AGENDA ITEM: 01
MEETING:
RSSB Board Meeting
DATE:
06 March 2014
SUBJECT:
Annual Risk Review
SPONSOR:
Anson Jack
AUTHOR:
Colin Dennis
1.
Purpose
1.1 This is the final paper in the Strategic Board Agenda for 2014. It shows how the board
has considered the modelled safety risk for the industry. It considers the process
relating to the review of the safety risk; summarises the responses of the board and
discusses the strategic agenda from April 2014.
2.
Key points
2.1 From the review of the safety risk profile for the railway by the board over 2013/14 the
following key points have been identified:






The HLOS safety targets, requiring a 3% reduction in the risk to passengers and
the workforce over CP4, are likely to be met
The risk trajectories for CP4 that were defined in the Strategic Safety Plan are
likely to be met
The review of international train accidents gave confidence that industry has the
necessary control measures in place to manage such risk but highlighted that there
is no room for complacency in tackling safety risk
However, the risk associated with train accidents based on the estimates from the
Precursor Indicator Model suggests that at present there is an increasing trend
mainly due to a rise in the number of operating incidents with higher potential
consequences
While the platform-train interface, workforce road driving and workforce health and
wellbeing have been specifically identified as areas for improvement, the board has
recognised that wider industry cooperation in the management of risk is necessary
to reduce risk during CP5
In light of the above the board has established the System Safety Risk Group, its
sub-groups and other associated groups to enable ongoing review of 100% of
system risk.
2.2 It is noted that for CP5 Network Rail, in its Strategic Business Plan, has identified the
key outcomes for the end of CP5 as being;



