Management assurance
All railway organisations must confront a range of hazards (threats to safety), and manage the resultant risk. To do so, organisations are required (by the Railways and Other Guided Transport Systems (Safety) Regulations 2006) to implement a ‘safety management system’ (SMS) to control its risks. In essence, an SMS is required to identify the control measures that have been established to manage the risk associated with the known threats to safety.
By means of risk assessment, organisations can satisfy themselves that risks are being managed so far as is reasonably practicable. However, since few organisations stand still, the SMS is also required to incorporate mechanisms to control the risk of change and to incorporate learning from experience.
Management assurance is the control mechanism that monitors and reviews the health and robustness of the SMS. It is, therefore, critical to the safe operation of any railway organisation and should be a key focus for railway safety leaders.
It provides assurance that safety defences are functioning as intended, and enables leaders to address areas of weakness. Good management assurance is about an organisation’s leaders and managers being aware of any gaps between theory and practice, and then taking action to address them.
An underlying theme in many of RAIB’s investigations has been the divergence between what the management system said should be happening, and what was actually going on.
For example, RAIB’s investigation into the accident at Margam identified that Network Rail’s management assurance system was not effective in identifying the full extent of procedural non-compliance and unsafe working practices, and so did not trigger the management actions needed to address them.
Similar issues with management assurance were also identified in the investigations into the death of a train driver at Tyseley depot (report 09/2020) and the fatal accident involving a track worker at Roade in April 2020 (report 03/2021).
The RAIB investigation of the incident near Loughborough (report 10/2020), in which a train delivering new rolling stock to a storage depot passed a signal at danger, found some significant deficiencies in the way that the train operator was managing safety.
This led to a train being driven faster than was permitted on the route, and therefore being unable to stop before passing a red signal by a significant distance.
There was a gap between documented safety processes and what was happening. There also appeared to be no management awareness of how well (if at all) the company was following its own safety processes, including those related to competence management.
Certainly, good management assurance relies on formal systems. However, RAIB investigations reveal that a positive, open and honest culture is also needed if leaders are to be properly informed and protected from wishful thinking. There needs to be recognition that only very rarely are accidents caused by people who are reckless or irresponsible.
What we often observe is people trying hard to get the job done, often in a very difficult working environment. It is that commendable eagerness to complete the task that can so easily cause people to overlook the risks that they are taking. Since it relies on good information about what is really happening in the field, processes such as audit and formal management reviews have a role to play. However, more important still is the free flow of accurate intelligence between the front line and leaders.
The leader of any organisation needs to appreciate that they will never be fully assured that their risks are being managed so far as is reasonably practicable.
Management assurance is not a once-only activity, it’s a continual process of learning, questioning and challenge. It also relies on an understanding that there is always more to learn about the way that an organisation is delivering safety and its areas of weakness.
Conclusions
After 17 years at RAIB, I am encouraged by the progress that the railway industry has made in the way that it manages safety. Leaders in the railway industry ‘get’ safety and are mature in their understanding of safety management.
However, it is my view that the biggest obstacles to further improvement are risk awareness and management assurance.
With regard to risk awareness, leaders need to promote a better corporate understanding of risk. To do this, leaders need to ensure that their organisation has:
1: Relevant high-quality data and intelligence (quantitative and qualitative).
2: Sufficient analytical skills.
3: Recognised the value of imaginative thought to the identification of safety threats.
However, there is also more that needs to be done to ensure that leaders can accurately assess the effectiveness of their corporate safety management systems. It is my view, based on hundreds of ‘case studies’ (i.e. RAIB investigations), that any review of management assurance needs to answer the following fundamental, and sometimes uncomfortable, questions:
