Taking Safe Decisions Worked Example
Introduction of DOO(p)
• Controlled tests/trials can be a useful approach
to identifying hazards and suitable controls when
making a change.
• Monitoring and reviewing post-change can feed
back into identifying and implementing safety
measures.
Summary:
This worked example describes how an
RU adapts work done at a national level
to support assessment of the viability of
operational changes proposed for business
reasons at an individual franchise level.
1. Origin of change
The McNulty Report (Realising the Potential for
GB Rail, final independent report of the Rail Value
for Money Study, 19 May 2011) proposed that
there should be an increase in driver only operated
passenger services (DOO(p)) across the GB
network to reduce the costs of running the railway.
In DOO(p) the driver is in sole control of the door
operation of the train and is the only designated
safety critical person on board. There may be other
train staff on board, but they will not have a safety
critical role.
Key learning points:
This worked example illustrates where:
• A change in operations requires a new set of risk
controls to be identified and implemented.
• Non-safety issues, such as industrial relations,
can be critical to successfully making a change
and therefore need to be anticipated and
addressed prior to, and throughout the change.
A Railway Undertaking (RU) wishes to reduce their
costs by introducing DOO(p) across their operations.
They therefore need to determine whether
introducing DOO(p) can be made both financially
viable and acceptably safe.
• Cooperation between different parties in the
industry can save time and effort, for example,
where previous work and experience can be
shared and reused to prevent unnecessary reworking.
Factors to consider
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 introduction of DOO(p) for one RU
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2. Analysing and selecting options
The RU considers two options: introducing DOO(p)
services, or maintaining the current mode of
operation which will require the use of the train
guard for dispatch. For introducing DOO(p) services,
several variations are identified in terms of both the
exact method of DOO(p) for each location (e.g. look
back, mirrors, CCTV monitors) and, specifically for
the financial case, the level of on-board staffing after
the removal of the guards’ role.
To construct a business case for introducing DOO(p)
operations, the RU considers the technical and
operational practicalities, safety issues, financial
viability and impact on industrial relations. There is
already operational experience of DOO(p) in other
RUs across the network and studies had been done
by RSSB and the Rail Delivery Group (RDG) on
the safety and financial issues. The RU therefore
decides to build upon and adapt this previous work
to help them decide whether to introduce DOO(p) on
their services.
Although DOO(p) is already in use elsewhere which
provides extensive operational experience for
reference by the RU, the decision regarding how to
approach this specific assessment is taken at Board
level. Implementation is initiated by developing a
business case over a period of months alongside
local and regional consultation, due to the
SFAIRP
considerations
potential impact on industrial relations. This level
of consultation is also required due to the issues
relevant to the change being shared by several
organisations – for example, the Infrastructure
Manager (IM) is involved with the platform DOO(p)
equipment.
Financial considerations
Prior to this specific assessment, RDG had
commissioned a quantitative cost benefit analysis to
show the cost savings, benefits and risks that could
occur across the railway industry from having an
integrated roll-out programme for DOO(p). This had
indicated a robust long-term financial benefit for the
extension of DOO(p) on the network. However, over
shorter terms, there could be insufficient financial
benefit for a RU, due to the costs associated with
implementation.
The RU determines that the financial case for
DOO(p) is favourable for them as they are near
the beginning of their franchise, and that savings
will outweigh the implementation costs of DOO(p)
equipment over a 5-6 year period.
Safety considerations
The RU also considers the safety impacts of the
proposed changes to determine whether the system
can be made acceptably safe if they extended
DOO(p) throughout their operations.
Costs
Benefits
The following costs are included:
• Considered to be marginally safer
by many workshop participants but
not quantified.
• Installation of equipment (CCTV monitors,
mirrors etc.) on trains and platforms.
• Equipment maintenance.
• Financing costs.
• Staff contract changes (e.g. Driver salary
increase, guard transition costs).
The following savings are set against the costs:
• Reduced train staff costs (salaries, training).
• Reduced performance regime compensation
payments due to fewer cancelled trains
during disruptions.
Wider business
case CBA
Potential for increased fare evasion.
• Costs of industrial action to the RU.
• Potential for human factors type issues
for drivers (musculoskeletal, ergonomics,
workload).
• Improved punctuality strengthening
reputation.
• On board staff able to be more
customer focused.
Table 1:Summary of Cost Benefit Analysis (CBA)
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RSSB had previously done a research project to
develop safety arguments for the introduction of
DOO(p) by applying the CSM RA process to a
representative railway operation as a template for
various other RUs. The RU adapts these arguments
for their operations using workshops which include
safety experts and staff with operational experience
to consider specific local factors, such as the
characteristics of each platform, and any additional
appropriate safety measures that they will need to
implement.
The study gives the RU confidence that they are
capable of implementing DOO(p) safely, and indeed
many workshop participants consider it to be
marginally safer than operations with doors operated
by guards in certain circumstances. Overall, the
change in safety and therefore the monetised value
of any safety benefits are considered to be relatively
small.
