Greg Morse
Operational Feedback Specialist
RSSB
Block 2, Angel Square
1 Torrens Street
London EC1V 1NY
020 3142 5400 enquiries@rssb.co.uk
The report may be downloaded from the RSSB website: www.rssb.co.uk
.

Rail Safety and Standards Board 2010

Executive summary
1 Introduction
1.1
Aims and scope of document
2 Learning from Operational Experience
2.1
Overview of main line risk profile
2.1.1
Review of train accident risk
2.2
Why do accidents occur?
2.3
The development of LOE
3 RSSB’s role in rail industry learning
3.1.1
Safety performance analysis and planning
3.1.2
Incident causal classification system
3.1.3
Human Factors
3.1.4
Safety Management Systems
3.1.5
RED DVD
3.1.6
Operational Feedback
4 Rail industry learning
4.1
Role of RAIB, Formal Inquiries and investigations in the learning process
4.2
RAIB investigations
4.2.1
Ongoing RAIB investigations
4.3
Progress against Formal Inquiry recommendations
4.4
Learning in 2009
4.4.1
RSSB analysis of key RAIB recommendation themes
4.4.2
RAIB Bulletins
4.4.3
ICCS analysis
4.4.4
Confidential Incident Reporting and Analysis System
4.4.5
RSSB Human Factors
4.4.6
Operational Feedback Updates issued in 2009
4.4.7
RED DVDs issued in 2009
4.4.8
European Rail Agency
Appendix 1.
Bibliography
Appendix 2.
Appendix 3.
Appendix 4.
Appendix 5.
Appendix 6.
Worldwide multi-fatality rail accidents
Rail accidents involving passenger fatalities since 1997
Chief Inspector’s foreword to the RAIB Annual Report 2008
Definitions
Glossary
17
17
21
21
25
25
28
29
32
35
39
41
42
43
13
13
14
15
15
16
16
17
5
5
7
9
11
3
4
4
44
45
46
48
53
Page 2 of 54

Statistics indicate that the railway in Great Britain is safer now than it has ever been.
However, October 2009 saw the tenth anniversary of the Ladbroke Grove collision, in which
31 people were killed. This brought the issue of train accidents back into the public eye, despite train accident risk being only 5.4% of the total system risk.
Over the last ten years in particular, the rail industry has seen institutional reorganisation, significant growth and further investment. Sustained improvements in safety performance and risk have resulted from many of these extensive changes, together with the efforts of railway managers and staff to continuously improve.
Yet with good performance can come complacency – a subject which has been the emphasis of many recent Public Inquiries. To quote the Baker Panel report into the BP Texas
City oil refinery accident of 2005:
‘The passing of time without a process accident is not necessarily an indication that all is well.’
Writing about the Nimrod accident of 2006, Charles Haddon-Cave also commented that
‘[t]here [should] be much greater focus on People in the delivery of high standards of Safety
[…] (and not just on Process and Paper)’. The Inquiry into the Mid-Staffordshire NHS
Foundation Trust further reminded us of the dangers of becoming ‘disconnected from what was actually happening [and choosing instead to] rely on apparently favourable performance reports by outside bodies […], rather than effective internal assessment and feedback’.
This Learning from Operational Experience Annual Report highlights these issues, while reflecting on the industry’s ongoing efforts to minimise the risks associated with running a railway.
Tracking summary
•
167 recommendations were issued from 27 RAIB investigations involving incidents on
NRMI. This compares to:
−
127 recommendations from 18 RAIB investigation reports in 2008; and
−
158 recommendations from 22 RAIB investigation reports in 2007.
•
RSSB and its predecessor Railway Safety produced 49 Formal Inquiry reports between
2002 and 2006, containing a total of 533 recommendations. Of these, 523 (98%) had been closed by 1 January 2009. A further 3 recommendations were closed during the year, leaving 7 open.
Page 3 of 54

One of RSSB’s constitutional functions is to report on progress against recommendations from Formal Inquiries.
1
Until 2006, this was published in a separate report, which from 2007 was integrated into the Annual Safety Performance Report (ASPR) following the cessation of
RSSB’s involvement in conducting accident inquiries after 2005.
In the 2008 edition of the ASPR, the recommendations chapter evolved to cover the Learning from Operational Experience (LOE) programme.
Throughout 2009, RSSB has worked with industry groups to shape the definition and objectives of LOE to meet industry requirements. At the same time, the relevance of reporting solely on Formal Inquiries is progressively diminishing, while opportunities for learning from wider sources of information are developing.
RSSB has produced this separate report, which describes the LOE processes and their evolution, while retaining the recommendations tracking function of previous documents. As learning is also a two-way process, some of the learning points raised in 2009 are also included.
The LOE Annual Report covers the calendar year 2009. It has been written to provide railway companies, the general public, the government and its agencies with:
•
Recent developments in sharing learning from experience.
•
Learning points arising in 2009.
•
A clear picture of Industry progress against recommendations from accident investigations.
•
A summary of related RSSB deliverables.
Note that hyperlinks (underlined blue text) have been used throughout this document to aid navigation and for access to relevant documents and websites.
1
Clause 2.3, part a).iii of RSSB’s Constitution Agreement (01/04/03) states that the company shall
‘maintain a current record of’: a) ‘recommendations of accident investigations and formal inquiries’; b) the responses of all the organisations to which the respective recommendations are directed; and c) the state of progress towards implementation within timescales recommended or prescribed by such investigations or formal inquiries’.
Page 4 of 54

The rail industry’s primary safety objective is to avoid harm to people and property. However, there is always some residual risk associated with the transportation of people and goods.
The industry seeks to reduce the frequency of events that can cause harm, and for those that do occur, to minimise the impact on passengers, staff and the public. One of the main contributors to the improvement of safety is the learning that flows from operational experience, near misses and accidents.
In fact, the industry – and whichever regulatory body oversees it – has been learning lessons from accidents and incidents since its inception. Early incidents like the death of William
Huskisson MP at the opening of the Liverpool & Manchester Railway in 1830, for example, led to the first Railway Regulation Act (1840), which required all injurious accidents to be reported to the Board of Trade. Within 50 years, block signalling, interlocking and continuous braking on passenger trains had been made mandatory. The twentieth century saw further advances, ranging from continuous welded rails and multi-aspect signalling, through to automatic train protection systems.
Chart 1 presents the railway’s current fatality and weighted injury risk profile, as per Version
6 of the Safety Risk Model (SRMv6), which was published in 2009.
Chart 1. Fatality and weighted injury risk profile from SRMv6, excluding suicide
Inner circle
Risk to :
Passengers
Public
Workforce
2% 1%
77%
21%
16%
7%
40%
97%
39% 48%
Outer circle
Risk from :
Passenger behaviour
5%
17%
30%
Public behaviour
Workforce behaviour
Engineering
•
The accidental FWI risk from all sources on the railway is estimated to be to 141.3 FWI per year.
•
The largest proportion of the risk to passengers arises from passenger behaviour, but a notable proportion is under the responsibility of the workforce. This is because events like slips, trips and falls are partly due to station management issues.
Page 5 of 54

•
Most of the risk to passengers arising from the public is due to assaults
2
, with a much
smaller part arising from road vehicle drivers at level crossings.
•
Most of the risk to the workforce arises from the workforce itself. Around 16% is due to assaults from the public, with a lesser proportion arising from engineering causes.
•
The risk to members of the public is almost entirely the result of their own actions, with only a very small proportion due to other causes.
October 2009 saw the tenth anniversary of the Ladbroke Grove collision, in which 31 people were killed. The anniversary brought the issue of train accidents back into the public eye, despite train accident risk being only 5.4% of the total system risk.
Over the last ten years, the rail industry has seen institutional changes, significant growth and further investment. Sustained improvements in safety performance and risk have resulted from many of these changes, together with the efforts of railway managers and staff to continuously improve. Some improvements derive from the learning that is taken from operational experience and accidents – which of course includes Ladbroke Grove.
Since 2001, the fatality risk to passengers from train accidents has decreased from 2.45 per ten billion passenger kilometres to 0.45 per ten billion passenger kilometres. For staff, the train accident fatality risk per one billion train kilometres has decreased from 5.21 to 1.14.
3
Appendix 3 lists fatal rail accidents which have occurred since 1997. The causes that led to
them include infrastructure failure (points, track), signals passed at danger (SPADs) and road vehicle incursion. Many steps have been taken to reduce the risk from each of these event types and the likelihood of their reoccurrence, including:
•
The application of better technology, such as the Train Protection and Warning System
(TPWS).
•
The withdrawal of Mark I coaching stock from the main line network.
•
Smarter appreciation of operational safety issues, including a broader understanding of the human factors that relate to driver and signaller behaviour in relation to SPADs.
•
Non-rail stakeholders playing their part to protect the impact their activities have on the railway at relevant interfaces, such as the Highways Agency putting in flank protection on road bridges.
•
A broader execution of a risk-based approach to safety, such as Network Rail’s management of level crossings.
The combined effect of all the actions to manage the risk is to reduce the frequency of accidents. In order to reduce both frequency and consequences, the industry’s research programme has undertaken work that includes a review of lifeguards and deflectors, which may provide protection against obstacles on the line, the structural and interior crashworthiness research, passenger and traincrew containment issues, and evacuation and escape strategies.
3
2
The 2008–10 SSP assigns all assaults to the ‘public’ risk area, even if the offender was a passenger.
These figures are derived from the RSSB Safety Risk Model, which is compiled using pan-industry data, collected through the Safety Management Information System (SMIS) over the last 11 years.
Normalisers for these figures have been chosen to best reflect the exposure to risk for each person type.
Page 6 of 54

More information may be found in RSSB’s Report on improvements in the safety of passengers and staff involved in train accidents .
Over the last decade, 51 passengers and nine members of staff have lost their lives in train accidents.
Chart 2. Passenger and workforce fatalities in train accidents
4
35
31
30
Workforce
Passenger
25
20
15
10
10
7 7
5 4
1
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Train accidents involving loss of life are thankfully rare. Indeed, as Chart 3 shows, their
frequency has fallen significantly over the last 50 years.
4
Chart source: RSSB, Report on improvements in the safety of passengers and staff involved in train accidents (RSSB, 2009), p. 4.
Page 7 of 54

Chart 3. Train accidents leading to passenger and workforce fatalities
5
11
10
Train accidents with passenger or workforce fatalities
Average number over the preceding 10 years
9
8
7
6
5
4
3
2
1
0
Despite this positive downward trend, the rail industry continues to analyse the potential causes of events and the various factors that can affect the extent of injuries or fatalities when these events do happen.
RSSB provides an indicator of underlying risk by tracking changes in the occurrence of accident precursors though the Precursor Indicator Model (PIM).
6
The current output from
the model is shown in Chart 4 .
Chart 4. Trends in train accident risk per the Precursor Indicator Model
6
5
See RSSB, Overview of safety performance 2009 , p. 1.
See RSSB, Annual Safety Performance Report 2008 (RSSB, 2009), pp. 139–142 for more information on the PIM.
Page 8 of 54

