Safety Risk Model: Risk Profile Bulletin, version 8.1 This report is issued by RSSB. If you would like to give feedback on any of the material contained in this report, please contact: Marcus Dacre RSSB Block 2, Angel Square 1 Torrens Street London EC1V 1NY 020 3142 5476 risk@rssb.co.uk © RAIL SAFETY AND STANDARDS BOARD LTD. 2014 ALL RIGHTS RESERVED This publication may be reproduced free of charge for research, private study or for internal circulation within an organisation. This is subject to it being reproduced and referenced accurately and not being used in a misleading context. The material must be acknowledged as the copyright of RSSB and the title of the publication specified accordingly. For any other use of the material please apply to RSSB for permission. This publication can be accessed via the RSSB Rail Risk Portal at www.safetyriskmodel.co.uk. This is Issue 1.1 of the report. It details SRM version 8.1 and contains corrections to hours worked by workforce groups and associated results. Issue 1.1 – published December 2014 This page has been intentionally left blank Version 8.1 - Issue 1.1 - December 2014 ii Executive summary Executive summary The Safety Risk Model (SRM) consists of a series of fault tree and event tree models representing 131 hazardous events (HEs) that collectively define the overall level of risk on the railway. It provides a structured representation of the causes and consequences of potential accidents arising from railway operations and maintenance. The reported risk estimates relate to the network-wide risk and they indicate the current level of residual risk (ie the level of risk remaining with the current risk control measures in place and with their current degree of effectiveness). Version 8 of the safety risk model has an extended scope to previous versions as it merges mainline railway risk (as previously modelled in SRMv7.5) and risk on yards, depots and sidings (previously modelled in the YDS-SRM). The version 8 SRM update also included a number of modelling changes, precursor additions/restructurings and a refresh of data up to the data cut-off date of 30th September 2013. Following the completion of SRM v8 changes were made to the classification of a number of suicide and trespass events. This resulted from improved liaison and data sharing between RSSB and British Transport Police, which allowed for more accurate distinctions between suicide and non-suicide events. Due to the magnitude of these data changes the risk associated with affected hazardous events was recalculated to create a further version of the SRM, version 8.1, using the same model structures and data cut-off date as version 8. It is the results of version 8.1 that are reported on in this document. The risk results are presented as a measure of the absolute risk on the railway. As with any quantified risk assessment, the results are estimates and are dependent on modelling assumptions and limitations of the available data. Quantified risk estimates can be a useful input to the decision making process, but should not be the only input, and their inherent uncertainty must be taken into account. Overall risk SRMv8.1 estimates that the overall level of risk on the railway is 139.6 FWI/year1. This represents a decrease of 4.8% from the figure of 146.6 FWI/year estimated by SRMv7.5 and the YDS-SRM Risk by person type The overall figures for SRMv8.1 broken down by each exposed group are given in Table 1. Table 1: SRMv8.1 results by person group Person category Passenger Workforce Public Total SRMv8.1 (FWI/yr) 58.4 33.4 47.8 139.6 Passenger risk is 58.4 FWI/year. The main contributors to this risk are slips trips and falls and assaults. 1 Unless otherwise specified all risk figures quoted exclude the direct risk from suicide events. That is, injuries to the suicidal person are excluded whilst secondary injuries, eg, train driver and crew shock/trauma injuries are included. Version 8.1 - Issue 1.1 - December 2014 iii Executive summary Workforce risk is 33.4 FWI/year. The main causes of workforce risk are slips, trips and falls and contact with objects. Risk to members of the public is 47.8 FWI/year. The majority of this risk is due to trespass. Risk by accident type Alternatively, the overall risk figure of 139.6 FWI/year can be broken down by accident type as shown in Table 2. Table 2: SRMv8.1 results by accident category Accident category HET HEM HEN Total SRMv8.1 (FWI/yr) 8.0 49.6 82.0 139.6 Where: HET: Train accidents HEM: Movement accidents HEN: Non-movement accidents Further information is available on the Rail Risk Portal: www.safetyriskmodel.co.uk. Version 8.1 - Issue 1.1 - December 2014 iv Contents Table of contents Executive summary .................................................................................................... iii Table of contents ........................................................................................................ v List of tables ........................................................................................................... vii List of figures .......................................................................................................... viii 1 Introduction ......................................................................................................... 1 2 SRM objectives and overview ............................................................................. 3 2.1 Objectives ..................................................................................................... 