AGENDA ITEM: A2
MEETING:
RSSB Board Meeting
DATE:
07 May 2015
SUBJECT:
SPAD Risk Reduction Strategy: Outline Strategy
SPONSOR:
Chris Fenton
AUTHORS:
Mike Carr and John Abbott
1.
Purpose of paper
1.1
This paper sets out the strategy to address the safety risk posed by signals passed at danger
(SPADs) over the next 10 years, covering the period before widespread installation of the
European Rail Traffic Management System (ERTMS). The paper updates the board on progress
with development of the strategy and provides an outline of the proposed framework to be
adopted.
1.2
The January 2015 board discussed and agreed the need to develop a forward strategy for the
risk management of SPADs which although relatively low in frequency, have the potential for
high consequence loss. The strategy has also been initiated in response to an increasing
number of signals being passed at danger over the past two years. It will be delivered through
three key phases, consider the need for new controls and mitigations in the short, medium
and long term, and capture existing good practice.
1.3
It’s important to note that existing management activity to address SPAD risk will continue
during the development phases of the strategy though established industry mechanisms, local
tactical groups such as Operational Risk & Mitigation groups (OPSRAMs), and at national level
through the System Safety Risk Group (SSRG) and its expert sub-group; the Train Operations
Risk Group (TORG). These existing mechanisms will help inform phase 1 of the strategy.
1.4
The SPAD Risk Reduction Strategy, developed through industry collaboration will also form
one component of the new Rail Health & Safety Strategy.
2.
SPAD Risk Reduction Strategy - Framework
2.1
Following RSSB board endorsement of the proposal for a SPAD Risk Reduction Strategy
focused on the next two control periods, the strategy will comprise three key phases:
Phase 1 – Review of existing management activity, tactical improvements and good practice
Phase 2 – Next generation of risk mitigation
Phase 3 – Delivering the long term plan
Note. Phases 1 and 2 will run in parallel.
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2.2
A SPAD Risk Reduction Strategy Steering Group (SPAD RRSSG) will be created to provide
executive level commitment and support for the strategy, establish and set the remit for
expert sub-groups, make strategic decisions, monitor progress with individual projects or
workstreams, and assist with any cross industry issues. It will develop the ‘vision’ for SPAD risk
management, endorse business cases, set the critical success factors, and where appropriate
set specific targets for risk reduction over time, aligned to the phases and various controls
proposed.
2.3
Steve Murphy, Chief Operating Officer, MTR Crossrail has agreed to be the Chairman of the
SPAD RRSSG and nominations for members of the group are currently being confirmed. A draft
‘Terms of Reference’ are attached as Annex A for endorsement.
2.4
The SPAD RRSSG will be supported by three expert groups for; operations, human factors and
infrastructure & engineering. Each of the three collaborative groups will form an expert
cohort with members selected from a cross section of the industry with experience and
specialist knowledge in the subject area, and will work together to develop the necessary
controls and mitigations required. These will be used to create a matrix of short, medium and
long term objectives set against the identified industry learning and detailed data analysis,
and provide input to the Rail Health & Safety Strategy. They will also endorse the proposed
industry tactical improvements and good practice in the specialist area.
Phase 1 – Review of existing management activity, tactical improvements & good practice
2.5
The factors that affect SPAD performance and risk are varied and multi-faceted and have been
the subject of considerable analysis and review over many years. This has resulted in cross
industry improvement initiatives to address the prime causes of SPADs including:










