'The Toss of a Coin', Chapter 14 / 2

International Railway Safety Consultant (cont’d)

By the time I’d returned from New Zealand I’d only a month to go until retirement after a 36 year career on the railways. I was given a farewell send-off by my colleagues in the Royal Society of Medicine atrium in Wimpole Street (a further coincidence was an invitation to become a Fellow of the RSM some ten years later as a Chairman of a charity involved with the health care of children) and then started to order my life – as I thought – 33% to the safety consultancy work with International Risk Management (IRMS), 33% to the development of the charity and 33% to home and the family.

Even before I started work with IRMS, however, I was asked by Transmark to join a former colleague from Safety Audit, Ben Keen, to train Mexican Railways management staff in safety management. Although we stayed in a five star hotel in Mexico City we were both queasy – I seemed to make a habit of only ever succumbing to upset stomach overseas in five star premises having been sick in the Bombay Gymkana Club and among the gold taps of the washroom of the Calcutta Club. Between us we somehow managed to complete the training well enough to be asked back a second time. The Mexican Railways were very concerned about the extent of their claims from customers whose freight had been destroyed by a number of derailments and were keen to become more proactive.

I took advantage of the visit to spend a day at the end of our assignment travelling the 70 miles south by road to Puebla where Railway Children had partnered its second overseas charity, ‘Juconi’. The street children used the bus terminus to change from buses from the rural and indigenous land in the south to the shuttle service using the dual carriageway to the capital and our charity funded staff to work with the bus companies to bring children found there to a half-way home in Puebla for rehabilitation and return to their families where possible. I had turned up, however, on the very day that the Duchess of Gloucester was making a visit to the charity with Embassy officials and for convenience I was made a member of the Duchess’s party for the tour.

Another brief interlude was a visit to Pakistan in October 1996. Cyril Bleasdale, my former General Manager in the late 1980s, was Director of the Institute of Transport & Logistics that year and he invited me to their annual international conference in Rawalpindi to give a presentation during a two day seminar on the application of a modern safety management system to the issue of environmental management. It was relatively easy to transfer the concept using risk management to identify the hazards and potential consequences and cost-benefit analysis to prioritise possible control measures. During the conference the Institute’s AGM was chaired by its President, the Princess Royal, who conducted the meeting in a brisk and business-like fashion, and then the delegates were treated, with their partners, to a couple of spectacular sight-seeing excursions.

Firstly, we were guests of the Pakistan section on a trip on the Khyber Pass railway from Peshawar to Landi Khotal, climbing past the tribal villages that seemed still to dwell in an era of 2,000 years ago, in an ancient train, topped and tailed by two venerable 2-8-0 freight locomotives built by Armstrong Whitworth in Manchester around the time of the first World War. We were accompanied by Pakistani Army riflemen standing at every door, and three or four perched on what seemed to be a garden bench balanced on the buffer beam of the leading locomotive.

We endured no more than a few stray stones thrown by young boys; in fact the majority of children ran to the trackside to wave to us, as the sight of a train to the Khyber Pass was a rarity in those days. The train wove between the bare mountains reversing and twisting through many tunnels until the border post with Afghanistan was reached and we could look over the gun emplacements to the valley of the Pass. The next day we were due to be guests of PIA, the Pakistan national airline, for a quick flight around the Karakoram range including encircling the second highest mountain, K2, but unfortunately the cloud cover would make it dangerous so we set off in a group of jeeps on a hair-raising climb to 14,000 feet in the snow covered mountains and spent a somewhat chilly night in a lodge at 12,000 feet.

After my retirement from the government owned Railtrack a few days before privatisation, I undertook my first consultancy assignment for IRMS, which involved flying to Hong Kong as they had won a contract to undertake a full scale risk assessment of the five main divisions of the Kowloon Canton Rail Corporation (KCRC) whose railway ran from Kowloon to the Chinese border at Guanzhou. The corporation ran EMU suburban services, a tram system, freight train and road terminal activities and an administrative organisation. They also ran a couple of through trains to mainland China each day.

The exercise was similar to that carried out by BR in 1990-1, although on a smaller scale. Most of their activities were well inside the ‘ALARP’ boundaries although the tram unit had suffered staff injuries in tram/lorry collisions and we recommended strengthening of the shell encompassing the tram cab. The main Division where we had many significant recommendations to make concerned the road vehicle and freight depot activities where we had identified a number of hazards which needed rectifying. One outcome from this was an invitation to present a paper to the Asia Rail Conference, which led in turn to a request several years later to lead a three year review of the Hong Kong Mass Transit Railway.

