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Safety by leadership, delegation and motivation or training? – And why site visits are so important

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Colin Wheeler Reports…

Using precious time, adding little value?

A lecture is to be given in Westminster next month titled “Safety and Simplicity” focussed on what the advanced publicity describes as “an increase in the use of behavioural based safety programmes and approaches”.

Network Rail’s Gareth Llewellyn (Director Safety and Sustainable Development) is one of the advertised speakers. The questions it will try to answer are “Do behavioural based programmes have a positive impact or use precious time with extra procedures, adding little value? Do they only work at Project level? And should the focus be on behavioural safety or behavioural leadership?”

I am in little doubt that we have too many rules and procedures and far too much paperwork which has become a distracting burden on those trying to get work done. Much of it is recorded but only referred to if things go wrong.

This diverts supervisors and management away from spending time each and every week on site with those doing the work. Listening to staff ideas and concerns and dealing with them inevitably leads to an improvement in safety culture.

Conscious rule breaking

A reader has told me a little more about how the industry is planning to take forward Network Rail’s “Life Saving Rules”. Network Rail is confident that it can establish the root causes of accidents. Genuine mistakes, errors of judgement etc. will not lead to disciplinary action but under the “culture of fairness” will be explored to identify areas for improvement.

However it is believed that conscious rule breaking (as distinct from making a mistake) is involved in 10% of accidents and incidents. Such actions will have consequences for individuals in future.

I understand detailed discussions with the relevant trades unions are still continuing, but agreement is now in sight on the principle of implementing a system where deliberately breaking a Life Saving Rule results in similar consequences to breaking the well-established standard on drugs and alcohol.

I welcome this, and merely suggest that the time may now be right for the industry to accept that the capacious, all-embracing Rule Book should be seen as a reference volume with some of its components used to draft operating instructions for individuals!

Behavioural Safety

Network Rail’s “Safety Central” website contains references to behavioural based safety initiatives, but you have to find them. I looked in the currently listed initiatives of their Infrastructure Safety Liaison Group.

They feature occupational health together with proposals for industry wide core induction training, site access training, Controller of Site Safety suitability and contractor competency assurance and well as fatigue management. All very laudable, but I question the inclusion of only contractor competence rather than the competence of all organisations including Network Rail itself?

Contractors are still wary of raising concerns locally in case it affects their future order books and there are still people working on track who believe that getting the job done is all that matters, and accidents only happen to other people.

Meanwhile I hear that resistance to putting safety first and the conviction that safety rules are not strictly applicable to Network Rail’s supervisors and front line managers continues.

Human Factors people are doing their best, but authoritative action is now needed! The Projects section of the website is better. It includes “developing a strong, continuously developing behaviour based approach throughout the company and wider industry as part of building a positive safety culture”. It also helpfully lists the contact details of four Network Rail employees offering “behavioural change team services”.

RAIB – remit and reports

Every Rail Accident Investigation Branch (RAIB) report includes the following: “the purpose of an RAIB investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences” and “RAIB does not establish blame or liability or carry out prosecutions”.

Linking their reports to human errors of judgement or deliberate unsafe working deserving action by others is important if safety is at last to become our top priority. Arguably there is still work to do here!

Clearly prosecutions are only brought where convictions are possible, but I suggest the naming and shaming of individuals whose deliberate actions have resulted in an accident or incident should become the rule for the future.

Track twists and locked suspensions

Recently published reports include the derailment at Bordesley Junction of four of 30 empty aggregate wagons whilst being hauled by a diesel-electric locomotive at 0044 hours on August 26th last year. It happened between Banbury and Barrow-on-Stour.

The wagons ran on the rail head for 3.6 metres having flange climbed just before the junction. They then re-railed but “extensive damage was caused to track and signalling equipment”. The cause was a combination of faults with wagon suspensions and track twist.

Track twists more severe than 1 in 200 were long standing and were measured as 1 in 140 and 1 in 172. RAIB concluded that the first of these led to the locking up of the suspension of the first wagon to de-rail. The suspensions of the wagons had a number of well-worn components that had not been detected nor checked during maintenance and this contributed to the derailment at the second severe twist site.

“No-one took ownership of the problems”

Network Rail maintenance staff were aware of the recurring twist faults but had only repaired other faults nearby. Work had been planned at the actual sites four days earlier but due to time running out during the overnight possession had not been done.

Maintenance staff had attended twist sites in the area no less than 6 times during 2011, repeat faults were not investigated and tamping planned for August did not take place. But for me the critical factor is the lack of responsible leadership.

The track was regularly patrolled and the faults had been identified. Wagon suspension problems and their solution was known about, but as the report says “no-one took overall ownership of the problem or its resolution”. The report includes a listing of similar earlier incidents.

200 metres of OLE progressively collapsed

Midland Metro is not often featured in RAIB reports. But on 20th April last year a partial collapse of the 750-volt DC overhead line equipment (OLE) resulted in three adults and three children needing hospital treatment.

It happened near the Jewellery Quarter Tram Stop at pole 18512 between Wolverhampton St George’s and Birmingham Snow Hill. Tram 13 is an AnsaldoBreda 2-car tram that was being driven from its “B” end when it struck a cantilever that was partially detached from its support pole. This resulted in the progressive collapse of about 200 metres of the OLE which caused further damage to the train.

The tram was travelling at below its permitted speed of 70 kph on an off-street section just ten-foot away from an adjacent Network Rail double track railway. RAIB report that the reducing sleeve attaching the cantilever to its pole had fractures due to being mechanically overloaded.

Brechnell Willis who designed and installed the OLE in the 1990’s were contracted to provide technical and inspection support for modifications to the OLE between October 2010 and April 2011.

Modifications and material changes

Although the Centro system is owned by West Midlands PTE operation and maintenance is contracted to National Express Midland Metro. Damage to the tram included a broken windscreen, side window and the driving cab partition screen, resulting in passengers being showered with broken glass. The driver controlled his train for a further 200 metres onto the tram stop.

RAIB report that “significant repairs” were made to pole 18512 in August 2009 following a derailment, and “further modifications work” was done in October 2010. Regular inspections after that “did not detect any loss of mechanical clearance”.

The original reducing sleeves were malleable iron but after 1997 aluminium bronze was used until this too was superseded by an aluminium alloy in 2007. The damaged sleeve was one of these installed in August 2009 but neither Brechnell Willis nor National Express West Midlands were aware of the new materials used for the replacement sleeves.

A lack of training for emergency situations was uncovered by RAIB and Customer Service representatives now carry cab keys. There is also now a 40 kph precautionary speed restriction in place from 260m metres before pole 18512.

Network Rail’s “Safety Central” website seems to focus on occupational health, contractor competence assurance, site access training, fatigue management and safety performance indicators although its project specific section does include references to building a safety culture and behavioural based approaches.

For me it’s too much jargonese. Just one commitment would do far more. If every responsible manager and supervisor spent a minimum of two days each week listening to those on track doing the work, hearing about their concerns and making sure he or she knew what was happening on their part of the railway both safety and performance would improve.

The consequences are likely to be fewer computerised records and meetings – but I see that as another advantage!


  1. You are right that there are too many records and meetings but this is the only way to protect people when before a judge – the real problem today is that the main objective today is to find someone to blame and convict or sue.


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