Rail Safety 2014

MAKINGSENSEof Safety

2 www.railsafetysummit.com

With Network Rail’s funding from the Office of Rail Regulation in place for the next five years I welcome the overdue inclusion of specific project funding for the development of automatic warning systems which should at last consign the use of lookouts with horns and whistles on our railway to history.

The dangerous nonsense of using people with such rudimentary means of warning workers that a train is approaching perhaps at a speed as high as 125 mph surely defies belief in 2014? Network Rail’s new Chief Executive may not have begun this process but I hope and pray that he will deliver it. Their new Ten Point Plan looks good but can it succeed?

Respected engineers have for some years been pleading for

infrastructure development plans to be agreed for timescales exceeding five years. Longer term planning as the recovery from recession continues is needed not only for the south east but for the nation as a whole. High Speed 2 and I believe 3, 4 too can relief the pressure on our airports and result in a delay for the building of more runways. In terms of our economic growth, the environment and sustainability this must be the right way to go.

The programme of improvements to our capital’s 150 year old underground railway system is impressive as is the “on time and within budget” construction of Crossrail.

Tragically despite the progress being made in increasing the productivity on track, bridge and

station sites with better machines and working methods fatalities to track workers still occur every year. Already this calendar year both Network Rail and the Docklands Light Railway have suffered in this way. What is to be done? Money has been spent on removing and improving level crossings but they are still responsible for tragic accidents and suicides are all but accepted by train drivers as part of the job.

My cynicism over claims that employers are focussed on “Zero” or even going “Beyond Zero” remains. I am encouraged that the form filling exercise of pre-dated structured site safety tours has lost favour. Unannounced site visits by top executives asking their own questions and listening to workers

replies is the way forward.What we need now is for top

management to show that they are listening. Some initiatives are beginning to do so at last. I suggest that future organisation charts need to be inverted to look like upside down pyramids. Chief Executives should be shown alone supporting their directors, then the management, supervisors, charge-hands and on top those who do the actual work.

Whether or not you agree with any of my philosophy for safer working I recommend you try for one of the remaining tickets for this year’s safety summit, hear what others think and have your say!

Colin Wheeler BSc(Eng) CEng FICE FPWI

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Rail Safety Summit28th April 2014 • The Royal College of Physicians, London

www.railsafetysummit.com

3

THE SAFETY AGENDA08:00 Registration

Register for the event, then enjoy a coffee and pastries as you network and meet fellow colleagues.

09:00 Welcome from our host, Colin Wheeler.

SESSION 1: SETTING THE SCENE

09:05 Video: Dead Serious About Safety Ken Burrage, Chairman, IRSE Licensing Scheme

09:20 What are the problems? CarolynGriffiths,ChiefInspector,RAIB

09:40 2013: The ORR Health and Safety Report Sue Johnston, Deputy Director - Railway Safety, ORR

10:00 KEYNOTE Mel Ewell, Chief Executive, Amey

10:20 Q&A with Speakers Panel

10:30 Coffee Break

SESSION 2: CONTROLLING SAFETY RISKS

11:00 Managing Passenger behaviour David Statham, Managing Director, First Capital Connect

11:20 Mission Room Dr Bryan Denby, Managing Director, Mission Room

11:35 Interfaces Steve Featherstone, Programme Director Track, Network Rail

11:55 Systems Allan Spence, Director, Safety Strategy, Network Rail

12:15 Design for safety Darren Selman, H&S Manager, Assurance, Crossrail

12:35 Q&A with Controlling Safety Risks Panel

12:45 Lunch

SESSION 3: OCCUPATIONAL HEALTH

13:45 Staff welfare John Abbott, Director of National Programmes, RSSB

14:05 Fatigue Stuart Spriggs, HSQE Director, VolkerRail

14:35 Q&A with Occupational Health Panel

14:45 Coffee Break

SESSION 4: LEARNING LESSONS

15:15 Learning lessons from the top Pino de Rosa, Managing Director, Bridgeway Consulting Limited

15:35 Finding the root cause using Tripod Beta Ken Maddox, Tripod Beta: practitioner, trainer and assessor, EPEX

16:05 Q&A with Learning Lessons Panel

16:15 Outcomes from the day Panel discussion with some of the members of the Advisory Board

16:40 Summary and close Colin Wheeler closes the Summit.

Over the past few years there has been a significant push to improve the safety record within the rail industry. This has often meant significant change both in design and process.

All areas of the industry felt that this often caused confusion due to the amount of change that happened at one time:

• Which policy to implement? • Have I missed anything? • Which part applies to my organisation? Over the coming year, we will see more change as the industry streamlines

processes through collaboration in a bid to cut through red tape and ultimately make sense of safety.

Making sense of safety is a key challenge in 2014 for the industry, whether that be through learning from other industries, through product and process design or through industry collaboration.

Join us on the 28th April to learn more from the experts.

Anson Jack Deputy Chief Executive RSSBBill Free Head of Business Development, Rail Carillion RailDarren Selman H&S Manager Assurance CrossrailDavid Shirres Engineering Writer Rail MediaDr Ian Gaskin Head of Management Systems, Health, Safety and Environment, TfLIan Prosser HM Chief Inspector of Railways and Director of Railway Safety ORRPaul Clyndes Health & Safety Officer RMTPeter Sheppard Senior Safety Engineer and Validator Bombardier TransportationPino de Rosa Managing Director Bridgeway ConsultingRoan Willmore Safety & Sustainability Development Director Network RailSeamus Scallon Safety Director UK Rail FirstGroup

MAKING SENSEof Safety

SAFETY SUMMIT ADVISORY BOARD

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WE ASKED KEN BURRAGE...

Visible and committed leadership is essential if rail safety is to improve.

Communication by e mail and mobile phone can never be as effective as face to face.

A policy step change is needed away from “measure it to manage it” to a co-operative listening management style that values people and fosters a better safety culture.

