It is 20 years since the Ladbroke Grove train crash killed 31 people, and more than 30 years since a collision at Clapham Junction resulted in the loss of 35 lives. These two incidents -- as well as those at Southall in 1997, and at Hatfield and Potters Bar in 2000 and 2002 -- left an indelible mark on the UK rail sector's collective psyche and its approach to safety. The subsequent investigations led to changes in the industry's structure, regulation, processes, management and culture.
Sir Anthony Hidden, who chaired the inquiry into the Clapham disaster, made it clear that "the concept of safety must be at the forefront of all thinking at all times". But, with ever greater commercial and performance pressures, and the prospect of further upheaval promised by the Williams Rail Review into the industry's structure and delivery of services, is this mantra sufficiently embedded across the sector? Has the industry truly learned from the lessons of the past and, if it has, is it applying and adapting them to new and evolving challenges?
Without doubt, there have been sustained improvements in rail safety over the past two decades. As chief inspector of railways Ian Prosser confirmed in the Office of Rail and Road's (ORR) latest annual safety report, "the UK railway remains one of the safest in the world". But he also acknowledged some worrying signs that "although risk remains at historically low levels, the rate of improvement has slowed".
Passenger fatalities on the mainline railway rose from six to 13 last year. There was also a rise in the number of the most serious SPADs (signals passed at danger), and two rail workers died. A further two track workers were killed at Margam near Port Talbot in July this year. Introducing the ORR's report, Prosser noted that "despite continued overall improvement in workforce safety levels", the persistent high number of near-misses involving track workers "demonstrates the need to keep working towards the goal of zero [industry-caused] fatalities every year".
There remain circumstances when human lookouts wave flags to signal to people to move clear of the line
The Rail Accident Investigation Branch (RAIB), set up as a result of Lord Cullen's report into the Ladbroke Grove crash, has also raised red flags, warning that some of the lessons from Clapham Junction "are fading from the railway industry's collective memory". Its recent investigations into incidents at Waterloo and Cardiff East highlighted several parallels with Clapham, including unacceptable and dangerous working practices, lack of documentation, sub-standard testing, failure to communicate effectively both up and down the lines of management, and issues with fatigue.
Timidity over change
The ORR report highlighted infrastructure operator Network Rail's failure to address "the unacceptably high" number of track workers involved in near-collisions with trains. The Margam incident reinforced concerns that "Network Rail's progress has been unsatisfactory". The criticisms centred not only on technical, procedural and competence failings, but also on cultural and management failures.
Referring to Network Rail's "imperfect realisation" of its ambitions to improve track work safety enshrined in its 'Planning and delivering safe work' (PDSW) initiative, the ORR suggested this had "resulted in timidity about future change". PDSW included a revised standard 019 (launched in 2017), which introduced a 'person in charge' to be accountable for safety on site and involved 'in planning to identify and control site and task risks'. A year later, Network Rail admitted the standard had been embedded within the routes and railway with varying levels of compliance and its introduction had left many aspects "open to interpretation". This led to teams taking different approaches across the network and working to the standard in different ways, bringing what Network Rail itself described as "an increased level of risk".
The ORR also reported how last year's inspections had revealed non-compliance with Network Rail's "processes, standards and procedures that make up its framework for risk control -- and that too many preventative and mitigating controls therefore remain vulnerable to variation in human performance". In particular, Network Rail's efforts to secure improved workforce safety had been "hindered by inefficiencies in its planning system", the slow adoption of technologies, and "the cultural acceptance of arrangements that are far from optimal".
The ORR concluded that the next stage of improvement would be secured only by:
more widespread adoption of technology and engineering controls to reduce the potential for human error
selecting the right staff for critical roles
maintaining rigorous competency requirements
enhancing supervision, monitoring and assurance
promoting better safety culture
simplifying procedures and paperwork and making roles, responsibilities and accountabilities absolutely clear and
helping planners to see what access is available in the medium to long term so planning can be more effective.
After the fatalities at Margam, Network Rail announced a £70m safety task force to improve track worker safety (see box, below).
Keith Morey, a committee member of IOSH's Railway Group, says it is critical to deploy the latest technologies: "We should be using them more to protect workers on the track and warn if a train is coming." Under the current system, there remain circumstances when human lookouts wave flags to signal to people to move clear of the line. "This process has its roots in the early 19th century," Morey adds. "It's been modernised but not fundamentally changed. And it still relies on human behaviours and human visibility to protect people."