The need for fit for purpose and continuously improving Safety Management Systems
(SMS)
Optimisation of the ‘as is’ infrastructure, including signal risk assessment and
management of multi-SPAD signals
The opportunities and risk posed by infrastructure renewal schemes
Recruitment, competence, fitness and human performance of train drivers
Environmental conditions – poor adhesion conditions or assessing the effect of signals
being obscured by sunlight
The effects of timetabling and performance on SPADs
Ensuring Train Protection Warning System (TPWS) remains an effective and reliable
system
Delivering and managing the ERTMS fitment programme
Risk methodology - making sure we have robust SPAD and signal risk assessment tools
that people can understand and use to make informed decisions
Undertaking comprehensive investigations and learning from identifying underlying
causes.
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2.6
The industry continues to invest considerable resources and efforts to mitigate SPAD risk and
although these efforts have been successful in driving improved performance over the past
15 years (mainly through the implementation of TPWS), this improvement has slowed since
2006 and in late 2012 started to rise again.
2.7
These improvements have been achieved through mitigations introduced in a fragmented way
and the challenge facing the industry now is how to further improve risk control performance
without devoting disproportionate resources considering the relatively low risk that SPADs
now present.
2.8
This phase of the strategy will therefore consider the ‘as is’ situation, through understanding
the existing SPAD mitigations in place within the industry, reviewing previous research and
literature, identifying patterns and trends, and capturing existing good practice. It will also
seek to understand the industry cost for management of SPAD risk in order to assist
development of future business cases.
2.9
This will be achieved through a collaborative approach with industry partners using existing
meeting structures and cross-industry groups, supported by workshops and focus groups to
build an inventory of existing practice. Progress has already been made in this area, for
example the Network Rail ‘deep dive’, development of a SPAD ‘bow-tie’, and an initial focus
group has been arranged on 18/19 May 2015 with a group of train drivers from one train
operating company.
2.10
The output of this phase will be the identification of existing and new good practice in SPAD
mitigation and short to medium term enhancements for adoption by the industry. Many of
these will involve the utilisation of existing resources in a more effective way, and the creation
of more consistency of application of mitigations through the sharing of good practice.
Phase 2 – Next generation of risk mitigation
2.11
The framework to support this phase of the strategy will be based broadly on the model used
for the platform train interface (PTI) strategy, with a similar governing Steering Group and
outputs developed through three key expert groups delivering workstreams on operations,
human factors, and infrastructure & engineering. These groups will also consider the good
practice delivered through phase 1 as inputs.
2.12
The outputs from phase 2 are likely to require industry funding through Control Period 6 (CP6)
and beyond, therefore this phase of the strategy will build the business case for seeking
funding either from within the industry, or through the ORR determination for CP6, provided
industry support for seeking such funding is agreed.
2.13
Work has commenced on development of this phase of the strategy which provides a
structured ‘whole system’ approach to considering the longer-term mitigations required, by
following the principles set out in ‘Taking Safe Decisions’ which are aligned to overarching
legislative requirements.
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2.14
‘Taking Safe Decisions’ - presents a framework which comprises three related activities:
monitoring of safety performance; analysing and selecting possible options to implement, and
then implementation of agreed change. Changes made are then monitored and the cycle
begins again. Implementation of this phase therefore requires the need for initial analysis to
underpin the selection of options and initiatives. This will include not just data and expert
judgement but the collation of existing good practice through phase 1. Robust and approved
industry processes and tools will be used to determine which measures should ultimately be
put forward for funding to implement.
2.15
RSSB has recently made significant progress with its ability to understand and analyse SPAD
risk, in particular through recent work that is identifying the SPAD rate per demand on a signal
by signal basis. This phase is therefore timely as this analysis should drive a more targeted
appreciation of risk, and therefore the ability to understand and implement more targeted,
cost effective control strategies can be proposed.
2.16
This phase of the strategy will be delivered through the three expert groups for operations,
human factors and infrastructure & engineering, discharging their activity through the
following staged approach:
2.17
The expert sub-groups will each work to a specific terms of reference developed by the
steering group (once established) which will set out the scope of their activity. Early
nominations for the groups have already been sought for the operations, and infrastructure
& engineering groups, and the existing Human Factors SPAD Review group will continue with
its existing membership, but to a revised remit once set.
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2.18
The scope of the three expert groups are to be agreed at the first SPAD RRSSG, but are
expected to cover the following areas within their individual areas of expertise:
2.19
On-going development and delivery of the first two phases of the strategy will be
communicated to key industry groups, conferences, roadshows, etc., and findings shared with
the International Union of Railways (UIC) sponsored SPAD Task Force, of which Mike Carr is a
member. This will provide for learning on a European scale.
3.
Phase 3 – Delivering the long-term plan
3.1
Phase 3 of the strategy will be delivery of the longer-term mitigations to reduce the risk from
SPADs through CP6 and beyond, supported by the business cases developed as outputs from
phase 2.
3.2
Many of these mitigations will be aimed at engineering solutions and to be successful will
require a step change in the industry’s approach to strategies such as this, and in particular
funding mechanisms. A new approach will need wide industry ownership and support in order
to seek appropriate levels of funding in future control period determinations.
3.3
In particular, funding for engineering led mitigations will often fall to the infrastructure
manager to fund, but with the majority of the benefits being realised by train operators in
reduced industry costs, rather than in terms of risk reduction.
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4.
Specific questions for the board
4.1
Does the board support the 10 year timeframe for the strategy which is based upon the
assumption that a significant portion of the network will be fitted with ERTMS by 2025 as part
of the digital railway project?
4.2
It is planned to develop the strategy and support the various groups through a combination
of part-time RSSB resource working alongside industry experts which could affect the pace of
delivery due to conflicting priorities and deliverables. Do the board support this approach?
4.3
There is no dedicated budget to support the deliverables of phase 2 and 3 of the strategy,
some of which are likely to require significant expenditure in CP6. Business cases developed
for deliverables will need to consider:



