London's underground railway is one of the busiest mass transit systems in the world, carrying four million passengers a day -- five million at peak, more than the population of the Republic of Ireland. Trains on the busiest of its 11 lines run on average every 100 seconds.
But it is also the oldest city metro in the world; parts of the infrastructure were installed 150 years ago. Age and the wear and tear caused by 1.34 billion passenger journeys a year necessitate a never-ending programme of maintenance and repair. Most of this work has to be carried out in the few short hours between the last train at night and the first in the morning, a window that the demands of a 24-hour economy are closing even further.
Marian Kelly career file
February 2017-present: Head of health, safety and environment, LU Operations, Transport for London
2014-2017: Senior manager, health, safety and environment, Transport for London
2006-2014: Environment manager, London Underground
2002-2006: Policy executive, Environmental Services Association
Managing the safety challenges posed by this combination of factors is the job of Marian Kelly, who heads operations health, safety and environment for London Underground (LU).
But Kelly is quick to dispel any idea that the safety and health of LU's 17,000 employees or those millions of passengers rest in her hands or in those of the 50 OSH practitioners in her function (see "in the scheme of things" box below).
"We build a lot of day-to-day safety into the running of the railway, so it's part of everyone's job and part of the DNA of the operation," she says.
Nevertheless, there are plenty of issues where her OSH teams are working to secure improvements, particularly in the network's most hazardous activities. One of these is working around electrical equipment.
"We have very few electric shock accidents," she says, "but we do have some and they can be quite serious. So we are pulling apart our electricity at work procedures, [such as] how we lock off equipment such as fuse bays in signal equipment rooms."
Work at height is, predictably, another high-consequence hazard the team is working on. "Our signals are usually on poles," she says. "Can we bring the signal heads down rather than have someone climb up to them?"
Similarly, in the confined tunnel environments where much of the engineering and maintenance work on the lines takes place, LU is experimenting with battery-powered generators to remove the noise, fumes and flammable materials that accompany diesel-powered units.
This last aspect is particularly important, since the organisation remains highly mindful of the lessons of the fire in its station at King's Cross in 1987, which started on an escalator and spread rapidly, killing 31 people.
The tragedy triggered a public inquiry led by Queen's Counsel Desmond Fennell, which criticised the tolerance by LU's management of previous smaller fires on escalators and lack of fire safety training for station staff.
"On my first day at LU as an environment manager I was handed the Fennell report," says Kelly.
There were 440 physical assaults by members of the public reported by LU staff and contractors in 2016-17. Though this represents a minuscule proportion of the passengers the network carried over the period, it keeps workplace violence in one of the top slots for the safety function's attention.
"We monitor physical violence and verbal abuse incredibly closely," says Kelly. "We have a small team who look at that specifically and who work with the BTP [British Transport Police, which has officers throughout the network during the hours it is open]."
A trial in 2016 equipped 30 LU staff with body-worn video cameras -- which help gather evidence and may deter assailants -- and the results were encouraging. "We are rolling it out to more stations," she says.
It's hard to say, 'We love the commendations but you also have to look after yourself'
In the meantime she is hoping that a behavioural campaign over the past 12 months to convince staff to "step away" from situations in which they are abused or threatened will cut violent incidents.
"If they intervene there's the potential for them to get hurt," she says. "So we are asking them not to get involved.
"The advice was always to look after themselves," she adds, "but it's about reinforcing it. Because in trying to do the right thing, to protect revenue by intervening with people who are jumping [ticket] gates or whatever, they will put themselves at risk. There is a time to challenge but also a time to step back."
In the scheme of things
As head of health, safety and environment (HS&E) for London Underground (LU), Marian Kelly oversees the OSH function in one of the three divisions of the UK capital's transport infrastructure operator Transport for London (TfL) -- the other two are projects and surface transport, which includes roads and buses.
She reports directly to TfL's director of HS&E, Jill Collis, but also has a line to LU's senior team. Kelly oversees a group of 50 OSH practitioners, mostly health, safety and environment managers, attached to individual underground lines, infrastructure elements such as track, signals, rolling stock and workshops, and maintenance functions.
The main focus of her work is operations, she says: the running of tube trains, stations and engineering and maintenance. "I make sure we provide support to the management team and the people from top to bottom to make sure health, safety and environment are managed appropriately.
