'The Toss of a Coin', Chapter 13 / 2

Managing Safety after the Clapham Junction Accident (cont’d)

One reason for the decision to fund the ‘Train Protection Warning System’ (TPWS) despite the high cost for every life saved was because of research work we had been carrying out in the Safety Directorate on human error or ‘human factors’ as it is known by professionals. We linked with Professor James Reason (an appropriate name) at Manchester University who had advised British Airways and had been a member of the team commissioned by the government to look at the Hinkley Point nuclear power station plans from a safety viewpoint. He worked closely with a number of European researchers, including Jens Rasmussen, a Dane who had done a lot of work on the potential for human error in the nuclear industry.

Professor Reason had evidence for the potential risk of error with certain types of decision under normal or stressed conditions. The evidence suggested that the human brain made around 3 errors per million decisions when undertaking routine work in normal conditions - such as drivers observing and obeying signals. We assessed that a driver over a 40 year career might have had to obey around 2 million red signals, therefore it would not be surprising if he (or she) had at least two or three ‘signals passed at danger’ (SPADs) in a driving career which was not considered acceptable because of the potential heavy consequences of a train collision. Some form of support technically for a driver was therefore essential, and TPWS would substantially reduce, if not eliminate, the risk.

There was one other safety issue which came to the fore in our list of priorities revealed by the risk assessment and cost benefit analysis. People had been falling from trains from time to time - about twenty a year on average - and traditionally railway management had tended to give these low priority, assuming them to be drunks or people messing around with doors. However there were around this time one or two cases where this was obviously not the case - a young girl fell to her death from a train crossing a viaduct and then there were five fatalities in three months from trains on the West Coast Main Line between Nuneaton and Lichfield - it became known in the media as the ‘Tamworth Triangle’.

The maintenance department continued to argue that it was not faulty doors, but there were many tests which revealed that some doors could get caught with the lock not engaging properly, and one of our Board members made the succinct remark that he was unaware we had the death penalty yet in the UK for being drunk. I was asked to look at the case for fitting locks to all doors of mainline stock using our new ‘As Low As Reasonably Practicable’ (ALARP) criteria and found that there was a good investment case based on a forecast of around £300,000 to save a life annually. There was a speedy decision to equip all InterCity rolling stock with a guard operated door secondary locking system.

A few months later I was spending a day at the Grove Staff College lecturing to a group of senior Indian railway officers who were undertaking an eight week management course in the UK. I quoted this example of the way we were using cost benefit analysis for safety investment and received the rather incredulous query from one officer who wanted to confirm that he had heard aright when I mentioned twenty deaths a year. He revealed himself to be the manager of the Bombay suburban service and said they had twenty fatalities a day from falls from trains or passengers knocked over while trespassing. Having travelled on the service from Bombay Churchgate station to Bombay Central in the rush hour, I well understood his point.

However, I later compared the individual risk to a passenger on UK railways with one on Indian Railways and found the risk was almost identical despite a number of horrific train crashes reported each year in India. The reason was that the sheer number of passengers meant that the risk to any one individual was spread much wider. As an example, I was told that the number of commuters travelling into the three major Bombay stations of Churchgate, Central and Victoria Terminus was around 6 million a day - compared with Waterloo’s 170,000!

By this time the safety organisation had matured into three main groupings - the Safety Policy unit, which I headed, looking at BR’s safety management systems, measuring annual performance and setting objectives through an annual Safety Plan, using our research into risk assessment and human factors; the Safety Standards unit which had an overview of operational rules and engineering standards; and the Safety Audit unit that conducted periodic reviews of safety in the field to ensure standards were being maintained. Mike Siebert had been brought in from outside the industry to set up and run the Audit function and he took over the Directorate after Maurice Holmes retired, although I reported directly to David Rayner, Board Member, for the research and innovative work the Policy Unit was progressing.

The other main activity of the Policy Unit in which I was personally heavily involved was in the training of senior management in BR’s new safety management systems. We devised a 3 day residential course in which I was assisted by consultants, initially from the Safety Science unit of Birmingham (Aston) University. The course was unique for senior BR managers in that there was a one hour written examination at the end of the course which managers were required to pass. This at least meant it was taken very seriously for a couple of people were taken out of their jobs when it was found that they were unable to meet the standard even when offered extra tuition.

In the initial pilot course, we deliberately brought together people from different functions and one, who was an architect, kept moaning that he failed to see the relevance for his job. It was only at the end of the course that we discovered he was the architect responsible for the terrazzo tiling floor at Waterloo station which - in wet weather - had been the cause of more slips and falls of passengers there than any other reason for injury. Even two of the high level Business Sector Managing Directors managed to fail the exam at first go - I suspect it was 30 years since they had last taken an exam and one of them admitted not reading the questions properly - a classic schoolboy mistake. We were kind and arranged for both to attend Aston for a special day’s personal tuition from the Professor there - and we did it on a Bank Holiday so that there were no questions asked by their staff as to where they were! We also gave the Executive and Non-Executive Board Members a 48 hour course, although we refrained from examining them on it - we chickened out on that!

The work we were doing on British Rail was becoming well known among railway circles. This led to enquiries from railway systems worldwide on safety management – especially from Commonwealth countries whose railways had been built by the British. The first safety conference we attended was in Japan in 1990 which inspired annual seminars thereafter. The Japanese do these things in style – vast conference hall, 500 attendees, lavish gifts. After the conference David Rayner and I were invited to visit the JR driver training school to see their simulators and both of us were introduced to the controls of a cut down EMU to drive to a half hour realistic video unfurling on a wide screen in front of us.