3 3 2.2 Overview ....................................................................................................... 4 2.3 Key assumptions and exclusions .................................................................. 5 SRM update strategy .......................................................................................... 6 3.1 Overview of the SRMv8 update..................................................................... 6 3.2 4 Update to SRM version 8.1 ........................................................................... 7 Total risk on the railway ...................................................................................... 9 4.1 Overall profile ................................................................................................ 9 4.1.1 Mainline profile ..................................................................................... 12 4.1.2 Yards, depots and sidings .................................................................... 16 4.1.3 Estimation of YDS underreporting ........................................................ 19 4.2 Risk by ASPR hazard categorisation .......................................................... 20 4.2.1 Risk by annual FWI .............................................................................. 20 4.2.2 Risk by annual fatalities ........................................................................ 20 4.2.3 Detailed risk profiles ............................................................................. 20 5 Key risk areas ................................................................................................... 23 5.1 Other risk groupings .................................................................................... 25 6 7 SRM risk vs observed risk ................................................................................. 26 Uncertainty in the SRM risk estimates .............................................................. 28 7.1 Introduction ................................................................................................. 28 8 9 7.2 Uncertainty methodology ............................................................................ 28 7.3 SRM uncertainty results .............................................................................. 29 7.4 Uncertainty analysis next steps ................................................................... 32 Individual fatality risk ......................................................................................... 33 8.1 Introduction ................................................................................................. 33 8.2 Fatality risk .................................................................................................. 33 8.3 Passengers ................................................................................................. 34 8.4 Workforce .................................................................................................... 35 8.5 Members of the public ................................................................................. 37 Multiple fatality risk: the F-N Curve ................................................................... 39 9.1 F-N results................................................................................................... 39 9.2 F-N modelling approach .............................................................................. 43 Version 8.1 - Issue 1.1 - December 2014 v Contents 10 Remodelling risk at the platform-train interface ................................................. 44 10.1 Background and objectives ......................................................................... 44 10.2 The remodelling process ............................................................................. 44 10.2.1 Scope of changes ................................................................................. 44 10.2.2 Remodelling steps ................................................................................ 45 10.2.3 PTI structural changes .......................................................................... 45 10.3 Impact on the risk profile ............................................................................. 46 11 SRM governance and RPB updates ................................................................. 48 11.1 Data and Risk Strategy Group .................................................................... 48 11.1.1 SRM Practitioners Working Group ........................................................ 48 11.2 Update history ............................................................................................. 48 11.3 Updates to the SRM during CP4 ................................................................. 50 11.4 Future updates during CP5 ......................................................................... 50 12 Contributors ...................................................................................................... 51 13 Acronyms and glossary ..................................................................................... 52 13.1 Acronyms .................................................................................................... 52 13.2 Glossary ...................................................................................................... 53 14 References ........................................................................................................ 