HomeHSEQExpert commentary - RAIB Human Factors team

Expert commentary – RAIB Human Factors team

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RailStaff regularly reports on the investigative findings of the Rail Accident Investigation Branch (RAIB), but what exactly is the organisation’s purpose and how does it respond to accidents and incidents on the rails? We caught up with Becky Charles, Tabitha Steel, and Mark Young of RAIB’s Human Factors team to discuss their work and the role of human factors in the investigation of unfortunate events.

Hi everyone, thanks for joining us. To start off, could you provide us with an overview of the RAIB, its work, and how it came to be?

Mark: RAIB is the independent safety investigator for the UK railways. We were formed as a result of Lord Cullen’s investigation into the 1999 Ladbroke Grove disaster. At that time the UK had an independent Air Accident Investigation Branch and an independent Marine Accident Investigation Branch, but we didn’t have a similar independent body for rail. We began our work in October 2005 and since then we’ve completed over 500 investigations, bulletins and safety digests.

We’re independent of the industry, so we’re not part of Network Rail, the British Transport Police (BTP), or the Office of Rail and Road (ORR). We work separately, but alongside them, so we’ll share certain parts of evidence that we collect with them, but one part that we absolutely cannot share – and this is laid down in legislation – is witness evidence. Our role is purely about safety learning rather than blame or prosecution, and we want witnesses to be open and honest with us as far as they can be.

Our remit only covers accidents involving moving trains, so we don’t get involved with things like slips, trips, and falls at stations, trespass, or suicide. We are obliged to investigate certain types of incidents, for instance those involving fatalities, serious injuries to five more people, and those causing extensive damage, i.e., damage of over £2 million.

Thankfully, the UK Rail Industry is a very safe one and we don’t have to deal with many major accidents, but we do investigate incidents and near-misses as well. We investigate those on a discretionary basis and the primary criterion for what we investigate is the potential safety learning that can come out of it. At the end of the day, our investigations are written up as reports which are made public on our website, and our primary instrument for improving safety is the recommendations made in those reports.

How exactly does the RAIB respond when an incident occurs? How are you made of aware of these events?

Mark: When an incident or accident occurs which is within our scope, the industry is duty-bound to notify us. That alert will be received by one of our inspectors who’s been rostered as a duty coordinator. The duty coordinator will triage that initial call and decide if it’s within our scope or is something that’s of potential interest to us. If it is, we’ll deploy one or more of our rostered on-call inspectors to the accident site to gather evidence for what we call a preliminary examination.

When we get a call, we aim to be out of the door and on the way to an investigation site within 30 minutes. Since we are based in Farnborough and Derby, the Emergency Services will likely be on site before we arrive, but legislation means that at the more serious end of the spectrum, they can’t touch or move anything without our say so.

So how does Human Factors fit in to this?

Mark: There is a common perception that Human Factors is all about human error, but it’s not just about what people have or haven’t done wrong on the front line. Of course, we do have to look at this, but from our perspective human factors as a discipline goes much wider than just those individual actions and decisions. It’s all about the influences on peoples’ performance at a systemic level. We’re much more interested in how a person came to be in a particular place at a particular time, how they came to make particular decisions, and what influenced that. That may be the environment they’re working in, the equipment they’re using, the procedures they’re working to, and the training they’ve received. Their state of mind, level of fatigue, distractions, and workload are all extremely important factors, as is the culture of the organisation they’re working in, and how things like safety management systems are implemented. Safety on the front line goes much deeper than the actions of one or a team of individuals.

How do you go about starting an investigation? What are your first steps and what are you looking for at that point?

Mark: In the first instance we’re trying to understand what happened, as best we can, on the basis of the evidence returning from the site. That includes surveying, photography, physical evidence from the vehicles and infrastructure involved, and witness evidence from the people involved.

We have about 40 staff, roughly split 50/50 between our Farnborough and Derby offices and roughly half of those are inspectors.  Every Monday, in branch, we have a preliminary examination review meeting. If there has been a deployment in the previous week, or couple of weeks, inspectors will come back from that and present to the entire branch. Everybody attends that meeting and contributes to the Branch’s decision as to whether or not we’ll take that forward for an investigation or do something different with it, such as one of our safety digests which is a shorter version of a report.

You need to strike a balance between not prejudging what might have happened but also having some sort of theory to structure your evidence collection strategy. If you were completely open-minded, you’d just collect everything, and you can’t really do that.

Normally, when a call comes in, let’s says there’s been a derailment, you get an idea of the conditions surrounding it because of the way it’s called in and you might start forming some impression. If it’s in the middle of the night, and it’s a freight train, you might start thinking about whether fatigue played a part, and what questions you might have to ask the driver.

