities or duties.ComponentsThe risk assessment mustdescribe the circumstances that triggered the requirement to conduct the risk assessment;identify and describe the risks associated with those circumstances;identify the factors taken into account in the risk assessment, including the persons who may be affected and whether property or the environment is affected;indicate, for each risk, the likelihood that the risk will occur and the severity of its consequences;identify the risks that require remedial action; andidentify the remedial action for each of those risks.CommunicationA local railway company must communicate the risks identified as requiring remedial action, and the remedial action to be implemented, to the employees of the local railway company who are affected by any of the circumstances referred to in subsection 76(1).Procedure and methodA local railway company must include, in its safety management system,a procedure for identifying the risks that require remedial action, taking into account, for each risk, the likelihood that the risk will occur and the severity of its consequences; anda method for evaluating the level of risk, taking into account the likelihood that a risk will occur and the severity of its consequences.Process for Implementing and Evaluating Remedial ActionRemedial action — implementationA local railway company must implement remedial action with respect to the risks that it has identified in its risk assessment as requiring remedial action.Remedial action — evaluationThe local railway company must evaluate the effectiveness of the remedial action in reducing or eliminating the risks.ProceduresA local railway company must include, in its safety management system,a procedure for selecting the remedial action to be implemented; anda procedure for implementing the remedial action and evaluating its effectiveness.RecordsReview, analysis and evaluationA local railway company must keep a record of the factors taken into account in, and the results of,the annual review of its safety policy;each analysis conducted under section 74; andeach evaluation conducted under subsection 79(2).DateThe record referred to in subsection (1) must include the date on which the review, analysis or evaluation was undertaken.CommunicationFor each instance in which a local railway company communicates with its employees in accordance with this Division, the local railway company must keep a record of the date and subject matter of the communication and the manner in which it was carried out.Risk assessmentA local railway company must keep the documentation relating to each risk assessment conducted under section 76.DurationA local railway company must keep the records referred to in sections 81 to 83 for three years after the day on which they are created.Filing and NotificationFiling with the MinisterA local railway company must, at the request of the Minister, file with the Minister an up-to-date copy of the index referred to in subsection 69(1).Notification and filingA local railway company that proposes to make a change referred to in paragraph 76(1)(b) or (c) must, before making the change, notify the Minister of the change and must, at the request of the Minister, file with the Minister the documentation relating to the risk assessment that it conducted with respect to the change.Consequential Amendments, Repeal and Coming into ForceConsequential Amendments to the Railway Operating Certificate Regulations[Amendment][Amendment]Repeal[Repeal]Coming into ForceApril 1, 2015These Regulations come into force on April 1, 2015.