…a handful of rules together with the right Safety Culture
Written by Colin Wheeler
I met with Gareth Llewellyn late last month. As Director Safety and Sustainable Development for Network Rail he has an interesting and useful past.
He spent eleven years as Head of the National Centre for Risk Analysis and Options Appraisal at the Environment Agency. Also he worked for seven years as Group Corporate Responsibility Director for the National Grid. He joined Network Rail last September.
Too many rules
I asked about working with the devolved Route Managing Directors to improve Network Rail’s safety performance. He replied his main concern was the lack of coherence. He believes too many standards, processes and rules demanding compliance do not improve safety performance. I agree!
He plans to move to a system aimed at creating the right culture throughout the rail industry. He is committed to doing all that he can to ensure that everyone “goes home safe at the end of every day”.
We discussed the splitting of technical standards etc. into red, amber and green categories. He sees “life-saving rules” as falling within the red category and green ones as matters that should rely on the competence of individuals”.
Twelve life-saving rules only
To reach his goal he intends to mandate only things that must be mandated. The example he quoted was from Shell who had just twelve “life-saving rules”. It is left to trained people to use their competence and knowledge, a principle I support.
I referred to the project currently underway at the Rail Safety and Standards Board to simplify the Rule Book. Gareth recalled how his father, who worked for the railway, read up his Rule Book before promotional interviews.
He was impressed at the time, but is far from convinced of the future relevance of the Rule Book in improving safety. Yet again I agree. Simplifying it down or even out of existence would really only upset the lawyers!
A Network Rail sanity check
Having led the way through a complete Dupont Safety programme, he admitted to “still having all the scars to prove it!” He told me that a Dupont “sanity check” has already been carried out at Network Rail.
Amongst a string of quotable slogans he included the following: “Zero is achievable, safety is not optional, being safe is the best way of increasing business and everyone needs to focus on today.” (I leave you to choose a favourite.)
Route Safety Improvement Managers
He has been working with the ten appointed Network Rail Route Managing Directors interviewing and appointing their Route Safety Improvement Managers. Half of the appointees come from outside of the industry.
Together they will form a national safety strategy group working with Allan Spence (Deputy Chief Inspector of Railways from the Office of Rail Regulation) who has been seconded to Network Rail for six months.
The Route Safety Improvement Managers will work with 250 area level safety representatives. He believes the culture change must come from a shared “aspirational vision” and a small number of life-saving rules endorsed and shared (as they were at Shell) by contractors and subcontractors.
More encouraging still was the assertion that a devolved focus onto every individual is critically important.
CIRAS “sticking plaster”
I asked about CIRAS – the confidential incident reporting and analysis system for the rail industry. I had seen issue 39 of their newsletter “The Reporter”. It features a report of a contractor allegedly working on track without either Lookout protection or a Controller of Site Safety (COSS) on site.
The Network Rail response after investigation was “it was felt there was sufficient merit in the concerns to review the contractor”. What weasel words! I trust the word “review” was an understatement!
Gareth Llewellyn was forthright about CIRAS, describing it as “sticking plaster to be used if the safety culture is rubbish.”
450 incident investigations in 2011!
He plans to tackle the problems by changing the culture that last year (2011) led to just 1,200 near miss or close call reports being made to Network Rail. Gareth suggested that comparing this to Shell’s annual figure of around 35,000 indicated the current situation in respect of the safety culture.
I suggested the investigation into what RSSB and the Unions described as a “climate of fear” was the main factor. He drew my attention to the safety effort used last year to investigate 450 separate safety incidents and said that the time would have been better spent in preventing the incidents occurring in the first place! Agreed!
As I made ready to leave Kings Place I was reminded that the industry may expect to see the publication and release of the new “aspirational” Vision for Safety this month. I look forward to reading it!
Near miss between Clapham and Earlsfield
The need is evident. The latest report released by the Rail Accident Investigation Branch (RAIB) reports on two incidents between Clapham Junction and Earlsfield Stations around 0600 on the morning of 8th March 2011.
Either of them could have resulted in a fatality and the circumstances are far from unique. Both gangs were setting up Emergency Speed Restriction (ESR) Boards following the discovery of Class 1 A rail defects by planned ultrasonic rail testing.