The word “Zero” has been overused in safety management jargon and is no longer respected.

I agree. Because this is the way to convince the workforce that safety is of primary importance to senior management.

I agree. Because although email and the mobile phone are efficient and convenient modes of communication, face to face communication is the best way to communicate true commitment and check that the message has been understood.

I agree. Because teamwork achieves the best results.

I agree that there is an unfortunate tendency to overuse this term. There is usually an alternative way of expressing the safety aim with just as much force and clarity.

I strongly agree. There is no doubt at all that this is the best method of working and examples from the military, sport, and many other hazardous industries such deep sea fishing, mining, oil exploration etc. all confirm this.

It is essential for senior managers to spend time with the front line workforce to communicate, inspire, encourage and motivate and also to learn of the difficulties and concerns of front line staff at first hand.

I agree that an independent accident reporting system can be helpful in promoting the safety culture.

I disagree. The rule book is indispensable to defining the procedures and processes that if followed will produce a safe railway and it is essential that the front line staff know and understand what they must do to be safe themselves and to ensure that the railway is safe for its users, however it is important to ensure that the rules are written in a manner that is easily communicated and understood.

Groups who regularly work together can outperform others in both safety and productivity.

The most senior managers still spend too little time walking the job on the front line and listening to the workforce.

A respected and independent accident, incident and concern reporting system is essential for the safety culture of the rail industry.

Railway Rule Books should no longer be regarded as working documents for front line staff.


Ken Burrage FREng

ChairmanIRSE Licensing Scheme

Ken is a career railwayman having served the industry for over 50 years. He is a Chartered Electrical Engineer specialising in railway signalling and has dedicated his career to the safe running of the railways and is known for his impressive leadership of the railway signalling profession in the wake of the Clapham disaster.

He has directed and implemented robust engineering standards and safety management systems throughout British Railways and its successor bodies. He was formerly Director of S&T Engineering for BR and after privatisation became Deputy MD for Westinghouse Signals Ltd.

He is currently an IRSE Council member and Senior Engineer for the Institution of Railway Signal Engineers’ Licensing Scheme that certifies the competence of the engineers and technicians who carry out safety critical signalling and telecommunications work on Britain’s mainline railways and on London Underground.










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David Shirres reports

Hansard records that, in 1914, a Parliamentary debate on the need for Government action to reduce the deaths of railway workers was overwhelmingly defeated despite 420 railwaymen having been killed in the previous year, of which 102 were track workers. The debate referred to a 1907 Board of Trade recommendation to issue platelayers with whistles to warn of approaching trains that had been rejected by half of Britain’s railway companies.

Attitudes to safety have improved since then. However by 1985 there was still some way to go with 18 railway workers killed that year, of which 11 were track workers. At this time there was a cavalier attitude to safety which was addressed with cultural programmes such as Du Pont and “Dead Serious about Safety” following which track fatalities were reduced to low single figures in the mid-90s. Since then although initiatives such as Sentinel and RIMINI have had some impact, it remains a sad fact that people are still getting killed and injured whilst working on the rail infrastructure.

Everyone Home SafeAgainst this background Network Rail is now committed to a target that from 2019 there will be no fatalities and major injuries resulting from work on its infrastructure. Allan Spence, Network Rail’s Director of Safety Strategy explains why this demanding target is far from wishful thinking. This is because it is supported by a fundamental review of all aspects of workforce safety with resultant actions from a Workforce Safety 10 point plan.

This plan was launched in April 2013 and seeks to learn from both the workforce and other industries. Speaking a recent conference Network Rail’s Chairman Richard Parry-Jones emphasises this point. He considers that the company’s track worker safety performance has to improve and that there is much to learn from the oil, gas and mining industries.

As far as track safety is concerned, the key aspects of the 10 point plan are Safe Contractors; Technology Interventions; Roles & Responsibilities and Control of Work. Allan Spence feels that an effective approach to track safety has to address People, Plant, Place and Process.

PeopleTrack safety incidents show there is much to be done as far as competence, roles and culture are concerned. In recent times Network Rail and its Principal Contractors have introduced some excellent safety culture initiatives. However it is difficult to cascade this to the contingent workforce who generally work limited hours for various different contractors and may not get the support they need. Allan feels this situation is aggravated where labour supply contracts are price driven.

For these reasons Network Rail is developing a call-off contingent labour contract with the intention that this will be used by all its Principal Contractors. This will ensure that such workers get the required support and will result in a more professional workforce with more certainty about their employment. It will also include a code of conduct for employers.

The review of roles and responsibilities is a fundamental part of the new approach to track safety. There are felt to be too many safety critical roles (COSS, PICOP, ES and PC) and often there is conflict between these roles and the (often more senior) works Supervisor / Manager. This can result in confused responsibilities and

TRACK SAFETY:


GETTING IT RIGHT

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unnecessarily complex communications and, on occasions, has resulted in accidents.

Network Rail’s new approach will ensure a single controlling mind responsible for the planning of work, its safe delivery and hand back. The working title for this new role is Safe Work Leader (SWL) who will always be an employee of Network Rail or a Principal Contractor. For straightforward work the SWL would be a Team Leader whereas for complex task the SWL would be a more senior manager. Whatever the type of work, there will always be a “single accountable mind”.

PlantEliminating risk is the most effective way of improving safety. Hence Network Rail is committed to using technology to reduce or remove completely work done on the open line. By 2015 it is considered that primary track inspection will not require foot patrols. Red zone working with unassisted lookouts will then be prohibited at night; within 200m of a junction; where the line speed exceeds 100mph and for moving worksites.

If line blockages cannot be planned in such situations, lookout operated warning systems (LOWS) will be used.

Between 2014 and 2019 £10 million has been assigned to develop and implement technology to improve the safety of track workers. This includes warning systems that will either be integrated with the signalling system or use lightweight, mobile equipment. The progressive introduction of such equipment will reduce the number of lookouts used. In a change in safety arrangements it is also intended that warning systems will give those on blocked lines warning of trains on adjacent open lines. More robust and efficient methods of blocking lines are also being developed including the use of TCODs and similar devices.