The PIM indicator has decreased significantly over the past 10 years. The most notable reduction has been in the risk from SPADs. Ten years ago, SPADs contributed the largest element of the PIM indicator value; the most significant contributor to risk now arises from level crossing misuse.
7
The outcome of the work the industry has undertaken in the last decade, both to avoid accidents happening and to mitigate the effects when they do occur, is an overall significant reduction of the risk to passengers and staff. This is illustrated by the table below, which shows the changes since July 2001 in the modelled risk from accidents involving different fatality levels (as estimated by successive versions of the SRM).
Table 1. Return periods of train-related incidents leading to multiple fatalities
Time between incidents (years)
Number of fatalities
(passengers, staff and members of the public)
SRMv2
(Jul-01)
SRMv3
(Feb-03)
SRMv4
(Jan-05)
SRMv5
(Aug-06)
SRMv6
(May-09)
>=5 fatalities 1.4 2.4 3.8 5.3 5.4
>=10 fatalities 3.1 5.6 7.9 9.1 15.3
>=25 fatalities [not included] [not included] [not included] 48.5 50.2
Another way of looking at the risk is to show how the modelled fatality risk from train accidents has changed for passengers and members of the workforce with each version of
the SRM published since 2001 (see Table 2, below).
Table 2. Fatality risk from train accidents since July 2001
SRM version
(release date)
8
SRMv2
(Jul-01)
Normalised fatality risk
9
SRMv3
(Feb-03)
SRMv4
(Jan-05)
SRMv5
(Aug-06)
SRMv6
(May-09)
Passenger risk per
10 billion passenger kms
Workforce risk per billion train kms
2.45
5.21
1.58
2.88
0.97
1.70
0.72
1.52
0.45
1.14
For both passengers and staff, the fatality risk has decreased by around 80% in the last eight years.
In part, Professor James Reason’s famous ‘Swiss cheese’ description answers this question.
A company or industry’s defence mechanisms against failure are modelled as a series of barriers, represented by slices of cheese. The holes in the slices signify weaknesses in parts of the system. When all of the holes in each of the slices align, it creates a ‘trajectory of
7
Note that the PIM includes the risk to road vehicle occupants who are involved in collisions with trains (for example, at level crossings).
8
The release date is later than the cut-off date for the data used in each version of the SRM.
9
Normalisers have been chosen to best reflect the exposure to risk for each person type.
Page 9 of 54

opportunity’, so that a hazard can pass through all the holes in all the defences, leading to a failure – or accident.
10
Figure 1. Reason’s ‘Swiss cheese’ model
At the 2006 Risk Management Forum, however, Reason gave a keynote address which challenged the audience by suggesting that the ‘pendulum of culpability’ may have swung too far towards focussing on the organisational or latent failures, giving them more weight than the unsafe acts of the operator.
11
The recent report into the Nimrod accident of 2006 seemed to support this view by
highlighting that ‘[t]here [should] be much greater focus on People in the delivery of high standards of Safety […] (and not just on Process and Paper)’.
12
Yet when considering the significant process accidents of the last 10–15 years – including Ladbroke Grove – a sense of inevitability is revealed, the committing of any unsafe act being in effect the ‘last straw’.
Time – and its effects – can play a large part. To quote the Baker Panel inquiry into the BP
Texas City oil refinery accident of 2005:
13
‘The passing of time without a process accident is not necessarily an indication that all is well and may contribute to a dangerous and growing sense of complacency.’
14
Similarly, all three phases of the Nimrod Safety Case were shown to be undermined by an assumption by all the organisations and individuals involved that the aircraft was ‘safe
10
See (for example) James Reason, Managing the Risks of Organizational Accidents (Ashgate
Publishing Ltd, 2002).
See also RSSB, Understanding Human Factors – a guide for the railway industry
( http://www.rssb.co.uk/expertise/human_factors/human_factors_good_practices_guide.asp
), and
RSSB, RS/232 Good practice guide on cognitive and individual risk factors
( http://www.rgsonline.co.uk/Railway_Group_Standards/Traffic%20Operation%20and%20Management
/RSSB%20Good%20Practice%20Guides/RS232%20Iss%201.pdf
).
11
12
RSSB (2006) Information Bulletin 96 (July 2006), p.3.
Charles Haddon-Cave QC, The Nimrod Report – an independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 (HMSO, 2009), p.491.
13
On 23 March 2005, the BP Texas City Oil Refinery, a ‘process accident’ resulted in an explosion which caused 15 deaths and injured more than 170 other people.
14
Baker Panel, The Report of the BP Refineries Independent Safety Review Panel (BP, 2007), p. i.
Page 10 of 54

anyway’, because the fleet had successfully flown for 30 years .
The Nimrod Safety Case thus became more of a paperwork and ‘tick-box’ exercise.
15
While GB investigation reports continue to reveal instances where weaknesses in a Safety
Management System have not prevented an accident, the figures presented in section 2.1
might suggest that the rail industry has little cause for concern – it is, after all, on a clearly improving trend in actual observed events. But one of the problems with the Mid-
Staffordshire NHS Foundation Trust, according to the recent Independent Inquiry , was that its board was ‘disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies […], rather than effective internal assessment and feedback from staff and patients’.
16
This takes the issue
back to Baker
17
and the danger of complacency.
One way in which the rail industry seeks to avoid complacency is to focus on Learning from
Operational Experience (LOE) – a function in which RSSB provides analysis and support to its members, the rail industry, under the supervision of the Safety Policy Group.
18
After consultation with a wide range of Industry representatives, LOE has been defined as the process by which knowledge from the operation of systems is gained, exchanged and used, leading to continuous improvement and the development of a positive safety culture.
There are five high-level principles which support this vision for the railway industry in Britain:
•
Industry decision makers should have access to good quality intelligence in a way that meets their needs.
•
Accidents and incidents should be investigated promptly and proportionately with relevant learning points effectively identified and acted upon.
•
Good practice should be proactively identified, shared and used among industry partners.
•
Organisations should have processes to understand, interpret and embed lessons so as to prevent recurrence of similar/repeat events.
•
Industry processes should support the retention and communication of knowledge and experience.
LOE is discharged through the rail industry’s national stakeholder groups, with the industrywide Safety Policy Group having overall stewardship (see Figure 2 for a graphic presentation of the key relationships).
15
Haddon-Cave, p. 190.
16
This is a comment made by Robert Francis QC, who led the Independent Inquiry, at the publication of the resulting report. See http://www.midstaffsinquiry.com/news.php?id=30 .
17
RSSB is currently conducting research into the development of safety performance indicators in response to requests from members for work to address the underlying issues raised by the Baker
Report.
18
The Safety Policy Group is a senior cross-industry body, consisting of RSSB members, who supervise and advise on the delivery of RSSB’s functions that support the industry in managing safety.
The Safety Regulator (the ORR) and Department for Transport are observers on the group.
Page 11 of 54

Figure 2. LOE channels of industry learning
Individual duty holders & duty holder groups (eg OPSRAMS, ATOC Safety Forum)
Research
National activities:
Strategic Safety Plan
SRM / SMIS
Safety Performance
Reporting
Safety Management
System
Intelligence
Requirements
National Groups:
Operations Focus Group
Community Safety Steering Group
Road Rail Interface Safety Group
Infrastructure Safety Liaison Group
SPG
RSSB Board
The national groups shown in the right-hand box have all been established by the RSSB
Board. Click on the graphic below to link to relevant web content for each one:
Operational   Focus   Group
Road ‐ Rail   Interface
Safety   Group
LOE
Infrastructure   Safety
Liaison   Group
Community   Safety
Steering   Group
The groups review the outputs from a number of RSSB activities, including:

Safety performance reporting – information on the latest trends, updated every month.

Operational Feedback – RSSB’s arrangement for analysing and disseminating lessons
from rail and other industry accidents.

CIRAS – the rail industry’s Confidential Incident Reporting and Analysis System.

Human Factors – RSSB’s specialist team involved in this important safety area.

Stakeholder visits to facilitate learning via the Safety Management Systems programme .

R&D – RSSB’s management of research and development (R&D) on behalf of government and the railway industry.
Page 12 of 55

Much of the work undertaken by RSSB on behalf of the rail industry is LOE-related. RSSB builds consensus and facilitates the resolution of difficult cross-industry issues. It provides analysis, knowledge, a substantial level of technical expertise, along with powerful information and risk management tools, and delivers to the industry across a whole range of subject areas.
These services help the industry to:
•
Where reasonably practicable, continuously improve the level of safety in the rail industry.
19
•
Drive out unnecessary cost.
•
Improve business performance.
All accidents and incidents which occur on the mainline railway are input into the industry’s
Safety Management Information System (SMIS), which was introduced in 1998.
These events are then coded, categorised and validated by analysts for many purposes, the results being fed into the industry’s cycle of safety planning and performance reporting, which supports both duty holder and joint industry safety improvements. Key outputs include
RSSB’s Annual Safety Performance Report (ASPR), the industry Safety Risk Model (SRM) and a Precursor Indicator Model (PIM).
Railway companies use this data and intelligence, together with their own experience and understanding of risk, to compile their own safety plans. Periodically, RSSB collates these plans, together with company initiatives and projections of the safety benefits they will achieve, into the railway Strategic Safety Plan (SSP). Monitoring the delivery against the trajectories defined in the SSP helps the rail industry combat the risk from complacency in safety management against which the Baker Panel warned.
20
RSSB generally works on the ‘plan, do, review’ learning principle outlined in the HSE document Successful health and safety management (‘HSG65’), which fits into elements of rail industry safety management systems. This is referred to as the ‘industry data to decision
making audit trail’ (see Figure 3).
19
This issue is considered in some detail in the RSSB publication Taking safe decisions , which sets out the rail industry consensus for how to make such decisions.
20
See Baker Panel, p. i.
Page 13 of 54

Figure 3. Industry ‘data to decision-making’ audit trail
RSSB receives investigation reports from all railway organisations, which is a mandatory requirement under Railway Group Standard GO/RT3119 ( Accident and incident investigation ). Currently, around 4,500 investigations have been stored, dating back to the late 1990s.
The conclusions in these reports hold much valuable information about event causes, but once the recommendations therein have been acted upon, there is a danger that some of their learning points will be lost or will not reach other parties who could benefit from them.
RSSB is working on a system to analyse all accident reports through an Incident Causal
Classification System (ICCS). Work commenced in 2009 to help provide information relating to previous accidents in a consistent and efficient manner, which will seek to identify systemic shortcomings – for the purpose of learning from operational experience – to accident investigators, safety managers and analysts across our industry.
It uses a taxonomy developed by RAIB which splits the cause of accidents into five levels.
The first levels are Industry area and Sub-area . The Industry area is the sector of the industry where the incident occurred (for example, infrastructure , operations etc). The Subarea adds more detail by focusing on a specific task, like shunting or train driving . The last three levels are independent of each other, and of Industry areas and Sub-areas ; they deal with weaknesses, barriers and controls, and the combinations of failures thereof, in order to build up a picture of the cause.
Page 14 of 54

The ICCS holds all RAIB reports, along with a number of Formal Investigations and rail accident investigations from outside Great Britain. It is also being populated with reports from other industries in a move to ascertain how other industries learn from safety events which may have parallels with our own. An example is the Baker Panel report into the Texas City oil refinery process accident.
21
The report was far reaching and its lessons in safety culture
could be applied to the rail industry.
22
We have noted that the investigation into the explosion at Buncefield Oil Storage Depot
23 recommended the use of RSSB’s national incident reporting system (NIR), showing that the oil industry is also prepared to learn from rail. The ICCS will help facilitate these learning patterns as it is developed over the next two years.
Sample analyses may be found in section 4.4.3 ( ICCS analysis ) and in RSSB’s recent
Roadrail interface safety performance safety performance report .
RSSB’s Human Factors (HF) capability supports Industry and other groups within RSSB across a wide range of topics and activities. RSSB supports industry and specialist professionals serving the railway in:
•
Integrating human factors within risk management approaches.
•
Taking a risk-based approach to human factors.
Examples of the HF input into LOE may be found in section 3.3.6
.
Working closely with Industry Stakeholders, RSSB provides support to Industry with regard to the development, implementation and continuous improvement of Safety Management
Systems.
In support of LOE, RSSB is currently developing guidance on accident and incident investigation within an industry agreed framework. The guidance is scheduled for publication at the end of 2010.
Other projects due for completion in 2010 include R&D Project T847 : High level SMS
Guidance and Good practice and guidance on Industry Safety Assurance .
For further information on the SMS programme and related projects, please contact Stuart
Parsons, SMS Programme Manager: stuart.parsons@rssb.co.uk
. Stuart’s presentation at the
2010 Risk Management Forum may be found by logging on to www.safetyriskmodel.co.uk
.
21
On 23 March 2005, the BP Texas City refinery experienced a process accident. It was one of the most serious US workplace disasters of the past two decades, resulting in 15 deaths and more than
170 injuries.
22
RSSB is currently conducting research into the development of safety performance indicators in response to requests from members for work to address the underlying issues raised by the Baker
Report.
23
In the early hours of Sunday 11 December 2005, a number of explosions occurred at Buncefield Oil
Storage Depot, near Hemel Hempstead. At least one of the initial explosions was of massive proportions and a large fire engulfed much of the site. There were no fatalities, but over 40 people were injured.
Page 15 of 54