The RAIB report concludes that “staff did not follow the rules for setting up a safe system of work” but it qualifies this saying the cause was “excessive workload, pressure to complete the work, tiredness/fatigue, the complexity of the rules, the absence of checking arrangements by a third party, the ineffectiveness of Network Rail’s competence management process and a shortage of staff”.
The defects had been discovered earlier that same morning. The more senior COSS (Controller of Site Safety) was contacted at 0335 hours whilst working under possession and advised of the additional work he was required to do following the ultrasonic testing.
He discussed arrangements with the Signaller and expected to hand back the planned possession and then re-take possession for the erection of the two ESR boards.
Lookout only had a whistle!
The COSS’s involved in the incidents were both working in the same area during the night. Their worksites finished work at 0432 and 0500 hours respectively and the third rail electrification isolations were re-energised at 0539 hours.
When the PICOP (Person In Charge of Possession) handed back at 0539 the Signaller asked him if the ESR work was complete and he answered that he believed everyone was now clear of the running lines in what is a red zone working prohibited area.
The COSS who had completed his work at 0432 spoke to the signaller at 0517 and requested a line blockage to erect his ESR board, but this was refused since the possession was still in place. He later spoke to the other COSS and advised him of this before briefing his staff that all lines were open and asking his lookout who had no equipment, except for a whistle to look out for them.
Luckily they had 20 seconds rather than just 8!
The red zone working prohibition is due to restricted sighting. The RAIB reports that at line speed only 8 seconds warning time is available, but that morning the empty coaching stock trains were travelling at well below line speed giving around 20 seconds.
In the event the first gang was passed by a train with no casualties. The second train experienced a near miss with the gang and stopped following the resultant emergency brake application at 0610 hours.
Both trains were 8 coach long Class 455 Electric Multiple Units.
Assessment in the Line
It is inevitable that ultrasonic rail testing teams will find defects. That is their purpose. In my experience the discovery of defects requiring immediate ESR’s is far from unusual. Surely contingency plans should have been made in advance?
Network Rail’s assessment in the line system is criticised. I believe it needs to be re-examined. I presume the local manager with delegated power to undertake in the line re-assessment of track-competences is also under pressure to pass individuals so as not to worsen his manpower situation for day to day working.
The criticism of the complexity of the rules is also in line with Gareth Llewellyn’s approach. The initiatives he proposes in his “Vision for Safety” I suggest would have prevented this incident provided the staff concerned were motivated to always put safety first!
Struck at 100 mph, off for 18 weeks
More lessons can be learnt from the recently released RAIB report of the accident that happened on January 8th 2011 at Torworth Level Crossing. Whilst walking with his back to traffic a Tamper Driver was taken unawares by a passenger train travelling at 100 mph. He took evasive action when he heard the train’s warning horn.
He was struck a “glancing blow” and his bag was torn from his shoulder. He was off work for 18 weeks but recovered. Again a shortage of staff was involved. He was a member of HOBC 4 (High Output Ballast Cleaning Machine 4 team located Willesden).
The work was being undertaken by the Doncaster based team but due to shortage of Tamper Drivers they requested a volunteer for the 8/9 January shift. The Site Access Control was at Bawtry Old Station but the tamper driver could not find it having not visited the site before the work began.
He found the level crossing at Torworth. Believing that both tracks were under possession he took the shortest route towards the tamping machine, walking in the four-foot of the Down Main with his back to traffic.
Bristol for Willesden and sometimes Doncaster!
On the 6th January there had been a “White Board Meeting” led by the Site Supervisor but the Tamper Driver did not attend. Before his shift he had driven to the Doncaster area from his Bristol home.
The report gives the cause as the “unsafe actions of the driver” but also points out that “he did not have the information he needed to get to his tamper safely” and that “it was not uncommon for drivers to walk to trains in work sites without having first received a safety briefing”.
The implication of the latter to me is that there existed an acceptance that safety briefings were not needed by tamper drivers! I suggest the thinking behind a Willesden based organisation with a member of staff living in Bristol and then driving to Doncaster needs review!
These two RAIB reports illustrate the importance, relevance and urgency of Network Rail’s “Vision for Safety” and why we all need to get behind it!