61 Appendix A. SRM outputs...................................................................................... 62 Appendix B. ASPR hazardous event groupings .................................................... 63 Appendix C. Individual fatality risk summary.......................................................... 65 Appendix D. Modelling approach ........................................................................... 66 D.1. Key assumptions .................................................................................. 66 D.2. Hazardous event definitions ................................................................. 67 D.3. Normalisation data ................................................................................ 67 D.4. Significant modelling changes for SRMv8 ............................................ 67 D.4.1. Inclusion of YDS-SRM risk ................................................................... 67 D.4.2. Remodelling of risk at the PTI............................................................... 67 D.4.3. Inclusion of MCB+OD and AOCL+B crossing types ............................. 67 D.4.4. New approach to assault data analysis ................................................ 67 Appendix E. Railway lines in SRM scope .............................................................. 68 Version 8.1 - Issue 1.1 - December 2014 vi List of tables List of tables Table 1: SRMv8.1 results by person group ........................................................................... iii Table 2: SRMv8.1 results by accident category.....................................................................iv Table 3: Scope of the railway infrastructure .......................................................................... 4 Table 4: Exceptions to the physical boundary of the SRM ..................................................... 4 Table 5: Risk changes from SRMv8 to SRMv8.1 ................................................................... 8 Table 6: Total risk by accident category ................................................................................ 9 Table 7: Total risk by person category ................................................................................ 10 Table 8: Total risk to each person category from each accident category ........................... 10 Table 9: Total risk by accident category .............................................................................. 12 Table 10: Total risk by person category............................................................................... 13 Table 11: Total risk to each person category from each accident category ......................... 14 Table 12: Total risk by accident category ............................................................................ 16 Table 13: Total risk by person category............................................................................... 17 Table 14: Total risk to each person category from each accident category ......................... 17 Table 15: Grouped risk figures for SRMv8.1, not including YDS risk ................................... 23 Table 16: Selected SRMv8.1 risk groupings........................................................................ 25 Table 17: Comparison of SRM and uncertainty model risk estimates .................................. 29 Table 18: Total passenger individual fatality risk ................................................................. 35 Table 19: Workforce individual fatality risk breakdown ........................................................ 37 Table 20: Frequency of train-related incidents leading toRI multiple fatalities ...................... 39 Table 21: Return periods of train-related incidents leading to multiple fatalities ................... 39 Table 22: Remodelled PTI HE descriptions ......................................................................... 45 Table 23: Remodelled PTIHEs. Summary of changes......................................................... 46 Table 24: Summary of the changes in risk for PTI hazardous events .................................. 47 Table 25: SRM update history ............................................................................................. 49 Table 26: Accident groups used within the ASPR ............................................................... 63 Table 27: Workforce group individual fatality risk by cause classification. ........................... 65 Table 28: Key modelling assumptions in the SRM .............................................................. 66 Table 29: Railway lines in and out of scope of the SRM ...................................................... 68 Version 8.1 - Issue 1.1 - December 2014 vii List of figures List of figures Figure 1: Summary of the SRM remodelling and data updates. ............................................ 7 Figure 2: Total risk profile by person type (% of total FWI/year) .......................................... 11 Figure 3: Mainline railway risk profile by person type (% of total mainline FWI/year) ........... 15 Figure 4: YDS risk profile for workforce (% of total workforce FWI/year) ............................. 18 Figure 5: Risk profile in FWI/year (with % change from SRMv7.5+YDS) ............................. 21 Figure 6: Risk profile in fatalities/year (with % change from SRMv7.5+YDS ........................ 22 Figure 7: Breakdown of SRMv8.1 (excluding YDS risk) by risk area ................................... 