Once you’re at the site, the preliminary examination process is a really crucial time, because you’re not going to be able to go back to and get that evidence again. It’s always best to get more evidence than you need and end up not using it than not getting enough and potentially missing the key piece that you need. Another thing is that memories fade very quickly – they’re very perishable in terms of evidence.

Witness evidence is very important to us and we get interview training. Due to legislation, if an event is deemed to be an accident and not relate to serious criminality we take primacy on the investigation and we should really be the first to interview those involved as soon as possible after the event. However, when we arrive on site, those involved in the event might also be traumatised. We’ve got to try and manage that as well. They might need to go home and get some sleep before talking to us but, as soon as we reasonably can, we’ll get an interview with that person to get that best evidence out of their memory.

We have to build a good rapport with witnesses too. We don’t just steam in and start the interview straightaway. We’ll spend a good 10-15 minutes building a rapport with the witness, explaining who we are, explaining the no blame aspect, and explaining the fact that the interview is protected under legislation. We also have to remember that although we’ve conducted many interviews ourselves, for the witness it’s probably the first they’ve ever had to do. It’s a big event for them, especially coming after a traumatic incident. Part of our job is to manage that process, and ensure they understand what the outcome of the interview will be.

How do you become an RAIB inspector? Is any particular specialisation required?

Becky: We all come into the branch with our own specialisms. We’ve got track engineers, level crossing specialists, surveyors, etc. Everyone that comes into the branch is very experienced in their own specialism and I’d say that’s the key to becoming an accident investigator. Once an application is accepted, we’re all trained to the same level and given everything we need to fulfil the inspector role. One way it’s been described is that we’re the GPs of the rail industry. We all know a bit about everything, and then we all have a greater depth of specialism in a particular area. The reason for that is because we could be sent to anything. Any one of us could be deployed next week to a derailment or a signalling failure. We have to be able to go out there and know what we’re looking at and, more than anything, be able to talk the language. For instance, if we’re talking to S&T engineers we need to be able to understand what they’re talking about, but also make them confident that we know what’s going on, and that we’re collecting the crucial evidence.

It must be a tough role at times. What support do you receive if you’ve visited a traumatic scene?

Tabitha: In our branch we use a process called TRiM (Trauma Risk Management). That means that if someone has been deployed to a site which could be potentially traumatic, one of our TRiM practitioners will go through a risk assessment process with them when they come back into the office. This is to discover whether there are any issues, and there’ll be a follow-up meeting at a later date. The idea is to offer advice and reassurance to people and direct them to further help if required. It’s been very successfully implemented. We use a similar process for people who may have to look at distressing images as our work may involve looking at CCTV footage or photographs which can be potentially traumatic.

Alongside all of that, we have Mental Health First Aiders within the branch, and we also get involved with a lot of wellbeing initiatives. These things are good not just for our own internal support, they help us do our job better. We go out and meet with the bereaved and the injured on a fairly regular basis, and although we’re not counsellors, things like Mental Health First Aid training can make us more sensitive towards witnesses in those situations.

Are you seeing any key trends or themes behind the causes of recent incidents or accidents?

Mark: Our Annual Report for 2021 was published back in May and one of the main issues to come out of that was around track worker safety. That covers all kinds of things like poor decisions and local management issues, all the way up to organisational matters. Another issue that stands out surrounds level crossings.

In terms of Human Factors, the recurring issues we see are generally things like workload, stress, distraction, and fatigue. Being a 24/7 industry, fatigue comes up as a problem very regularly. The most recent report I worked on, published back in July, was a quite serious Signal Passed At Danger (SPAD) at Sileby, near Loughborough. Fatigue played quite a large role in that incident. The incident came at the end a long night shift, and night shifts are not very good for our bodily rhythms. While the industry runs around the clock, and a lot of work takes place at night, the human body isn’t necessarily geared up for that, and it’s important to manage that risk.

Tabitha: One of the pieces of work that we’ve done in the branch is to make sure that investigations are going deep enough and looking at the organisational factors. That means not only looking at, say, the safety management systems in place, but also to look at the safety or reporting culture, underneath all of that. In human factors, we try to make a distinction between how people think work is being carried out, and how the reality of that may differ.

Finally, is there anything about your work that you’d like to make rail staff more aware of?

Mark: One thing we try to emphasise to the people we interview is that the evidence they give us is purely for the purpose of improving safety. We do not apportion blame and we do not share interview transcripts.

Also, it’s important to remember that most of the time, people carry out their jobs safely and correctly, but every now and then things can go wrong. Nobody ever goes out to have an accident – we’re all just trying to get our job done and go home safely.

Human factors go much deeper than focusing on the one person who made a mistake. For us, human error is the start of our investigations, not the end because that one error came at the end of countless inputs. In the event of an incident or accident, people find it very easy to blame themselves, but there’s always more to the story. We’re here to understand exactly why those errors are made so they can be prevented in future.