Eliminating all fatalities and major injuries
A 50% reduction in train accident risk
An 8% reduction in risk at level crossings (which has now been updated to the
maximum risk reduction achievable given the additional funds made available in
the final determination)
RSSB Board Meeting Final: 06 March 2014
Page 1 of 4
3.
Background
3.1 During the course of the year the board has considered a number of strategic papers
and presentations on the main elements of system risk (see annex A). Each meeting
considered a system safety item (together comprising coverage of the risk to
passengers, the workforce and members of the public), stewardship reports from
cross-industry groups that RSSB facilitates and other areas of risk such as the
platform train interface and learning from train accidents. This paper provides a
summary of the risk reviewed by the board over 2013/14.
4.
Progress on risk during 2013/14.
4.1 The latest overview of safety performance, which covers the calendar year 2013, was
published in January 2014 and is reproduced as Annex C to this paper.
4.2 For the purposes of monitoring progress on risk reduction over CP4 the HLOS Safety
Metrics, which required a 3% reduction in both passenger and workforce risk over
CP4, were established at the start of CP4. The outputs from the SRM is used as the
basis for assessing the change in risk. Based on the estimates from v8 of SRM
(currently being developed1) the risk reduction at the end of CP4 for the workforce is
likely to be well below the target level (greater than 10% reduction) and the risk
reduction for the passengers is likely to be around the target level of 3%.
4.3 Also for CP4 15 Strategic Safety Plan Trajectories were established for risk
monitoring. At the end of September 2013 performance in 14 of the 15 trajectories set
out in the 2009-2014 SSP currently satisfies the trajectory, with varying levels of
stability. For the trajectory related to rolling stock failure, performance at that time was
marginally outside the trajectory. The contribution to the total system risk from this
source is less than 1%.
4.4
Train accident risk - At the end of January 2014, the overall Precursor Indicator Model
(PIM) measure stood at 8.222, 7.2% higher than January 2013 at 7.67, and 5.7% lower
than the January 2009 estimate of 8.72. For the risk to passengers only from train
accidents at the end of January 2014, the PIM measure stood at 3.70, 19% higher
than January 2013 at 3.11, and 4.2% higher than the January 2009 estimate of 3.55.
Charts for the overall PIM measure and the passenger only case are presented in
Annex B. The recent increase in the measure is due mainly to a rise in the number of
higher risk operating incidents. Operating Incidents are acts or omissions by railway
staff which result in an actual or potential safety loss.
5.
System safety risk 2013/14
5.1
Figure 1 summarises the system safety risk areas covered by the Strategic Board
Agenda papers. As defined by RSSB’s Safety Risk Model Version 7.5 (SRM v7.5), the
board considered the modelled residual risk on the mainline railway through the three
papers on passenger, workforce, and public risk. Each of the risk papers focussed on
particular areas of risk within the category under discussion represented by the darker
shades in Figure 1. Risk areas represented by lighter shades for the three person
types were covered in appendices, which showed all of the risk from the SRM,
including summaries of how industry including RSSB address all risk areas. Each of
1
Due for release in early April 2014
Note: the way results for the PIM are presented has recently changed from a relative measure compared to a
baseline of 100 to an estimate of the Fatalities and Weighted Injuries (FWI) per year from the Potentially High
Risk Train Accidents
2
RSSB Board Meeting Final: 06 March 2014
Page 2 of 4
the individual risk papers included a table showing the RSSB projects, industry
cooperative actions and duty holder actions are undertaken to understand and
manage the risk in each risk area. For completeness these tables are presented in
Annex D. Together these show how the industry is managing the safety risk defined
by the SRM.
5.2
In general the attention paid to each area of risk has been considered appropriate, and
the board noted that the arrangements in place for duty holders, or collectively through
RSSB or cross industry groups, are adequate to address the relevant risks. Where
system issues were remitted to RSSB or relevant cross industry groups, the actions
identified have been noted in minutes and subsequent board papers.
6.
Strategic risk review
6.1 During the discussion on the Annual Risk Review paper in March 2012 the board
agreed that they should take time out from their normal agenda to look forward
strategically at the system risk profile and identify if there are any factors/issues, from
their perspective, that could affect the risk profile in the coming years and consider if
adequate understanding and/or mitigations are in place to manage the identified
factors. Nine key strategic risk areas were identified, namely;
1. The settlement for control period 5, and the implications that this will have for the
railway,
2. Changes to the labour force,
3. Capacity to grow,
4. Changing societal expectations,
5. Ageing infrastructure and the modern environment,
6. Workforce risk in a 24/7 railway,
7. Increased use of IT and software based systems,
8. Electrification, and
9. European legislation and TSIs.
6.2 The results were presented and discussed at the September 2013 board meeting.
It was felt that the strategic risk review had been a valuable exercise identifying some
key industry risk issues and how the industry intends to tackle them going forward.
The outputs are being fed into the ongoing System Safety Risk Group (SSRG) horizon
scanning activities and will be discussed more widely at the RDG sponsored Industry
Safety Meeting in April 2014.
7.
Key safety risk management initiatives considered in 2013/14
7.1 Platform Train Interface – Following the accident at James Street in October 2011 and
other PTI related incidents there was considerable interest in improving the
management of the PTI with discussions being held at an Industry Safety Meeting in
February 2013 and the ORR/RSSB industry workshop in April 2013. In September
2013 the board agreed to establish a PTI Strategy Group to take both a short term and
longer term approach to improving the PTI including safety, operational performance,
right of access for train operation including freight services, accessibility, public
behaviour/perception, consistent industry approaches, reducing cost, etc. The group is
now established and work packages are developing.
7.2 Road driving risk – There were two workforce fatalities in a road accident in 2013.
RSSB has initiated a cross industry project to understand the true scale and extent of
this risk involving the ORR and HSE. A strategy has been developed to address the
major systematic underreporting of Road Traffic Collisions (RTCs) and personal
RSSB Board Meeting Final: 06 March 2014
Page 3 of 4
injuries that exists across the industry, in addition to the lack of awareness and
understanding by rail companies of the consequential impact and costs that RTCs
have on their business and workforce.
7.3 Signals Passed at Danger – The issues relating to SPADs were considered in a paper
in May 2013 resulting in a request for an update in March 2014 (Agenda Item 2).
7.4 Modernisation of safety cooperation – This initiative has developed further during
2013/14 with SSRG and its sub-groups being established and the old groups they
replace being ended with a clear disposition of their activities to the new groups or
discontinued where appropriate. Further consolidation of these arrangements will
continue during 2014/15.
7.5 Learning from accidents – Following the four serious train accidents outside the UK in
July 2013, the board examined the range of notable train accidents and incidents from
the last few years to consider if there are any gaps and highlight the need to maintain
focus on train accident risk in the future. From the information gathered it was
concluded that there is evidence that there are controls in place on the GB mainline
railway to protect/mitigate against this range of train accidents with no major gaps
being identified, but noted that there is no room for complacency in tackling these
areas of risk.
7.6 Data quality – the quality of the safety related event data reported into SMIS by the
industry was maintained during 2013 based on the RSSB data quality healthchecks.
8.
Strategic board agenda for 2014/15
8.1 After several years of following a consistent format, the strategic board agenda will be
different for 2014/15. It was agreed at the November 2013 board meeting that SSRG
should take responsibility for the workforce, public and passenger risk papers which
would then be considered annually at the board through a consolidated report on how
all risks are understood and mitigated. This report, once considered and approved by
the board would then be published in the Annual Safety Performance Report (ASPR)
to demonstrate to all interested parties that due consideration had been given to the
subject. Any significant risk issues identified by SSRG during the year would be
brought to the boards attention where appropriate. The space made available in the
board agenda as a result of these changes will enable selected topics to be discussed
in more detail as they arise. Suggestions from board members would be appreciated.
9.
Completeness of review
9.1 The executive and members of RSSB staff have reviewed the risks covered in both
safety and strategic non safety areas and consider that overall the company has
considered and reported on the most significant risk and opportunity areas where
RSSB can support the industry. As part of the overall governance of the risk issues for
the industry, this paper will be sent to the ORR and will be summarised in the 2013/14
ASPR.
10. Recommendations
10.1 The board is asked to;