RED is a series of programmes about operational safety initiatives, including SPADs, which are of potential interest to anyone operating and managing the railway – from drivers and signallers to managers and specialists at all levels. It makes extensive use of incident reconstructions to make clear learning points which remain in the memory.
By funding and facilitating this series, RSSB assists the Operational Focus Group (OFG) in promoting a more progressive and open safety culture in which there is respect for the contribution of all and a recognition that there are still many systemic issues that must be addressed if improvements are to continue to be delivered. OFG and RSSB hope that the
RED series will help to shape the attitudes and perceptions of every viewer throughout the industry, by improving knowledge and understanding about SPADs and operational issues.
A summary of the learning points raised by RED DVDs released in 2009 may be found here .
If would like to receive RED, please contact the Susan Cassidy, Programme Manager
(Operational Safety): susan.cassidy@rssb.co.uk
.
Learning is a two-way process, so your general comments are also most welcome, as they will help to improve the content and distribution of future editions of the programme.
RSSB’s Operational Feedback (OF) function tracks recommendations from Formal Inquiries on industry, along with recommendations on RSSB from RAIB investigations. Learning is also facilitated by considering qualitative information, which is provided to internal staff,
RAIB, European safety partners and the national programme cross-industry groups. OF’s current suite of publications include:
•
Worldwide Accident Investigation Summary This monthly summary covers rail accident investigations from across the world, providing a synopsis of the event, its causes and the recommendations that have been made to mitigate them. It forms part of OF’s regular set of papers to the national programme groups. Of these, OFG cascades the information to the OPSRAMs, thus facilitating wider learning throughout the industry. The Worldwide Accident Investigation Summary may be downloaded freeof-charge from the RSSB website and Opsweb .
•
Operational Feedback Updates These are ad hoc reports produced to highlight issues raised by overseas rail accidents and inquiries into non-rail events with a view to promoting pan-industry learning. Updates released in 2009 have covered:
−
The collision between two passenger trains in Washington DC on 22 June 2009.
−
The collision between a passenger train and a freight train in Chatsworth , California
on 12 September 2008.
−
The issues raised by the Independent Review into the RAF Nimrod air crash of 2
September 2006.
−
The multiple failures of Eurostar trains on the night of 18/19 December 2009.
•
Red Alert articles In 2009, RSSB’s OF team began submitting regular articles to Red
Alert
magazine. These are abridged versions of the Operational Feedback Updates
and are designed to reach a wider audience and encourage debate.
Page 16 of 54

The principal investigation of any safety event is conducted by the party immediately responsible for the activity. To facilitate this, railway companies have their own arrangements for carrying out internal formal and local investigations, as defined in Railway Group
Standard GO/RT3119 ( Accident and incident investigation ). This includes the possibility of undertaking independently chaired investigations when appropriate. The outputs are managed by the companies concerned, with actions being picked up by their own tracking systems. The results of duty holder-led formal investigations are also summarised in SMIS to give others the chance to learn from the information.
The more significant accidents (involving loss of life or potentially significant consequences) are investigated by the Office of Rail Regulation (ORR) as safety authority, and the Rail
Accident Investigation Branch (RAIB). RAIB was established in 2005, following which RSSB ceased its accident investigation role (2006).
RAIB was set up following a recommendation made by Lord Cullen’s inquiry into the accident at Ladbroke Grove (a subsequent European Directive on rail accident investigation also required Member States to create such bodies).
If an accident involves a derailment or collision which results in, or could result in, the death of at least one person, serious injury to five or more people or extensive damage to rolling stock, the infrastructure or the environment, then RAIB will lead an investigation, draw conclusions and make recommendations.
24
RAIB investigates incidents on UK railway infrastructure without apportioning blame or liability. It is independent of the rail industry and the ORR, with the Chief Inspector of Rail
Accidents reporting directly to the Secretary of State for Transport. RAIB’s recommendations on the rail industry are addressed to the ORR
25
, which must then ensure that they are
considered and that, where appropriate, action is taken. More information on RAIB may be found on its website .
RAIB published 33 reports in 2009, covering the following categories:
•
Heavy rail – on NRMI ( 27 )
•
Channel Tunnel ( 1 )
•
Northern Ireland ( 1 )
•
Heritage railways ( 1 )
•
Light Rail ( 2 )
24
RAIB may also investigate other incidents that have implications for railway safety, including those which, under slightly different circumstances, may have resulted in an accident.
25
RAIB can also address recommendations to other safety authorities and other public bodies, such as the police, the Department for Transport and so on.
Page 17 of 54

•
Metro ( 1 ).
Table 3 (overleaf) lists each of these investigation reports (with links to the reports in
question). Note that:
•
167 recommendations were issued from 27 RAIB investigations involving incidents on
NRMI. This compares to:
−
127 recommendations from 18 RAIB investigation reports in 2008; and
−
158 recommendations from 22 RAIB investigation reports in 2007.
Page 18 of 54

Table 3. RAIB investigations published in 2009
26
Report
Publication Date
Report Title Infrastructure Owner
20/01/2009
22/01/2009
11/02/2009
12/02/2009
25/02/2009
12/03/2009
18/03/2009
19/03/2009
30/03/2009
30/04/2009
27/05/2009
27/05/2009
03/06/2009
11/06/2009
18/06/2009
22/06/2009
24/06/2009
02/07/2009
16/07/2009
28/07/2009
12/08/2009
20/08/2009
27/08/2009
14/09/2009
17/09/2009
07/10/2009
29/10/2009
10/11/2009
12/11/2009
19/11/2009
19/11/2009
19/11/2009
Accident at West Lodge crossing on 22 January 2008
Derailment of a freight train at Ely on 27 June 2007
Derailment of a road rail vehicle at Terryhoogan, Northern Ireland on 9
March 2008
Derailment near Exhibition Centre station, Glasgow on 3 September 2007
Runaway of a road-rail vehicle at Glen Garry on 5 December 2007
Fatal accident at Morden Hall Park footpath crossing on 13 September 2008
Derailment of a freight train near Moor Street station, Birmingham on 25
March 2008
Uncontrolled movement of a road vehicle in a Channel Tunnel passenger shuttle train on 4 April 2008
Fatal accident at Tackley station level crossing, Oxfordshire on 31 March
2008
Derailment at Santon near Foreign Ore Branch Junction, Scunthorpe on 25
January 2008
RAIB report into road-rail vehicle runaway incidents at Brentwood, Essex and at Birmingham Snow Hill
Detachment of containers from freight wagons near Cheddington and
Hardendale on 1 March 2008
Investigation into safety at user worked crossings
Near miss at Poplar Farm level crossing, Attleborough, Norfolk on 1 July
2008
Collision between a passenger train and two rail-mounted grinding machines at Acton West on 24 June 2008
Derailment of a Docklands Light Railway train, near Deptford Bridge station on 4 April 2008
Minor collision near New Southgate on 27 July 2008
Derailment of a passenger train on the Ffestiniog Railway on 3 May 2008
Accident at Grosvenor Bridge, near London Victoria on 13 November 2007
Near miss at Llanbadarn AOCL near Aberystwyth on 21 October 2008
Incident involving a container train at Basingstoke station on 19 December
2008
Collision with debris from bridge GE19 on 28 May 2008
Trackworker struck by a train at Stevenage on 7 December 2008
Freight train collision at Leigh-on-Sea on 26 April 2008
Derailment at St Peter's Square on 29 June 2008
Fatal accident at Wraysholme crossing, Flookburgh, Cumbria on 3
November 2008
Investigation into runaways of road-rail vehicles and their trailers on Network
Rail
Derailment of two locomotives at East Somerset Junction on 10 November
2008
Serious injury sustained by a signal technician at Kennington Junction on 23
May 2008
Accident at Dalston Junction on 30 March 2009
Container doors hitting passenger trains at Penrith station and Eden Valley loop on 4 July 2009
Double fatality at Bayles & Wylies Crossing, Bestwood, Nottingham on 22
November 2008
Collision and derailment of a passenger train at North Rode, between
Macclesfield and Congleton on 18 December 2008
14/12/2009
Key:
= Off-NRMI
NRMI
NRMI
NI Railways
NRMI
NRMI
Tram
NRMI
TML/Channel Tunnel
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
DLR
NRMI
Heritage
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
Tram
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
26
Source: RAIB website.
Page 19 of 54

Table 4 provides information on all RAIB recommendations closed out prior to and during
2009.
Table 4. RAIB recommendations closed out (all years)
27
Incident date
18/10/2005
19/10/2005
26/10/2005
26/10/2005
28/10/2005
02/11/2005
04/11/2005
26/11/2005
03/12/2005
05/01/2006
11/01/2006
12/01/2006
18/01/2006
27/01/2006
06/02/2006
25/11/2005
14/01/2006
21/01/2006
31/01/2006
09/02/2006
15/02/2006
21/02/2006
19/03/2006
07/04/2006
01/05/2006
22/05/2006
10/06/2006
28/06/2006
29/07/2006
18/08/2006
27/08/2006
08/09/2006
11/09/2006
12/09/2006
25/09/2006
31/10/2006
17/03/2007
12/09/2006
13/01/2007
28/02/2008*
15/01/2007
28/01/2007
23/02/2007
29/04/2007
10/05/2007
01/08/2007
10/08/2007
22/08/2007
27/08/2007
29/08/2007
29/08/2007
29/11/2007
01/02/2008
20/01/2008
16/04/2008
04/07/2009
30/03/2009
19/12/2008
18/12/2008
07/12/2008
22/11/2008
10/11/2008
03/11/2008
21/10/2008
27/07/2008
01/07/2008
18/07/2008
24/06/2008
19/06/2008
28/05/2008
23/05/2008
26/04/2008
31/03/2008
25/03/2008
01/03/2008
22/01/2008
25/01/2008
05/12/2007
13/11/2007
04/11/2007
03/09/2007
22/06/2007
Recs issued RAIB investigation
14/07/2006 Freight train derailment at Hatherley, near Cheltenham Spa
21/07/2006 Collision at Black Horse Drove Crossing, near Littleport, Cambridgeshire
11/08/2006 Derailment near Liverpool Central
25/08/2006 Track worker fatality at Trafford Park
28/03/2006 Derailment at Watford Junction Yard
02/11/2006 Runaway manually-propelled trolley between Larkhall and Barncluith Tunnel
02/11/2006 Derailment at Oubeck North, near Lancaster
29/11/2006 Derailment of a train at Moy
11/12/2006 Investigation in station pedestrian crossings initiated by a fatality at Elsenham Station
20/12/2006 Broken rails at Urchfont and Kennington after transit of freight train
18/08/2006 Cutting of rail from a line that was still open to traffic, near Thirsk station
20/07/2006 Station over-run at Haywards Heath
14/11/2006 Derailment at York
20/12/2006 Collision between train and buffer stops at Sudbury
19/09/2006 Derailment of a Ballast Plough Brake Van at Carlisle
Recs issued 2006 Total
08/01/2007 Autum n Adhes ion incidents 2005 including Es her and Lewes . Reports 1, 2 and 3
30/01/2007 Derailment incident at Edinburgh Haymarket
30/01/2007 Derailment incident at Waterside, East Ayreshire
23/01/2007 Derailment incident at Cricklewood
23/01/2007 Derailment at Brentingby Junction, near Melton Mowbray
30/04/2007 Train door incident at Huntingdon
21/02/2007 Unsecure load incident at Basford Hall
25/07/2007 Near miss involving track workers at Manor Park
30/04/2007 SPAD incident at Camden Road
29/05/2007 Near miss incidents at Crofton Old Station Level Crossing
26/04/2007 Train collision with a road vehicle at Bratts Blackhouse Level Crossing
30/08/2007 Power door incident at Desborough
18/07/2007 Derailment at Maltby Colliery
29/05/2007
08/08/2007
24/05/2007
Fatal accident at Deal
SPAD incident at Purley
Runaway incident at East Didsbury
21/09/2007
18/12/2007
13/09/2007
05/09/2007
22/08/2007
18/12/2007
Derailment at Washwood Heath
Derailment at London Waterloo
Derailment at Epsom
Collision at Copmanthorpe
Collision at Badminton
Near miss at Tinsley Green
Recs issued 2007 Total
13/05/2008 Derailment at Croxton Level Crossing
28/02/2008 Derailments at Merstham, near Redhill and Kemble
23/12/2008 Network Rail's management of existing earthworks / Kemble (15/01/2007)
27/03/2008 Derailment of a passenger train near Kemble
24/04/2008 Runaway wagon at Armathwaite
23/10/2008 Derailment at Grayrigg in Cumbria
28/02/2008 Fatal accident at Ruscombe
31/01/2008 Derailment at King Edward Bridge, Newcastle Upon Tyne
10/01/2008 Collision near Burton on Trent
31/07/2008 Derailment at Duddeston Junction
20/11/2008 Incident at Didcot North Junction
11/06/2008 Incident at Aylesbury North
30/10/2008 Incident at Ty Mawr
23/10/2008 Accident at Leatherhead
28/10/2008 Member of staff hit by a train at Reading East
25/09/2008 Damaged footbridge at Barrow on Soar
23/12/2008 Near miss at Bishop's Stortford
23/12/2008 Fatal level crossing accident at Staines, Surrey
19/11/2009
Recs issued 2008 Total
Collisions between container doors and passenger trains at Eden Valley
19/11/2009
12/08/2009
14/12/2009
27/08/2009
19/11/2009
10/11/2009
07/10/2009
28/07/2009
Track worker injury near Dalston Kingsland Station
Incident involving a container train at Basingstoke Station
Collision and derailment of a passenger train at North Rode
Workforce struck by a train at Stevenage
Fatality at Bayles and Wylies footpath crossing
Derailment at East Somerset Junction
Level crossing fatality at Wraysholme
Near miss at Llanbadarn Level Crossing
24/06/2009 Incident at New Southgate
11/06/2009 Incident at Poplar Farm level crossing
29/10/2009 Collisions and runaways involving road-rail engineering machines / Whinhill (18/07/2008)
18/06/2009
06/03/2009
20/08/2009
12/11/2009
14/09/2009
Collision at Acton West
Investigation into User Worked Crossings / Loover Barn Level Crossing (19/06/2008)
Incident at Bridge GE19 near London Liverpool Street station
Workforce hit by a train at Kennington junction
Collision at Leigh on Sea
30/03/2009
18/03/2009
29/05/2009
20/01/2009
30/04/2009
25/02/2009
16/07/2009
27/05/2009
12/02/2009
22/01/2009
Level crossing fatality at Tackley station
Derailment of a freight train at Moor Street station
Two incidents at Cheddington and Hardendale
Level crossing fatality near Haltwhistle
Derailment at Scunthorpe
Collision at Glen Garry
Workforce struck by a train at London Victoria
Runaway engineering machine at Romford, Essex
Derailment at Glasgow
Derailment at Ely
Recs issued 2009 Total
Total
7
6
5
4
5
4
127
3
3
29
7
4
4
8
9
4
8
158
11
9
6
2
4
14
3
2
4
9
5
8
9
6
8
9
4
6
5
3
2
6
100
25
3
7
6
10
Total recs
5
4
8
9
4
16
6
10
10
6
8
2
4
8
8
7
3
7
5
2
3
11
5
8
3
3
3
6
8
6
3
10
4
9
7
9
6
4
16
167
552
1
0
2
3
3
0
6
2
3
4
0
4
4
3
4
0
2
63
4
1
9
1
0
0
6
4
5
0
0
7
8
2
3
0
1
1
1
3
4
5
0
4
15
2
0
2
Recs closed in
2009
0
0
0
2
0
0
1
4
0
0
1
1
0
2
0
0
12
3
2
3
2
2
1
0
2
0
0
0
0
0
2
0
1
0
0
0
0
43
0
34
155
6
6
3
1
2
8
3
2
0
25
5
0
0
1
2
2
4
32
7
1
5
1
0
1
1
0
3
0
1
0
0
0
0
0
1
14
0
0
0
0
0
0
7
0
0
0
Recs in progress
1
0
2
0
1
2
0
1
0
0
3
8
7
7
6
4
4
3
1
7
6
6
6
3
5
5
2
3
11
5
6
3
2
3
6
8
4
77
3
133
249
1
0
2
3
3
0
6
2
3
4
2
4
4
8
4
0
3
9
2
2
3
4
126
4
8
5
5
9
5
8
9
4
6
5
2
11
3
7
6
10
2
6
93
8
2
4
Total recs closed
4
14
6
9
8
6
4
7
9
4
1
1
0
2
0
0
12
3
2
3
2
2
1
0
2
0
0
0
0
0
2
0
1
0
0
0
0
50
0
34
303
All recommendations completed/closed in 2009
All recommendations completed/closed previous years
27
Source: ORR.
Page 20 of 54

