'The Toss of a Coin', Chapter 13 / 3

Safety Management on BR after Clapham Junction Accident (cont’d)

Further sharing of information was encouraged and networking between safety professionals in different industries became common. As well as with my colleagues in other railways, I met
regularly with the Safety Directors of British Airways and Shell UK and also at the Parliamentary Advisory Committee on Transport Safety (PACTS) at the House of Commons. There were sub-committees which met regularly to brief parliamentarians on shipping, air, road vehicle design and highways and I helped set up a rail sub-committee chaired by Professor Andrew Evans of London University, a chair funded by London Transport. Each quarter we would meet altogether with the Transport Secretary of State or one of the opposition party spokesmen on transport which was where such issues as the different standards of risk laid down by different departments and regulatory authorities were aired.

In the late 1980s Margaret Thatcher had instructed the Treasury to pull together the different standards used and try to find some common ground - apparently her specific words were ‘How many bangs do I get for my bucks?’ (A Reaganism?) The Treasury laboured and when the Prime Minister became entangled later with other issues such as the Poll Tax, she forgot about her request and the Treasury never completed their study which they were finding ‘too difficult’. By the time PACTS debated the issue the only party spokesman that took any interest was the Liberal Democrat - perhaps he’d had his ear bent by Lord Bill Bradshaw, ex General Manager of BR’s Western Region. He accepted that the different standards were a major obstacle to rational decision-making on societal safety, but saw the entrenched position of many civil servants defending their own departmental practices as a major stumbling block to progress, and were unlikely to change unless a strong political will came from their Ministers.

One of the key findings of our own investigation into Clapham had been the role played by organisational change and, in particular, a hurried implementation without all the checks required for safety assurance taking place. As a direct result, the Safety Directorate devised a ‘Safety Validation’ process that every organisational change proposed had to go through. This involved identification of all the posts associated with safety and tracing where their responsibilities moved to in the new organisation. Was the activity still of vital importance for safety reasons and was it adequately covered? Were the posts filled with qualified people? Was additional training required? If so, had it been done before the reorganisation was implemented? This became a critical part of the privatisation safety assurance process.

One safety issue which was extremely hard to tackle was that of suicides on the railway. There were around 250 - 300 suicides a year, by far the largest number of fatalities on the railway from any cause. Not only was this of great distress to the victims’ families, but it affected the train drivers involved and the track staff that were forced to deal with the consequences. I remember when Regional Operating Manager on the London Midland Region travelling in the cab of a diesel with a 28 year old driver on a train diverted from Nuneaton to London via the Midland Main Line, because of a line blockage south of Rugby. As we approached Wigston Junction to gain access to the Midland, just south of Leicester, this driver suddenly told me that he’d suffered three suicides in front of his train at this spot in the previous few months. I was horrified, but the guy seemed calm and I guess he was suppressing the experience. Apparently the suicides had escaped from the Rampton Hospital nearby. With the subsequent policy of getting people suffering from mental health problems back into the community where possible, such concentration of incidents is now no longer common.

This of course means that an instance of suicide might happen anywhere and the systems we set up with the management of Mental Health hospitals to advise us when a patient had gone missing so that we could warn station and signalling staff to be on the lookout at the ‘black spots’ ceased to be of so much help. In the early 1990s I had set up a special initiative to discuss with the Samaritans and other counselling organisations and see if we could control any of this situation or whether it was something the railways could do absolutely nothing about. Aidan Nelson, then at York, and the Community Affairs Officer there, Sue McKinstry, were interested and got involved – in fact when I retired Aidan was my successor and continued work in this area.

We identified that railway suicides had a distinct difference from the national average ‘stereotype’. They were mainly male and 50% had had recent psychiatric help for mental health problems. One clear message was that a railway suicide meant it – it was not a cry for help. Another issue was that, despite my experience with the Nuneaton driver, such incidents were traumatic for drivers and caused lost time through subsequent sickness and shock. We established that this was worse if a driver had made eye contact with the victim immediately before the person was hit by the train. The consultations also identified the underground drivers’ problems from suicides jumping in front of trains as they emerged from the tunnel at the platform end. Drivers of LT trains were advised to switch on their cab lights when entering stations as it was suggested that seeing the driver, another human being, caused a would-be suicide to hesitate for a crucial few seconds and station staff alerted before the next train entered the station. I hesitate to say that we made a significant inroad to the problem, but we gained insights which we briefed to people who managed staff who were most likely to be affected and the managers of hospitals dealing with those at most risk were alert to our concerns and encouraged to contact us when possible.