"It's mainly a facilitation and co-ordination role," she says. "The safe operation of the tube isn't done by me or my team. That's done by the people working on that line. We put the framework in place. We make sure the rules are set out in our HS&E management system and that they are clear and easy to use."
Her team provides the OSH input into change programmes, whether they involve restructuring or new equipment or operational patterns such as the night tube (see main text), ensuring staff and management understand and control for potential changes in the risk profile.
It also gives the operations guidance on compliance with changes in regulations. "So when CDM [the Construction (Design and Management) Regulations] changed a couple of years ago, we made sure they understood what that meant for their areas."
LU is regulated by the Office of Rail and Road (ORR) and Kelly is the railway's key point of contact with the body's chief inspector. "We let them know what we are doing and make sure they issue us with the necessary certificates and authorisation to work."
Every five years, LU's licence to operate is renewed by the ORR -- "without that we can't run a train service for London" -- and Kelly took the lead in preparing for the last renewal in February, compiling a full description of LU's safety management system for submission last October.
"The things that will often change are governance structures and reporting line changes; like any big organisation we go through those, and all of that is described in our submission document. The ORR will challenge us on how we continue to run a safe railway with those changes."
The document, which has similarities to a safety case for high-hazard installations in sectors such as oil and gas, must also be resubmitted if there are significant operational or structural changes between the five-yearly renewals.
Lastly, there is an important co-ordinating role to her function, helping to ensure that lessons from any of the 270 stations and 11 lines are transmitted to others.
"So we will say, 'Oh do you know they have found a way of dealing with that in Harrow [station]', or will make sure that, if something goes wrong in one area, other parts of the business involved in similar activities learn that lesson too."
She admits it is a difficult message to make stick sometimes. "We have incredibly committed station staff and if they see someone who is vulnerable -¦ there was a dog which attacked a blind person's guide dog recently and we are saying, 'Don't get involved' because there is a pitbull tearing chunks out of another dog.
"We get so many commendations from customers saying staff have gone above and beyond the call of duty. So it's hard to say, 'We love the commendations but you also have to look after yourself'."
All employees have also been issued with a phone app that allows them to report abuse and violence directly.
Time off after assaults and due to musculoskeletal disorders (MSDs -- more common among maintenance staff), push LU's absence rate to 5.5 days a year per employee.
"Some of our track environments are tight," Kelly says. "When you are bringing in materials you are bringing them in on what we call 'iron men', metal frames that carry rail or ballast. We can't get vehicles into some areas so it has to be manual labour."
Like workplace violence, she sees manual handling as partly a behavioural issue. "If you have to get all your material down from Oxford Circus in a short period and our way of working is to carry X amount at a time but you can physically carry twice that, you'll save yourself a number of journeys up and down the stairs. So that's about trying to plan things better and then to maintain the right behaviours so people don't try to cut corners thinking they are doing it for the right reason."
Kelly is also tasked with minimising passenger accidents. These are most often falls on station stairs and escalators and incidents at what is known as the platform/train interface, which have risen with increased passenger numbers. Regular travellers on LU are familiar with the repeated public address exhortations to "mind the gap" between the train and platform, but there are also risks from closing doors and trains entering and leaving stations beside crowded platforms.
Kelly says her team is trying "nudge" techniques to steer station users towards safer behaviour. Obvious examples include fixing hand-shaped decals on the handrails of the escalators -- which can descend or ascend up to 27 m -- to encourage people to hold them and even messages on the step risers saying "hold the handrail". A more subtle one involves the combs fixed to the floor at the tops and bottoms of escalators where the moving surface passes back into the mechanism. Small feet and soft shoes are sometimes caught by the combs.
"We have realised that children who get their feet caught are usually in London for the day," she says. "Those who live here understand what the risks are, so it means we are trying to target a different audience."
The current initiative to reduce such incidents involves painting the previously plain steel combs red. "If the combs are red, people will tend to step over them," she says.
"One of our initiatives to make escalators safer doesn't even involve escalators," she notes. "Because some of our stations are old you cannot see the lifts easily." So at Kings Cross, the wide-aisle ticket gates designed for people with large luggage or buggies now have a painted line on the floor leading from them to the lift to platform level, nudging those who might block escalators and increase the risk of an accident, towards a safer descent for them and other travellers.