This was part of a safety briefing all Japanese drivers received which included testing in an emergency situation. All we knew was that we would be faced with some emergency during our 30 minute drive to which we would have to react. After a few minutes, passing through a station at 60mph, a person threw themselves off the platform in front of me committing suicide. I braked fiercely – not that I could avoid him – and went through the emergency procedures when the train came to a stand. It was so realistic that I found that I was trembling with the shock! David then took over and a quarter of an hour later he had collided with a JCB on an ungated farm crossing.

As a result of the work we had initiated post Clapham, I found myself making presentations at international safety conferences and attending an annual seminar for safety specialists, which we initiated with the Japanese and New Zealanders. I was asked over the following three to four years to provide advice from BR to the railways of Australia, New Zealand, South Africa, Canada and Hong Kong and I set up and attended quarterly meetings in Europe with my opposite numbers from Germany, France, Switzerland, Holland and Belgium, which we hosted in turn, discussing the learning from any serious incidents we’d had and research that might be of mutual benefit.

I found that we and the Dutch had an immediate rapport and were developing similar lines of research - especially on human factors - which we shared. The French and German Safety Managers were somewhat envious of the high level status of safety in the BR management team and were still constrained in what they could achieve by being a relatively lowly unit within their Operations function. After a bad train accident at Rüsselsheim near Frankfurt, I was asked to share my views on the accident with DB management and there was hope that this might be the catalyst for a review of the German approach to rail safety as the Clapham accident had been for ours, but it was not to be.

In 1990 I attended a 1,300 delegate World Congress of Safety Science in Cologne and in 1993 I was invited to address the Second World Congress in Budapest on the pioneering work we had been doing to transform BR’s reactive safety management system to a proactive one. The work we’d done on cost benefit analysis and human factors caused great interest and led directly to some of the consultancy work I undertook in later years. In one of the main presentations a distinguished Indian scientist presented research he’d been undertaking on developing a similar prioritisation system for evaluating hazardous work and when asked to give examples of the results of the application of his sophisticated mathematical technique he quoted the top industrial risk in India was ‘women carrying hods of bricks all day’ and the second highest was ‘children under ten carrying water in buckets for more than a mile’. So much for sophistication! This shook the assembly and I related it to my experience of visiting India in 1989 and 1992, more of which in the last chapter on the ‘Railway Children’.

From the mid 1990s I was invited as one of only two industry managers (the other was from Shell in the Hague) to share experience with safety science academics from Europe and the USA. We met annually at the Werner Reimer Institute, a conference centre in beautiful grounds in the spa town of Bad Homburg, a few miles north of Frankfurt-am-Main. My job and that of Kurt Visser, the Shell Manager, was to provide case histories from our industries which would be discussed in the light of the theories and research they were presenting and to challenge the practicality and usability of their ideas. Each year the papers presented by the academics were edited into a book by one of the conference professors, either Bernhardt Wilpert from Berlin or Andrew Hale from Delft, and published - mainly as a text book for students - by the Pergamon Press. I contributed a number of chapters over the years on the application of safety science methodologies and philosophies to the UK railway industry and impact of state regulatory authorities and the Inquiry process.

I also attended a number of meetings with the Union Internationale de Chemins de Fer (UIC) in Paris to exchange safety data with other railways so that we could identify railways that had particularly good safety records in specific activities and from which one might learn. Equally, the knowledge of where one was weak compared with other railways could point to lessons that could be identified in order to improve. This was only partially successful as nearly every railway collected different data over different periods of time making true comparison difficult. For example, we even found it hard to define a fatality from a railway event, with at least three different definitions of the time span in which a fatality could be ascribed to a railway related event - only immediate deaths counted, or within 30 days or within a year. I wrote a paper giving some examples of comparisons of safety - individual risk - from a number of industries, with data obtained mainly from Aston University and then collated some data from railways and put it in the context of societal safety.

However, attempts to standardise data between European railways failed as not only was it difficult to get railways to change their data requirements but in many cases the form in which it was produced was required by the state regulatory authorities. A similar attempt at our annual international railway safety seminars failed also - the conference in Hong Kong in 1994 made a big attempt to do this and again papers were written which I thought might have been the first steps in the process, but they were not followed up as organisations changed, for instance, the BR Safety Directorate moved to Railtrack and key people in other railway administrations who were interested changed jobs or retired.

The most success we had was in our quarterly European exchanges, when we would look at specific accident causes or research in sufficient depth to understand comparisons. We shared data on SPADs and BR and NS (the Dutch railways) exchanged a lot of our research and information. We were able to do many helpful comparisons of staff safety and I particularly remember - because it was such a surprise - the poor record of the Swiss Railways on track safety. The results we’d achieved with Du Pont’s input caused their management to hire the same company to advise them on this issue.

We all identified that we were particularly vulnerable when the normal routine protection systems were disturbed for some reason - usually planned or emergency engineering maintenance work. During our briefing to each other on incidents that had caused injury or death we noted in a couple of sessions that over 80% of what we were recounting was associated with disruption of traffic during engineering line possessions. As technology was increasingly providing protection against human error, so when that protection was removed the likelihood of human error was much increased as staff had less practice in working with reliance on knowledge and experience. This was a subject which much exercised the academics at Bad Homburg with a lot of discussion on how to train staff to cope with emergencies when normally their routine was to watch an automatic system perform.