PlaceOperating a 21st century railway on lines built in the 19th century has its challenges, not least for those who work on the track. Tight clearances, a narrow six foot and the lack of a continuous walking route are

often hazards for track workers. Moreover often the location of equipment requires unnecessary access to the track.

Network Rail’s Safe by Design initiative will ensure such hazards do not result from new infrastructure projects. However it will be some time before this has a significant effect. For now, as part of its Asset Information data project, Network Rail has developed ORBIS TrackView which provides aerial images and track-level imagery to ensure that planners are aware of trackside hazards. TrackView is layered to display the type of information required and enable worksite details to be shown on the diagram.

Much can also be done to maintain safe clearances and places of safety by routine maintenance such as vegetation and scrap clearance.

ProcessStuart Browning is programme manager for the Control of Work part of the 10 point plan. Stuart explains that initially the brief was to

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9www.railsafetysummit.com 9

CarolynGriffithsBSc Hons CEng FIMechE

Chief InspectorRAIB

Carolyn joined British Railways in 1979 and during her time there was promoted through a series of roles, culminating in running the train depot in Brighton with a team of around 120 technical and operational staff.

In 1987 Carolyn took up a role with the Singapore Government to set up and run the maintenance of what was then the world’s most advanced mass rapid transit system. By 1991 the system was fully operational and delivering positive and lasting benefits for those that lived and worked there.

In 2003 Carolyn was appointed by the Secretary of State for Transport in the UK to create and lead the independent Rail Accident Investigation Branch UK (RAIB). The RAIB is now a leading world-class organisation which undertakes around 25 investigations a year. All RAIB’s reports are public and contain recommendations which aim to prevent future rail accidents.










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convert the current text-heavy Safe System of Work (SSOW) pack into a simpler, clearer information pack that used diagrams. However this evolved as good practices in other industries were understood, leading to the requirement to develop a workable permit to work system.

The result is ePermitting, a process that has been developed with the active involvement of many frontline staff and the RMT and TSSA. The principle is that “those who do the work are involved in planning the work”. This requires site and task risk information to be readily available in an easy to use format. Therefore this initiative is supported by both TrackView’s digital mapping and a newly-developed task and location risk assessment tool.

Currently it takes time to find information from different sources and complete the required paperwork. With ePermitting risk controls are derived from the readily available information and displayed on a diagram. This, says Stuart, is a tool to drive thought. It is also a tool that is now ready for its first pilot after successful trials in a simulated environment.

ePermitting also recognises that work has

different levels of risk. The planning effort for work designated as Level 3 (complex work, complex delivery) will be greater that for the Level 1 work (routine work, simple delivery) which amounts to 90% of all work plans.

Making it happenFor years, concern has been expressed about SSOW packs, confused responsibilities and the lack of automatic track warning systems. It’s therefore good to see that Network Rail has and is developing solutions to these issues in a systematic, cohesive manner. The challenge is the implementation of this new way of working which, amongst other changes, will significantly change the work done now by 22,000 COSSes.

For any Sentinel card holder this article will raise many questions. Whilst it may take time fully answer these, no-one will question the need for clearer responsibilities, less complex communications, reduced paperwork and better use of technology. Also the basics remain the same. There will still be the need for a robust process to block lines and, if this is not reasonably practicable, for those on open lines

to receive sufficient warning of trains and have a place of safety.

This new approach also addresses the reality of engineering access typically requiring large amounts of work within short timescales with the inevitable resultant demand for sub-contracted labour. Whilst many see this as a problem, Network Rail is offering a solution in the form of a call-off contingent labour contract. Also, although there are many competent sub-contracted COSSes, it is right that the person with responsibility for the work (the SWL) should be an employee of Network Rail or its Principal Contractors.

The result is significant change for those planning and executing work on track. The new ePermitting system and diagrams from TrackView will both support the new SWL role and ease its implementation. This makes Network Rail’s commitment to introduce the SWL by the end of 2014 a realistic aim. Also achievable should be the objective of zero track worker fatalities as it is supported by a credible plan. For this new approach Network Rail deserves the thanks and support of the rail industry.


Sue JohnstonDeputy Director – Railway SafetyORR

Sue started her career in health and safety regulation in 1979, when she joined the Health and Safety Executive in Scotland. Previously she had worked for a short time in the safety department at British Steel in Corby and as a project manager with Short Brothers in Belfast. She has significant experience of health and safety regulation in a wide range of industries, including major hazard industries, such as the chemical industry.

She joined HM Railway Inspectorate in 2002 as a team manager, with responsibility for health and safety regulation of the railway industry in Scotland, including Network Rail and its contractors. In 2006, the Office of Rail Regulation (ORR) was created as the independent safety and economic regulator for Britain’s railways. She is now Deputy Director Scotland and Railway Safety. In her railway safety role, she leads ORR’s national team ensuring that Network Rail complies with health and safety law, through a programme of proactive inspection and investigation work. In her Scotland role, she ensures that ORR’s approach to economic regulation is consistent with the requirements of ministers as set out in the High Level Output Specification (HLOS) and Scottish Ministers Advice to the ORR, by leading a cross-office Scotland team, with a focus on value for money and service to customers.










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WE ASKED MEL EWELL...





As leaders we have to be able to look back over our careers and be able to truly believe that we have done everything within our power to keep people safe, every day. If we cannot say that, we are doing something fundamentally wrong.

Senior managers need to spend more time walking the job on the front line and listening to the workforce. I am a firm believer that if you want to be an effective leader, you have to get out into the business. I spend a huge proportion of my time out at my depots or with my operational teams. Nothing is more powerful than face to face communication and leaders have to have a clear understanding of the environments and risks that our employees face on a daily basis in order to lead a safe culture.