Having undertaken the comprehensive risk assessment of all BR activities in 1991, I was now under pressure to disaggregate that to identify the key hazards to be addressed on specific routes or at particular locations. This was prompted initially by concern over the growing practice of replacing double junction leads by single leads with the potential for collisions if the signals protecting the junction were overrun. This concern grew when just such a collision occurred at Newton near Glasgow and operators began to challenge the business intention of cutting costs at Ely by installation of such single leads at the 4-way junction to the north of the station. Consultants A.D.Little undertook a specific risk assessment with us, but many began to ask whether a computer model could not be developed to inform such decisions on a routine basis.

David Rayner and I therefore commissioned a project to develop a ‘Risk Model’ that could be used by businesses, operators and engineers. We started with a consultancy organisation with great confidence, but the first problem we identified was the sheer number of ‘top events’ that we could specify and the myriad combinations of circumstances of geography, route layout and weather conditions that could be relevant and without which the model would only be a broad indicator with management interpretation to play too large a part. I seem to remember that we had amalgamated over 800 such nodal risk points which were beyond the computer’s capacity for pursuing all the options that were conceivable. The team then suggested using heuristics instead of the standard computer logic programming which would have the drawback of not being able to prove all the assumptions built into the model to assure that these were reasonable. However, the team were optimistic and began to load data into the model. We decided to demonstrate the model to interested engineers, operators and business managers when I had been assured that there was sufficient data in the system to show what it could do.

I made the mistake of not seeing the demonstration in advance and pressing the consultants to show some examples knowing that our audience would be wanting to see something concrete and not just abstract theory. As soon as the model began to spew out results on the first suggested download, I knew we were in trouble. The risk figures produced were highlighting 98% of the hazards on a particular route were from so called ‘bridge-bashing’ – lorries or double-deck buses colliding with rail underbridges – a clear nonsense. We were able subsequently to identify the reasons for this absurdity but only because the area of error was so obviously with the data assumptions about this hazard, which to date had never caused a serious train accident although the potential was there. Apart from losing the confidence of our audience, we realised that without a logical trail of data and decision-making processes open to inspection, we would be powerless to investigate results that were dubious but less obvious, and the project was aborted. We were too ambitious on this occasion, but I understand a ‘Risk Model’ has now been subsequently produced and used.

British Rail’s Safety Directorate was transferred ‘en bloc’ to the newly formed Railtrack in 1994 and it is pertinent to understand just how much BR had achieved in the five years since the Clapham accident. A totally new proactive safety management system had been embraced and accepted throughout the organisation. BR’s experts on this were being sought throughout the world to advise on the application of such systems to other railways. And most important of all, BR’s safety performance had dramatically improved through 1989 to 1994. There had been no major train accident involving significant loss of life since Clapham. Staff safety had dramatically improved, with a couple of years having no fatalities compared with the previous decade’s average of twenty deaths a year. Twenty passenger deaths from train falls every year had been virtually eliminated. There were many people out there in the community who owed their lives to what we had all achieved although neither we nor they knew who they were.

The transfer of the Safety Directorate under Mike Siebert to Railtrack took place in March 1994 virtually without noticeable effect. Railtrack would be government owned for a further two years and we continued life as usual. The most obvious change was in our designations. I had become Controller, Safety Policy, instead of Head of Safety Policy although my duties and responsibilities were exactly the same. It made no difference to my salary. I had a small but very able team of a dozen people with Roger Taylor leading the small unit to develop and implement our annual Railway Safety Plan with all the necessary negotiations with businesses, operators, engineers and the railway regulatory authorities. Julian Marshall led the Risk Management unit and, having been our lead with the UEA studies on societal risk, was now researching the potential application of the Safety Case methodology as used by the off-shore oil industry since ‘Piper Alpha’. Sarah Tozer was my expert on human factors liaising closely with Professor Reason and other academics and with Hilary Wharf and her colleague, Adam Sedgwick, who were undertaking many studies on the issues of fatigue and human error, especially looking when SPADs were mostly likely to occur within the shift, where data they were uncovering was producing some surprising results.