Network Rail's safety task force
In July, after the deaths at Port Talbot, Network Rail launched a task force, backed with £70m, to target track worker safety. The company claimed the task force, led by Martin Frobisher, Network Rail's group safety, technical and engineering director, would accelerate the organisation's Near Miss Reduction Programme and pull together various initiatives to improve safety. These include:
a safer trackside working programme -- designing and developing new protection and warning systems using digital technology to warn workers of approaching trains
planning and delivering a safe work programme -- to improve the planning of trackside work, giving clarity on who is in charge and ensuring good-quality briefings before work starts
improvements to Sentinel, a software platform that manages workers' competencies
a fatigue improvement programme -- better managing working time, travelling time and the impact of personal lifestyle on alertness and fitness for work
procuring for safety -- to encourage and reward contractors for positive safety performance
a medical standards project -- to improve the workforce's health and fitness
a mental wellbeing and resilience project -- to reduce stigma associated with mental health, and provide tools and guidance to line managers and employees
risk management -- introducing more thorough work activity risk assessments and
a 'safety' hour programme -- a dedicated hour a week when all workers take part in a facilitated hour-long conversation about health and safety.
The ORR did recognise that wider pressures on Network Rail staff in the past year may have affected safety management. These include: an extra round of business planning submissions for the periodic review (which sets outputs and funding for Network Rail); sustained attention on train performance; and significant changes in the senior leadership team and the introduction of a wide-ranging review and restructuring of the business.
This restructuring, based on Network Rail's 'Putting passengers first' programme, promises a new model that will "bring track and train closer together, embed a customer service mindset and ensure a better focus on performance". At the core of this is further regional devolution, which Network Rail claims will make routes more responsive to local needs and enable more localised decision-making.
But this approach is not without risk. The ORR cautions in its report that, as accountability shifts away from the centre, regions and routes "will need to be even more effective in monitoring, supervising and reviewing risk control activities". In addition, Network Rail must centrally assure itself that "its businesses have the capability to take on their new safety responsibilities" and must manage this change "so that there is robust scrutiny of preparedness and maturity before each step is taken".
David Porter, chair of IOSH's Railway Group, says: "Devolution puts greater emphasis on route managing directors to make decisions on safety. That's the way Network Rail wants to run its business, but it needs checks and balances to make sure everyone is skilled enough, and sufficiently supported, to get those decisions right."
Vice-chair of the Railway Group Des Lowe agrees that the push for devolution presents challenges. "A central government process drives efficiency," he says. "With devolution, you start to lose that. From Aberdeen to Penzance, things change. The signals will be the same, but the communication processes, the safety review meetings, the approach to risk assessment, what is deemed as a priority, or resourcing levels could change several times through a journey."
Commitment v reality
The ORR's recommendations for moving to the "next stage of improvement" focus not only on technical, planning and procedural issues, but also on leadership, competence and culture. These challenges were echoed in the Clapham and Ladbroke Grove investigations. In the Clapham report, Hidden said "the concern for safety was permitted to co-exist with working practices which-¦ were positively dangerous" and this "unhappy co-existence was never detected by management". He added that, although the evidence showed the sincerity of the concern for safety, it also showed the reality of the failure to carry this through into action.
The RAIB raised this issue again in its recent investigations into the incidents at Waterloo and Cardiff. There was no evidence that the staff and organisations involved "lacked a commitment to safety". But still "the accidents resulted from people taking actions which were inconsistent with the processes in which they had been assessed as competent".
The question of how commitment to, and concerns for, safety are translated into practice is not unique to rail. But it is something the industry needs to address, particularly through leadership, communication, training and a supportive, inclusive culture.
"There is a lot of emphasis in the sector on the idea of a 'just culture' and on relying on people reporting things," says Porter. "That is great, but there is also evidence that the nature of modern contracting and employment relationships, combined with pressure to put passengers first and get the job done, doesn't lend itself to that happening very well. If you add this to the response people may get if they raise concerns, this ties into an important cultural issue."
Commenting on an RAIB investigation into a near-miss involving a track worker in December 2018 between Horley and Gatwick Airport stations, Simon French, chief inspector of rail accidents, noted how staff given defective plans did not challenge them. "It was considered OK to take a risk to get the job done, and no one felt able to challenge this," he said.