CONFIRM that they are content that during the year they have reviewed and
considered the significant items of system safety risk that impact on the industry and
are satisfied with the overall arrangements.
RSSB Board Meeting Final: 06 March 2014
Page 4 of 4
AGENDA ITEM: 01
Annex A
How system risk was considered by the board
100%
Cumulative proportion of total system risk, excluding suicide
and suspected suicide
100%
Passenger risk (also covered)
90%
11%
Passenger risk (highlighted in paper)
Public risk (also covered)
80%
Platform train interface
Slips, trips and falls
Train accidents
Public risk (highlighted in paper)
Workforce risk (also covered)
70%
28%
Worforce risk (highlighted in paper)
61%
3%
60%
50%
Trespass
Level crossings
Vandalism
40%
39%
30%
20%
19%
6%
10%
14%
Assault and abuse
Road traffic accidents
Slips, trips and falls
Struck/crushed by train
Train accidents
0%
Jul 2013 - Workforce
Sep 2013 - Public
RSSB Board Meeting Final: 06 March 2014
Nov 2013 - Passenger
Page 1 of 1
AGENDA ITEM: 01
Annex B
Outputs from the Precursor Indicator Model (PIM)
PIM - Overall risk prolife for train accidents
PIM – Passenger risk profile for train accidents
10.0
Passenger - Infrastructure
Passenger - Public Behaviour
Passenger - SPAD
Public
9.0
Passenger - Operating incidents
Passenger - Environmental
Passenger - Trains and rolling stock
Workforce
8.0
FWI per year
7.0
6.0
5.0
4.0
3.0
2.0
1.0
RSSB Board Meeting Final: 06 March 2014
Page 1 of 1
Jan 14
Oct 13
Jul 13
Apr 13
Jan 13
Oct 12
Jul 12
Apr 12
Jan 12
Oct 11
Jul 11
Apr 11
Jan 11
Oct 10
Jul 10
Apr 10
0.0
Annex C
Overview of safety
performance for 2013
Introduction
On behalf of the industry, RSSB takes a key role in the monitoring and reporting of safety
performance on Great Britain’s mainline railway. In advance of our detailed reporting in the
Annual Safety Performance Report (ASPR) for the financial year 2013/14 1 we are
presenting a high-level overview of safety performance for the calendar year 2013. The
recorded performance should be viewed against an overall context of increasing passenger
usage, with levels having increased by around 25% over the last five years.
Key headlines

For the sixth year in succession, there were no passenger or workforce fatalities in train
accidents.

Excluding trespass and suicide, the total number of fatalities in 2013 was 19, compared
with 11 in 2012.