24 Figure 8: Passenger observed FWI vs SRM FWI approximation ......................................... 27 Figure 9: Risk distribution for the total SRMv8.1 HEM/HEN risk .......................................... 29 Figure 10: Risk distribution for the SRMv8.1 risk for HEM and HEN separately .................. 30 Figure 11: Risk distribution for the SRMv8.1 risk by person type ......................................... 31 Figure 12: Fatality risk for each person category per year (SRMv8.1) ................................. 34 Figure 13: Causal breakdown of passenger fatality risk ...................................................... 34 Figure 14: Expected annual fatalities by workforce role....................................................... 36 Figure 15: Individual fatality risk by workforce role .............................................................. 36 Figure 16: Causal breakdown of MOP fatality risk ............................................................... 38 Figure 17: The F-N Curve – all person and train accident types. ......................................... 40 Figure 18: Estimated frequency of train accident-related fatality events .............................. 41 Figure 19: F-N curve – plotted separately for three categories of train accidents ................ 42 Figure 20: Contribution of key hazardous events to the F-N curve ...................................... 43 Figure 21: Timeline of updates of the SRM and RPB that occurred in CP4 ......................... 50 Version 8.1 - Issue 1.1 - December 2014 viii Introduction 1 Introduction RSSB works with its members to support the development of safety strategies, develop standards and monitor and report on the safety performance of the industry. An understanding of the overall risk level and risk profile of the railway is a key foundation for this role. RSSB supports its members — who comprise the railway industry — by providing risk information to help them understand their own risk profile and benchmark their performance. This in turn helps them formulate their own safety policies, plans and measures. The Safety Risk Model (SRM) provides the network-wide risk profile and this information is communicated to the industry in a range of ways, the primary one being the SRM Risk Profile Bulletin (SRM-RPB). The SRM consists of a series of fault tree and event tree models representing 131 hazardous events (HEs), which collectively define the overall level of risk on the mainline railway. It provides a structured representation of the causes and consequences of potential accidents arising from railway operations and maintenance on railway infrastructure as well as other areas where the industry has a commitment to record and report accidents. The SRM has been designed to take account of both high-frequency, low-consequence events (occurring routinely, and for which there is a significant quantity of recorded data) and lowfrequency, high-consequence events (occurring rarely, and for which there is little recorded data). The results for each HE are presented in terms of the frequency of occurrence (number of events per year) and the risk (number of fatalities and weighted injuries (FWI) per year). The FWI weightings equate injuries of differing degree with a fatality, which allows all of the risk on the railway to be totalled and contrasted in comparable units. These FWI weightings are shown in Section 13.2. The risk estimates presented can be used to support risk assessments and for judging how the risk relating to particular operations compares with and contributes to the network-wide risk. The information contained in this document relates to the network-wide risk on railway infrastructure covering all running lines, rolling stock types, stations, yards, depots and sidings currently in use. The system boundaries are detailed in Section 2.2. The risk estimates are for the current level of residual risk on the railway, which is the level of risk remaining with the current risk control measures in place and with their current degree of effectiveness. Because of the network-wide nature of the SRM, it is necessary to make average assumptions that represent the general characteristics of the network. The model also hinges on the definitions of the HEs and precursors by which risk estimates are reported. These definitions are available on the RSSB Rail Risk Portal at www.safetyriskmodel.co.uk, and a thorough understanding of them is essential to the correct interpretation and use of the risk information reported here. The SRM does not provide risk profiles for specific lines of route and train operating companies (TOCs), although a Risk Profile Tool is also available from the Rail Risk Portal to help scale the results for this purpose. The information in this report should not be considered to be representative of the risk for any particular line of route or TOC, without further localised analysis. This risk profile bulletin details the risk estimates made for version 8.1 of the SRM. Version 8.1 is a partial update from SRM version 8 that came about as the result of significant changes being made to the classification of suicide and trespass events (detailed in section 3.2). The Version 8.1 - Issue 1.1 - December 2014 1 Introduction cut-off date for incident data used to inform SRMv8.12 was 30 September 2013.3 Comparisons are made against the combined SRMv7.5 and the Yards, Depots and Sidings SRM, referred