Investigations are, of course, only part of the story. Once the data has been gathered, and the causes and consequences identified, the lessons then have to be acted upon.
Over their history the railways have become used to this process. Improvements to braking, signalling, the installation of the Advanced Warning System, and many other developments in technology have emerged in the aftermath of major accidents.
For example, the horrific and all-too-recent accident at Ladbroke Grove in 1999, which cost 31 lives and injured a further 520 people, prompted another major change. The Rail Safety and Standards Board was established in April 2003, following the recommendations of Lord Cullen in the Public Inquiry into the accident. The RSSB is a not for profit company owned by key stakeholders in the industry themselves. Len Porter was its Chief Executive until 2014.
“Most of my life was spent in the oil and gas sector. Most industry sectors managed their safety based on compliance with standards. You set standards, you comply with them diligently, and it was considered you were safe.
“In truth the best way to manage safety is to identify hazards, quantify the risk associated with them and their precursors, and then reduce the risk to as low as practicable. Only one of the ways of managing that risk down is compliance with standards.”
Again it took an accident to drive change. In 1988 the North Sea oil platform Piper Alpha was destroyed by an explosion and the fire that followed.
“The report into that completely changed the industry - from one which managed safety based on compliance with standards, to one that did so based on understanding of risk,” recalls Porter.
Was it a large job to bring that thinking to the railways?
“When I joined the rail sector, it was an industry that was broad but old, and still managed safety in compliance with standards. It was a huge job. Fortunately, it started to happen quickly and we had willing participants in Network Rail and the train operators. They sat on the board of RSSB and allowed us to move them towards a risk-based approach.
“It is a matter of defining the data, spending the money on the systems, getting them much better than before, populating the risk models. Anybody working on the railway was called to supply the data to RSSB, and they did.” The data was fed into SMIS (Safety Management Information System). SMIS in turn was used to populate the SRM (Safety Risk Model) and the PIM (Precursor Indicator risk Model). The PIM in particular allowed the industry in Porter’s words, “to get underneath” accidents and examine what the precursors to them were.
“The biggest one was, of course, SPADS (Signals Passed at Danger), but also for example infrastructure failures. The industry managed that risk, very hard, down - and it tumbled quite considerably. It was about identifying incidents that could have led to accidents. Like looking after the pennies, and the pounds - in this case the big accident problems - looking after themselves.
“I think it is more difficult for roads. Railways are much more rigidly controlled, but there are still things you can do to quantify the primary risks. To be fair I think they are moving in the right direction, but it is still controlled by Government. It is very large and it is slow.”
Backing up the industries’ own proactive approach to safety is of course the statutory regulator. The Office of Rail Regulation was established in 2006. In late 2015 it picked up a brief to monitor and hold Highways England to account, in the process transforming into the Office of Rail and Road.
Ian Prosser, the Chief Inspector of Railways and Director of Railway Safety, is another ‘transferee’ - he came to the railways after decades in the chemical, pharmaceutical and automotive industries. He describes ORR as a “medium touch regulator”, where inspectors in the field still work closely alongside the industry, but are fewer in number than a decade ago. They do however spend more time on proactive inspections resulting in a more efficient operation.
“The whole issue of culture and management maturity is something we have been pushing,” he says. “It’s what we have to build on to get to the next level. Increasing management maturity so there is less intervention from the regulator and fewer and fewer enforcement notices and prosecutions, so that slowly but surely - well they won’t put us out of business, but we’ll be doing less reactive inspections, in particular.”
ORR’s brief between rail and road is subtly different. It monitors Highways England (so therefore has no say in the trunk roads of the devolved nations), rather than enforces safety policy.
Given the combining of steel and tarmac into one office, does Prosser envisage a progression towards a situation one day where he has an equivalent… a chief inspector of roads?
