Research
Brief
High level safety management system guidance
and good practice
T847 - September 2011
Background
The Railways and Other Guided Transport (Safety) Regulations
(ROGS) 2006 have led to a greater emphasis on the need for
safety management systems (SMS) of GB rail organisations to at
least maintain current levels of safety, albeit with less prescriptive
requirements. To embrace fully the potential of this change, and
to inform thinking about SMS at a European level, the GB rail
industry Safety Policy Group (SPG) requested this project to
support efforts to further develop the SMSs of GB rail
organisations.
At a simple level an SMS can be considered to be the totality of
an organisation's arrangements for managing, assuring, and
improving safety. As ROGS guidance puts it: 'the safety
management system is the basis for making sure a transport
system runs safely and in line with ROGS'. However, major
accidents in many different industries and various parts of the
world have occurred where an SMS was present but apparently
ineffective. Understanding the underlying factors that contribute
to an effective SMS is therefore regarded as a key contribution to
the continuous improvement of SMSs in the GB rail industry.
Furthermore, it is considered that infrastructure maintainers and
transport undertakings elsewhere in Europe, that have not had an
SMS previously, may find it useful to see the benefits of a nonprescriptive SMS clearly set out, which this research aims to do.
Aims
The objectives of the study were to:
• Support the continuous improvement of SMS development
in the GB rail industry through the development of informed,
high level, non-prescriptive guidance and good practice.
• Inform and influence European SMS developments.
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High level safety management system guidance and good practice
T847 - September 2011
Findings
In summary, the findings from the study demonstrated that:
• GB rail organisations are comfortable with their
interpretation of the legal requirements associated with an
SMS.
• Information is available to improve understanding about the
development and application of an SMS.
• There is good information available to improve the
effectiveness of the SMS in practice.
The study visits presented a picture of rail organisations that are
becoming familiar with dealing with the concept and application of
an SMS, albeit to differing degrees of depth. Aside from
organisational and personal experience, the main area of SMS
knowledge came from the use of documents such as Health and
Safety Guidance 65 'Successful health and safety management'
(HSG65) and British Standard 'Occupational Health and Safety
Management Standard' OHSAS 18001.
Organisational standards and procedures were seen as playing a
large role within the rail SMS. It was not known from the study
visits whether these internal company standards and procedures
changed post ROGS or whether they have remained for the most
part the same as they were in the earlier safety case regime.
Certainly some respondents regarded the SMS as having evolved
from the safety case with little change. SMS structures as well as
standards and procedures appeared to provide a rigidity to rail
SMSs that may have accounted for the continued good
performance of safety within the rail industry to date but perhaps
also accounted for a desire not to move beyond generalised SMS
guidance documents.
From the visits to other industries the various uses of SMSs
presented no clear, single best practice way to manage the SMS,
although there were many good practices within each of the
industries studied. This is thought to be because safety has been
aligned to management practices and that there is no one
successful way to manage an organisation. Generally other
industries were seen as attempting to progress SMSs in similar
ways to the rail industry, such as in better understanding of safety
culture. It was also identified that they were experiencing similar
issues with getting the organisation to 'live' the SMS instead of
just complying with safety requirements on paper.
Major findings from the in-depth review and comparison of key
SMS texts identified that:
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• Good information is spread across a number of documents
and could usefully be drawn together into one resource.
• Key information is missing from some of the texts or is
replaced by bullet points.
• There were some gaps in the SMS components covered
within the guidance information.
As a body of information, the various guidance documents were
seen to bring together areas of good and advanced safety advice.
Whilst the various guidance documents contained some useful
information, there was not one consistent message that all
adhered to but rather a number of individual messages that could
be useful if taken into consideration when working on a particular
component of the SMS. The documents reviewed often offered
generic checklist guidance which could assist with achieving legal
compliance or gaining certified accreditation but provided little
supporting information to develop or embed leadership and a
positive culture, or to facilitate continuous improvement. Many
guidance documents contained little information to help readers
understand the reasons why particular good practice should be
followed.