You absolutely need both because if you don’t measure it, you cannot manage it. However, when it comes to safety statistics, we have to always keep front of mind that the numbers we are measuring are actually people. They are people with lives, and families and loved ones. Nobody comes to work to get hurt and as leaders we can never celebrate a statistic until the statistic is zero harm.

If zero is getting clichéd, then replace it with another word that means the same thing. If you’re not accepting the concept of ‘zero harm’ then you’re accepting that accidents are inevitable, and I simply do not and cannot accept that.

In Amey we have ‘Collaboration’ as one of our company values for that very reason. I cannot think of a better subject to apply it to than safety.

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Mel EwellChief ExecutiveAmey

Mel Ewell is Chief Executive and an Executive Director on the Amey Plc Board. He successfully guided the company through its sale to Ferrovial in 2003 and the subsequent acquisition of Enterprise plc in 2013. He has been key in creating the organisation Amey is today.

Mel began his career working for the shipping company United States Lines before moving to Rank Xerox.

In 1990 he moved to logistics company TNT International. Mel represented the UK business in international development programmes and led the successful integration of XP Europe into the TNT organisation following its acquisition in 1994.

In 1995 Mel moved to Amsterdam to lead on key corporate account development. He also spent time in Asia working on supply chain development, focusing on value added services. After four years in the role of Vice President Corporate Accounts, Mel returned to the UK as Managing Director of TNT International, UK and Ireland.

In 1999 Mel was appointed Managing Director of ADI Group, a provider of outsourcing aviation services in the UK, Germany, France and the Netherlands. He was appointed to the Board of the European business, with responsibility for aviation services and investing and growing the business in other markets. Following the acquisition of ADI by Securicor, Mel led the merger of the UK operations for both companies.

Mel joined Amey in 2001 as Group Director for Operations, overseeing the company’s service delivery and its strategic development. He became Chief Executive at the start of 2003 and successfully guided Amey through its sale to Ferrovial and into profitability. In April 2013 Amey acquired Enterprise plc and became one of the most diverse players in the UK public and regulated sectors with a turnover of £2.3bn and 21,000 employees.

Mel has led Amey’s positioning within the sector as an organisation that can add value through it’s unrivalled range of services which includes utilities, highways, waste management, rail, justice solutions, social housing and facilities management that are all uniquely underpinned by leading consulting and asset management capabilities.

In 2011, Mel also became a Non-Executive Director of SIG plc, a leading European supplier of Insulation, Exteriors, Interiors and Specialist Construction Products.

Mel studied at Kingston University where he gained a BSc (Hons) in Geography. He is an experienced sailor and following graduation, spent a year sailing round the Caribbean in a boat he helped to build. His other interests include deep-sea fishing, rugby and golf.










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WE ASKED DAVID STATHAM...

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The culture of a company is set by the leadership. At FCC all the Executive take part in the safety initiatives we have completed in the term of our franchise.

Measurement is of course important, without that how do you know if your activities are having the desired effect? There is a move away from “lagging” measurements such as accident rates, to “activity and outcome” indicators to ensure that risk control measures are being appropriately applied. This should help us all to improve safety. However, we are reinvigorating the Injury Prevention process, which encourages two way face to face communication on safety matters between colleagues, and promotes safe working practices whilst listening to colleagues safety concerns.

Of course every company must aspire to zero injuries, but being pragmatic a zero rate in practice is impossible to achieve, particularly where large numbers of people are actively moving around. It is probably misinterpreted rather than misused. No one wants anyone to be hurt.

We are fostering cross functional “Good to Great” safety improvement teams in the belief that regular working together, identifying and sharing best practices will enable us to continually reduce our injury severity rates and as a side effect improve productivity. Recognition of the “safe way to do it”, frequently brings productivity gains as a side effect.

Again, we recognise the importance of senior managers getting out and about on the route, visiting colleagues at depots and stations and participating in conversations about safety. Analysis of their reports of discussions enables us to identify local problems early, and identify if there are systemic trends, for example a number of problems with a certain new piece of equipment or procedure.

Absolutely! If we don’t find the root causes of incidents we are bound to repeat them! We have a number of ways to report near hits as well as injuries, and have teams of well trained and experienced investigators. Investigation reports are critically examined by senior managers, along with our independent safety team. Recommendations are tracked to ensure completion.

The Rule Book is a vital document to manage the interfaces between the Infrastructure Controllers (Signallers) and Train Operators, and will continue as such for a great many years yet. It is absolutely essential to have clear agreed practices for managing perturbed services when the regular working instructions may not fully apply.

Whilst the EU led move away from National Safety Rules is a laudable aim, until a completely standardised modern railway system is in place, a Rule Book enables users to have a consistent approach to every circumstance, which is obviously a key safety control measure.





Email and mobile phone are both vital means of communication between workplaces, particularly in the rail industry where colleagues can be many hundreds of miles apart, or traveling around. We at First Group recognise, however, that this can lead to isolation and lack of identified leadership. All senior company managers and Directors are required to undertake a number of visits to all of our stations and depots each year, in order to establish face to face contact with colleagues. It is especially important to go to the smaller and more remote locations to ensure that they are engaged with the activities of the whole business.


David StathamManaging DirectorFirst Capital Connect

David Statham was appointed as Managing Director for First Capital Connect in May 2013, and has since improved customer satisfaction through a range of schemes aimed at enhancing the cleanliness of trains, information provision to customers and the reliability of services.

Prior to that, he was Projects Director and Deputy Managing Director when he led on several capacity enhancement schemes on First Capital Connect’s Great Northern route which increased peak seating capacity by over 20%. In January 2012 he led FirstGroup’s bid for the Thameslink, Southern and Great Northern franchise; and from 2008-2011 he led First Capital Connect’s team that implemented the first stage of the transformational Thameslink Programme. This gave the Bedford to Brighton Thameslink route new and longer trains – including the first 12-carriage services and new or upgraded stations at Blackfriars, Farringdon and West Hampstead in London.