Sometimes, the RAIB makes recommendations on organisations outside the railway industry. Examples include the Cumbria Police, Department of Health and the Department for Transport.
There were a further 17 events that occurred during 2009 which were still under investigation
by RAIB at the end of the year. These are listed in Table 5.
Table 5. Ongoing RAIB investigations (at 31 December 2009)
Incident date RAIB investigation
22/12/2009
Investigation into a near-miss involving a freight train and two passenger trains at Carstairs, South
Lanarkshire
19/12/2009
Investigation into a near-miss at Victory level crossing near Taunton
02/12/2009
Investigation into a fatal accident involving a track worker at Whitehall West Junction, Leeds
28/11/2009
Investigation into the derailment of a train on the approach to Gillingham Tunnel, in Dorset
14/11/2009
Investigation into the failure of a railway bridge over the River Crane, near Feltham
11/10/2009
29/09/2009
Investigation into a derailment at Windsor and Eton Riverside station
Investigation into a fatal accident at Halkirk level crossing, near Wick
28/09/2009
Investigation into a passenger train derailment at Hampton Loade station, on the Severn Valley
Railway
23/09/2009
15/09/2009
Investigation into the failure of the overhead line power system at St Pancras International station
Investigation into a collision between two trams on the Great Orme Tramway
25/08/2009
05/08/2009
Investigation into a freight train derailment at Wigan North Western station
Investigation into an accident at Norbreck on the Blackpool tramway
01/06/2009
06/05/2009
27/03/2009
Investigation into a derailment at Cummersdale, Cumbria
Investigation into a fatal accident at Fairfield level crossing, Bedwyn, Wiltshire
Investigation into an incident on the London Underground at Hanger Lane Junction, Ealing
22/03/2009
11/09/2008
Investigation into an incident at Greenhill Upper Junction, near Falkirk
Investigation into a fire on an HGV shuttle train in the Channel Tunnel
RSSB and its predecessor Railway Safety produced 49 Formal Inquiry reports between 2002 and 2006, containing a total of 533 recommendations. Of these, 523 (98%) had been closed by 1 January 2009.
RSSB continues to track industry progress on these outstanding recommendations. This is achieved through regular correspondence with RSSB members and/or by using the SMIS recommendation tracking tool. In 2007, the system of recommendations tracking was improved and many recommendations were found to be closed. For the purposes of this report, a recommendation was marked closed in 2007 when it was communicated to RSSB in 2007, even if the work had been completed beforehand.
Page 21 of 54

Chart 5. Recommendations closed per formal inquiry
28
70
Open
60
61
1
Total recommendations closed in 2009
Total recommendations closed before 2009
50
40
30 27
1
60
23
3
20
10
8
2
6
26
15
1
14
9
1
8
11
1
10
20
0
Blake St Great Heck Hatfield Hednesford Liverpool Lime
St
Nailsea Ufton
Chart 5 shows that, of the ten recommendations
29
open at the start of 2009, three were closed during the year. This leaves seven open as of April 2010.
Formal Inquiry recommendations closed
The three closed recommendations relate to the report on the Ufton accident of November
2004, which occurred when a train derailed after striking a car that had been parked on Ufton
AHB level crossing by a suicidal motorist; not only was the car driver killed, but the train driver and five passengers also died.
The details are as follows:
Ufton recommendation 6
The operation and design of the AHB level crossing emergency telephone system should be reviewed from a human factors, environmental and technical viewpoint and modified to promote successful contact with the signaller.
This was addressed by Network Rail via the successful commissioning of a new level crossing telephone at Ufton AHB.
Ufton recommendation 9
The exemption for axleloads greater than 17 tonnes from the general requirement in Railway
Group Standard GM/RT2100 to fit obstacle deflectors to new-build leading vehicles should be reviewed, taking into account the mechanism of derailment of the leading power car at
Ufton.
28
Source: SMIS.
29
Note: recommendations addressed to more than one RSSB member are only counted once.
Page 22 of 54

This was addressed by RSSB via the adoption of the requirements set out in Euronorm
EN15227 ( Railway applications – crashworthiness requirements for railway vehicle bodies ) in
Railway Group Standard (RGS) GM/RT2100 ( Structural requirements for railway vehicles ),
Issue 4 of which is currently undergoing industry consultation and is scheduled for publication in Spring 2010. For more information, see page 19 of RSSB’s Report on improvements in the safety of passengers and staff involved in train accidents .
Ufton recommendation 12
The requirements in Railway Group Standard GM/RT2456 and ATOC Standard AV/ST9001 relating to the provision of laminated windows should be extended to cover vehicles undergoing major internal refurbishment. The RSSB research work on the provision of windows for emergency egress should be accelerated so that implementation of the requirements on vehicles undergoing major refurbishment is not delayed by lack of information on the optimum disposition of toughened and laminated windows.
RSSB split this recommendation into two activities. The first stipulated that the progress of research project T424 : Requirements for train windows on passenger rail vehicles should be examined to determine whether the research findings could be released sooner than programmed, as it had direct relevance to this recommendation. This action was closed out after the publication of a summary of the extensive research work on seat belts and windows
(T424) in July 2007. The second activity involved the ensuring of uniform practice via a standards change, further details of which may be found on pages 19 and 20 of RSSB’s
Report on improvements in the safety of passengers and staff involved in train accidents .
Page 23 of 54

Formal Inquiry recommendations currently open
Table 6 provides details of the remaining seven open Formal Inquiry recommendations,
along with the latest status update available in SMIS.
Table 6. Open Formal Inquiry recommendations
30
Inquiry Date Recommendation
Hednesford 28/09/2004 13 Contract staff offered employment on safety
Track workers struck by road-rail vehicle critical work on NR infrastructure should be actively questioned about any other planned work commitments and previous duties to ensure they take the requisite rest periods.
Responses should be recorded. Objective To reduce the likelihood of a recurrence of the accident.
Directed to
NR & IMCs
Blake Street
Locomotive runaway and derailment
Detail
Network Rail and almost all infrastructure maintenance contractors (IMCs) have addressed this recommendation, the subject of which has been widely discussed in various fora since 2004. One comment is awaited from one IMC in order to complete the paper trail for the recommendation.
07/08/2005 1 Revise the parking brake control/indication system on Class 66 locomotives, including: a)
A major reduction in the latching time for the parking brake motor contactors. b) Providing positive indications of the latching of motor contactors, and of the brake being On or Off on the driver’s console. c) Amending the Dowty indication to display the chevrons whenever the
EWS (now This recommendation has also largely been dealt with by the industry. One freight
DB Schenker) operator has action plans outstanding, but completion is expected by Autumn
2010.
(and other class 66 operators) parking brake status is indeterminate or in transition. d) Maintain the electrical supply to the parking brake motor after operation of the battery isolation switch, for a sufficient time to allow application/release of the parking brake to be completed. Objective: To simplify the manmachine interface and avoid uncertainty over its status.
07/08/2005 2 Drivers stabling locomotives detached from trains should draw clear of the trains by a specified minimum distance. Objective: To prevent any adjacent vehicles from exerting a force on a stabled locomotive which could trigger movement.
EWS (now The lead organisation has addressed this recommendation. One of the support
DB Schenker) organisations remains to complete the action plans it has in place.
& TOC's
(operating locomotives)
Great Heck
Road vehicle incursion followed by collision
28/02/2001 16.6.1
Railway Safety and the owners and operators of Class 66 locomotives should: - review the design of the fuel tank and its attachment to the underframe and ensure that any changes considered to be reasonably practicable are implemented as soon as possible. - consider means of emergency escape from the locomotive cabs, particularly when there are two occupants. The appropriate standards should be changed if necessary and any resulting modifications should be carried as out as soon as practicable. Objective: To ensure that means of escape for crews of class
66 locomotives is adequate.
Railway The lead organisation has addressed this recommendation. One of the support
Safety
(RSSB) (& the organisations remains to complete the action plans it has in place.
owners and operators of
Class 66 locomotives)
Hatfield
Passenger train derailment in broken rail
17/10/2000 1.2
An approach involving both wheel and rail must be taken towards developing solutions to
Railway
Safety gauge corner cracking which seeks to preserve a fair balance of accountability between all the
(RSSB),
Railtrack parties involved. Objective: To ensure the (NR) and widest possible approach to finding appropriate TOCs (in solutions.
conjunction with
ROSCOs)
Wales and Nailsea 4 The practicality of avoiding starter motor
Train fire cables that are permanently live and electrically unprotected against a short circuit should be considered and adopted if economically viable.
West
Passenger
Trains
Liverpool Lime St
Buffer stop collision
28/10/2004 1 The inclusion of requirements within Group
Standards GM/RT2041 and GM/RT2044 for braking performance standards for trains when
WSP is active to be considered.
(Porterbrook)
RSSB
The lead organisation has addressed this recommendation. One of the support organisations remains to complete the action plans it has in place.
This recommendation is yet to be fully addressed.
RSSB addressed this recommendation by submitting a proposal to the Rolling
Stock Subject Committee to change Group Standard GM/RT2045 ( Braking principles for rail vehicles ).
Research project T877: Supplementary GB requirements for wheel slide protection also reviewed the WSP test and requirements in Euronorm EN155995.
T877 was reviewed by the Adhesion Working Group (AWG) as key stakeholder.
The output from T877 has now been incorporated into a new RSSB drafted
Guidance Note GM/GN2695 ( Guidance on testing of wheel slide protection systems fitted to passenger rail vehicles) . This was reviewed and approved by the
Rolling Stock Standards Committee. Consultation began in February 2010; the proposed publication date is March 2011.
30
Source: SMIS.
Page 24 of 54

