HomeRail NewsCurrent approach will never achieve the zero in safety we all seek

Current approach will never achieve the zero in safety we all seek

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Written by Colin Wheeler

On April 23rd Steve Hails became the new Health and Safety Director for Crossrail. In line with most of our railway industry, Crossrail’s aim is to prevent accidents happening. I have no difficulty in supporting this principle.

The Press Release however refers to their “target zero philosophy as driving every action undertaken by Crossrail staff and our delivery partners”. The use of the word drives hints at a misunderstanding of people and their motivations. I hope it came from their public affairs department not Steve Hails.

Leading by example

The old adage “you can lead a horse to water but you can’t make it drink” is true when applied to creating a safety culture. To encourage people at work to work safely and be passionate about it, for both their own safety and that of those working alongside them is an excellent goal. But leading by example and showing commitment are how it can be achieved; not coercion.

I believe that similar statements are also true when it comes to managing and motivating people to get things done at work generally. Management through fear or by threat is unsustainable and generally ineffective.

Beware of safety statistics

I have seen many variations on the signage of contractor’s working on large road schemes. “1,750,000 safe hours worked on the site” is one I spotted recently. The pressure such a well-publicised slogan puts onto those working there must be huge. Rather than encouraging safe working I suggest it is likely to encourage under-reporting and the concealment of minor accidents and near misses.

Many now realise the importance and value of reporting near misses and indeed all incidents which could have become accidents. Proclaiming achievements in terms of safety can be counterproductive. Presenting awards for safety statistical achievements is surely always likely to promote the hiding of any incident on the day before the award is to be made?

Network Rail safety initiatives

Recalling the comments made by Network Rail’s Gareth Llewellyn of Network Rail that I reported last month, I am still looking forward to reading what I hope will be a small number of easily understood and evidently sensible “Life Saving Rules” within our mainline infrastructure owning organisation.

I note from the details on their safety website that Network Rail’s Project Safety Leadership Group are now addressing the issues of double shifting, electrical isolation safety issues, workforce safety reporting of near misses and close calls, and the restoration of Task Briefing sheets back to where they began as single page briefing aides memoire rather than cover-all method statements running to many pages.

However, I am concerned that even they are looking to mandate every company they use to have a close call reporting system within six months. This last initiative will produce close call reports. But the mandating could well lead to individuals being told to ensure reports are generated which will alienate the workforce I suggest! Indeed it is not beyond the realm of possibility that some may even invent close calls so as to comply with Network Rail’s mandate!

I am delighted to see that the task of rationalising the number of Sentinel accredited competences has at last begun. That is one initiative which should save money, improve safety, and even go some way in convincing those who do the work that their skills are appreciated.

RAIB reports

The Rail Accident Investigation Branch (RAIB) has published a number of reports since last month and issued a couple of accident investigation alerts. The report on the incident at Kings Cross Station on October 10th last year illustrates the sort of incident which, although only minor injuries resulted could easily have had a serious outcome.

A passenger rushing to board a train due to depart got a hand trapped in the closing doors and was pulled someway along the platform. Luckily she merely suffered bruising to the fingers of her left hand. The train was made up of two 8-coach Class 365 EMU’s under driver-only operation.

The report suggests that the design of the door seals should be reviewed.  In my opinion more significantly the report adds that “dispatch staff had adopted the practice of using their experience and observation of passenger behaviour to determine whether it was appropriate to give the Right Away.”

If the dispatch staff were adequately trained and their managers and supervisors had created a good open management and safety culture would the potential for this incident not have been realised before it happened?

Three hours without toilets or air conditioning

Another case in point was the incident that occurred on 26th May last year. The RAIB report was released on May 23rd. A Brighton to Bedford train suffered a loss of power and came to a halt. The public address system failed after around 45 minutes and during the three hours it took to rescue the train the air conditioning ceased to function and the toilets stopped working.

Not surprisingly, if unwisely some passengers decided to force the doors open. Eventually it was hauled into Kentish Town Station. Unusually the RAIB used YouTube, Facebook and Twitter images in their investigation. The concerns of the report centre on poor communication with the passengers, the inadequacy of the training and briefing of the staff and the arrangements for rescuing a train with no power.

Again I suggest the right open attitude of trust between workers and their managers should have resulted in adequate training and the use of understanding and initiative to deal with the situation.

Tram safety in Europe

Manchester Metorolink trams have been running through Manchester city streets and around Piccadilly Gardens since July 1992, as I remember having been the railway civil engineer in Manchester when its first phase was constructed.

The RAIB report into the fatality of a 67-year-old pedestrian who fell whilst running into the path of a tram travelling at just 9 mph. He became trapped under the front of the leading vehicle and subsequently died of his injuries.

The report calls for research into the front ends of trams and the potential for causing injury of the current designs of under-run protectors.  I am surprised that it does not also recommend a full review of the designs used across the European mainland with particular reference to those countries which have enjoyed the uninterrupted use of trams since they first began to replace horse drawn vehicles.

Train guard fatally injured in Yorkshire

Another fatal accident occurred at about ten past noon on the North Yorkshire Moors Railway on May 21st. The 60 or so year old volunteer guard had uncoupled one coach from a rake of coaches stabled in the platform.

It was being drawn off by a steam locomotive when the locomotive unexpectedly changed direction and moved back towards the remaining rake of coaches crushing the guard.

The preliminary investigation report from the RAIB says that the ex-Southern Region Class S15 locomotive was working tender first but “the reverser could change from reverse into forward gear unless it was prevented from doing so by the operation of a locking device. Should the reverser not be secured in any position, any change may not be noticed by the driver and in these circumstances, would only become evident on opening the regulator, when a change of direction would occur”.

Cyclist killed on user bridleway crossing

Also in May a fatal accident occurred on Wednesday May 2nd at Kings Mill Number 1 Bridleway Crossing Mansfield, Nottinghamshire.

The 1555 hours passenger train from Nottingham to Mansfield Woodhouse struck and killed the 34-year old male cyclist as he was cycling over this user operated crossing.

The railway is two- track and runs close to both housing and industrial estates. The crossing is equipped with signage including “cyclists dismount”, telephones and self-closing gates according to the preliminary alert from the RAIB.

Are we wrong not to identify blame?

The common theme behind all of these reports from RAIB (and indeed the views I have expressed about motivation for those who work in our rail industry) is the importance of recognising the fallibility and potential for making mistakes which we all share as human beings.

The remit of the RAIB clearly excludes establishing blame or liability. That is the business of the Office of Rail Regulation, the Police etc. But if we are to learn from the mistakes that are made and indeed share that learning across the industry then highlighting the details of blame, liability or indeed simply flagging up where and by whom errors of judgement contributed needs to be done.

I believe that being briefed on the circumstances that led to accidents and incidents makes situations seem more real to those at work. We are all then more likely to remember the details when faced with similar situations. A bland instruction, however strongly worded does not have the same impact.

One of the values of the old style report issued by Her Majesty’s Railway Inspectorate each year was that it did just that and used the details of significant safety events to set out concerns and lessons to be learnt for the future.

I question whether there is any publication today which does so; but the need is surely still there?


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