In 2006, he helped win FirstGroup’s bid for the First Capital Connect franchise and was the director responsible for mobilising the franchise and combining the Great Northern and Thameslink businesses

David Statham joined British Rail as a management trainee in 1992 and undertook a wide range of customer service roles culminating in his appointment to Customer Service Strategy Manager at First Great Western.










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WE ASKED DR BRYAN DENBY...





Agree as it is the key to changing safety culture.

Generally agree as email is devalued these days. Exceptions occur when rapid dissemination of critical information is required

Agree that a change is required as evidence shows that safety is not improving.

Agree.

Agree as teams who clearly understand strengths, weaknesses and skill distributions will work better and safer.

Agreed but not sure how this will change as time is always a scarce resource for top people.

Agreed but not sure if this is not currently the case.

Not sure. Rules are required but attitude is more important.






Dr Bryan DenbyManaging DirectorMission Room

Dr Bryan Denby spent 25 years in engineering higher education, ending up as a Professor at the University of Nottingham. His research interests were always at the applied end of engineering and this led to the creation of two spin-out companies AIMS Solutions Limited in 2000 and Mission Room Limited in 2011.

Currently Dr Denby is Managing Director of Mission Room, a technology company that is focussed on the development of immersive applications for hazardous engineering industries. The company is growing rapidly and won the prestigious Network Rail Partnership Award for Safety in 2013.










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WE ASKED STEVE FEATHERSTONE...





Agree - Leaders cast a shadow that our organisation and teams work within.

Disagree - All types of communication have a part to play in our safety improvement journey.

Agree - The best advice that I ever had was from my father who told me to listen to the people who dig the holes as they have the answer.

Disagree - Safety targets are about generating a positive reaction that drives a change in safety performance. Target zero does that when used properly. Otherwise it is just words.

Agree - The best example of this is formula one teams

Agree – Evidence suggests that engaged managers have both better safety and better business performance.

Agree – We have to know what the ground truth is so that we can work to fix the problems.

Disagree - There will always be a place for rulebooks. They however need to be simple to use and easy to understand supported by effective training and development.






Steve FeatherstoneProgramme Director, TrackNetwork Rail

Steve is responsible for Network Rail’s track renewals programme covering conventional plain line, high output plain line, conventional switches and crossings and modular switches and crossings.

Prior to this Steve was Network Rail’s Maintenance Director responsible for maintaining track, line-side, signals, power, telecoms, stations and buildings across the GB rail network.










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WE ASKED ALLAN SPENCE...





Absolutely, this is a core element of the Network Rail Safety and Wellbeing Strategy, and is a focus for the Safety Leadership and Culture Change Team.The presentations being delivered by Network Rail will concentrate on the role of leadership in improving safety.

While electronic methods of communication can be made innovative and engaging these only really act to reinforce messages. Nothing replaces face to face communications for delivering a message.

Agreed, Network Rail is focusing within the strategy on “competent people taking sensible risk based decisions”, within a much simplified framework of rules.

Network Rail consciously chose a vision that is ambitious and positive in tone – the intent is the same but it does not focus on numbers or risk a focus on measures.

There is a fine balance to be struck. Work groups with local knowledge and developed working relationships that respect each other can definitely achieve safe and productive delivery, but close relationships can also lead to complacency.

Definitely – Network Rail is focusing on a move away from Safety Tours, which have been a measure of the number of safety checks undertaken, to a programme of Leading Safety Conversations. This has a deliberate focus on the quality of open questioning and active listening to gain a better insight into safety issues from the workforces perspective.

Network Rail has established a Close Call Reporting Line to enable the reporting of all unsafe acts and conditions observed by the workforce. This is key to the delivery of our strategic objectives in terms of building a reporting culture, but also focusing on a learning culture where we can eliminate repeat accidents using this precursor knowledge.

A few simple, easy to understand rules, such as the Network Rail Life Saving Rules, are essential in providing a framework for individuals to make risk based decisions within. However, too many overly complex rules are counterproductive in enabling a competent workforce to make safe decisions.






Allan SpenceDirector, Safety StrategyNetwork Rail

Allan started work with Network Rail in 2012 as Director of Safety Strategy, developing the company strategy for transforming safety and wellbeing.

Allan’s career has largely been as a safety regulator, initially in agriculture then, after experience across a range of industries, in a national operational policy role applying expertise in matters as diverse as sheep dips, equine safety and fish farming.

In 2000, he joined the then HM Railway Inspectorate. After leading work to oversee major structural changes in the mainline infrastructure, he moved with the inspectorate to the newly combined safety and economic regulator - the Office of Rail Regulation.

His experience spans all aspects of British Industry including infrastructure management, operators, major projects, light rail and the heritage sector as well as work with regulators in Europe, the Middle East and Hong Kong.










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5 6 7 8

WE ASKED DARREN SELMAN...





Unless leadership is committed and seen to be committed, any safety message will only ever be seen as ‘words from the ivory tower’. Leaders need to be seen ‘in the field’ learning about the safety issues that affect their people, and demonstrating their commitment to making the workplace safer for them. Management safety tours are a good starting point, but participation needs to be more than an hour a month – it should be frequent and should give the workforce an opportunity to raise their concerns to the people who are in a position to drive change.

Email is a useful tool but has become an abused one. It is far too easy to cc in everyone and assume that everyone has received the message. In reality many people filter out cc’s in an effort to avoid their inboxes becoming clogged – this leads to an ever present risk of important information being ignored. The phone, although more time consuming is a much better way of communicating – the conversation is between two people and the exchange of information is personal and direct. But nothing is as effective as face to face communication where body language becomes part of the discussion; messages are relayed completely and effectively and there is less room for misinterpretation.