to throughout this document as SRMv7.5+YDS. The main part of this report sets out: An overview of the SRM and its objectives (Section 2.1) The SRM update strategy (Section 3) Total risk on the railway (Section 4) Breakdown of risk by the Strategic Safety Plan (SSP) risk areas (Section 5) A comparison of observed FWI with SRM risk estimates (Section 6) Detail of the uncertainty involved in the SRM risk estimates (Section 7) A summary of individual risk (Section 8) A summary of multi-fatality risk (Section 9) Modelling changes made for SRMv8.1 (Section 10) SRM governance arrangements (Section 11) The SRM Practitioners Working Group (SRM-PWG) was the industry governance body for the SRM throughout Control Period 4 (CP4). It was formed under the authority of the Safety Policy Group (SPG) to engage stakeholders in the development and control of future versions of the SRM and its related outputs. The modelling changes implemented as part of the update of the SRM to version 8 have been endorsed by the SRM-PWG. The revised version 6 figures (SRMv6.7) and the version 8 figures (SRMv8) were presented to the group and approved in March 2014. As part of the modernisation of safety co-operation (MOSC) initiative, SPG and SRM-PWG have been wound up and oversight for future SRM updates and developments will be provided by the Data and Risk Strategy Group (DRSG) which is a subgroup of the System Safety Risk Group (SSRG). The Department for Transport (DfT) has been using the outputs from the SRM as the primary means of measuring the performance of the industry against the High Level Output Specification (HLOS) safety metrics. The risk estimates derived from SRMv6 provided the initial baseline against which to compare safety performance through CP4 (April 2009 to March 2014). This is achieved by comparing the risk metrics derived from SRMv8 against the baseline safety metrics determined from SRMv6 (and subsequently updated to SRMv6.7). A full report of the HLOS metric calculation is given in the report HLOS Safety Metrics – baseline and progress metrics following completion of the update of the SRM to version 8 [Ref. 1] which was delivered to SRM-PWG on the 27 March 2013. Additional appendices for this document may be downloaded from the RSSB Rail Risk Portal at http://www.safetyriskmodel.co.uk. 2 The term SRMv8.1 is used to refer to the full SRM scope of events including those events which did not need to be recalculated in the partial update. 3 There are four hazardous event models that are exceptions to this data cut-off: HEM-12, HEM-25, HEM-31 and HEN-77. The mapping of incidents to these HEs is influenced by coroners’ reports, which may not be available until a considerable time after the event. Therefore, to ensure there is confidence in the data used to analyse them, an earlier cut-off date (30 September 2012) was used. Version 8.1 - Issue 1.1 - December 2014 2 SRM objectives and overview 2 SRM objectives and overview 2.1 Objectives The SRM has been developed and published to support RSSB members. The primary objectives of the SRM are: To provide an estimate of the extent of the current risk on the railway. To provide risk information and risk profiles relating to the railway. This information is used for risk assessments, appraisals and to inform decision making throughout the railway industry. Taking Safe Decisions, [Ref. 2] sets out the rail industry’s consensus view on how safety is taken into account when making decisions. The guidance was updated in 2014 to reflect changes to the legal environment and evolving industry practice. In the Great Britain (GB) rail industry, almost every policy, investment or operational decision has an impact on safety. In order to make these decisions and to ensure that risk is acceptable, the rail industry needs to understand safety risk, its causes and consequences. The SRM is one of the key tools used to help support this decision making through: Monitoring: are operations safe or might changes be required? Analysing and selecting options: what (if anything) should I change and can it be done safely? Making a change: how do I make sure a change is safe? This includes: Enabling risk-informed assessments and cost-benefit analyses (CBAs) to be carried out to support decisions taken about: Whether changes to the railway can be made safely. Which risk control measures should be applied or can be relaxed or changed. Technical modifications and upgrades such as new infrastructure investment. Revision of Railway Group Standards (RGS), in terms of their contribution to risk mitigation (including development of impact assessments for proposed changes to the RGS). Providing risk information to support: The development of priorities for the Industry Strategic Business Plans 2014– 2019 [Ref. 3]. Transport operator risk assessments, as required by The Railways and Other Guided Transport Systems (Safety) Regulations 2006. Identification and prioritisation of issues for audit and/or research. RSSB’s contributions and comments on the development of Technical Standards for Interoperability (TSIs), National Technical Rules and National Safety Rules. Version 8.1 - Issue 1.1 - December 2014 3 SRM objectives and overview 2.2 Providing an understanding about the contribution of a particular item of equipment or failure mode to the overall risk. Overview The SRM includes the safety risk from incidents which could occur during the operation and maintenance of the railway. For SRMv8.1 the scope has been extended