'The Toss of a Coin', Chapter 12

Clapham Junction

In December 1988 BR suffered the tragic multiple train crash at Clapham Junction. I was asked by David Rayner, the Board Member to whom I now reported, to use the techniques I had developed for reliability management to evaluate BR’s safety management systems and compare with best practice in British industry. He asked me also to chair a team of operators and engineers collating the evidence to brief BR’s legal team at the Judicial Inquiry ordered by the government on the accident, following a similar public outcry after the Kings Cross underground station fire the previous year. As well as chairing this team which included experts from the Signals & Telecommunications function and from the Southern Region, I was asked to look at safety management systems used by other industries and to assess the robustness of BR systems in comparison.

I had been developing risk assessment methodology as part of my reliability management armour and from the evidence given to me by other members of the team I constructed a comprehensive Fault Tree starting with the top events which were essential ingredients of the accident - the error by an S&T technician when decommissioning wires in the old signalling system, the movement or disturbance of the offending wire during subsequent renewal work a couple of weeks later, the absence of supervision or auditing to pick up the error, the absence of personnel or functional standards to ensure the fitness and competence of the technician to undertake the work and the inability or absence of action by others who may have noted something unusual about the signal at fault that morning.

I then traced the underlying causes for each of these top events and eventually drew a tree that had ultimately 50 roots deep and hidden. These ran through the long hours the technician worked and his fitness, his lack of training other than learning bad practices from others ‘on the job’, the absence of the required safety audit because of a hurriedly introduced reorganisation, the way in which the engineering work at Clapham had been planned between trains to minimise disruption to passengers - the list went on and on. If any one of those fifty root causes had been identified earlier and action taken to correct them, one of the ingredients to a top event would have interrupted that line and the accident might have been prevented.

I established that BR’s safety management was heavily dependent on a rules culture, particularly in the Operations function, and the adherence to technical standards in the engineering functions. In both cases this meant learning, often by rote, information necessary to be retained in the memory and correctly applied. Elsewhere I have written about the way in which British education had changed from the 1950s heavy dependency on prescriptive learning and moving towards experiential learning and problem solving. I had discovered, as written in a previous chapter about the Dorridge accident, that this prescriptive rules learning in the 1980s was not effective when confronted with a different culture. Basically BR’s systems - like those of other traditional industries such as coal mining, ship building and heavy engineering - were reactive. An accident occurred, it was thoroughly investigated and as a result new rules or technical standards were introduced to cover that particular fault or failure in future. As a result rules and standards had become complex and often difficult to understand or interpret and were all too often used after the event to blame rather than prevent.

I then talked to a number of safety specialists in British Airways, one of the oil companies and at the Ministry of Defence as well as a safety management consultant, David Shillito, and identified some of the ingredients in proactive systems such as risk assessment and understanding human error and instituting control measures to minimise risk. It was clear to me that BR, like the other traditional industries - and railways abroad as I discovered later - were not abreast of these proactive systems developed by the high tech industries in the 1970s and early 80s and it was likely that we would receive criticism at the Inquiry as a result. I shared my findings with David Rayner and Roger Henderson, the QC representing the company, and we agreed that whatever the outcome of the Inquiry, BR would review its safety systems and would make that commitment publicly during the Inquiry proceedings. Because basically the proactive systems were the Total Quality Management process applied to safety, David Rayner asked me to stay on after the Inquiry was over and apply my TQM experience that I had gathered over the previous two years to apply to safety management in the future.

During the course of the meetings of my small working group, we had a meeting room at the Paddington headquarters office of the Board’s Operations function beside platform 1 at that station. One day, attending one of our frequent get-togethers, I nearly had an accident that both almost terminated my career and forced me to think about safety in its widest application - to staff and the public as well as trains and their passengers. Contractors were undertaking renovation work on the outside of this office block which was some four storeys high and ran from the taxi rank at the departure side of the station to the Bishop’s Bridge Road at the West end of the station. They had scaffolding the entire length of the building.

I was walking one morning down the taxi road as the entrance door was off that side and happened to look up just in time to see the top rung of scaffolding begin to bend over like the crest of a huge wave and the whole scaffolding the length of the wall began to come away and curl over and came crashing down. I fled back between parked cars arranged in a herringbone fashion against the retaining wall of Eastbourne Terrace above and the poles slammed down either side of me crashing through the roofs of the parked cars. When the dust settled, I emerged shaking and made my way to Maurice Holmes’ office where I duly made my entry into the accident book and despite protestation, was accompanied home and told to take it easy and rest for fear of delayed shock. I’m not sure about the ‘delayed’ bit - I was pretty shaken at the time. Apparently the investigation identified that an inexperienced member of the contractor’s staff had started untying the scaffolding at the bottom and had weakened the entire structure. I only know that someone subsequently wrote in the last column of the accident book the cause as ‘overenthusiastic dismantling’!