Recommendations tend to reflect the nature of the incident from which they arise, but they also indicate the weighting given to the event by the investigating organisation. In other words, only the tip of the accident/incident/unsafe act or condition pyramid is represented here.
It should be noted, therefore, that numeric analysis of recommendation trends has little statistical validity as it may not reflect actual safety trends. Indeed, a single report may generate multiple recommendations for one category. In the interests of continuity, however, we have used the categorisation process applied in previous years to RAIB and formal inquiry recommendations.
Table 7. SMIS recommendation categories
A
Cat code
B
C
D
E
F
G
H
J
K
Recs category
Signalling system
Competence management
Description
Lineside SPAD controls, signal sighting issues, train planning and regulation, operation of the signalling equipment.
Training and development, driver management, competence systems, briefing, assessment, staff selection procedures, drugs and alcohol, fitness for duty, fatigue.
Rules, standards and instructions Modification /development of rules and predefined standards for operation, standards/process change management.
Vehicle operation and integrity
Infrastructure asset management
Train-borne safety equipment, fire protection, vehicle maintenance, train data recorders, crashworthiness, incab ergonomics.
Managing contractors, track/signalling maintenance operations, work planning, technical specifications, method statements.
Event mgmt/investigation/ reporting SPAD management, public accident investigation, site investigations, post-accident management, formal investigations, formal inquiries, public inquiries, fault
Monitoring and audit
Research and development
Safety communications reporting, emergency procedures.
Monitoring activities, safety performance monitoring, follow-up processes.
Suggested research topics/specific areas of research.
Culture
Defining and communicating safety responsibilities, general safety related communications, meetings, techniques, methods and equipment.
Management commitment, organisational change.
Page 25 of 54

Chart 6. RAIB recommendation distribution (%) – 2009
Research & development
4%
Safety communications
12%
Culture
1%
Monitoring & audit
3%
Signalling system
2%
Competence management
11%
Rules, standards & instructions
18% Event mgmt/investigation/ reporting
9%
Vehicle operation & integrity
10%
Infrastructure asset managment
30%
In its Annual Report 2008 , the Chief Inspector of RAIB noted the ‘key areas of industry activity’ where issues are recurring notably. These include:
•
Worksite planning and management.
•
Management of fatigue for safety critical staff.
•
Planning possessions and the weaknesses in the arrangements for conveying key information to safety critical staff.
•
Inspection standards for track and related guidance to staff.
•
Location and signage of decision points at crossings, examination and assessment of risks associated with crossings and design for good sighting.
•
Management and operation of Road Rail Vehicles (RRVs).
The full text of the Chief Inspector’s foreword may be found in Appendix 4.
RSSB’s figures suggest that, in 2008, the largest component of the recommendations was the rules, standards and instructions category (21.7%). This has fallen to 18%, which may reflect some improvement to the pre-publication consultation process.
The recommendations story of 2009, however, is infrastructure asset management , which
has risen from 17.7% in 2008 to 30%. This is also evident in Chart 7, which presents a
comparison between the distributions of recommendations issued between 2006 and 2009.
Page 26 of 54

Chart 7. Recommendation categorisation – by year
35
32
30
30
25
20
15
10
5
0
1
0.4
2 2
15
17
15
12
20
22
18
22
9
13
10
14
11
18
Recs issued in 2006
Recs issued in 2007
Recs issued in 2008
Recs issued in 2009
4
6
10
9
3
4
7
3 3
5 5
4
7
14
8
12
11
2
1
1
Recommendations category
Comparing 2009 with 2008, reductions in the percentage of recommendations can be seen for:
•
Rules, standards and instructions ,
•
Monitoring and auditing ,
•
Vehicle operation and integrity,
•
Event management/investigation/reporting , and
•
Competence management .
However, there has been a rise in the percentage of recommendations which deal with:
•
Safety communications, and
•
Infrastructure asset management .
Of these, Infrastructure asset management has seen the most acute rise over the analysis period. Twenty-one RAIB investigations include recommendations in this category
31
, which
break down as follows:
•
7 investigations into derailments ( Ely Dock junction , Exhibition Centre station , Moor
Street station , East Somerset Junction , North Rode , Acton West , Santon near Foreign
Ore Branch Junction ), 2 of which occurred after a collision ( North Rode , Acton West ).
31
Infrastructure asset management covers issues related to managing contractors, track/signalling maintenance operations, work planning, technical specifications and method statements.
Page 27 of 54

•
6 investigations into level crossing incidents, four where a person was struck ( Bayles &
Wylies , Tackley , West Lodge , Wraysholme ) and two near misses ( Llanbadarn , Poplar
Farm ). There was also 1 class review into safety at user worked crossings .
•
2 investigations into Road/rail vehicle runaways ( Brentwood , Glen Garry ). There was also 1 class review into runaways of road-rail vehicles and their trailers on Network
Rail .
•
3 investigations into track workers struck by a train ( Dalston , Grosvenor Bridge and
Stevenage ).
•
1 investigation into a collision with debris from a bridge ( GE19 near London Liverpool
Street ).
Note: The ORR also keeps a record of the status of all RAIB recommendations. This is available on its website .
When RAIB’s preliminary examination of an incident suggests that a full investigation would not lead to further significant safety lessons for the rail industry, in some cases it still provides related information or advice in the form of a bulletin.
During 2009, RAIB issued nine such bulletins:
Table 8. RAIB bulletins published in 2009
Publication Date Title
28/08/2009 Passenger train derailed in June 2009
26/08/2009
29/06/2009
29/05/2009
20/03/2009
18/02/2009
27/01/2009
20/01/2009
07/01/2009
Collision between a moving tram and a stationary tram
Freight train derailed in May 2009
Runaway small infrastructure hand trolley
Collision between a passenger train and the door of an open wagon
Passenger train derailed in November 2008
Locomotive struck by runaway train from quarry in October 2008
Tamping machine derailed in September 2008
Collision of Tram and double decker bus in September 2008
Page 28 of 54

The ICCS causal classification taxonomy is based on the one developed by RAIB, which is aligned with the European Rail Agency. Each cause is split into five levels and the user can pick more than one cause depending on what is written in the conclusions section of an investigation report. The five levels are:
1 Industry area is the general area of the industry where the cause originated.
2 Sub-area adds more detail to the industry area.
3 Phase
4 Safeguard add increasing detail as to what went wrong and why.
5 Weakness
Chart 8 shows the various report types stored in the ICCS, broken down by incident type and
report type. At present, most are RAIB reports, but the demographic is expected to change as more sources are included.
Chart 8. All report types and incident types within the ICCS
Inner circle
Investigation report type:
RAIB
Network Rail
International Body
TOC
28%
7%
1%
64%
Outer circle
Incident type:
Collision
Collision with third party
Derailment
Other
Operating irregularity
Person harm (movement)
SPAD
Person harm (non-movement)
Most of the Network Rail investigations received by RSSB in 2009 concern SPADs. Although the risk from SPADs has fallen to 7.08% of the March 2001 baseline figure (much of which has resulted from the fitment of TPWS), the industry is still proactive in its efforts to maintain its good record.
32
For more information on the industry’s work to reduce the number of SPADs, see: http://www.rssb.co.uk/national_programmes/operational_safety.asp
.
32
There were 264 Category A SPADs during 2009, which is the lowest annual total since the systematic collection of data began in 1985. For more information, see RSSB’s Category A SPAD and
TPWS activity report, year-end 2009 .
Page 29 of 54

Chart 9. Industry areas covered by all RAIB reports within the ICCS
Inner circle
Industry area:
GB Rail
Tram
Heritage Rail
London Underground
N. Ireland Rail
6%
4%
10%
15%
65%
Outer circle
Incident type:
Collision
Collision with third party
Derailment
Other
Operating irregularity
Person harm (movement)
SPAD
Person harm (non-movement)
Clearly, most RAIB reports (46) have dealt with derailments. Chart 10 shows that 74% of
these reports (34) give Infrastructure as an Industry area cause. This information is broken
down further in Chart 11, which reveals
Maintenance to have been the largest single Subarea failure:
•
16 reports (47%) feature issues involving plain line.
•
13 reports (38%) feature switches and crossings. A significant proportion of each attributed to maintenance.
An example of a maintenance failure on plain line occurred on 25 January 2008 at Santon, near Foreign Ore Branch Junction . At around 10:48, all wheels of the tenth wagon’s leading bogie left the rails; the train continued for just over a mile before stopping.
There were no injuries, but considerable damage was done to the infrastructure, which resulted in the closure of the line for over a week.
The RAIB concluded that there had been two causal factors behind the incident:
•
The combined effect of two types of track geometry fault: a dynamic three-metre track twist and lateral alignment irregularities.
•
The fact that the local inspection and maintenance regime did not detect and repair these faults.
Previous action by the local maintenance staff did not prevent these faults, which had been detected by the track geometry recording run in November 2007, from quickly appearing again.
Page 30 of 54

Chart 10. The Industry area causes stated by 46 RAIB investigation reports into derailments
34 reports (74%) state Infrastructure
8
21 (46%) reports state Others
6
18
3 7
4
14 (30%) reports state Operations
Chart 11. Causal detail from 34 RAIB investigation reports stating Infrastructure as an
Industry area cause
33
18
16
14
Total reports
Maintenance
Modification
Operation
Other issues
Design
16
13
12
12
10
9
8
6
7 7
6
6
5
4
4 4
2 3 3
2
2 2
1
2
1 1 1 1 1 1 1
0
Buildings, platforms etc
Earthworks Obstruction on line Track - plain line Track - switches & crossings
Sub-area
33
Note that the numbers in the bars on Chart 11 do not add up to the total shown; this is because the
Sub-system failures overlap is not illustrated.
Page 31 of 54

The Confidential Incident Reporting and Analysis System ( CIRAS ) is one way of capturing information that can be used to prevent an accident from happening.
Outputs from CIRAS fundamentally differ from the industry’s primary reporting system, SMIS, and conventional accident investigations in that they rarely describe actual accidents and incidents. Reporters to CIRAS focus mainly on ‘near miss’ events or perceived deficiencies in safety systems and arrangements. Valuable lessons can be learnt from near misses, or even what might be termed as an ‘accident waiting to happen’ – learning does not have to occur solely after an accident has occurred. By systematically capturing knowledge from the workforce who have daily operational contact with the railway, it is possible to identify potential issues before they cause injury.
Maintaining confidentiality is a key aspect of CIRAS. It is recognised that this may sometimes restrict the information that can be disclosed. However, the advantage is that reporters may be able to state their real concerns and describe underlying causes, often more openly than they would to their line manager. The result is that CIRAS has the potential to provide unique insights into safety issues. CIRAS reports not only serve to supplement evidence from more conventional analyses, but can also describe the potential circumstances for accidents in some detail. Such information can be used proactively to reduce the possibility of such accidents and incidents from ever happening in the first place.
In 2009, a far more robust screening process for contacts was delivered in response to industry needs. This has enabled CIRAS to maximise the learning from all contacts, even where contacts are ultimately redirected and are not taken through the complete reporting process.
CIRAS encourages reporting, no matter how insignificant it may seem at the time.
Operational experience tells us that what appears to be insignificant may have repercussions for safety later on. We may never know exactly what information has been able to prevent an accident through timely intervention.
An ongoing, structured programme of industry engagement has also been initiated.
Stakeholders are asked for feedback on every single report, and often provide valuable suggestions as to how the service can be improved. CIRAS also exhibits throughout the year at key industry events to raise awareness of the service.
Who reports to CIRAS?
Chart 12 shows the distribution of reports categorised by reporter occupation.
Page 32 of 54