The massive flows through the stations seven days a week offers an unrivalled laboratory for such experiments.
"It's all evidence-based," she says. She can trial ideas on a few escalators at a time and see within months which works best. Her next challenge is how to convey safety messages to tube users under the influence of alcohol, who may be less aware of the risks of standing near a platform edge, for example, but also less susceptible to subtle nudge messages that work on other passengers.
"What I want to do is put a red line down outside the station and challenge people to walk it in a straight line, with the message, 'If you find this challenging, stay away from the platform edge'. It's something that's almost fun and gets them thinking about the risk."
Open all hours
"Sometimes we can be quite risk averse," says Kelly, "and this allowed us to go back to look at the actual level of risk and manage that."
She is talking about the introduction of the night tube, which started 24-hour services on Friday and Saturday on two lines in August 2016 and extended to three more by the end of the year. It now operates on five of the 11 lines, adding an estimated 6.5 million passenger journeys to the annual total.
Go, look, see
Any lost-time injury on the London Underground network triggers a "go, look, see" excursion.
The tours were started six years ago for maintenance staff at the organisation's Neasden depot in north-west London. Recently they have been extended to other operational groups.
A "go, look, see" brings together the individual who has been injured, their line manager, a health and safety rep, an OSH manager and a senior management representative, at the spot where the injury occurred.
"They ask, 'What happened? What went wrong? How do we fix it?'," says Marian Kelly.
"We had an example recently where a member of station staff at Baker Street fell and twisted their ankle as they were coming out of the station because there was some work going on, so there were hoardings up. They had planned to put in new lighting after the work had finished. But when they did the 'go, look, see' they realised that poor lighting may have been a contributory factor, so they have put in better lighting now.
"Because you have a senior manager there who can make things happen, things get done very quickly. And the employee can see the result."
The safety and health manager shares any transferable lessons from the visit with their colleagues in Kelly's function. Some are publicised in the line or depot's newsletter.
All-night operation at weekends reduces the number of five-hour night slots between the last and first trains, during which the current can be switched off and all track inspection and repair completed. The previous rules further restricted engineering hours to between 1am and 4.30am.
"If you are setting up something that requires scaffold or you have to get equipment down from the main station on to a platform, your work window reduces to two or three hours," Kelly says.
In the run up to the launch of the night tube, the safety department carried out a thorough review of the rules on track and tunnel access, then redrew the processes, reducing the number of stages needed to gain permission to access a stretch of track and ensure the power is shut off.
"It's a much clearer, direct contact between our track control team and the service control team that manage the area and the individual team booking on to work on the track," says Kelly of the new process.
"We have freed up a lot more hours between Sunday night and Thursday night, which means we can compress what we used to do over seven nights into five.
"The safeguards are stronger because we have cut out some of the layers, where A called B, who called C, who confirmed with D. In the past, because we thought we had more time, we gave ourselves that time and it didn't matter that we took twice as long to book on. But by making it shorter we have made it safer."
This safety gain was not apparent immediately. In early 2016 after the new working practices were introduced there were three incidents in two weeks on the Piccadilly and Jubilee lines where staff booked on to work on a section of track and the members of staff briefing them misunderstood which section they were to work on, giving them access to one that could have brought them into the path of a slow-moving engineering vehicle.
"After that we realised we had put the structure in place but the culture and understanding needed improvement."
The new rules were suspended until a new code of practice was drawn up setting out clearly all the roles and responsibilities of the people briefing the parties who were booking on and making sure there were records kept at all stages. There have been no similar incidents since.
Under the old rules, no maintenance work was allowed on station platforms during the "traffic day" when the stations are open to the public because of the risks from train movements, and work within 60 cm of the platform edge was prohibited.
"It might be something small: putting up a few tiles, changing loudspeakers, a bit of painting," says Kelly, "but you couldn't do it."
These rules were also revised to allow work on platforms within temporary enclosures during traffic hours. Such work is carefully planned: "We make sure the project assesses the risk jointly with the station so they know the risks specific to that environment.
"The maintenance teams were worried they were bringing equipment into an open environment where you would have customers, some of them under the influence, which is a problem for us."