If it gets measured it gets done. The risk is that if it doesn’t get measured, it won’t get done. If your measures are wrong are you going to miss critical opportunities to improve? It’s impossible to target areas for improvement if there is no method for identifying those areas; measurement and analysis provide a clear indicator of safety performance and where efforts need to be focussed to bring about improvements. However, managing safety by numbers is impersonal and mechanical and shifts the focus away from human behaviour which provides a more qualitative measure.

The word ‘Zero’ may now be seen as something of a cliché in safety management but it is impossible to escape from the fact that zero has to be our aspiration. Legislation requires us to reduce risk to ALARP, so zero must be the only logical target. Zero can be used as a personal as well as an organisational target; it enables us to measure our performance in our efforts to eliminate risk and harm in the workplace. We all want there to be no injuries, no harm, no damage in our workplaces – what can we aim for if it isn’t zero? While ‘zero’ may have lost some if its impact through overuse, it provides a clear target to aim for whether it is respected or not.

There is plenty of anecdotal evidence that groups who work together closely build bonds which lead to a camaraderie that generates a ‘watching each others’ back mentality. This evolves naturally, rather than being forced by safety campaigns and initiatives. This evolved shared respect and understanding leads to an innate link between members of a team; they know how each other works, and develop their own methods to accommodate these. Looking out for someone you know comes more naturally than with a stranger, so safety performance improves by default.

As with question 1, senior managers need to spend more time ‘in the field’ with the workforce. This will as a minimum give a level of assurance to the workforce that management are aware of (and engaged in addressing) workplace issues. More importantly it will enable managers to get a real understanding of the risks that their people are exposed to – an understanding that cannot be gained by only reading performance reports which give a very sterile view of safety in the workplace.

Both local and national systems are essential to enable workers to report concerns without fear of repercussions. It is important that the owners of any system are even handed in their approach. There is always a risk that some reporters will use the system to gain leverage on issues that management already believe have been addressed. As long as the system is demonstrably impartial it will be accepted as a tool across the industry for identifying areas of both concern and best practice – this is invaluable. It is important that all users of any system understand what it is for and how it is to be used. Any reports issued as a result of data entered into the system should be transparent – and users should understand this to be the case. Appropriate training in the use of both the system and the reports that are generated by it should be available.

Rule Books have always been the ‘go to’ whenever there has been any lack of clarity over what actions to take in the railway environment; they give explicit instructions over what can and can’t be done, are a fundamental part of training for railway operatives and are an invaluable source of information for users. Although they may be seen as cumbersome, they are necessary; there would have to be a fundamental change in working culture for staff to agree not to have them. If Rule Books were to be withdrawn what would they be replaced with? And how would users gain critical information if they were no longer available? In the absence of a suitable replacement Rule Books should be made available to workers for as long as the Rules within them remain valid.






Darren SelmanH&S Manager, AssuranceCrossrail

Darren has worked in the railway industry for over twenty years and has held safety management roles covering activities in the UK and abroad including 11 years at Eurostar where he led the team responsible for fleet engineering safety.

He has managed teams overseeing fleet, stations, track, signalling and civil engineering safety on London Underground and prior to joining Crossrail in 2012 was responsible for assurance at Bombardier as part of the London Underground signalling upgrade team.

At Crossrail he leads the Assurance team which is tasked with overseeing the activities of multiple contractors as the project moves from construction through to railway installation and ultimately, operation.










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WE ASKED JOHN ABBOTT...





Agree with the statement but it has to be the right sort of leadership which engages with practitioners to understand the challenges and issues that they face and then help provide practical solutions and support.

Disagree. It is not always going to be practical to communicate face to face. The importance is the clarity of the message. What is the purpose of the communication and do both sides have a common understanding at the end of it all. Although face to face would be better much practical safety critical communication within our industry or others, such as aviation or shipping, face to face communications is not always possible. Therefore, the challenge is how to do it properly.

Safety is critically dependent on having quality information and data but is equally dependent on individuals and organisations working together cooperatively. Indeed the whole approach to system safety on the modern railway is founded upon cooperative understanding and management of shared risk. But this still has to be underpinned data information and metrics. It is however acknowledged that dumb application of management driven targets will produce an undesirable management culture and outcome.

Agree. We should be aiming for the concept of continuous improvement but also recognise the legal obligation which is to do what is reasonably practicable to manage risk.

Agreed in principle but you could equally argue that if complacency sets in then performance can deteriorate as people cut corners.

Can agree in principle for people to be out there engaging with their operational colleagues but in order to do this managers need to be properly equipped and competent. There is also a danger that senior management can undermine their line managers and supervisors who should be empowered to act.

Agree. Such a system is essential to understand the true risk associated with your operation.

Disagree. An organisation’s competency management system should ensure that all roles are properly equipped to do their jobs including necessary competency of all relevant components of the rule book.






John AbbottDirector ofNational ProgrammesRSSB

John Abbott is the Director of National Programmes for RSSB responsible for the delivery of cooperative member support programmes (such as operations), projects (such as workforce health) and schemes (such as CIRAS).

He began his career as a British Rail management trainee in 1981 where he gained experience with the BR regions, engineering workshops and HQ before joining Trainload Freight in 1991. In 1993 he was appointed to establish the new infrastructure and property maintenance contract regime for Railtrack and in 1996 became the Head of Procurement. From 1998 he was the Director of Assurance and Safety for Railtrack and then Network Rail before joining RSSB in 2007.










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1 2 3 4

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WE ASKED STUART SPRIGGS...





Agree – without the visible demonstration by senior management of strong safety leadership the culture within the organisation is flawed and cannot develop.

Agree – research undertaken by VolkerRail and Leeds Metropolitan University Psychology department supports this and face to face briefings is critical to ensure understanding and the opportunity to effectively ‘discuss’.

Agree to a certain extent – safety conversations are widely recognised as the way forward to bring about the necessary change, however there still needs to be an element of data capture for trend analysis and an educated focus for the conversations.