to include risk within yards, depots and sidings, previously covered by the separate Yards, Depots and Sidings (YDS) Risk Profile Report [Ref. 4]. For SRMv8.1 the extent of the railway infrastructure in question is defined below in Table 3. Table 3: Scope of the railway infrastructure Inclusions The sections of the operational railway4 which are managed or operated by Network Rail. Any assets, structures, stations, yards, depots and sidings associated with the above. Any yard, depot or siding that is connected to but away from the running lines on railway infrastructure, where train maintenance, stabling, marshalling and/or servicing (including refuelling) takes place under the management of other infrastructure managers. Exclusions Station car parks. Offices (except areas normally accessible by MOP). Mess rooms. Training centres. IECCs/SCCs. Outside of the entrance to stations. Station and site toilets. Retail units and concessions in stations. Construction sites which are completely segregated from the public areas. Track sections closed for long term construction, maintenance, renewal or upgrade. This defines the physical boundary of the SRM. Any incidents which occur inside this boundary, and are listed in GE/RT8047, are included in the SRM. Conversely, any incidents outside this boundary are excluded from the SRM. The exceptions to this rule are listed below in Table 4. Table 4: Exceptions to the physical boundary of the SRM Inclusions outside the SRM boundary Exclusions inside the SRM boundary Injuries to people which are directly caused by operations or maintenance inside the boundary. Injuries to railway staff who are on duty and travelling between sites, except if their destination is one of the excluded areas in Table 3 (eg an office).5 Long-term occupational health issues. Terrorist activity. 4 The operational railway includes all lines for which the infrastructure manager & railway undertaking have been granted a safety authorisation & certificate respectively by the ORR (under European Safety Directive 2004/49/EC [Ref 5]). This provides evidence that there is a suitable SMS in place, and that operations are being conducted in accordance with that SMS. 5 For instance, this would include delivery of goods to a trackside location, but exclude travel to a training centre. Version 8.1 - Issue 1.1 - December 2014 4 SRM objectives and overview Appendix G of the YDS Risk Profile Report contains a more detailed discussion of the SRMYDS scope and the boundaries of yards, depots and sidings. It also gives specific guidance as to what aspects of the operation and maintenance of the railway are within scope of the SRM. 2.3 Key assumptions and exclusions Appendix D.1 lists key assumptions that are applicable to the SRM. Further clarity on the definitions and assumptions applicable to individual HEs can be provided on request. Version 8.1 - Issue 1.1 - December 2014 5 SRM update strategy 3 SRM update strategy 3.1 Overview of the SRMv8 update The SRM was used by the DfT as the primary means of measuring the performance of the industry against the HLOS safety metrics throughout control period 4 (CP4). It was therefore necessary to be able to distinguish between changes in estimated risk arising from genuine changes in safety performance and changes due to modelling refinements (for SRM versions 6 through 8). To incorporate YDS risk modelling and to enable the HLOS comparison to be meaningful, the update of the SRM to version 8 has been split into three distinct stages. 1. Bring the YDS risk model into the main risk model framework. 2. Produce risk estimates for SRMv8 incorporating: a. Changes to the model structure. This included: i. Restructuring of the various platform-train interface (PTI) hazardous events following industry requirements for greater understanding of risk at the PTI (explanation of this remodelling is covered in detail in Chapter 10). ii. Extension of the seven level crossing hazardous events to include the recently introduced crossing types: MCB with obstacle detection (MCB+OD) and AOCL with half barriers (AOCL+B). b. Changes to the calculation methods. This included: i. Improved estimates of the risk from passenger and public assaults utilising a refined matching of records between SMIS and the BTP CRIME database. ii. Correcting minor errors from previous SRM versions. c. Changes to historical data (incidents which occurred prior to the data cut-off for previous versions). This included: i. Inclusion, exclusion or reclassification of incidents in the light of new information. ii. Inclusion of late reported incidents. d. Inclusion of new data for incidents which occurred since the data cut-off for the previous version and the SRMv8 data cut-off of 30 September 2013. 3. Apply step 2a) to 2c) above to SRMv6 to create SRMv6.7. This updated version represents the risk as would have been calculated for SRMv6 had the modelling changes for the mainline railway risk implemented in SRMv8 been implemented at the time SRMv6 was first created. The required comparisons between risk estimates can then be meaningfully made: 1. SRMv6.7 and SRMv8 can be compared to provide the estimated change in risk over CP4 as required for HLOS. Version 8.1 - Issue 1.1 - December 2014 6 SRM update strategy 2. SRMv7.5 and SRMv8 (without YDS) can be compared to give the estimated change in risk due to remodelling and the refresh of the data up to 30 September 2013 (compared to 30 June 2012 for SRMv7.5). 