Each of the guidance documents reviewed contained a set of
definitions. Very few of them agreed completely about the
definitions and some of the documents actually disagreed as to
meanings. Therefore there is currently little clarity as to how a set
of definitions regarding SMSs should be developed. As greater
responsibility has been placed on the organisational SMS
following the implementation of ROGS, it could be viewed that
within the internal organisation, and during external cooperation,
the need for assurance in the understanding of SMS definitions
had increased.
The review of accident investigation reports highlighted common
SMS faults and potential gaps or weaknesses in current SMS
guidance. From the 22 SMS-related topics identified through the
accident reviews, seven of them were common to five or more of
the accident investigations, and were therefore highlighted to be
of particular interest. These were: safety assurance, learning
lessons from operational experience, training and competence,
safety culture, skill and staff shortages, change management, and
risk management.
The findings suggested that there is a strong culture of
compliance within the rail industry regarding an SMS but that
there are still difficulties in making the SMS dynamic and relevant
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T847 - September 2011
to everybody within an organisation. The findings highlighted that
a more effective SMS may be delivered by developing a better
understanding of management systems. This would lead to
refinement of the SMS purpose, the methods of effective
management systems and the SMS structure.
Deliverables
Deliverables from this research include:
• A research report (and associated appendices) that clearly
sets out the study undertaken and demonstrates the basis
for decisions taken to produce the guidance document.
• An SMS guidance document to help railway organisations
further develop their SMS and increase its effectiveness in
practice. The guidance is set out in four sections.
The deliverables are available via the RSSB website and enquiry
desk at enquirydesk@rssb.co.uk
Method
The method for carrying out this research consisted of a literature
review, study visits, workshops, and stakeholder visits assisted
by input from an industry steering group.
The review of SMS related literature identified 135 SMS and SMS
related documents through internet and journal searches, advice
from professionals, and references within other documents. For
the major SMS guidance documents identified, a question set
was developed to evaluate the strengths and weaknesses of each
document and to assist comparisons made between them. The
SMSs were also analysed to identify frameworks and models,
thus enabling a comparison to be made of the types of models
used. Analysis of the literature associated with a number of
serious accidents identified major organisational safety failings.
Emerging themes from the review of SMS texts focused further
literature searches and reviews on particular SMS components.
For the study visits, industry perspectives were obtained from
safety professionals across the breadth of RSSB membership. To
elicit information, an extensive open-ended questionnaire was
developed. The planned study visits were initially piloted with two
steering group partners and then meetings were set up with a
range of partners, totalling 18 rail industry organisations. The
questionnaires were completed on a one-to-one basis and
responses were written by the interviewers and then repeated
back to the respondent. External professional opinion was also
sought by identifying industries with comparable safety risks to
the rail industry, such as nuclear, aviation, chemical and shipping.
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Eight organisations were engaged to develop an external
perception of SMS use. The questionnaire developed for the
internal study visits was used as part of a semi-structured
interview.
Following the development of an interim report based on the
research findings and acceptance of this report by the steering
group, a number of options for developing guidance for the rail
industry were put forward. The development of guidance focused
on the creation of a skeleton document, setting out the main
sections and SMS themes to be included, which was agreed by
the steering group and safety professionals within the rail industry
at regional workshops.
Next Steps
SPG encourages duty holders to review this research and
consider whether they need to take action to improve and develop
their SMS and/or its application. They suggest that this research
is read alongside The application of leading and lagging
indicators to the rail industry (T852) and the guidance document
Measuring safety performance. Furthermore, SPG and the
project steering group have asked that the SMS guidance be
placed on the RSSB website alongside other SMS material.
Contact
For more information please contact:
Michael Woods
Head of Operations and Management Research
R&D Programme
RSSB
enquirydesk@rssb.co.uk
RSSB
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