Around the same time I suffered a more embarrassing accident that involved a caustic response from whoever would see the entry in the same accident book. I have always since early childhood had a phobia of butterflies and moths. One day I opened the cupboard to pull out a file and a Small Tortoiseshell butterfly flew out into my face. I turned instinctively to rush out of the door, and in my moment of panic, I slammed into the half open door and hit my nose and cheekbone rather badly on the door’s edge, luckily not breaking any bones. We deliberated at length what to write in the accident book as the cause and eventually I reluctantly permitted them to write ‘victim chased by a butterfly’ with ‘lepidoptoraphobia’ added in brackets!

When we had completed our investigations into the Clapham accident and written up our conclusions, we briefed the legal team who would be representing BR at the Judicial Inquiry and the key management witnesses including the senior managers who would be giving evidence - senior S&T management, Gordon Pettitt, GM of the Southern Region, Chris Green, MD of Network SouthEast and the Chairman, Sir Bob Reid, as well as David Rayner. Roger Henderson, our QC, had been heavily critical of London Underground management at the Inquiry on the Kings Cross fire the previous year. In fact he had only agreed to represent BR if we revealed everything to him as the London Underground team had suffered embarrassing revelations dragged out of them throughout the Inquiry. He said that he would make an opening statement that BR accepted complete responsibility and had committed themselves to learning the lessons and implementing the recommendations including an undertaking to review its safety management systems by an organisation of high repute. We therefore received banner headlines in the press on the first day of the Inquiry but after that, relatively low media attention compared with the Kings Cross fire as there was very little new evidence coming available - all had been put on the table on the first day.

It had been decided that I should give evidence on my findings on safety management systems and state what BR had been developing under TQM, especially the application by BR of BS 5750. One of the things I had uncovered was that the Signal & Telecommunications Department had committed itself to implementing this standards system before the accident and the very first standard to be written up, which was in progress the day of the crash, was of all things about the correct procedures to follow when wiring and decommissioning wiring, the very aspect of major concern to the Inquiry. I duly spent most of the day in the witness box at the Methodist Central Hall Westminster where the Inquiry was held and I’m told that it was the only day on which no press bothered to appear - they’d seen the draft of my evidence and concluded that nothing of substance or interest would emerge - in fact I was BR’s secret weapon to bore the media away!

We ploughed through BS 5750, what it was, what the S&T organisation was doing to implement it and whether it would have prevented this accident had it been in place earlier. Whilst it’s good practice to have such standards properly considered and recorded, I’m unconvinced that this - of itself - will be the definitive saviour of safety. It can too easily become a ‘tick-box’ process and a means of covering one’s backside without changing reality. It must at least be combined with the ‘softer’ side of systems as instanced in the Leadership 500 course and the addressing of safety culture.

Anyway, the Inquiry duly took it on board and it took up another day of an Inquiry which was running out of time. In hindsight, the Inquiry management spent too much time calling witnesses about the detailed clerical audit and safety check systems and never really got to the crucial issues of the safety culture, the loss of status and influence of the production functions in the new business sector world and the impact of reorganisations that were hurried and not fully thought through. However, BR management had learned this despite the Inquiry failing to identify these as crucial and BR’s senior management ensured that these issues were part of the remit in the review of BR’s safety management systems, which were to be undertaken by Du Pont, one of the most reputable (and expensive) safety consultancy companies in the business.

When the Inquiry was over and before the report was produced, David Rayner immediately contracted a very senior consultant from Du Pont to carry out a pilot review of BR’s safety management. I was appointed as the Project Manager for the five month assignment and worked closely throughout with Bob Webber, a ‘wise old owl’, whose approach and considered ways I came to appreciate and value very quickly. He was not the sort of American I had expected. He was a man of few words, but every one of them was weighed carefully and counted. We were assigned to the West Coast Main Line for our studies, convenient for me, but also providing the full mix of activities necessary to ensure we covered all aspects of safety.

I drew up a series of meetings with staff to Bob’s requirements and accompanied him on all his visits, introducing him to staff, taking due notes of any key issues emerging. He made me very much a part of his assignment using me to fill in about my roles in the Operations function and the TQM work. His approach was usually very informal - he would, after introductions, just ask staff how safe they were, how did they know, how did they compare with others, what were the hazards they faced, the risks they took. He was so informal and conversational that the men and women he spoke to were very open. No-one appeared to hold back. I liked the man immensely and had great respect for him.

