HomeEventsMajor incidents and the role of reporting

Major incidents and the role of reporting

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Safety conferences aren’t particularly emotional places. The legal and regulatory responsibilities often take centre stage. Delegates sit, take notes from colleagues on things they could probably do better and then go back to their offices. It’s rare that the concerns of real passengers are heard or the stories of those who have survived major incidents are told.

On 1 May, CIRAS, the rail industry’s independent confidential reporting service, followed the Rail Safety Summit with a conference of its own – the first of its kind. The two-day programme at London’s Royal College of Physicians included Network Rail chief executive Mark Carne, Govia Thameslink Railway (GTR) chief executive Charles Horton and Ladbroke Grove survivor Pam Warren.

Much of the second day was about the fall out of major incidents. Who is there to help when things go wrong and why services like CIRAS offer another layer of defence in preventing loss of life on the railway.

Delivering the keynote speech, Charles Horton, chief executive of GTR, said, ’Although Ladbroke Grove is only 16 years ago, there are many, many people in this industry who were not around at that time. For those of us who were I’m sure we will remember it as a time which was painful – a time when the consequences of failure were all around us.’

From behind the mask

Pam Warren, known commonly as the lady in the mask, has made a career from public speaking, having made it out alive from the disaster where 31 of her fellow passengers didn’t.

Countless surgeries were required to repair the damage to her face and body caused by a fire ball that engulfed the carriage she was in. Her story will no doubt stay with everyone sat in that lecture theatre – something that was made clear by the number of people buying copies of her book, ‘From Behind the Mask’, in the lunch break.

‘Just as we neared Paddington the train lurched and it lurched violently,’ said Pam. ‘For a brief second I thought ‘oh somebody’s pulling the emergency cord’ because the sound of metal screeching was filling this carriage.’

She described the crash in detail. The sights, the smells – the sounds. ‘There was one sound that overrode all this that frightened me the most and that was the sound of screaming – it was the sound of men screaming and I don’t know why and I don’t hear men scream very often and that sound really, really unnerved me.

She added, ‘When I eventually took my hands down from my face, I didn’t know whether I was dead or alive. I just didn’t feel anything… There was no panic and no pain.’

Getting better

The industry’s confidential reporting system, CIRAS, was born out of the events at Ladbroke Grove. The industry had to make changes and it did.

Delegates heard from Paul Russell, head of CIRAS, about the work the organisation is doing. The aim of CIRAS is a simple one – to give people a safe outlet to raise safety concerns. What CIRAS wants to distance itself from is the perception that it’s a whistleblowing scheme – something that is working against the interests of the industry.

Reverend Liam Johnston of the Railway Chaplains, which has been serving the rail industry since 1881, has seen many accident sites and supported countless rail staff and their families during challenging times. His presentation touched on the important role played by Railway Chaplains for passengers and staff involved in life-changing incidents.

He too spoke about the important role CIRAS plays. ’Confidential reporting is a mechanism not to hold companies to account but a mechanism for people to raise issues in an environment where they feel safe. If they’re tired, if there’s problems and things are getting too much – all kinds of things cause safety issues.’

He added, ‘The cost is just too great for some families to bear and yet they have no choice, but we do have a choice, you have a choice by investing in the safety of your company, you have a choice. By allowing that confidential reporting you have a choice, by having a culture that’s not of blame but of responsibility, and responsibility not in a negative way but in a positive way.’

Other talks came from Network Rail’s health and safety director Emma Head, David Leckie, of legal firm Clyde & Co, TES 2000’s Mike McLean, Jill Collis from London Underground and Paul Oliffe from the National Audit Office, who gave a breakdown of the application of confidential reporting schemes across other industries.

David Leckie brought home the reality of the penalties that company directors and health and safety executives can face when things go wrong. Later in the day, Emma Head set out how the introduction of Network Rail’s Lifesaving Rules was contributing to the creation of a fairer culture within the organisation.

The weight of responsibility of rail disasters is carried by many. It’s what drives the industry to be better and the accounts of those who have experienced them first hand are one way of ensuring that the younger generation are just as acutely aware of the small margins that can be the difference between a safe operating railway and a national incident.


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