It was my privilege to open and host the 11th Rail Safety Summit on 1 November at the prestigious offices of Addleshaw Goddard in central London. I began by quoting from a report which now shows its age by the language it uses, but is arguably as relevant today as when it was written.
“Engineering maintenance should be planned and carried out under the protection of fixed signals; such work should be agreed between those involved and published in the Weekly Operating Notice.
“The root cause of our poor record in safety is the failure to eradicate the unsafe act and to convince our workforce that we believe in achieving our work goals safely rather than just achieving work goals.”
Both these conclusions were taken from a report written by Graham Ellis and submitted to the then British Railways Board in February 1993, some 25 years ago. I suggested that their contents are as relevant in 2018 as they were back then, although we have improved remarkably over the intervening years. However, the objective of only working on the tracks with fixed signalling protection has still to be achieved.
I then welcomed the appointment of Andrew Haines as chief executive of Network Rail and the appointment of an interim new chief at the Office of Rail and Road (ORR) and shared my aspirations for route devolvement improvements as Network Rail’s new structure beds in.
Lilian Greenwood, chair, Transport Select Committee
I indulged in more nostalgia by recalling the evening in Birmingham when the formidable, knowledgeable and impressive Gwyneth Dunwoody, as chair of the Commons Transport Select Committee, opened a RailStaff event. I then had the pleasure of introducing the current chair of the select Committee Lilian Greenwood MP (pictured right). I believe the influence and role of Select Committees should never be underestimated, and congratulated Rail Media for inviting her.
She referred briefly to a recent Nottingham tram incident before saying that the industry should be proud of its safety record, especially when compared to road injuries and fatalities. She asked whether or not safety performance had now plateaued despite avoidable accidents still occurring.
She went on to comment on platform overcrowding, referring to her personal experience earlier that morning on London Underground’s Northern line. She spoke of her concerns about the personal safety of vulnerable people, citing a recent train attack on a blind and disabled woman, and said that there has been an increase in reported incidents.
Network Rail – recent events!
The second keynote speaker was Allan Spence from Network Rail who was at the ORR before he joined Network Rail in 2012 where he created the strategy which led to the “Everyone Home Safe Every Day” initiative.
He commented that Grayrigg, which resulted in the death of an 80-year-old lady, was the last fatal train accident. He added that five years ago Network Rail began to look outside our industry, and we now have the lowest accident frequency rate ever. He reminded us of the serious irregularity at Cardiff East Junction in 2016 where the vigilance of a train driver prevented a derailment.
Also an incident at Waterloo in August last year which could have had serious consequences and the near miss at Egmanton (see RailStaff September). In making his emergency call, the train driver corrected the signaller saying “not just one, I hit a group”. Allan commented on the effect of such an incident on train drivers and added that there have been eight near miss events recently and we all need to listen harder and keep listening.
Four speakers then spoke focussing on the Sandilands Croydon Tram tragedy. Simon French, chief inspector of the Rail Accident Investigation Branch (RAIB), reminded delegates that the tragedy resulted in seven fatalities and 61 injured of whom 19 were seriously hurt.
He showed a short excerpt from the cab video before commenting on the driver’s lost awareness, inadequate signage and lack of an alertness checking system. The report made 15 recommendations, covering automatic braking, monitoring driver alertness, the crash worthiness of vehicles and the regulation of tramways. He drew attention to the line-of-sight driving arrangements used by trams and lack of regulatory understanding.
He commented on the organisational culture and management which made drivers reluctant to report mistakes, including late and heavy braking.
Ian Prosser, director railway safety at the ORR, began by commenting that the risk management model the ORR uses (RM3) was only partly in use at Croydon.
He said two questions needed to be asked, were there enough controls in place and what has happened since the incident? Provided standards board funding is agreed, improved regulation of trams will be introduced in December. Its objectives will include strengthening the existing system. Draft action on all 15 recommendations is due to be published before the anniversary date of the tragedy.
Light Rail Safety and Standards Board
Mark Ashmore, health and safety manager at UKTram, has particular light rail knowledge. He told delegates that a chief executive for the new, joint industry Light Rail Safety and Standards Board has been recruited although funding is still awaited.
To meet RAIB’s recommendation a Light Rail Risk Analysis Model based on RM3 is to be deployed and Atkins are already working to develop a common framework, including speed controls, vigilance devices, signage reviews and visual cueing. For the containment of passengers, fully welded doors will be specified.