3. The YDS-SRM and the YDS subsection of SRMv8 can be compared to give the estimated change in YDS risk. This is the third time the SRM update has required previous models to be simultaneously updated. The other occasions being for SRMv7 and SRMv7.5. This has been necessary in order to provide a framework that is compatible with the requirements for monitoring the HLOS metrics and to provide risk estimates for different points in time that are calculated on a likefor-like basis. Figure 1 summarises the different SRM versions and how they have been derived. For HLOS comparative purposes, the light grey boxes show valid comparisons based solely on changes in data between different versions of the model. Figure 1: Summary of the SRM remodelling and data updates. Date of version release 1st HLOS comparison Data cut-off date SRM v6 SRMv6.5 SRMv7 KEY Remodelling YDS-SRM 2nd HLOS comparison SRMv6.6 Final HLOS comparison SRMv6.7 SRMv7.1 Partial Update SRMv7.5 Data refresh Extension of scope SRMv8 3.2 Update to SRM version 8.1 In 2013/14, BTP made more information about railway fatalities available to the rail industry as a result of the enhanced co-operation effected by the National Suicide Prevention Strategy Group. BTP provided additional information dating back to 2009/10, which has enabled the industry to update the classification of a number of fatalities6. 6 Further information on the suicide/trespass data reclassification is available in the Annual Safety Performance Report 2013/14. Version 8.1 - Issue 1.1 - December 2014 7 SRM update strategy The reclassified data only became available after the SRMv8 update had been completed. However, due to the expected scale of the impact RSSB decided to update risk estimates for the relatively small number of affected hazardous events and incorporate them in a partial update to SRMv8 to create SRMv8.1. The hazardous events for which data was recoded and the risk recalculated are: HEM-31-Suicide (or attempted suicide) involving rolling stock in motion. HEN-77-Suicide (or attempted suicide) not involving rolling stock in motion. HEM-12-MOP (trespasser) struck/crushed by train while on tracks at station. HEM-25-MOP (trespasser) struck/crushed by train while on railway infrastructure not at station. HEN-38-MOP (adult trespasser) electric shock (conductor rail). HEN-71-MOP (adult trespasser) fall/jump onto railway infrastructure. Other hazardous events were indirectly affected due to dependencies on the above, these were: HEM-31-YDS-Suicide or attempted suicide involving rolling stock in motion. HEN-45-MOP (non-trespasser) fall onto railway infrastructure. HEN-72-MOP (child trespasser) fall/jump onto railway infrastructure. HEN-77-YDS-Suicide (or attempted suicide) not involving rolling stock in motion. The overall effects of these changes are given in Table 5. Table 5: Risk changes from SRMv8 to SRMv8.1 Change in FWI from v8 to v8.1 Absolute Percentage Suicide risk 7.97 3.4% Other risk -11.59 -27.1% These changes only had a negligible impact on passenger and workforce risk so did not affect the HLOS calculations. Throughout this report all values, charts and tables reflect the SRMv8.1 results. Version 8.1 - Issue 1.1 - December 2014 8 Total risk on the railway 4 Total risk on the railway 4.1 Overall profile This section presents the overall risk on the railway for the 131 HEs which make up the SRM. Risk is presented as: Injury severity by accident category (Table 6) Injury severity by person category (Table 7) Person type injured by accident category ( Table 8) The total risk from the 131 HEs is estimated to be 139.6 FWI/year7. This is made up of approximately: 55 fatalities per year8 567 major injuries per year 2494 class 1 minor injuries per year 11833 class 2 minor injuries per year 1887 shock/trauma events per year This compares to the 146.6 FWI/year calculated in SRMv7.5 and SRM-YDS9. These total risk estimates are broken down by accident category and injury type in Table 6. Class 1 minor injuries/year Class 2 minor injuries/year Class 2 shock/trauma/ year Major injuries/ year Train accidents 8.0 6.1 14 79 39 4 38 Movement accidents (excl. trespass) 25.2 12.4 76 372 1822 253 217 Non-movement accidents (excl. trespass) 72.8 5.6 457 2024 9964 9 1340 Trespass 33.6 31.3 21 19 9 26 0.4 Total 139.6 55 567 2494 11833 292 1595 Accident category Class 1 shock/trauma/ year FWI / year Fatalities/year Table 6: Total risk by accident category 7 The values presented exclude direct risk due to suicide and attempted suicide. Indirect suicide risk (eg the shock/trauma of witnesses) associated with these events is included. 8 Note that, due to rounding, values in tables and the text throughout this document may not match. 