He also insisted on meeting members of the Board and asked them very similar basic questions. I shall never forget the interview we had with Sir Bob Reid, I actually thought we might get thrown out of his office. Bob Webber just asked the Chairman how he judged safety - what information did he use for its management. There was a long pause and eventually the Chairman asked his secretary to find the latest Railway Inspectorate report, which was produced annually, later to come under the Health & Safety Inspectorate. The latest report could not be found and one about two years old was produced. Bob then asked, all innocently, ‘I suppose, Chairman, you use information of similar vintage to manage your financial performance.’ I saw the Chairman’s knuckles tighten and go white, his face went bright red and I awaited the explosion. It didn’t come. Sir Robert realised the point that Bob Webber was making and thenceforth all Board meetings had safety on their agenda - a subject that had previously been considered by top management as the responsibility of the operators and engineers. The point was well made and despite the fact that I was party to it, I could never have made such a remark to the Chairman and got away with it. That was part of the value of having a guy we were paying £2,000 a day in 1989! He could and did say things that the Board may not have wished to hear.

When he produced his final report - a simple document with ten recommendations - a bit like the ‘Ten Commandments’ - he felt able to say to the Board that ‘you say one thing and do the opposite’. He meant that we’d produced rule books and standards but that if these stood in the way of getting things done, instead of challenging the rules and changing them if justified, we’d long condoned rule ‘shortcuts’ as long as nothing happened - ie we’d left staff at ground level to take the risks and receive the blame if things went wrong.

This was typified by an incident I observed at Bletchley during shunting operations we were watching. A shunter was riding on the steps of an 08 shunting diesel and hopped off while it was still moving. Bob watched to see what the supervisor who was standing by us would say. He said and did nothing. Bob then asked him if such a movement was allowed. The supervisor then said ‘no’ and chased off after the shunter to tell him not to do it again’ (at least while being observed by management - my interpretation). Bob Webber called the supervisor back and said he’d not intended that. He wasn’t saying it was wrong but wanted to know if the supervisor thought it was. Bob said that if the shunter had safety boots, the siding ground was even and the steps on the loco were suitable and safe for riding on, the lighting was good etc., then perhaps it was safe but what did the rule say? Bob was strongly of the view that there should be more delegation to local staff to develop in conjunction with management realistic safe methods of working and sign off for them as long as the working was local and did not require people like main line train crews to have to face different rules in every location.

Du Pont had a long history of excellent staff safety and it took some time for Bob Webber to enhance the normal Du Pont response to incorporate train, passenger and public safety as well as workers. He wanted to institute managers watching staff working on a regular basis and ensure safe methods, not just the environmental conditions but safe methodology of working. He wanted staff and management to be trained in this. I arranged for a group of General Managers and Functional Chiefs to meet us one evening in Willesden freight yard and Bob briefed them to carry out a typical Du Pont style inspection called ‘STOP’. There was a certain amount of cynicism until we went out in the yard and actually watched the conditions under which the staff were working. The underfoot conditions were deplorable and we saw staff flying around trying to get trains away thinking we were watching their performance in despatching trains to time rather than their safety working methods. The point was driven home when Cyril Bleasdale stood on a metal plate covering mechanism of a point handlever and the metal subsided and squirted a stream of filthy water over several participants. The freight manager was persuaded to spend a relatively small amount of money cleaning up the yard after that.

The one thing that I never got Bob Webber to totally accept was the concept of risk management. He was much more for setting proper realistic rules, training people in them fully, getting staff involvement and commitment and then ensuring 100% compliance without exception backed by strict discipline. Bob and I used to have a friendly difference of opinion at the pedestrian crossing outside Euston House. He would wait for the little ‘green man’ to appear before he would set foot on the road. I would look at the oncoming traffic in both directions, assess the risk and if nothing was coming I would ‘jay walk’ ignoring the sign on the traffic light. Bob’s huge palm would suddenly rest on my shoulder with an admonitory pursing of the lips. However, it was Bob Webber, not me, that actually got knocked over by a cyclist who ignored the traffic lights, a fact that I knew was a common hazard at that location. Luckily he was not injured although a little shaken. I tried to persuade Bob to take risk assessment more seriously, but I think he was more on the side of requiring the police force to prosecute cyclists who disobeyed the highway code and cycled through red lights!

At the end of the five months’ pilot studies the Du Pont report was received and endorsed by the Board despite some harsh things it said about them. I was charged then with developing an implementation plan for the whole of BR and Du Pont was retained for a further year on a part time basis to assist me. One of the key recommendations had been to pull together all the different strands of safety management throughout BR - train safety with operators and engineers, staff safety with Personnel, public safety all over the place - and recommend the setting up of one Safety Directorate to be an advisory service to all managers, pulling together the development of safety policy and strategy, the administration of rules and standards and safety audit to ensure compliance.

I was appointed to the role of Head of Safety Policy to implement the Du Pont recommendations, develop an annual safety plan, devise a means of justifying and prioritising safety investment and developing research into safety management methodology. David Rayner moved Maurice Holmes to be the first Director of Safety - from the important role of Director of Operations, thus signifying in one action the importance now attached to safety management.