Disagree – ‘zero’ is what we strive to achieve. It can be achieved. If we think that it cannot then we are in the wrong business.

Agree but only if the culture is right within these groups. Peer pressure should never be ignored or underestimated. We, as an industry, need to ensure we create the right environment for positive peer pressure to ‘snowball’.

Disagree. There has been a noticeable change in perceptions that spending time on site, looking, listening and engaging with the workforce brings about demonstrable benefits in terms of safety, efficiency and productivity. Most senior managers welcome the opportunity to spend more time on site.

Disagree. If the culture is right within a company / industry and fair culture is properly and consistently applied then there is no call for an independent system. However I do agree in the current climate and there is a necessity for organisations such as CIRAS to exist to give a confidential and independent ‘place to go’ where all other attempts have failed.

Disagree. The current move towards less descriptive handbooks is welcomed as front line staff need clear and concise rules to hand but to put that into context in line with their relevant competencies.






Stuart SpriggsHSQE DirectorVolkerRail

Stuart joined VolkerRail from the automotive industry in 2001 as a Quality Assurance Officer and progressed over a 10 year period to HSQE Director where he has been instrumental in implementing a robust and effective integrated safety management system supported by a dynamic, diverse and forward thinking team of like minded professionals.

Stuart is a committee member of the IOSH Railway Group. He is also Deputy Chair of the Infrastructure Liaison Group (ISLG) and a past Chair of the Rail Infrastructure Assurance Group. He holds a BEng (Hons) Degree in Mechanical Engineering.










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Things just got real…the railengineer

by rail engineers for rail engineers

iPad EditionI N T E R A C T I V E

COMING SOON


Pino de RosaManaging DirectorBridgeway Consulting Limited

Pino De Rosa is Managing Director of Bridgeway Consulting Limited which he co-founded in 1995, following railway privatisation. The company delivers a diverse portfolio of services, specialising in Rail Civil Engineering, Geomatics, Ground & Site Investigation, Structures Inspection, Access Management (including Isolations and Possessions), Rail Training and Assurance Services. Safety consultancy services are undertaken both nationally and internationally.

Pino is Managing Partner of Bridgeway Railcare LLP which operates the “Railvac” - an on-track high powered air /vacuum excavation machine in partnership with Swedish based Railcare Export AB.

An active and passionate rail industry stakeholder, Pino is a founding board director and secretary of RICA (Rail Industry Contractors Association), a founding board member of NSARE (National Skills Academy for Rail Engineering), and represents industry suppliers at both Network Rail’s Project Safety Leadership Group and Infrastructure Safety Liaison Group.

Pino started his career with British Rail as an apprentice, progressing into civil engineering which he went on to study at Nottingham Trent University. In 1991 he was selected to become a member of the British Rail national underwater inspection team having successfully completed commercial diver training.










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Those attending the Safety Summit will be well aware of the need to understand the underlying causes of accidents and that it is rare for an individual to be solely responsible for an accident. Many will be also aware of James Reason’s Swiss cheese model (diagram one below) which shows how accidents can happen if fl aws in controls are aligned. So why have a presentation apparently telling those present what they already know?

The answer is that today’s presentation on “Finding the root causes using Tripod Beta” is about a tool that off ers improved learning from accidents. This comes about by a better understanding of what led to the accident and what needs to be done to prevent recurrence. This is due to its complete, concise graphical model being much clearer than a lengthy report.

Commissioned by ShellTripod Beta was borne out of research commissioned by Shell International and carried out at the Universities of Leiden and Manchester during the early 1990s. It builds on the Swiss cheese model and helps accident investigators model incidents in a way that allows them to understand the infl uencing environment and uncover the root organisational defi ciencies that allowed that incident to happen.

Today it is promoted by the Stichting Tripod Foundation who set standards for practitioners, trainers and assessors. Tripod Beta trees are drawn with Investigator 3 software. Data is entered at each element as the tree is being developed enabling the fi nal report to be produced automatically.

It is currently used by Shell and many other organisations in the oil industry. In the UK, it is used by Centrica, and Corus among others. Perhaps as a result of its pedigree, it is widely used in The Netherlands to investigate railway and healthcare accidents. It is also used by the Dutch Safety Board.

A picture is worth 1,000 wordsTripod Beta proves the adage that “a picture is worth a thousand words”. It does by so by showing all aspects of an accident, typically on a single sheet of A3, in a way that is clear to someone new to the process. The advantages of this are:

• It is easier to share thoughts on the nature of the accident and reach a consensus during the investigation,

• It keeps the investigation team focused on what is relevant i.e. there is less chance of following false leads

• It speeds the investigation since it focuses on the required lines of inquiry

• Managers and analysts reviewing many incidents fi nd it attractive since it is not necessary to read a lengthy report to understand the accident

• More commitment throughout the organization to implement recommendations as since the reasons for them are made clear by the cause / eff ect relationships shown clearly throughout the tree


TRIPOD TELLS IT ALL

Some holes dueto active failure

Other holes due tolatent conditions

Successive layers of defenses, barriers and safeguards

The Swiss Cheese Model of Accident Causation

HAZARDS

LOSSES

David Shirres reports

Diagram one.


It is important to stress that Tripod Beta is only a tool to analyse incidents. It still relies eff ective evidence gathering. Its use throughout the investigation will help identify lines of inquiry and thus focus evidence gathering. Once the Tripod Beta tree is complete further study is required to establish the reasons for the underlying causes.

Understanding the elementsThe foundation of Tripod Beta is the Trio in which an Event occurs when an Agent (of Change) acts on a Target if there is a Failed Barrier(s). For each failed barrier there is an unsafe act i.e. an Immediate Cause which is promoted by Pre-Conditions. However such Pre-Conditions will not necessarily result in an Immediate Cause. The relationship between them is therefore probabilistic. The Tripod Beta philosophy is that it is such performance infl uencing factors in the workplace that lead to unsafe acts.