the mechanism for funding - in some cases the reduction in SPAD numbers alone may
not reduce the risk level sufficiently for a business case to be successful
the benefits flow will not be equal across all parts of the industry - an example would
be a reduction in the number of multi-SPAD signals through Network Rail installing
TPWS at these locations (where not already installed). Although the Network Rail
business case would be unlikely to succeed on the basis of risk reduction, the benefits
to train operators from reducing future SPAD events may be sufficient to make this a
cost effective course of action
whole industry costs – the need to drive industry costs down and be more efficient
The board are invited to consider the above points.
4.4
Once the deliverables of each phase of the strategy have been determined, how will the board
support adoption of them across the industry to ensure the benefits are realised?
5.
Recommendations
5.1
The RSSB board is asked to:
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
NOTE this paper and ENDORSE the outline framework for the SPAD Risk Reduction
Strategy
ENDORSE the Chairman of the SPAD Risk Reduction Strategy Steering Group as Steve
Murphy, and the proposed ‘Terms of Reference’ for the group (subject to any additional
specifics in the ‘Purpose’ section required by RSSB board)
DISCUSS the ‘specific questions’ set out in Section 4 of the paper
ENDORSE that an update is provided to the November 2015 RSSB board meeting
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AGENDA ITEM: A2
ANNEX A
TITLE: SPAD Risk Reduction Strategy Steering Group (SPAD RRSSG) - Terms of Reference
GOVERNANCE AND ADMINISTRATIVE ARRANGEMENTS
GOVERNANCE: The SPAD RRSSG ToR will be approved by the RSSB Board (to be presented at May 2015 meeting).
FREQUENCY : Quarterly - 3 hours (Maximum), up to 2 years
CHAIR: Steve Murphy, MTR Crossrail
DEPUTY CHAIR: (TBC at first meeting)
MEETING MANAGER: Sonya Bhooma-Loader (Project Manager) RSSB
Core Members: Network Rail: Graham Goswell (TBC); TOC: Andrew Munden, (Ian Smith); FOC: John
Battershall (TBC) ATOC: Daniel Mann; RSSB: Mike Carr, Chris Harrison; LUL: TBC; ORR: Keith
Shepherd; ASLEF: Howard Kaye
Alternate Members:
[External guests: Where appropriate, SPAD RRSG may invite external guests to contribute to specific topics to further the
work of the group]
Location: RSSB offices, Moorgate, London
CONTEXT

The SPAD RRSSG was established following the decision of the RSSB Board in January 2015

The SPAD RRSSG will be disbanded once the strategy has been created and supported by the RSSB Board

Subsequent delivery of the strategy will be governed and overseen by the cross-industry System Safety Risk
Group (SSRG)