Six of the fatalities were passengers at stations, compared with none in 2012. 2012 was
exceptional in that it was the first calendar year where no passenger fatalities were
recorded; 2013 was more consistent with the longer-term average. Two members of the
workforce were fatally injured: the same number as in 2012. Excluding trespass and
suicide, 11 members of the public were fatally injured, compared with nine in 2012.

The number of potentially higher-risk train accidents (PHRTAs) in 2013 was 29,
compared with 36 occurring in 2012.

At 297, the number of category A signals passed at danger (SPADs) in 2013 was a 19%
increase on the 250 recorded in 2012. In contrast, SPAD risk remained relatively stable,
ending 2013 at 69% of the September 2006 baseline level, compared with 66% at the
end of 2012.

Fatalities arising from trespass and suicide totalled 304 in 2013, compared with 297 in
2012.
Trends in train accidents
The 10-year average for the number of train accidents resulting in passenger or workforce
fatalities remains lower than one every two years. The last such accident was the train
derailment at Grayrigg in 2007, in which one passenger lost her life.
10
Train accidents with passenger or workforce fatalities
Fatal train accidents
8
Average number over preceding 10 years
6
4
2
0
2013
2011
2009
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
1971
1969
1967
1965
1963
1961
1959
1957
1955
1953
1
More detailed safety analyses are presented in RSSB’s Annual Safety Performance Report (ASPR); the next
ASPR will cover the 12-month period April 2013 to March 2014, and is due for publication at the end of June 2014.
Information contained in this summary should be treated as provisional.
Published by RSSB, January 2014
Page 1 of 4
Overview of safety
performance for 2013
Potentially higher-risk train accidents (PHRTAs)
PHRTAs are those train accidents that have the greatest chance of resulting in physical
injury. They comprise statutorily reportable train collisions (excluding roll back and open
door collisions), buffer stop collisions, trains striking road vehicles (with derailment and
without derailment), other derailments, and trains being struck by large falling objects.
Three PHRTAs resulted in four fatalities to members of the public; each involved a road
vehicle being struck at a level crossing. In one of the events, two occupants of the same
road vehicle were killed. Eight PHRTAs resulted in injuries to members of the workforce or
passengers; one of the injuries was a major injury, and occurred to a passenger during a
low-speed collision between trains at a station platform.
Trains struck by large falling object
Trains striking buffer stops
Collisions between trains (excluding roll backs)
Trains striking road vehicles at level crossings (including derailments)
Trains running into road vehicles not at level crossings & no derailment
Train derailments (excludes striking road vehicles on level crossings)
PHRTA/million train km
80
62
49
45
45
49
42
40
36
25
28
2010
2011
29
0
0.3
0.2
0.1
PHRTAs/million train km
Number of PHRTAs
120
0
2004
2005
2006
2007
2008
2009
2012
2013
Precursor indicator model (PIM)
RSSB’s PIM measures the underlying risk from train accidents by tracking changes in the
occurrence of accident precursors and their potential consequences. In 2013, the PIM
methodology was improved to enable it to be ‘equated’ to the level of fatalities and weighted
injuries (FWI) that the underlying train accident risk represents. The PIM indicates that at
the end of 2013, the underlying passenger risk from train accidents was 3.6 FWI, compared
with 3.1 FWI at the end of 2012. The increase is due mainly to a rise in the number of
operating incidents. Operating Incidents are acts or omissions by railway staff which result
in an actual or potential safety loss.
Modelled FWI per year
12.0
10.0
Passenger - Infrastructure
Passenger - Environmental
Public
Passenger - Operating incidents
Passenger - SPAD
Workforce
Passenger - Public Behaviour
Passenger - Trains and rolling stock
8.0
6.0
4.0
2.0
Apr 10
May 10
Jun 10
Jul 10
Aug 10
Sep 10
Oct 10
Nov 10
Dec 10
Jan 11
Feb 11
Mar 11
Apr 11
May 11
Jun 11
Jul 11
Aug 11
Sep 11
Oct 11
Nov 11
Dec 11
Jan 12
Feb 12
Mar 12
Apr 12
May 12
Jun 12
Jul 12
Aug 12
Sep 12
Oct 12
Nov 12
Dec 12
Jan 13
Feb 13
Mar 13
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sep 13
Oct 13
Nov 13
Dec 13
0.0
Information contained in this summary should be treated as provisional.
Published by RSSB, January 2014
Page 2 of 4
Overview of safety
performance for 2013
Signals passed at danger (SPADs)
400
200%
350
175%
297
300
150%
250
250
125%
200
100%
150
69%
66%
100
75%
50%
Underlying risk (annual moving average)
50
25%
Number of SPADs (annual moving total)
0%
Sep 2006
Dec 2006
Mar 2007
Jun 2007
Sep 2007
Dec 2007
Mar 2008
Jun 2008
Sep 2008
Dec 2008
Mar 2009
Jun 2009
Sep 2009
Dec 2009
Mar 2010
Jun 2010
Sep 2010
Dec 2010
Mar 2011
Jun 2011
Sep 2011
Dec 2011
Mar 2012
Jun 2012
Sep 2012
Dec 2012
Mar 2013
Jun 2013
Sep 2013
Dec 2013
0
SPAD risk as % of Sept 2006 benchmark
Annual moving total number of SPADs
At 297, the number of SPADs in 2013 was 19% higher than the 250 occurring in 2012. At
the end of 2013, SPAD risk stood at 69% of the September 2006 baseline level, compared
with 66% at the end of 2012.
Fatalities
The following chart presents the number of accidental fatalities occurring over the past 10
years to passengers, the workforce and members of the public not involved in trespass.
There were six passenger fatalities; the average for the decade as a whole is 6.9 per year.
In 2012, there were no passenger fatalities; the first time this has occurred in a calendar
year since recording began.
40
Public
Workforce
Number of fatalities
31
30
Passenger
9
24
24
21
20
9
12
16
14
5
2
2
7
8
8
13
21
19
9
13
6
10
20
14
3
3
13
1
9
5
1
5
2005
2006
2007
2008
2009
2010
11
9
2
6
6
2
0
2004
11
6
2011
2012
2013
Information contained in this summary should be treated as provisional.
Published by RSSB, January 2014
Page 3 of 4
Overview of safety
performance for 2013
Summary of fatality events
There were 19 fatalities recorded in 2013, excluding those related to trespass or suicide. Six
were passengers, two were members of the workforce, and eleven were members of the
public.
Passengers