Other initiatives cover emergency lighting, escape hatches (but these may prove to be impractical), best practice and technical aids to combat fatigue as well as in-cab TV in place of rear-view mirrors. Recommendations nine and 10 are undergoing safety assessments and a Light Rail Engineers Group has been founded.
Mick Whelan, ASLEF General Secretary, arrived straight from Australia and deserves commendation for attending. He commented that, along with our concerns and condolences, we needed to make sure there was full access to the facts and learn lessons from the loss. He said unions, and in particular their safety committees, need to say why they had failed to raise issues, before adding his concerns over the existence of “right hand turns on railways”.
He added that future risk management for tram operation needs to have a mutual learning focus. He suggested that a shift-based system with appropriate breaks was needed to combat fatigue. He said he found little with which to disagree in the RAIB recommendations.
Collaboration in rail safety leadership
George Bearfield from the RSSB spoke about the Rail Delivery Group and publication in May of last year of “Leading health and safety on Britain’s Railways”. Its aim is to unify, challenge and ultimately bring the industry together; hence issue 2 is titled “A Strategy for working together”. Amongst current concerns, he listed suicides, trespass, loss events, system faults and cyber threats. He ended with a plea for collaboration and more inputs from the industry.
Mental Health-“OK to be not OK!”
Dr Richard Peters is Network Rail’s chief medical officer and Sharon Stevens (pictured left) their mental health champion. She spoke first and vividly described her experience of dealing with and recovering from depression.
She spoke of stigma and discrimination, not wanting to be ill and not wishing to let people down by her illness. She referred to the article published in the February edition of RailStaff, adding that she had spent too long ignoring the signs of depression. She recalled her personal experience of wanting to sleep 14 hours each day and thinking that the way out was to have an accident.
She then stressed that “it is time to change, and things are changing”. She emphasised the importance of letting people know and realising that “it is OK to be not OK”. She ended her presentation by challenging us all to ask people tomorrow “are you OK?” and to listen to the replies.
Richard Peters – Health, wellbeing and mental health
Dr Peters surprised us by commenting that there are more than 200 classified forms of mental illness. He added that stress is a symptom not a condition but can lead to mental illness.
He showed a graph of pressure against performance and said that 37 per cent of ill health comes from work-related stress. He referred to Network Rail’s 2017 “Thriving at Work” report. The now agreed CP6 agreement with the ORR includes milestones to be achieved by June 2019 and is all about “breaking the stigma and measuring the success of so doing”.
Ian Nixon, Costain’s sector safety, health and environmental director, had experience of highways and nuclear industries before coming to rail. He spoke of their “Principles for Working” road map and the importance of designing jobs that are easy to do and then monitoring behaviours.
He commented on the Health and Safety Executive’s statistic that in 2017/18, days missed to injury and illness resulted in losses equivalent to £15 million. He explained the bronze, silver and gold project standards used by Costain and their policy of carrying out medicals at intervals depending on age and occupation.
He used their experience of working on Crossrail to illustrate the approach they take. 250,000 holes needed to be drilled into the tunnel lining. To avoid hand vibration problems, new rail-mounted equipment was designed and the work was completed using just six people rather than the originally planned 40.
In addressing mental health, Costain took five years to develop its system but, starting this year, all managers now undergo a half day of training to recognise symptoms and its initiative has been recognised by the Samaritans. Stand down days are also initiated by top management.
Performance and mental health
Immediately before a splendid hot lunch, Peter Schofield, who is described as a performance coach, launched his perspective on mental health and depression.
He linked performance to mental health and described his successes using leadership programmes. He highlighted the problem of bullying to meet performance targets and described a paint shop incident from his own experience.
He cautioned against the imposition of work overload and used a graphical representation of circles of concern and influence to illustrate his point.
Learning from near misses
This was the title for Paul Appleton, who drew the short straw of being the first speaker after lunch. He is the deputy director of the ORR and leads three main line teams carrying out inspection and investigation work.
He began by outlining the circumstances of the 1889 Armagh train crash in which 80 people were killed and 260 injured. He opined that there is a lot which minor incidents and near misses can tell us. The potential for a very serious incident as a result of the Watford Tunnel incident, he said, was just such a case.