The various costs and benefits from the studies are
summarised to inform the decision of whether to
extend DOO(p), both in terms of the issues that will
need to be considered for explicit risk assessment
under the CSM RA if the change goes ahead using
the criterion of So Far As Is Reasonably Practicable
(SFAIRP), and the wider business case (Table 1).
Both approaches support the conclusion that it is
feasible to extend DOO(p) as there is likely to be
both a financial benefit over the franchise period and
the system post change can be made acceptably
safe. Operational benefits are also identified,
including a more reliable service and increased
staffing flexibility. Therefore the RU decides to
proceed with extending DOO(p) on all its services to
improve performance and reduce costs in the long
term.
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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3. Making a change
The CSM RA process is applied to the
implementation of the change of introducing DOO(p)
to all the RU’s services.
Site visits, a review of documentation, data and
incident reports for the applicable routes are used
to build the system definition. Hazards associated
with train dispatch and other guard’s duties are
identified using deskwork and workshops, with
further workshops to determine relevant ‘close
out’ arguments for all the identified hazards, and
to identify safety requirements. Recognising
the sensitivity of the proposed change to
industrial relations, driver union health and safety
representatives from each depot are included on
the project steering group from the outset so that
any concerns can be raised and addressed as they
arise.
The RU consults a RU that has three years
of experience of DOO(p) on comparable lines
using similar rolling stock. This allows the RU to
use ‘similar reference system’ as the main risk
acceptance principle. Relevant codes of practice
are also consulted with respect to some of the
hazards to show that they are controlled to a
level that is acceptably safe. Both the SFAIRP
and broader business case cost benefit analyses
developed during earlier go/no-go option analyses
are frequently re-visited and updated.
The implementation risk assessment identifies
additional issues to be addressed. For example,
it is recommended to introduce additional staff for
crowd control at busy stations during peak periods
or for special occasions that can increase station
use. During the previous year, a popular concert
in close proximity to one of their stations resulted
in an additional 6,000 passengers travelling on that
line and created a peak in passengers of double
the normal rush hour peak loading over a couple
of hours. A process is therefore set up to identify
similar events in advance and make provision for
this at the affected stations, including the provision
of additional passenger information. It is recognised
that although the crowd control staff will not play
a safety critical role in dispatch, they will help to
reduce the risk from a platform train interface
incident.
The RU also identifies several platforms that will
need additional lighting to make them suitable for
DOO(p) services.
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Test trains are run over a 6 month trial period in
a range of conditions with a driver union health
and safety representative and project manager on
board to check that all the safety requirements are
in place and working, and to identify any additional
issues. This allows each platform to be assessed
and signed off by the project team together with
the driver health and safety representatives. Where
issues are raised, improvements are suggested,
agreed and implemented before the platform is
signed off. This process leaves a clear audit trail
to show that each location has been agreed as
safe by the RU and driver union health and safety
representatives. The change is deemed ‘significant’,
as the RU does not have operational experience of
DOO(p) and the identified hazards have potentially
fatal consequences, so it is also independently
assessed and approved.
The RU considers acceptance of the change by key
stakeholders a success from an industrial relations
point of view. At the start of implementation of the
new DOO(p) scheme, the RU carefully considers
industrial relations, and provides for the possibility
of 5-10 days of industrial action. However, they
avoid such action by consulting with the Unions at
every stage of the process and gaining agreement
and associated confidence on all safety matters
throughout. Also, plans are put in place to redeploy
guards to ‘train captain’ or other commercial roles
to minimise the social impact which redundancies
would cause.
4. Monitoring safety
The early phases of implementation of DOO(p) are
subject to additional monitoring, of both operational
and safety performance indicators, with review
reports after 6 and 12 months.
The main issue that is raised by the drivers’ union
health and safety representatives is that certain
sunlight conditions interfere with the visibility of
monitors used by drivers for platform dispatch
duties. Therefore, a number of mitigation measures
are introduced such as colour monitors replacing
the black and white ones and putting in ‘hoods’ on
monitors to prevent sunlight glare. There is also
a concern about customer service, as train rolling
stock “car stop” markers are positioned to meet
operational requirements rather than considering
customer needs. For example, sometimes the
position marked for the train to stop means that
customers have to wait in an unsheltered area, or
travel a long distance to get from the ticket barrier
to the train, leading to them running and potentially
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slipping on the platform. In response to this the
RU undertakes a review of car stop markers in
the context of optimising customer comfort, whilst
meeting requirements for safety.
Other issues include vandalism to platform
equipment and the difficulty of viewing the dispatch
corridor on busy platforms. The RU responds to
all of these issues, for example, by adding extra
protection for platform DOO equipment and building
in extra service dwell time at busy stations to enable
customers to disperse.
Staff DOO progress newsletters are issued to keep
the front-line staff informed and reinforce confidence
that issues raised are being dealt with.
Overall, there is an 80% decrease in the number of
driver DOO-related incident reports between the first
and the second post implementation reviews, which
indicates that the new mitigation measures are
successful in addressing the majority of the issues
identified.
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