In the meantime, IRMS had bid for a contract advertised by the Irish Government to undertake a full review of Irish Railway’s (Iarnrod Eireann) safety performance. The company had lacked investment and was experiencing a number of accidents, especially severe and costly freight derailments, which were causing the railway company to demand urgently funding from government to invest in infrastructure renewal. The government was unsure how genuine this ultimatum was and wanted it independently assessed. If proven realistic – which it was – the state had then to decide to invest heavily in the system or cut back the service to the Dublin commuter trains (the ‘Dart’), the mainline to Cork and Athlone only.

Four consultancy companies were shortlisted and were instructed to make presentations to the Irish government railway inspectorate in Dublin. Unfortunately I was in Madurai in southern India at the time and I was summoned to the phone in pyjamas from my chalet accommodation in the grounds of a Methodist university to see if I could attend on a specific date only a few days away. Although I would be back in the UK by then, it clashed with the AGM of the Railway Children in London and I was required to chair it.

The Irish government personnel were good enough to transfer our presentation to 4pm to allow IRMS to charter a light aircraft to pick me up from London City Airport immediately at the conclusion of the AGM. It was all down to split second timing, whisked by taxi to the airport, light aircraft propellers already turning, with a car waiting for me at Dublin. I felt a bit like 007 until, just after take-off, I realised that in my haste I’d omitted a toilet stop and flew over the Irish Sea with my legs crossed as there were no facilities in the tiny plane! I’m pleased to say that we got the contract.

My role was to review the IE’s safety culture and performance overall and I had a number of interviews with the organisation’s senior managers as well as sampling activities on the ground. I discovered that broadly the culture was very similar to British Rail pre 1989 and many of the steps we had taken on BR were relevant to Ireland also. Of particular interest to the Irish Rail managers was the recommendation to conduct regular safety briefings with staff in small groups and these were put in hand before I returned a few months later to see how they were getting on.

We had discussed staff safety with the trade unions and were doing fine until one of our number talked about the problem of literacy among the track workers and we found headlines in an Irish daily newspaper accusing all its track staff of being unable to read! I found ready allies among the managers including Ted Corcoran, the Safety Director, and I’m pleased to say that the Irish government decided to invest in its rail network before the current financial crisis hit the Irish economy especially badly.

IRMS was also commissioned by Network Rail when it took over from the failed Railtrack to conduct due diligence on its safety regime in six key areas. I was asked in particular to look at signallers’ competence standards and training, route crime, and Network Rail’s revised track safety system, the latter in particular being controversial and subject at the time to much internal criticism. There is no doubt that in the early stages the revised methods of working were causing problems but I concluded that we were being ask to evaluate the new methods too soon before they’d had a chance to become ingrained in the network. I worked closely with Sue McKinstry (now Sue Nelson) and Aidan on the route crime programme and followed up on our earlier work on trespass and suicide in which both had taken a proactive and enthusiastic interest.

In addition to work with IRMS, Network Rail asked a number of retired Operators and Engineers to form a panel of experts willing to chair internal Network Rail Accident Inquiries, only some of which would be followed by formal Railway Inspectorate investigations. In the first four years after my retirement I chaired a number of these Inquiries, the most high profile of which was the train collision at Watford Junction when one member of the public was killed when the first coach of the down EMU commuter train overturned. The primary cause was obvious – a signal passed at danger (SPAD) by the driver of the train from London – but the root causes were more complex and went back to the design of the junction layout and the number of permanent line speed restrictions approaching the junction which might have confused or distracted the driver.

I soon became the panel member most asked to chair Inquiries caused by SPADs – a London Underground train at Harrow & Wealdstone, London Bridge, incidents at West Byfleet, Bearley Junction and Bickley Junction. All were clearly SPADs but in all cases there were other factors increasing the likelihood of error by the driver – in particular a sequence of delays caused by seeing a string of single or double aspect yellow signals which caused the driver to forget or misread the key signals he needed to obey. I also chaired a couple of level crossing accident Inquiries, one on the Newquay branch when road traffic signs misled a lorry driver and we found ourselves in dispute with the highway authority over recommendations to prevent a recurrence.

One accident Inquiry I was not available to chair was the Southall collision in 1997 between a High Speed Train (HST) from Swansea and a stone hopper train which was crossing from Down Relief line to the sidings on the Down side of the Main Line at Hayes. The HST was fitted with Automatic Train Protection (ATP) which on this occasion was not operative, and I was asked as an expert witness to examine the revised policy on train regulation promulgated by Railtrack as there were many who questioned why the stone train had been given the priority over the junction, stopping the HST in full flight.