Chart 12. Report distribution 2009 – by job category
80
70 67
60
50
40
30
20
10
0
46
35
20
16
14
10
8 8 8 8
6 6
3
1
•
The top four categories of reporters in 2009 were:
−
Drivers
−
Track workers
−
Station staff
-
-
67
46
- 35
−
Conductors/Guards - 20
•
Train drivers have consistently submitted the largest number of reports, but it is particularly positive to note that other groups feel able to raise safety issues too, including trainers, engineers and electricians.
Why do people report to CIRAS?
Perhaps surprisingly, the majority of issues (74%) reported have previously been taken through internal company channels, a figure that remains consistently high from year to year.
It is, however, true that some staff report to CIRAS because they find it difficult to raise sensitive issues with their managers – they still want their concern progressed, but in a way which guarantees confidentiality.
Chart 13 shows why reporters feel it necessary to raise an issue with CIRAS, even though it
has been reported first internally.
Page 33 of 54

Chart 13. Reporters’ views of company response after issue raised internally
No response
16%
Other
8%
Inadequate
58%
Adequate but not implemented
18%
•
58% believed the response from their company was inadequate.
•
18% believed the response to be adequate but had not seen any changes or implementation at work.
•
16% claimed they had received no response whatsoever.
It should be noted that concerns which get as far as CIRAS are likely to represent a small proportion of all the issues that are pursued through a company’s internal processes.
Key issues of concern in CIRAS reports during 2009
CIRAS received 530 contacts on a diverse range of topics in 2009. Of these contacts, 264
(50%) became reports after the screening process. A breakdown showing the percentage of
these reports recorded against industry risk categories is shown in Chart 14. Reporters
predominantly focus on the potential for accidents or incidents – the reports therefore represent the perceived risks that reporters identify in the course of carrying out their duties.
Page 34 of 54

Chart 14. Key CIRAS report topics – 2009
Level crossings
4%
Public safety
4%
Passenger safety
12%
Train accidents
19%
Workforce safety
61%
Positive outcomes from CIRAS reports
CIRAS monitors the outcomes from the reporting process to ascertain the value and benefits delivered to the railway industry. Positive outcomes from CIRAS reports are recorded where the CIRAS report prompted an investigation, briefing, review or change. Some of these positive outcomes are highlighted below:
•
Emergency speed boards Train drivers spotted a loophole in rules associated with emergency speed restrictions and reported their concerns to CIRAS. The Rule Book and Railway Group Standards (RGSs) have since been changed as a direct result, potentially helping to prevent a derailment.
•
Glare from headlights There will be a change to train headlight specifications following several CIRAS reports from drivers and track workers who were temporarily dazzled by the headlights of oncoming trains whilst doing their jobs. This led to an
RSSB research project and will now result in a change to the RGSs.
•
All subcontractor arrangements reviewed by TOC Prompted by a CIRAS report, the working practices of a particular subcontractor were reviewed and found to be inadequate. This lead to a wholesale review of the arrangements with other subcontractors too.
•
Assessment forms misused In a very serious case at a train maintenance depot, staff were pressurised to sign assessment forms despite the fact no assessments had taken place. An audit was undertaken and improvements made as a result.
•
Preventative maintenance: Extensive vegetation growth at a station was creating low adhesion near buffer stops. Preventative maintenance has now been arranged to prevent this from happening again.
The three HF work streams which feed into RSSB’s LOE strategy to increase the GB rail industry’s capability to learn HF lessons from incidents are detailed below:
•
HF review of railway incident investigation reports.
Page 35 of 54

•
HF Awareness Training Course to aid incident investigations.
•
HF contribution to SMIS Vision to improve the validity and reliability of HF incident causation information.
Work stream 1: HF review of railway incident investigation reports
RSSB has developed an evidence-based approach to reviewing the multi-causal nature of railway incidents. This has involved the review of a selection of industry formal investigations, local investigations and RAIB reports using human factors classifications to classify human error types and organisational factors. The review and classification is an ongoing process and has formed an RSSB research project (T635: An analysis of formal inquiries and investigations to identify human factors issues ). Further information may be found on the
RSSB website .
The review has applied classifications of human errors and organisational factors to railway investigation reports. Input from operations specialists has been used to support the reviews.
Currently, a total of 280 incident reports have been reviewed which occurred between 2006 and 2008. Examples of the incident types reviewed include Category A SPADs, train accidents (such as collisions and derailments), workforce fatalities, failures in track safety arrangements and maintenance-related events. The review has identified 2,283 errors and organisational factors, which equates to an average of eight errors and organisational factors per event.
This provides a positive indication that investigations are identifying a range of causal factors and the analysis highlights that these are not just human errors, but also wider organisational factors related to issues such as competence, work/task planning and work procedures.
The data is currently being used to feedback information to industry to improve human factors in the investigation process and to improve the collection of human error and organisational factors in SMIS. The long-term aim is to make the data available to industry via SMIS.
As an example from the database related to human error, Table 9 summarises all train driver
errors identified across different events by the task in which they occurred. The following are what would be considered traditionally as the key aspects of the driver task in which errors occur: observe/act on danger and caution signals and control train speed. However, they only make up 49% of the tasks in which errors arose. This highlights that there is a much greater diversity in the types of driver tasks where errors occur and which contribute to incidents. This information could be used to inform driver competence management systems, particularly when used in conjunction with the more detailed information on, for example, the types of human errors associated with the different tasks.
Page 36 of 54

Table 9. Driver tasks in which errors occurred (based on review of rail incident reports)
Driver Task
Observe/act on signal at danger. Errors with observing signals and controlling speed based on the approaching aspect.
Report an accident, fault or problem (e.g. a SPAD or trespassers)
Observe/act on signal at caution Errors with acting on previous signals and controlling speed based on the previous aspect.
Cab warnings (e.g. observing and acting on AWS, TPWS or
DRA)
Cab activities not directly related to train control (e.g. understand movement authority, contact signaller when required, problem solve train fault)
Control train speed (e.g. "Speeding") (note that this is not directly in relation to signals)
Train control not related to signals or speed (e.g. train control in relation to stations or setting back)
Communication protocols These are non-specific errors in application of Rule Book Module G1 Section 11. If communication errors are related to a specific task (e.g. movement authority) these will be presented as specific tasks.
Duties outside the cab (e.g. checking for train faults)
Distance stopped from signal (e.g. errors in pulling up too close to signals or shunting moves in relation to signals)
Observe/act on handsignal
Control access to train cab
Unrequired activities (e.g. receiving a text or distractions off the railway)
Preparation or disposal of train
Train control for environmental conditions
Observe/act on unlit signal
Total
Frequency Percentage
155
50
50
47
38
35
30
24
19
9
8
7
7
6
3
2
490
31.6%
10.2%
10.2%
9.6%
7.8%
7.1%
6.1%
4.9%
3.9%
1.8%
1.6%
1.4%
1.4%
1.2%
0.6%
0.4%
100.0%
The HF review of incident investigation reports provides a comprehensive means of summarising rail incident factors for HF assessment. Outputs are being produced which enable a picture of incident factors to be built up across the UK rail industry. The database can be used as an active tool to explore specific industry issues and it is hoped that in the future it will be provided for wider use throughout the industry, to maximise its potential benefits. Currently the design of the database is being re-visited to bring it in line with SMIS
HF cause module proposals.
For further information, please contact Huw Gibson, Senior Human Factors Specialist, RSSB
( huw.gibson@rssb.co.uk
) or Martin Stout, Human Factors Specialist, RSSB
( martin.stout@rssb.co.uk
). The Human Factors presentation at the 2010 Risk Management
Forum may be found by logging on to www.safetyriskmodel.co.uk
.
Work stream 2: HF Awareness Training Course for Incident Investigators
At the request of industry stakeholders, RSSB developed a training course to raise awareness and promote understanding of HF causation.
34
This training course has been developed as a ‘resource kit’, containing a number of different modules and tools that industry members can select and use as appropriate. The training course was developed for
34
T635: An analysis of formal inquiries and investigations to identify human factors issues .
Page 37 of 54

incident and accident investigators but would also be of interest to driver managers, trainers, and other personnel who have responsibilities for developing and maintaining staff competence. The content of the course is designed to introduce incident and accident investigators to HF.
The first training day provides a general introduction to HF and includes modules on human error and violations, understanding human performance, techniques for investigation, and performance shaping factors at the individual level. The Human error module examines why errors and violations occur and provides tools to assist the incident investigator in the identification and classification of errors and violations. The Understanding human performance module provides an overview of the human information processing system and explains how things can go wrong at the levels of perception, memory, decision making and situation awareness. Individual performance-shaping factors are also discussed, such as fatigue, experience and training. Throughout the course, real-world examples are provided to illustrate how human error has contributed to incidents in the rail environment and other highhazard industries, such as aviation, nuclear, and oil and gas.
The second training day focuses on job and organisational factors that can contribute to incidents. Job factors, such as workload, equipment design and communication are discussed in detail, with an emphasis on how to identify risks that could lead to an incident.
Organisation factors such as culture, leadership, systems and change are also discussed.
The emphasis throughout the course is on practical application of the theory, and this is achieved through a range of exercises and group activities. Practical tutorials are included to provide trainees with hints and tips about classifying errors and violations, effective interviewing skills and techniques that can aid the investigation process. A toolkit is also provided to amalgamate the practical tutorials and is intended to aid the incident investigator whilst on-the-job. The toolkit includes useful questions for the incident investigator to ask while conducting a real-time investigation. These questions provide a checklist of prompts and reflect the current HF proposal for the industry-wide Safety Management Information
System.
The Human Factors Awareness course has been delivered by RSSB via a series of ‘train the trainer’ sessions to a maximum of two representatives in each RSSB member organisation.
As a result of widespread interest, six 'train the trainer' sessions have been held to support its delivery across the industry. The training has been delivered to 21 train operating companies (TOCs), seven infrastructure companies, five freight operating companies (FOCs) and two suppliers.
The trainers who have attended these sessions are certified to deliver the course within their company. A number of companies have already delivered the training course to incident investigators and other staff. These companies include DB Schenker, East Midlands Trains,
Colas Rail and First ScotRail. The initial feedback has been very positive.
As the training course has been primarily developed for incident investigators, it offers an excellent opportunity to map the process and terminology to the HF module in SMIS to ensure that both are consistent, which will maximise the accuracy of the data captured.
For further information, please contact Sian Evans, Human Factors Specialist, RSSB
( sian.evans@rssb.co.uk
).
Page 38 of 54

Work stream 3: HF contribution to SMIS Vision to improve the validity and reliability of accident causation information
The HF team has been contributing to ‘SMIS Vision’ by proposing improvements to the underlying SMIS HF causation module. The objectives of the HF contribution to the SMIS
Vision include:
•
Increased accuracy: to improve the reliability and validity of HF related incident information.
•
Increased usage: to increase the frequency with which HF related incident information is collected.
•
Easy identification: to make it as easy as possible for incident investigators to identify
HF causal factors to be input in to SMIS.
•
Easy input and extraction: to make it as easy as possible for interested parties to identify trends and patterns related to HF from the incident information entered in
SMIS.
The links with RSSB’s HF Awareness training course for incident investigators encourages increased usage of SMIS and greater accuracy in the recording of error classification and performance shaping factors within it.
For further information, please contact Huw Gibson, Senior Human Factors Specialist, RSSB
( huw.gibson@rssb.co.uk
) or Martin Stout, Human Factors Specialist, RSSB
( martin.stout@rssb.co.uk
).
Washington – when trains vanish
The consequences that can arise when a rail vehicle is undetected by the signalling system were emphasised on June 22, when a
Metro train struck the rear of another in Washington DC. Nine people lost their lives and over 100 were injured.
Investigations by the National Transportation Safety Board (NTSB) found the local train control system to be susceptible to failure, as it did not ‘fail safe’ and stop a train when detection of a preceding one was lost.
RSSB’s Operational Feedback Update includes:
•
Details of the GB situation and current GB initiatives.
•
Relevant Rule Book requirements.
An abridged version of this Update featured in Red Alert 36.
Nimrod – ‘a failure of leadership, culture and priorities’
On 2 September 2006, RAF Nimrod XV230 was on a routine mission over Helmand
Province, Southern Afghanistan, in support of NATO and Afghani ground forces when it suffered a catastrophic mid-air fire, leading to the total loss of the aircraft and the death of all
14 people on board.
Page 39 of 54