Her team developed new inspection and assurance procedures for working on platforms to provide a further level of reassurance.
As well as managing the changes to the risk profile of tasks in altered circumstances, the workforce's perception of risk also had to be accommodated and was often "harder to deal with".
The safeguards are stronger because we have cut out some of the layers
Station staff were concerned that all-night opening might bring an increase in assaults. Her team worked with the BTP to make sure officers were deployed where they might be needed in the early hours at weekends. But some of the concerns were dealt with by simply waiting until there was operational data to allay them.
"So it's not only saying to staff we are getting more police out there; it's about saying actually we have looked at the stats and we haven't seen an increase in workplace violence across the network. And it's giving them the confidence that where incidents do happen, we will manage them.
"If we shut down an escalator during traffic hours, staff might be worried that's going to have an impact on congestion in the station," she adds. "You give them the opportunity to talk to people at other stations who have done it and they can see that, if it was possible there, it might be possible for them."
The introduction of maintenance during traffic hours has brought other benefits, she says, in that staff are less fatigued working in the daytime and some temporary station closures are avoided.
Kelly graduated in environmental science and completed a doctorate in environmental microbiology, concentrating on "treating really nasty waste water".
"As a teenager it just made practical sense to me," she says of the impetus to study the environment. "The resources we have are finite and the system has to be sustainable. You manage what you have to make sure you have what you need in the future."
But a career in academia did not appeal. "I wanted to be out there helping to fix the problems."
After a short spell as policy adviser to the UK's waste industry body she joined LU as an environment manager in 2006.
"Within LU health, safety and environment issues are very well integrated," she says. "The management processes and systems work for all three." So the move into a role that added OSH to her title in 2014 was not a big jump.
She admits her commitment to environmental issues made her pause before broadening her remit, "but moving into HS&E, I had much stronger ability to influence the senior management team from that position.
"It's always a choice of whether you stay as a technical professional. But I'm pleased I didn't because it's brought me closer to the operation of the railway than before."
Does the environmental background give her any advantage in managing safety and health?
"When I started working in the environment field it was definitely on the periphery. What I learned was that when you bring an idea to the table you have to understand who you are selling it to.
"So when I wanted to put a 'green roof' on one of our depots I sold it to the maintenance team on the basis its longevity would be 40 years rather than 20. I sold it to the finance people because we were able to get a grant we wouldn't have got for a normal roof. The depot manager might not have been interested in having butterflies on the roof but, if it cut down his draining and flooding problems, he was sold [on it].
"So what I learned from environmental management was to understand what people's drivers are and how to work with them to work with you. I worked really hard to make sure I ticked everyone's boxes."
In an organisation like LU, which is highly committed to safety, "you may not have to fight the same battle to get it on the agenda but you still have to understand that different people have different drivers. That's what I've taken to everything I've done, whether it is managing my team or managing the business."
I ask whether she has had to work on her leadership skills. "Yes! There can't be many people who say, 'No, I got it right first time'.
"I think to be a leader you need to care about what you are trying to do, the big things and the little things. So whether I am dealing with the directors or I'm spending a shift at one of our stations to understand what the issues are on the front line, people read whether you care or not. And if you care enough about making sure that whatever you do is going to be sustainable and long-lasting you will care enough to get people's input and bring them with you."
Another thing she has learned is to concentrate on a small number of priorities. "The variety of things that can go wrong in health, safety and environment at LU is huge; our workforce does such a variety of work, from cleaning to replacing lightbulbs to going on the track and I'm constantly bringing it down to our top safety issues.
"It doesn't mean I ignore everything else, it just means I know where our key areas of focus must be. I'm constantly saying to my team, 'I hear that, put it on next year's list. This year we are going to do electricity. When I'm confident that everything to do with electricity at work is in hand, then we'll move on to manual handling'."
She says it is important as you move up in a hierarchy not to try to do everything yourself. "We have really good comms people. We get them to help with some things and finance people to help with others. Draw on the resources around you. Bring the right people in and let them do what they are good at."
Her final tip is to cultivate patience. "I often say the success of our job is not being measured week to week; it's looking back over years to say the tube is safer than it was last year, safer than it was five years ago."