The Operations, Human Factors and Infrastructure & Engineering sub-groups, will support the SPAD RRSSG
during the development phases of the strategy and subsequently SSRG during delivery. They will consult with /
include rail industry specific subject matter expertise as required to support the activity and report through the
Train Operations Risk Group (TORG)
PURPOSE of the SPAD RRSG
The key purpose / objective of the SPAD RRSSG shall be to develop an industry agreed phased strategy for SPADs that:
1.
2.
3.
Reduces the safety risk from SPAD incidents
Reduces the number (volume) of SPAD incidents
Improves industry efficiency – safety, financial, performance, reputational and process
It will achieve this through a three phased approach setting objectives that:

reduces safety risk, optimises operational performance and availability of services, and financial efficiency in a
manner that promotes the long-term best interests of the mainline railway system

reflects the wide range of performance and engineering issues surrounding the SPAD issue

accounts for both the short term and long term needs of the industry

defines the research, where appropriate, needed to develop and deliver the phases of the strategy

has industry buy-in for the implementation of objectives, tactical improvements and good practice identified in the
strategy
In delivering this objective RSSB Board has requested the group to specifically consider:

…(to be clarified at the May 2015 RSSB Board meeting) …………………………………………………………………
The funding arrangements, or proposed funding arrangements, for any actions that are recommended should be identified.
SCOPE

The strategy will:
o
Focus on safety, performance and business risk that is impacted by SPADs
o
Address fatalities and weighted injuries (FWI), which includes: fatalities, major injuries, minor injuries and
shock and trauma.
o
Address any issues relating to SPAD specific trends
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
o
Give due consideration to any unique features related to SPAD risk
o
Consider the potential for multi-fatality incidents as a result from SPADs
Events in scope:
o
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SPADs (category A) with potential for a train accident
Events not in scope:
o
Buffer stop collision
o
Train collision risk due to irregular or permissive working
o
Train collision following derailment caused by track integrity, civils integrity or train overspeeding
o
Train collision with object on adjacent running line
o
Train collision with staff/items/vehicles/animals/plant on the line
o
Train collision with pedestrian or equipment at level crossing
Factors to be considered:
o
Other industry staff – the actions of a 3rd party either exclusively or contributory to the incident
o
Signalling operation – the actions of signallers, ground-frame operators, handsignallers, shunters, etc.
o
Infrastructure – including the layout design, signalling, interlocking, maintenance, ETCS, ATP, TPWS,
AWS, vegetation, etc.
o
Rolling stock – including design, braking systems, in-cab signalling, ATP, AWS, DRA, sight-lines, tripcock, train-stop, etc.
o
Train operation – the operation of the train, including the actions of on-board staff, dispatch procedures,
o
Third party – vegetation (outside boundary), street/highway lighting, vandalism, etc.
RELATIONSHIPS
SPAD RRSSG will have relationships with:

The RSSB Board

SSRG and TORG

RSSB (RSSB will be the delivery resource for the SPAD RRSSG and the meeting manager)

Network Rail

TOCs/FOCs, Charter Operators and OTMs

ROSCOs

Train Protection Strategy Group

RSSB will ensure that other relevant parties who are concerned with the management of SPADs are updated as
required during the strategy development. These parties will include:
o
Other Infrastructure Managers
o
International railway administrations
o
UIC SPAD Task Force
o
Other industry groups as necessary

ORR

ATOC
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OPERATION
Administrative support
Produce the draft minutes and action list for approval by the chair 1 week after the meeting – Mtg Mgr
Send out chair approved minutes and action list to members 2 weeks after the meeting – Mtg Mgr
Prepare draft agenda to be approved by chair using template 4 weeks before the meeting - Mtg Mgr / Chair
Request inputs for pack 4 weeks before the meeting: deadline for submission, 2 weeks before meeting – Mtg Mgr
Review action list and follow up actions 5 weeks before the meeting - Mtg Mgr
Compile meeting pack 2 weeks before meeting – Mtg Mgr
Send out meeting pack 1 week before meeting - Mtg Mgr
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