Each pre-conditions is caused by Underlying Causes. However in some cases, e.g. bad weather, there is no organizational Underlying Cause. A Missing Barrier is also the result of an Underlying Cause as shown in diagram two (above).

With Tripod Beta each Failed Barrier and each Underlying Cause should have at least one Recommendation. Those relating to barriers require immediate action to ensure the safety of operations. Actions to address Underlying Causes are aimed at correcting shortcomings in the management system and will take longer to implement.

In reality few accidents are just one event as the end event will be the result of a number of prior events. Tripod Beta guidance is that

usually a sequence of two to fi ve Agent-Object-Event Trios are enough to describe most incidents. In the Tripod Beta model an event can become an Agent or Target in the following trio as shown in the diagram. Diagram three (below) Producing the chain of trios that accurately represents the accident is an essential fi rst step of the tripod beta tree – many investigators draw the trios from data taken from a timeline. This sequence of trios shows what happened i.e. the direct cause of the accident, and can thus determine the scope of the investigation.

UNDERLYINGCAUSE PRECONDITION IMMEDIATE

CAUSE

TARGET

EVENTAGENT

FAILEDBARRIER

TARGET

TARGET

END EVENTAGENT

AGENT

AGENT

EVENT /AGENT

EVENT / TARGET

EVENT / TARGET

Diagram two.

Diagram three.


Mind the gapThe accident to a passenger who fell between train and platform when alighting from a train at Brentwood station on 28th January 2011 was the subject of a report 19/2011 by the Rail Accident Investigation Branch. The chain of trios that represents this accident, as shown below is derived from the information in the RAIB report. See diagram four (above).

For the end event, the failed barrier, immediate cause, pre-conditions and underlying causes are shown below. The full analysis of all the

trios associated with this incident would require an A3 page. See diagram fi ve (right).

Best ideas look simpleLike all good ideas the diagram looks simple. To anyone familiar with the industry concerned it provides an almost instant understanding of what (Trio), how (Failed Barrier / Immediate Cause) and why (Precondition / Underlying Cause) the accident happened. The production of such diagrams however is not as easy as might be fi rst thought and requires practice.

Indeed a recent paper comparing Incident Investigation Methods in the IChemE’s Loss Prevention Bulletin concluded that whilst Tripod Beta was the technique that most comprehensively met criteria for incident investigation it was not easy to learn and apply.

There is, however, no requirement for training if you wish to try to produce a Tripod Beta diagram using the Investigator 3 software. A four-week trial version can be downloaded from: http://www.governors.nl/support/download.html

safety on tracks

Schweizer Electronic AG Industriestrasse 3 6260 ReidenSwitzerland

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A real promise to the safety of railway traffic.

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Rail Safety Summit, London

28th April 2014

Diagram four.

Inattentive passenger

– wanting to get off at Brentwood

Late decision by passenger to get

off train

Closing train door

Passenger caught in door

Passenger struggles to free of door

Passenger pulls free of door

and becomes unbalanced

Gap between train and platform

Driver starts train

Passenger fell into gap between train

and platform

Train departs with passenger in gap between

train and platform POTENTIAL FATALITY

Train aboutto leave

Brentwood


Diagram fi ve.

Not applicable

No system in place to monitor driver compliance with

rule book

Failure in management system for reporting / dealing with driver’s

concerns

Network Rail failed to comply with system for reviewing DOO equipment setup

NXEA system for analysing driver’s tasks

for input to training and briefi ngs less than

adequate

78. Driver’s direct fi eld of vision

obscured by person on platform.

71. Driver did not see incident at 8th

carriage

31. 74. Driver starts train

44. Passenger fell into gap between train and platform

72. Driver completes safety checks before

departing

46. 2nd Passenger stops passenger from

falling onto track

46. Train departs with passenger in gap between

train and platform POTENTIAL FATALITY

80. Driver routinely made fi nal check after train was moving, i.e. with

monitor out of site

86. Replacement monitor image impaired since not angled, the same as the

original

94. Not being able to view monitor from

correct stopping point had not been reported/

acted upon

99. Misalignment of DOO monitor not identifi ed

when commissioned by Network Rail

106 to 120. Driver training and briefi ng not suffi ciently focused on

train despatch

Mission Room brings the track side environment into the office, giving

safe and instant access to complex and hazardous assets. The highly

immersive experience enhances understanding of real situations and

has applications in design, planning, induction, briefings and training.

Mission Room increases safety by reducing the need for access to track

and reduces costly mistakes by ensuring better preparation.

See More, Save Time, Stay Safe

For further information or to arrange an on-site demonstration contact [email protected] or call 0115 951 6800

• Jump to anywhere along your route

• Interactive SSOWP briefings

• New rapid tunnel filming service

• Access point walk-throughs

• Dynamic training scenarios


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Ken MaddoxTripod Beta: practitioner, trainer and assessorEPEX

Ken is a Tripod Beta practitioner, trainer, and assessor and owner of EPEX consulting company based in Aberdeen. He has applied Tripod principles in his consultancy work in more than 25 countries.

He has over 30 years industrial experience in plant: construction, operation, and maintenance. He also has 13 years experience as owner of EPEX, a company helping organisations to maximise their profits by minimising their losses.

He worked for Shell International Exploration and Production for 28 years in many locations around the world. Following the Piper Alpha disaster in the North Sea he worked for four years in Shell’s HSE department in Aberdeen. During this period he acted as project leader of Shell’s two year, £10M, major overhaul of their permit to work system and was co author of OGPA’s guidelines on permit to work systems.

He is a Chartered Engineer, a member of the Institution of Engineering and Technology and holds a postgraduate diploma from the University of Birmingham (UK).

He has investigated many incidents including: fatalities, process upsets and business failures.










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28th April 2014

Royal College of Physicians

Regent’s Park, London

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www.railsafetysummit.com

Documents

Rail Safety 2014