He commended their RM3 system saying it is able to use data and share it so that train operating companies can learn from one another. The creation of an environment of trust he said is crucial. Technological advances continue to offer new opportunities but also bring new risks.
He added that our British organisational culture has attracted the attention of both Australian and Chinese railway people hoping to learn from the ORR.
Route devolution and single sheet safe work packs
Rupert Lown, the Anglian route director for health and safety, described how his railway career began in the week of the Ladbroke Grove accident.
He believes the headquarters and routes reorganisation of Network Rail will work. He said there needs to be a tension between the two levels of organisation, with headquarters principles applied but achievement and accountability residing with the routes.
He explained the scorecard approach which will be used for behaviours, leadership, relationships with contractors, train operators, and customers.
He stressed the importance of route engagement with both staff and trade unions. Simplification of safe work packs into a single sheet and the introduction of a self-braking trolley wheel system to remove the risk of runaway trolleys are two of his route’s first initiatives.
No such thing as an unavoidable accident
Stephen Barber is head of permanent way engineering for Transport for London as well as being the current president of the Permanent Way Institution.
He spoke of his early working with heavy rail, with 800 metres of ballast cleaning or track renewal to be completed in just eight hours with a line-speed hand back.
He also recalled that in 1974 as many as 45 fatal accidents each year was accepted as normal, but heavy rail reduced the figure to zero in 2017. He suggested a deeper understanding of risk and a culture change since 1994 has brought about the improvements.
He insisted that there is no such thing as an unavoidable accident.
Safer, more productive and cheaper
As an example of what can be done within the four hours allocated for engineering hours, he described a design review they had undertaken.
Renewal work was labour intensive and generated both noise and vibrations due to the need to break out concreted-in sleepers and replace.
Coaching and training of staff has accompanied the use of hydraulic bursting machines for the breaking out and the use of resilient baseplates (found in Australia but made in China). The result is a 50 per cent increase in productivity and a 30 per cent saving in cost despite the use of more expensive components.
He went on to stress the importance of contingency planning and the use of videos, pictures and diagrams to brief staff.
The legal perspective
Addleshaw Goddard’s Darren Dunn spoke about accountability and the legal perspective. He outlined the sentencing guidelines issued by the Sentencing Council.
Three prosecutions in 2018 have resulted in high fines; but in 2017 although there were 13 Improvement Notices issued, no Prohibition Notices were served.
He said silica-laden ballast dust, staff competences and risk assessments for lone working were three areas of concern at present.
Whilst the number of RIDDOR reportable accidents dropped in 2017, trespass fatalities rose and there were six level crossing fatalities despite the overall downward trend on such incidents.
Designing and building a safe railway
Dr Reuben McDonald, head of safety systems for High Speed 2, reminded the delegates of the long-term nature of their project with work planned through to 2033. Once completed, half the population will have access through the 25 stations, with trains running every three minutes.
Safe integration means the adoption of a life cycle design concept. He described their use of a charted railway system strategy with a centralised database contractual structure. Hazard record modules will be used.
Tunnel ventilation, rolling stock specifications and a simulation of a fire evacuation have already been tackled and BIM used for a risk assessment of the Curzon Street station.
Certification and assurance
Stephen Clarke is Ricardo Rail’s Lead signatory. He outlined the system of certification and listed its use. He expressed relief at the delay to Crossrail from their perspective.
After testing and re-testing in service, updating becomes important. He described the application of Railway Interoperability Regulations and the 2009 amendments to ROGS 2006.
Train maintenance – are current methods fit for purpose?
Bombardier’s Simon Ellis drew the shortest straw being the last speaker of the day. He spoke of the increasing reliability of rolling stock on heavy rail systems and the falling failure trends on main lines, except for fires.
He suggested that maintenance still uses 20th century methods with practices such as the daily testing by technicians of doors when modern doors could be left unchecked for up to three months without detriment.
Less interference would improve safety, he said. Technology such as thermal imaging and monitoring systems could reduce working at height. The fact that paper manuals are still in use he cited as a further example of not progressing into the current century.
Robotics could be used, especially for routine tasks such as sandbox filling, and good design needs to take us forward to minimise maintenance tasks so that residual risks are largely left in the software!
Despite earlier delays and over runs we handed back the conference room on time and in giving the vote of thanks I was pleased to acknowledge the time and efforts made by all the speakers our hosts and the Rail Media people who had made the detailed arrangements. It was an excellent day for all who attended.