The issue was whether the policy had increased risk, whether it was a case of wrong regulation by the signaller - or both. The Railtrack policy on train regulation had moved away from the BR priorities which was the historic practice of giving priority in headcode order – ie class 1 express passenger trains had priority over class 2 local passenger trains, over class 3 express freights and so on. The infrastructure controller was now trying to give a better balance between the different business companies and the priority was now to regulate for the least delay to all trains rather than just the class 1s.

I examined the signalbox train registers on the day of the collision and discovered that for a potential two minute delay to the HST in order to clear the freight from the Down Relief line, not only was the freight not delayed but two further local trains behind it to Oxford and Reading would also have avoided delay. Had the freight not taken that opportunity to cross, there was no further opportunity for several minutes as there would be another express on the Down Main, then another on the Up. I expressed the view that the policy was defensible and that on this occasion the signaller’s train regulation would indeed have minimised the delay to all the trains concerned. The issue was clearly the driver’s SPAD at a location at which he did not expect to be cautioned and the various reasons for the train ATP not being operative and why the train was allowed to run in that state.

In 2000 I was asked to lead a small team to review the safety of the Hong Kong Mass Transit Railway Corporation (MTRC). It was the practice of this corporation to hold an independent safety review every three years and I was following one undertaken in 1997 by a team led by Gordon Pettitt, a former General Manager of the Southern Region of BR and then Vice Chairman of Railway Children. I was supported by David Sedgwick of Risk Solutions, engineer Bert Hope, formerly Signal Engineer of BR’s Scottish Region and James Catmur from the safety consultancy firm, A.D.Little. We spent two weeks looking at the network on which the citizens of Hong Kong relied and judged them against their mission statement – to be the best and safest system in the world. The company had to be efficient – a five minute delay warranted a paragraph in the local media and a twenty minute stoppage would cause a headline article!

We were given full co-operation, and a demonstration of the importance the top management gave to safety, being invited to the regular management meeting on the subject chaired by the Chairman of the company who was no figurehead on this. Data collection was all computerised and it was hard to identify areas for improvement except by taking the company at their word re wanting the very highest standards and therefore we judged every aspect of their plan and execution against the best practices in each activity that we were collectively aware of worldwide. Our study was to include also the new airport railway which was about to be opened.

Our report finally included seventy recommendations, which was a shock to our hosts and in particular there were a couple of bad instances of signal maintenance that our Signal Engineer expressed in his usual blunt manner that both shook the MTRC engineer responsible and caused him considerable embarrassment. We learned that there are cultural ways of being able to criticise the Chinese and direct blunt speech or written statements do not figure in that culture. The European members of the MTRC team understood us and accepted our premise that we indeed did rank them among the best systems in the world, but the Chinese engineers took a lot of diplomatic convincing.

In the year 2000 IRMS was sold to the consultancy company EQE as a limited cash flow always meant continuing problems as we had to take on new consultants to manage an ever increasing workload. Although one of the main reasons of the acquisition by EQE was to tap into the expertise of the small IRMS team, in fact many of the staff were not happy in the new situation and some left quickly for other companies. By 2002 many had graduated back to MHA, the company which had been closely associated with IRMS, which itself was taken over by Lloyd’s Register, with Andrew Smith, previously the MD of IRMS becoming Lloyd’s Development Manager in the USA.

One former IRMS consultant who had joined the Scandinavian owned consultancy firm, DNV, asked me to assist him with a review requested by the Network Rail safety directorate of which I was once a part – now Rail Safety & Standards Board (RSSB). The policy of ‘ALARP’ (‘As Low As Reasonably Practicable’) was under pressure in the political climate after privatisation and further high profile and disastrous accidents at Hatfield and Potters Bar, and RSSB had commissioned a study on societal risk and how it should be incorporated in safety decision-making.

This was exactly the subject I had researched with Julian Marshall and Dr David Ball at the University of East Anglia back in 1993-4, but in the organisation’s convulsions of 1994, 1996 and 2000, all traces of that work had been lost and the company’s corporate memory was lacking as so many experienced managers had been prematurely released in 1996 and subsequently. It seemed a bit profligate of Network Rail to have to pay again for work previously commissioned and little new was unearthed in this study. However, a new attitude was prevailing in the Railway Inspectorate, now under the UK Health & Safety Inspectorate, and it seemed that a more prescriptive approach was being adopted causing costs to rise considerably because of political rather than logical pressures.

There is no doubt that safety on Britain’s railways has improved enormously in the last twenty years, despite the much publicised ‘blip’ in the first couple of years of the privatised Railtrack, but in recent times safety regulatory requirements have been held responsible for much of the escalating costs of the infrastructure that the privatised railway industry has to bear.