Top-level initiatives such as 'Putting passengers first' clearly have an impact on culture. The ORR has focused on warning Network Rail to ensure it manages the practicalities of this approach, but the message itself could also have unintended impacts on safety.
If the focus on passengers leads to further pressure on rail maintenance to complete jobs without disrupting services, this could result in mixed messages to track workers and their managers. It relies on leadership at all levels to deliver the right balance.
Lowe says: "If you need to be delivering trains on the minute, there are challenges involved -- as there are for track workers if they are a bit late getting into a possession and have to ensure work is completed within a timeframe. Leaders have to make sure this happens effectively and safely, and get the right teams in place."
The UK Rail Industry in Numbers
21,000 Miles of track
6,300 Level crossings
Source: Rail Safety and Standards Board
Competence and skills
Porter adds: "Many of the trends and issues facing the sector have been around for a while. And there is the question of whether we have the right set of abilities for people to make these balanced judgements -- juggling all the finance, time, cost and safety issues. Perhaps there needs to be a greater emphasis on the competence of managers, because there is a question over the nature of managing safety in certain parts of the business."
Devolution puts greater emphasis on route managing directors to make decisions on safety
Referring to the near-miss in December 2018, French noted that the RAIB had already recommended that Network Rail "improve the leadership skills of team leaders and supervisors". He recognised this was being addressed, but added that "railway industry staff at all levels must understand the importance of good leadership: getting people to do the right thing, at the right time, all the time".
The Rail Safety Standards Board's (RSSB) strategy 'Leading health and safety on Britain's railways', launched in 2016, outlines 12 key risk areas, including workforce safety, public behaviour, fatigue and train operations. "This was introduced to provide strategic direction for the sector," says Lowe. "And everyone has worked hard together in these areas, with information sharing and risk groups."
Risks of change
In the RAIB's 2018 review, French highlighted the challenges involved in managing the risk of change, both technological and organisational. Although he welcomed the potential benefits of technological advances and the need for organisations to adapt to new circumstances, he noted how recent investigations "have demonstrated how well intentioned changes can result in unintended unsafe outcomes".
French cited how an investigation into a track worker near-miss at south Hampstead in March 2018 revealed problems with adapting to the new 'person in charge' role in Network Rail's 019 standard. "It is disappointing that our investigation found that the way in which this concept had been implemented lacked clarity, and the result of this was confusion on site," he said. "There is clearly a need for the railway industry to think carefully about how to bring about change while controlling the risk to the existing railway."
This warning is particularly apposite, given the wide-ranging structural changes that could emerge from the Williams Rail Review, which looked at how best to deliver organisational and commercial frameworks for the future of the railways. Despite its broad scope, its original terms of reference failed to include safety.
In its consultation submission, IOSH sought to address this by recommending that every option should include an assessment of how standards of health and safety will be maintained and improved. "Our submission is part of our commitment to keep the safety message in people's eyeline," says Porter. "Safety needs to be there in all thinking at the start.
"However the railways are run in the UK, it is critical to look at the safety upsides and downsides. We can't be prescriptive, but the industry needs to recognise that, when making these big long-term financial and organisational decisions, it mustn't forget the safety implications. You can't leave out safety and address it after you've made these big decisions."
This recalls Hidden's warning in the aftermath of Clapham. He maintained that the concept of safety must be at the forefront to meet both "human and commercial" requirements, adding that the "reasons are all too obvious: there is so great a potential for disaster if attention to that concept is permitted to drift. Management systems must ensure that there is in being a regime which will preserve the first place of safety in the running of the railway."
Progress on rail health
The ORR's annual report for 2018-19 was positive about improvements in the mainline rail industry's approach to work-related health. It noted: "Good progress is being made where ill health is visible or drives staff absence and costs, such as hand arm vibration syndrome, musculoskeletal disorders and mental health." The report also welcomed a new code of practice on fatigue management produced by the National Freight Safety Group.
However, ORR chief Ian Prosser also called for more focus on less visible health hazards, such as legionella in water systems, and the long- and short-term risks of occupational lung disease from exposures to asbestos, silica dust, diesel and welding fumes.
To address the challenges, the ORR wants the industry to collaborate to create better health risk assessment methods. "Risk modelling, and prevention of long-latency disease, should be as mature as equivalent methods for the prevention of low-frequency, high-consequence rail accidents," said the report.