There was one new major task in which the whole Department became heavily involved – that of ensuring the new privatised railway companies went through a vigorous validation process before they were allowed to take on their new responsibilities independent of BR. They were required to do this by preparing a wide-ranging and comprehensive ‘Safety Case’ which was then scrutinised by a team from within the Safety Directorate and further subject to questioning by the whole Safety Directorate top team and key engineering and operations managers. A Safety Case sets out the safety policy of the company and catalogues in detail how this will be delivered in practice through its commitment to standards, through issues such as managerial experience and competence, training, personnel policies, staff communications, understanding of safety management techniques and methodologies, data collection plans and use of past safety performance information to comprehend the risks its organisation will need to control.

The Safety Director appointed three senior managers – Phil Dunkley, Stan Judd and Jim Ward – to chair the Safety Case validation process on a full time basis and other managers were seconded on the days of the interviews with a new Train Operating Company’s management team to probe the areas in the documentation submitted for apparent ambiguous or contentious points. I was frequently present to seek clarity and commitment to the company’s safety policies and culture and looked for signs that the whole team understood and showed a personal resolve that safety would be treated at top level with the same priority as production or financial performance. I looked with interest at who took the lead on such fundamental questions and worried if the Managing Director looked to his safety specialist to answer and even more if a safety consultant hired in was the spokesperson, even if the written and spoken words were perfect. I would much rather gauge the personal interest and commitment of the MD and his senior managers, even if the words were not from the text book.

As the day approached when Railtrack would become fully privatised and no longer government owned, I began to discuss the implications with David Rayner, especially the future likely policy towards some of the ground breaking research and seeking of new initiatives to which we had been committed. There was the strong possibility that a privatised company would see its safety responsibility as meeting the set standards of good practice within the law rather than pioneering new thinking, which might be considered to be more the role of the regulator or consultants when a particular problem needed addressing. I had been privileged for some six years to be allowed a very free rein to drive the railway industry’s safety performance forwards within the priorities that I had been party to setting. However, the signs were that this freedom would be more constrained as shareholders might not see being among the world leading railways on safety as their priority - as long as they were protected from their company being found negligent of complying with its accepted Safety Case.

I had founded the Railway Children charity some nine months previously and David Rayner pointed out that, with just two years to go to retirement, I might find it more fulfilling to spend the time developing the charity, especially in the light of the financial incentives that Railtrack were offering to many senior experienced managers in an effort to reduce their costs and increase their profit potential. I think in hindsight that they let too many engineering, operating and safety managers with experience go, and several of us subsequently found ourselves hired back as consultants, often at fees greatly exceeding what we were paid as employees. I therefore decided to take early retirement and was immediately approached by a small new safety management consultancy and offered a part time Principal Consultant’s role. With my own financial future assured through pension and ‘golden handshake’ arrangements, I saw the opportunity to build the charity’s funds in its initial growth from the consultancy fees I could earn and committed myself to a minimum of 60 days a year to International Risk Management Services (IRMS) and their Managing Director, Andrew Smith.

Three months before my retirement my career was crowned by receiving the OBE in the 1996 New Year Honours list for my services to the railway industry and I saw this as a recognition from colleagues in the industry of all that my teams had been doing to turn around the industry’s safety performance in conjunction with dedicated managers and staff all over the system. I was well looked after by the company on the day I received the honour from the Queen herself and was able to celebrate with my family – Pat, my three children and my father – at lunch in the Savoy Hotel. My only regret was that my mother had died some seven years previously, as this might have vindicated her efforts to appease my two year old interest in trains when she would wheel me in the pushchair all the way to Esher Common where I insisted I could see ‘proper’ trains!