Taking Safe Decisions Worked Example
Removal of fire
extinguishers
use by passengers on trains, previously mandated
in Railway Group Standard GM/RT2177 issue 1.
Therefore, in subsequent standards there is only the
requirement for the provision of on-board emergency
equipment which can be directly accessed by staff.
Through monitoring of operations, a Railway
Undertaking (RU) encounters a spate of incidents of
criminal damage to fire extinguishers. Noting that
there is no longer a requirement for direct passenger
access to emergency equipment on trains, the RU
decides to review whether to remove or retain fire
extinguishers which can be accessed by passengers
on their services. The RU understands that the
industry is also experiencing a long-term reduction
in the risk from a fire on board a train due to a range
of factors such as introducing more flame retardant
materials, more efficient removal of rubbish and the
regulated public smoking ban.
Summary:
This worked example describes the removal
of a risk control considered to be no longer
providing an overall safety benefit.
Key learning points:
This worked example illustrates:
• Removal of a risk control that is no longer
providing an overall safety benefit.
• Decision based on expert judgement and
qualitative assessment.
2. Analysing and selecting options
1. Origin of review
Following an impact assessment, a cross-industry
Standards Committee decided to withdraw the
requirement for the provision of on-board emergency
equipment which could be directly accessed for
Factors to consider
The RU conducts an initial qualitative risk
assessment to assess and compare the options of
either removing or retaining fire extinguishers directly
accessible to passengers, considering the safety
hazards of a fire on board a train and other related
issues. Data indicates that when fire extinguishers
on trains are directly accessible to passengers they
Nature of the decision
Risk owner
Owned by one
organisation
Shared by many
organisations
Worst credible case
consequences
Insignificant
Multiple fatalities
Operational experience
Extensive
None
Technology
Mature
Novel
Complexity
Very simple
Highly complex
Ability to monitor and
act post change
Can identify problems
and resolve quickly
Difficult to monitor
and/or intervene
More likely to be catergorised as significant
Approach
for making
the
decision
More senior level decision taking
More consultation
More extensive and detailed analysis
More time to agree and implement the decision
Figure 2: Scoping the removal of fire extinguishers
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are often vandalised or misused, thus becoming
a potential source of hazard rather than a safety
device:
• There is potential for increase in injury should
a passenger or a train crew member go to a
location expecting to find a fire extinguisher, but
finds that it is missing or vandalised.
• Experience shows that fire extinguishers can
be used as offensive weapons on traincrew
members and passengers, or to vandalise the
railway vehicle.
• The cost of replacing emergency equipment
when it has been vandalised is high.
On the basis of this evidence the RU judges that
the disadvantages of retaining the fire extinguishers
would outweigh the benefits. The experience of
other railways operating under similar conditions
is used as a sense check. In one reference case,
a subsurface railway previously had a requirement
for fire extinguishers in each carriage. However,
they then decided that they would only provide
one fire extinguisher per train cab on the basis of
similar arguments to those above. In particular, their
analysis had found that passengers were reluctant
to use such emergency equipment even when it was
available and in good working order.
The RU also determines that removal of fire
extinguishers accessible for use by passengers is
in line with current fire safety good practice. The
advice from the Fire Brigade is that members of the
public should evacuate an area where there is a
significant fire and should not attempt to fight the fire
themselves.
The conclusions of the different analyses are
consistent with each other, increasing the level
of confidence in the case for removal of fire
extinguishers which are directly accessible to the
public, with associated safety benefits and cost
savings. On this basis, and in view of the potential
for vandalism and misuse of emergency equipment,
together with the decreased risk from a fire on board
a train, the RU decides that removal of these types
of fire extinguishers should be implemented.
In this case, there is considerable operational
experience of the issues involved and the risk is
completely owned by the RU. The decision can
therefore be taken by the RU senior management
with only a small amount of local stakeholder
consultation; and the change implemented through
instructions issued to staff.
3. Making a change
Following the decision to remove fire extinguishers
accessible to passengers, the RU identifies the
steps required to safely make the change as well
as any long term additional safety requirements.
The proposed system, post change, is therefore
defined, and then assessed using the risk
acceptance principles of qualitative risk assessment
and comparison with a similar reference system,
building on the options analysis. The change is
not considered significant under the Common
Safety Method on Risk Evaluation and Assessment
(CSM RA) so does not need to be independently
assessed.
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The RU identifies some additional safety measures
that they should take to manage the change from
this assessment process. In summary:
• A schedule is drawn up, to remove the old fire
extinguishers and fit the new ones along with the
appropriate signage, which minimises both the
disruption to services and the changeover period.
• The RU replaces their existing fire extinguisher
signage to communicate the new arrangements
to passengers.
• The RU holds initial briefing sessions for all train
staff prior to the removal of the fire extinguishers.
4. Monitoring safety
The RU undertakes a review six months after the
change is implemented to evaluate feedback and
data on the change. Reports show that there
have been fewer incident of vandalism since the
fire extinguishers were removed and industry data
continues to support the premise of decreasing risk
from fire on board a train (given the low number
of fires on board trains, the RU’s own data alone
on this change of risk over the six months is
inconclusive). Based on these conclusions, the RU
decides to retain the change and to continue to
monitor both vandalism and on-board fires, both on
their trains as well as in national data.
• All train staff have refresher training on how
to respond in the event of a fire on board the
train which covers both the use of the new fire
extinguishers and passenger management.
Selection of
Risk Acceptance
Principle
CODES OF
PRACTICE
SIMILAR REFERENCE
SYSTEM
EXPLICIT RISK
ESTIMATION
Application of Codes
of Practice
Similarity Analysis with
Reference System(s)
Identification of Scenarios
& associated Safety
Measures
Safety Criteria
Qualitative
Quantitative
Figure 3: Risk acceptance principles selected
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