On 15 February, a man lying at the platform edge was fatally struck by a train entering
the station.

On 20 March, a man received a fatal head injury after falling down stairs in a station.

On 30 March, a man fell between the train and platform, following an altercation with
other people in the station.

On 4 April, a woman fell from the platform edge, as a train was entering the station,
suffering a heart attack as a result of the event.

On 6 November, a man fell from the platform edge on to the track. He was taken to
hospital, where he died from his injuries.

On 21 December, a man fell from the platform edge, and was struck by a train.
Workforce

On 19 June, two infrastructure workers travelling in the same vehicle were fatally injured
in a road traffic accident while returning from a worksite to their depot.
Members of the public

Four people died when their motor vehicles were struck by trains at level crossings. Two
of the fatalities occurred in the same accident and were occupants of the one vehicle.

Six pedestrian users of level crossings died as a result of being struck by trains.

A child died after being struck by a train during an incident where his mother deliberately
accessed the track to commit suicide.
Trespass and suicide
The number of fatalities from trespass, suicide and suspected suicide in 2013 was 304, an
increase of seven compared with the 297 that were recorded in 2012.
Further information
More detailed safety analyses are presented in RSSB’s ASPRs. The 2013/14 ASPR will
cover the 12-month period April 2013 to March 2014 and is due for publication at the end of
June 2014. RSSB reports detailed safety performance on a financial year basis, for
consistency with Control Period 4, its associated High Level Output Specification and the
Railway Strategic Safety Plan for 2009-14.
RSSB is happy to take questions or comments on the information in this overview. Please
contact Liz Davies, Safety Intelligence Strategy Manager, with any queries or feedback:
liz.davies@rssb.co.uk, tel. 020 3142 5475.
Information contained in this summary should be treated as provisional.
Published by RSSB, January 2014
Page 4 of 4