October 2009 saw the publication of the independent Nimrod
Review into the accident, which found that the immediate cause of the fire was a fuel leak. Behind this, were fundamental flaws in the
Nimrod Safety Case, which was drawn up between 2001 and 2005.
It had ‘represented the best opportunity to capture the serious design flaws in the Nimrod which had lain dormant for years’.
35
But, as the report clarifies, ‘the Nimrod Safety Case was a lamentable job,’ which ‘missed the key dangers’ and was ‘fatally undermined by a general malaise: a widespread assumption by those involved that the Nimrod was “safe anyway” (because it had successfully flown for 30 years)’. The task of drawing up the Safety
Case ‘became essentially a paperwork and “tickbox” exercise’.
36
The report author clearly felt that there were some simple messages to be highlighted and devoted a single page at the front of the document describe the accident as ‘a failure of leadership, culture and priorities’.
RSSB’s Operational Feedback Update includes:
•
A synopsis of the incident.
•
A summary of the main safety issues and parallels the Independent Inquiry drew with other catastrophic accidents, such as Herald of Free Enterprise (1987), the King’s
Cross fire (1987), The Marchioness (1989), and BP Texas City (2005).
•
The four key principles recommended ‘in order to help assure and ensure an effective
Safety and Airworthiness regime in the future’
37
:
−
Leadership
−
Independence
−
People (not just Process and Paper)
−
Simplicity
Chatsworth – mobile telephones
Within a safety critical environment like the railway, it is not always safe to yield to the natural reflex to answer a ringing phone or reply to a text.
This was illustrated in the USA on 12 September 2008, when a Metrolink commuter service passed a protecting signal at danger and collided head-on with a freight train in Chatsworth,
California, at a closing speed of around 85mph. Twenty-five people lost their lives, including the Metrolink driver himself. On the day of the accident, he had sent and received several text messages while on duty, the last of which occurred just 22 seconds before the collision.
35
Haddon-Cave QC, Charles The Nimrod Report – an independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 (HMSO, 2009), p.
10.
36
Ibid.
37
Ibid, p. 490.
Page 40 of 54

The recommendations made by the NTSB included the requirement for driving cabs to be fitted with audio and image recorders to monitor drivers during the course of their duty. The full report may be downloaded here .
RSSB’s Operational Feedback Update includes:
•
Details of current GB initiatives.
•
Details of a Railway Industry Standard ( RIS-3776-TOM : Rail
Industry Standard on the Use of Mobile Telephonic
Equipment in Driving Cabs ) which will provide duty holders with a framework for producing a comprehensive company policy on the use of mobiles in driving cabs and setting minimum requirements that can be mandated in the policy.
•
News about a research project ( T904 : Development of a train driver education programme on mobile phone risk ) designed to produce a train driver education programme to help reduce inappropriate mobile use.
•
Practical tips for safety critical staff to help control/avoid mobile phone distraction.
•
Relevant Rule Book requirements.
Eurostar – winterisation, train reliability and communications
During the night of 18-19 December 2009, five Eurostar trains broke down in the Channel Tunnel and passengers encountered serious difficulties in reaching London.
As a result, an Independent Review was established to consider both the technical issues and the contingency planning and subsequent customer care over the period from Friday 18 to
Thursday 24 December. Its findings were published on 12 February
2010.
RSSB’s Operational Feedback Update includes learning points on:
•
The winterisation of rolling stock.
•
Train reliability.
•
Managing disruption at stations.
•
Station working under degraded conditions.
•
Evacuation procedures.
RED 23 (February 2009) – mobile phones
This DVD features two reconstructions. The first deals with a driver who passes a signal at danger whilst using his mobile telephone to text and talk to his wife. There are parallels
between this incident and the fatal rear-end collision at Chatsworth , California, in September
2008.
Page 41 of 54

The second reconstruction features a shunter who answered his mobile whilst operating a ground frame as a train was passing over the points. This led to the last two wagons of the rake being derailed.
News items in RED 23 include:
•
Network Rail track worker safety initiatives.
•
Arrangements for emergency permissive working.
Click here to access the RED 23 briefing notes.
RED 24 (May 2009) – safety on the track
The reconstruction in RED 24 portrays a near miss involving a driver and two fitters near
Bishops Stortford. The main learning point behind this incident is the importance of safety critical communications and the need to ensure the appropriate protection arrangements before going on or near the line. This incident was also subject to an RAIB investigation .
News items in RED 24 include:
•
Trends in National Safety Performance.
•
Digital voice communication recording technology.
Click here to access the RED 24 briefing notes.
RED 25 (November 2009) – SPADs and possessions irregularities at level crossings
This edition of RED features an incident which was initially classed as a SPAD, but was later redesignated a possession irregularity. The crew of a tamper and a PICOP saw that the barriers of a CCTV level crossing were still raised to road traffic as the machine was approaching. The operator was able to bring it to a stand some 120 metres short of the interface. Poor communication, Rules violation and a lack of teamworking are the learning points raised by this incident.
News items in RED 25 include:
•
The TPWS in Practice DVD .
•
How track worker safety can be improved.
Click here to access the RED 25 briefing notes.
The European Rail Agency (ERA) was established to help reinforce safety and interoperability across the European Union. The ERA also acts as the system authority for the European Rail Traffic Management System ( ERTMS ) project, which has been set up to create unique signalling standards throughout the continent.
The ERA produced regular reports, which it posts on its website . Accident Investigation reports, safety certificates, and many other documents may also be found on its Database of
Interoperability and Safety .
Page 42 of 54

Baker Panel, The Report of the BP Refineries Independent Safety Review Panel (BP, 2007)
Buncefield Major Incident Investigation Board, The Buncefield Incident 11 December 2005 – the final report of the Major Incident Investigation Board , 3 vols (The Stationery Office, 2008)
Columbia Accident Investigation Board, Report , 4 vols (CAIB, 2003)
Lord Cullen, The Public Inquiry into the Piper Alpha Disaster (HMSO, 1990)
Lord Cullen, The Ladbroke Grove Rail Inquiry Part 2 Report (HSE Books, 2001)
Francis, Robert, QC, Final Report of the Independent Inquiry Into Care Provided by Mid-
Staffordshire NHS Foundation Trust (The Stationery Office, 2010)
Haddon-Cave QC, Charles The Nimrod Report – an independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006
(HMSO, 2009)
HSE, The Health and Safety at Work etc Act 1974 (HSE, 1974)
HSE, Successful health and safety management (HSE, 2008)
Kolb, David A, Experiential Learning: experience as the source of learning and development
(Prentice Hall, 1984)
RAIB, Annual Report 2008 (RAIB, 2009)
RSSB, Taking safe decisions – how Britain’s railways take decisions that affect safety
(RSSB, 2008)
RSSB, Annual Safety Performance Report 2008 (RSSB, 2009)
RSSB, Overview of safety performance 2009 (RSSB, 2010)
RSSB, Road-rail interface safety performance report (RSSB, 2010)
Page 43 of 54

Date Place, country Fatalities Accident type Key issues
13/02/09 Bhubaneswar,
India
21/02/09 Brezno, Slovakia
15+
11
29/03/09 Gulwe, Tanzania 12+
22/06/09 Washington DC,
USA
29/06/09 Viareggio, Italy
09/07/09 Canton, USA
24/07/09 Rudine, Croatia
14/08/09 Scanteia, Romania 14
30/08/09 Yaounder,
Cameroon
5
05/10/09 Hua Hin, Thailand 7
21/10/09 Agra, India 21
24/10/09 Al-Ayaat, Egypt 18+
02/11/09 Uttar Pradesh,
India
05/11/09 Karachi, Pakistan
14
15
14/11/09 Banshkov, India
23/11/09 Hanoi, Vietnam
9
32
5
6
9+
7
Passenger train derailment. Train speed; infrastructure maintenance.
Crossing user behaviour. Bus/train level crossing collision.
Rear-end collision between passenger train and freight train.
Freight train driver stopped train without informing signaller (led to legal action).
Rear-end collision between two passenger trains.
Wrongside signal failure. See RSSB’s
Operational Feedback Update on
Opsweb .
Axle integrity. Freight train (LPG) derailment; tank rupture and explosion.
Level crossing collision. Crossing user behaviour.
Passenger train derailment. Local temperature; flange lubricant left on line.
Bus/train level crossing collision.
Crossing user behaviour.
Passenger train derailment. Possible infrastructure management issues.
Passenger train derailment. SPAD; fatigue/drug issues.
SPAD. Rear-end collision between two passenger trains.
Rear-end collision between two passenger trains.
Lack of signal protection.
Level crossing collision. Crossing user behaviour.
Collision between passenger train and freight train.
SPAD.
Passenger train derailment. Broken rail; possible train speed issues.
Bus/train level crossing collision.
Crossing user behaviour.
Passenger train derailment. Terrorist action (bomb). 27/11/09 Bologoye, Russia 39
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This table lists all train accidents that have led to passenger fatalities since 1997. The accident inquiries led to many and varied findings and recommendations which are not pertinent to this report have been followed up elsewhere. However, the issues listed in the fifth column of the table were highlighted in more than one accident and prompted some of the research listed in the final column.
The learning from these accidents, and the research that followed, contributed to the development of the overall industry approach to these issues.
Date Incident location
Incident type Passenger/ workforce fatalities
Issues raised R&D project (‘T’ number)
1997
1999
Southall
Ladbroke
Grove
Passenger train
SPAD and collision with freight train
Passenger train
SPAD and collision with passenger train
2000 Hatfield Passenger train derailment
2001 Great Heck Passenger train collision with road vehicle, derailment and subsequent collision with freight train
2002 Potters Bar Passenger train derailment
2004 Ufton
Nervet
2007 Grayrigg
Passenger train collision with road vehicle on level crossing and subsequent derailment
Passenger train derailment
7
31
4
10
6
6
1
Passenger containment, vehicle crashworthiness.
Vehicle crashworthiness, bogie retention, passenger containment, drivers’ cabs.
Bogie retention, coupler strength, vehicle crashworthiness.
Vehicle crashworthiness, bogie retention, drivers’ cabs, lifeguards and obstacle deflectors.
Bogie retention, passenger containment
(the latter discussed in the context of
Potters Bar post-investigation).
Passenger containment, bogie retention, coupler strength, drivers’ cabs, lifeguards and obstacle deflectors.
Passenger containment.
T424
T118 ,
T189 ,
T190 ,
T424
T118 ,
T177
T118 ,
T120 ,
T189 ,
T190
T424
T118
,
T118 ,
T189 ,
T424
T118 ,
T310
More information may be found in RSSB’s Report on improvements in the safety of passengers and staff involved in train accidents .
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Page 47 of 54

Term
Accident
Child
Fatalities and weighted injuries (FWI)
Fatality
Hazardous event
Irregular working
Key Risk Area (KRA)
Level crossing
Major injury
Definition
This term refers to an event that causes harm or damage that was not intended by its victims. Suicides are not therefore classed as accidental fatalities. However, injuries sustained as a result of other people’s behaviour
(for example, from assaults or trains striking objects that have been deliberately placed on the line) are classed as accidental if the injured party did not intend to come to harm.
Train accidents are accidents occurring to trains and rolling stock.
Individual accidents are accidents to people on railway premises or on trains, but excluding injuries sustained in train accidents.
This term is used to describe a person aged 15 years or below.
An overall measure of safety harm, taking account of injury and fatalities in the following way:
One FWI = one fatality = 10 major injuries = 200 RIDDOR-reportable minor injuries or class 1 shock/traumas = 1,000 non RIDDOR-reportable minor injuries or class 2 shock/traumas.
Death within one year of the causal accident.
An event that has the potential to lead directly to death or injury.
Irregularities affecting, or with the potential to affect the safe operation of trains or the safety and health of persons. The term irregular working applies to a disparate set of human actions involving an infringement of relevant rules, regulations or instructions.
A concept introduced by the Strategic Safety Plan . There are currently 15
KRAs, covering engineering, human error and public behaviour causes of risk. Individually, the KRAs make a significant contribution to the overall safety risk profile of the railway; collectively they represent over 95% of the residual risk on the railway.
The ground-level interface between a road and the railway.
Improper use refers to occasions when users cross when a train is imminent, but are either honestly mistaken about its proximity and the warnings given by signs, sirens and so on ( error ), or deliberately disregard them ( violation ).
Proper use refers to occasions when users begin to cross entirely legitimately, but unforeseen events lead to a transgression (as when a motor vehicle breaks down half-way across a crossing, or the level crossing fails due to an error outside the user's control).
RIDDOR-reportable level crossing equipment failures relate to any failure of equipment at a level crossing that could endanger users, where the level crossing is on a running line. Note it does not include misuse of equipment.
Sleeping dogs are crossings that have fallen into disuse, although individuals may still have the legal right to use them.
An injury to a passenger, staff or member of the public as defined in
Schedule 1 to RIDDOR 1995 (including most fractures, amputations, losses of consciousness), or where the injury resulted in hospital attendance for more than 24 hours.
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Term
Minor injury
Network Rail managed infrastructure (NRMI)
Passenger
Passenger train
Potentially higher-risk train accidents (PHRTA)
Precursor
Definition
Physical injuries to passengers, staff or members of the public that are not major injuries.
For workforce, minor injuries are RIDDOR-reportable if they result in greater than three days’ lost time. For passengers and members of the public, minor injuries are RIDDOR-reportable if the injured person was taken from the accident site direct to the hospital.
Other minor injuries are not reportable under RIDDOR.
This falls within the boundaries of Network Rail’s operational railway and includes the permanent way, land within the lineside fence, and plant used for signalling or exclusively for supplying electricity for operational purposes to the railway. It does not include stations, depots, yards or sidings that are owned by, or leased to, other parties. However, it does include the permanent way at stations and plant within these locations.
A person on railway infrastructure, who either intends to travel, is travelling or has travelled. Note this does not include passengers who are trespassing or who commit suicide – they are included as members of the public.
A train that is in service and available for the use of passengers.
Accidents that are RIDDOR-reportable and have the potential to result in harm to any or all person types on the railway. They comprise train derailments, train collisions (excluding roll backs), trains striking buffer stops, trains striking road vehicles at level crossings, and trains running into road vehicles not at level crossings (with no derailment).
A system failure, sub-system failure, component failure, human error or operational condition which could, individually or in combination with other precursors, result in the occurrence of a hazardous event.
Precursor Indicator
Model (PIM)
An RSSB-devised model that measures the underlying risk from train accidents by tracking changes in the occurrence of accident precursors.
Public (members of)
RIDDOR (Reporting of
Injuries, Diseases and
Dangerous Occurrences
Regulations)
Running line
Safety Management
Information System
(SMIS)
Persons other than passengers or workforce members (that is, trespassers, persons on business and other persons). Note this includes passengers who are trespassing (when crossing tracks between platforms, for example).
RIDDOR 1995 is a set of health and safety regulations that require any major injuries, illnesses or accidents occurring in the workplace to be formally reported to the enforcing authority. It defines major injuries and lists notifiable diseases – many of which can be occupational in origin. It also defines notifiable dangerous occurrences, such as collisions and derailments.
A line that is ordinarily used for the passage of trains, as shown in Table ‘A’ of the sectional appendices.
A national database used by railway undertakings and infrastructure managers to record any safety-related events that occur on the railway. SMIS data is accessible to all of the companies who use the system, so that it may be used to analyse risk, predict trends and focus action on major areas of safety concern.
Safety Risk Model (SRM) A quantitative representation of the safety risk that can result from the operation and maintenance of the GB rail network. It comprises 125 individual models, each representing a type of hazardous event (defined as an event or incident that has the potential to result in injuries or fatalities).
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Term
Signal passed at danger
(SPAD)
Strategic Safety Plan
Suicide and suspected suicide
Track worker
Trackside
Train accident
Derailment
Train fire
Train striking road vehicle
Definition
An incident when any part of a train has passed a stop signal at danger without authority or where an in-cab signalled movement authority has been exceeded without authority.
A category A SPAD is a SPAD that occurs when the stop aspect, end of incab signalled movement authority or indication (and any associated preceding cautionary indications) was displayed correctly, in sufficient time for the train to be stopped safely at the signal or end of in-cab movement authority.
This is a joint statement by the companies responsible for Britain’s mainline rail network setting out an agreed industry approach to managing safety.
The 2008-2010 plan was developed by bringing together commitments made by industry companies in their own individual safety plans, thus creating a linkage with the duty holder planning process.
A fatality is classified as a suicide where a coroner’s verdict is suicide. It is classified as a suspected suicide where the coroner has yet to return a verdict or returns an open verdict, but where objective evidence of suicide exists based on the application of Ovenstone criteria.
A member of workforce whose responsibilities include engineering or technical activities on or about the track. This includes track maintenance, civil structure inspection, S&T renewal/upgrade, engineering supervision, acting as a controller of site safety (COSS), hand signaller or lookout and machine operation.
This is a collective term that refers to the running line, Network Rail managed sidings and depots.
See Accident – Train accidents.
RIDDOR-reportable train accidents are defined in RIDDOR 1995. To be reportable under RIDDOR, the accident must be on or affect the running line.
There are additional criteria for different types of accident, and these can vary depending on whether or not the accident involved a passenger train.
This includes all passenger train derailments, derailments of non-passenger trains on running lines and any derailment in a siding that obstructs the running line. Accidents in which a train derails after a collision with an object on the track (except for another train or a road vehicle at a level crossing) are included in this category, as are accidents in which a train derails and subsequently catches fire or is involved in a collision with another rail vehicle.
This includes fires, severe electrical arcing or fusing on any passenger train or train conveying dangerous goods, or on a non-passenger train where the fire is extinguished by a fire brigade.
All collisions with road vehicles on level crossings are RIDDOR-reportable.
Collisions with road vehicles elsewhere on the running line are reportable if the train is damaged and requires immediate repair, or if there was a possibility of derailment.
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Term
Definition
Collision between trains This term describes collisions involving two (or more) trains. Accidents in which a collision between trains results in derailment or fire are included in this category.
Roll back collisions occur when a train rolls back (while not under power) into a train on the same line (including one from which it has decoupled).
Setting back collisions occur when a train making a reversing movement under power collides with a train on the same line, usually as part of a decoupling manoeuvre.
Shunting movement/coupling collisions arise when the locomotive or unit causing a collision is engaged in marshalling arrangements. While they characteristically occur at low speed and involve the rolling stock with which the locomotive or unit is to be coupled, accidents may involve a different train that could be travelling more quickly.
Coming into station collisions occur between two trains that are intended to be adjacent to one another (for example, to share a platform) but are not intended to couple up or otherwise touch. Normally, but not always, the collision speed will be low, because one train is stationary and the approaching train will be intending to stop short of the stationary train (rather as for a buffer stop). This operation is known as permissive working.
In running (open track) collisions occur in circumstances where trains are not intended to be in close proximity on the same line. The speed of one or both of the trains involved may be high.
Collisions in a possession occur where there is a complete stoppage of all normal train movements on a running line or siding for engineering purposes.
These collisions are only RIDDOR-reportable if they cause injury, or obstruct a running line that is open to traffic.
Open door collision
Buffer stop collision
This occurs when a train door swings outward, coming into contact with another train.
This occurs when a train strikes buffer stops. Accidents resulting in only superficial damage to the train are not reportable under RIDDOR.
Trains running into objects
Trains striking animals
This includes trains running into or being struck by objects anywhere on a running line (including level crossings) if the accident had the potential to cause a derailment or results in damage requiring immediate repair.
This includes all collisions with large-boned animals and flocks of sheep, and collisions with other animals that cause damage requiring immediate repair.
Trains being struck by missiles
This includes trains being struck by airborne objects, such as thrown stones, if this results in damage requiring immediate repair.
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Term
Train Protection and
Warning System (TPWS)
Trajectory
Workforce
Definition
A safety system that automatically applies the brakes on a train which either passes a signal at danger, or exceeds a given speed when approaching a signal at danger, a permissible speed reduction or the buffer stops in a terminal platform.
TPWS brake demands are classified as being interventions or activations .
These two terms are sometimes viewed as being mutually interchangeable, however, they do each have their own distinct meanings, which should be used when referring to TPWS brake demands associated with category A
SPADs, as follows: a) TPWS Intervention
A TPWS intervention occurs when the TPWS applies the brakes in the absence of (or prior to) the driver doing so. For example:
•
A train starting against a TPWS-fitted signal at danger without authority will result in an intervention when the train passes the signal.
•
A driver taking no action to apply the brake on approaching a signal at danger and passing over the overspeed loops too quickly will also result in an intervention .
In short the safety system ‘intervenes’ if the driver has not taken the appropriate action. b) TPWS Activation
This occurs when a driver has already applied the brakes before the
TPWS operates. For example:
•
A driver might already be braking on the approach to a red signal, but still passes over the overspeed sensor too quickly, resulting in an activation .
•
If a train passes a TPWS-fitted signal at danger, despite having applied the brakes in an attempt to stop at it, then an activation results.
In short the safety system ‘activates’ to back up the driver’s brake application.
TPWS reset and continue incidents occur when the driver has reset the
TPWS after an intervention (or activation) and continued forward without the signaller’s authority.
A concept developed for the Strategic Safety Plan. There are three aspects to a trajectory: a statement of current safety performance in a particular risk area, details of the actions being taken to address the risk and an estimation of the safety performance improvement that the actions are expected to deliver.
Persons working for the industry on railway operations (either as direct employees or under contract).
Page 52 of 54

Acronym Expansion
ABCL automatic barrier crossing locally monitored
AHB
ALARP automatic half-barrier crossing as low as reasonably practicable
AMA
AOCL annual moving average automatic open crossing, locally monitored
KRA
LOE
LUL
MCB
MCG
MOM
MOP
MPJ
MTM
MWL
HEN
HET
HLOS
HMRI
HSE
HSWA
ICCS
IM
AOCR
ASPR
ATOC
CCTV
CIRAS
COSS
CP
CPS automatic open crossing, remotely monitored
Annual Safety Performance Report
Association of Train Operating Companies closed-circuit television
Confidential Incident Reporting and Analysis System controller of site safety control period
Crown Prosecution Service
DfT
DFR
ECS
ERA
Department for Transport
Dean Forest Railway empty coaching stock
European Railway Agency
ERTMS European Rail Traffic Management System
FOC freight operating company
FP
FWI footpath level crossing fatalities and weighted injuries
FWSI
GB fatalities and weighted serious injuries
Great Britain
GSM-R Global System for Mobile communications – Railway
HEM hazardous event movement hazardous event non-movement hazardous event train
High Level Output Specification
Her Majesty’s Railway Inspectorate
Health and Safety Executive
Health and Safety at Work etc Act 1974
Incident Causal Classification System infrastructure manager
Key Risk Area
Learning from operational experience
London Underground Ltd manually controlled barrier crossing manually controlled gate crossing mobile operations manager member of the public million passenger journeys million train miles miniature warning light
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Acronym Expansion
NHS
NIR
NR
NRMI
OC
OFG
OHLE
ORR
National Health Service
National Incident Reporting
Network Rail
Network Rail managed infrastructure open crossing
Operations Focus Group overhead line equipment
Office of Rail Regulation
PHRTA potentially higher-risk train accident
PICOP person in charge of possession
PIM
RAIB
Precursor Indicator Model
Rail Accident Investigation Branch
RGS Railway Group Standard
RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
RMMM
ROGS rail-mounted maintenance machine
Railway and Other Guided Transport Systems (Safety) Regulations 2006
ROSCO rolling stock leasing company
RPB Risk Profile Bulletin
RPSG
RRV
RSSB
RU
RV
S&T
SIC
SMIS
Rail Personal Security Group road–rail vehicle
Rail Safety and Standards Board railway undertaking road vehicle signal and telecommunications
Systems Interface Committee
Safety Management Information System
SMS
SPAD
SRM
SSP safety management system signal passed at danger
Safety Risk Model
Strategic Safety Plan
TOC
TPWS train operating company train protection and warning system
UWC user-worked crossing
UWC-T user-worked crossing with telephone
V/TC&C
SIC
Vehicle/Train Control & Communications Systems Interface Committee
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