9 This version of the SRM is the first version that has included both mainline and yards, depots and sidings. Consequentially comparisons have been made to the combined results from SRMv7.5 and the SRM-YDS. Version 8.1 - Issue 1.1 - December 2014 9 Total risk on the railway Table 7 shows the risk to each person category on the railway, broken down by person category and accident category. Reasons for the changes in risk are explored in more detail in section 4.1.1 (which focuses on the changes in mainline risk from SRMv7.5) and section 4.1.2 (which focuses on the changes in risk on YDS sites from the YDS-SRM). Table 7: Total risk by person category Class 2 minor injuries/year 8.3 352 1616 6001 1.6 801 54.7 +6.9% Workforce 33.4 4.2 173 798 5683 289 763 34.0 -2.0% MOP 47.8 43 42 80 150 1.1 31 57.9 -17.5% Total 139.6 55 567 2494 11833 292 1595 146.6 -4.8% FWI/year Class 1 minor injuries/year 58.4 Class 2 shock/trauma/ year Major injuries/ year Passenger Person category Class 1 shock/trauma/ year Fatalities/year % Change from SRMv7.5+YDS to SRMv8.1 SRMv7.5+YDS FWI/year SRMv8.1 Table 8: Total risk to each person category from each accident category SRMv8.1 Accident category Total FWI/year SRMv7.5+YDS Passenger FWI/year Workforce FWI/year MOP FWI/year Total FWI/year % change from SRMv7.5+ YDS to SRMv8.1 HET 8.0 2.8 1.1 4.0 8.3 -4.4% HEM 49.6 11.7 6.6 31.4 56.4 -12.0% HEN 82.0 43.9 25.6 12.4 81.9 +0.1% Total 139.6 58.4 33.4 47.8 146.6 -4.8% The reclassification of suicide/trespass events has only been applied to this latest version of the SRM. This means that those hazardous events that were reanalysed for SRM version 8.1 are no longer directly comparable to their SRMv7.5+YDS counterparts due to the significant differences in the data. A significant proportion of the reduction in risk to both members of the public and HEM events can be attributed to this. Figure 2 presents the total risk profile for passengers, the workforce and members of the public. It shows that the bulk of the risk is split between passengers and members of the public, with 42% and 34% respectively — the remaining proportion (24%) is attributed to the workforce. Fatalities still dominate the risk to the public, comprising 90% of the total risk to members of the public (equivalent to 43 fatalities per year). Fatalities due to trespass make up 73% of member of public fatalities (equivalent to 31 fatalities per year). Version 8.1 - Issue 1.1 - December 2014 10 Version 8.1 - Issue 1.1 - December 2014 Class 1 minor injuries (12.0%) Class 2 minor injuries (17.0%) Class 1 shock/trauma (4.3%) Class 2 shock/trauma (2.3%) Fatalities (89.9%) Major injuries (8.9%) Class 1 minor injuries (0.8%) Passenger (42%) Class 1 shock/trauma (0.01%) Class 2 minor injuries (10.3%) Class 1 minor injuries (13.8%) Class 2 shock/trauma (1.4%) Class 1 shock/trauma (0.01%) Major injuries (60.3%) Total risk = 139.6 FWI/year Class 2 shock/trauma (0.1%) Fatalities (12.7%) Major injuries (51.7%) Workforce (24%) Members of the public (34%) Fatalities (14.2%) Class 2 minor injuries (0.3%) Total risk on the railway Figure 2: Total risk profile by person type (% of total FWI/year) 11 Total risk on the railway 4.1.1 Mainline profile This section presents the overall risk for the 122 hazardous events on the mainline railway (that is, excluding all hazardous and sub-hazardous events referring to YDS risk), which are considered within the SRM. Risk is presented as: Injury severity by accident category (Table 9) Injury severity by person category (Table 10) Person type injured by accident category (Table 11) The total risk from the 122 HEs for the mainline railway is assessed to be 132.0 FWI/year. This is made up of approximately: 55 fatalities per year 520 major injuries per year 2314 class 1 minor injuries per year 10609 class 2 minor injuries per year 1874 shock/trauma events per year These total risk estimates are broken down by accident category and injury type in Table 9. Table 10 shows the risk to each person category on the railway. Risk to passengers forms the greatest proportion of the total risk, at 58.4 FWI/year (an increase of 6.9% from SRMv7.5). However, over the same period passenger journeys have increased by 2% and passenger kilometres have increased by 3% (from 57.7 billion to 59.2 billion passenger km). Class 1 minor injuries/year Class 2 minor injuries/year 7.8 6.0 13 76 37 0.8 38 Movement accidents (excl. trespass) 24.6 12.3 72 357 1760 253 216 Non-movement accidents (excl. trespass) 66.2 5.3 414 1863 8803 9.2 1331 Trespass 33.4 31.1 20 19 9.1 26 0.4 Total 132.0 54.8 520 2314 10609 289 1585 FWI/ year Version 8.1 - Issue 1.1 - December 2014 Class 2 shock/trauma/ year Major injuries/year Train accidents Accident category Class 1 shock/trauma/ year Fatalities/year Table 9: Total risk by accident category 12 Total risk on the railway The increase in passenger risk is due to increases in several hazardous events, the top contributors of which are HEN-14: Passenger slip, trip or fall and HEN-64: Passenger physical assault. The rise in risk from HEN-14 is mainly driven by an increase in estimated frequency due to a larger number of observed slips, trip or falls on stairs and escalators. Absolute MOP risk decreased by 17.7% since SRMv7.5. This is due to a number of trespass events being reclassified as suicides following further information from BTP. Trespass events are still the largest contributor to MOP risk but following this reclassification, the trespass risk has decreased by 10.9 FWI/year. The risk to the workforce is now 26.1 FWI/year which represents a 2.9% reduction from SRMv7.5. The decrease in workforce risk is due to a decrease in the risk from several hazardous events, of which the top contributors are HEM-19: Infrastructure worker struck/crushed by train in motion and HEN-65: Workforce physical assault. Table 10: Total risk by person category Class 2 minor injuries/year 8.3 352 1616 6000 1.6 800 54.7 +6.9% Workforce 26.1 3.8 126 620 4463 286 754 26.9 -2.9% MOP 47.5 42.7 42 78 146 0.9 30 57.7 -17.7% Total 132.0 54.8 520 2314 10609 289 1585 139.2 -5.2% FWI/year Class 1 minor injuries/year 58.4 Class 2 shock/trauma/ year Major injuries/ year Passenger Person category Class 1 shock/trauma/ year Fatalities/year % change from SRMv7.5 to SRMv8.1 SRMv7.5 FWI/year SRMv8.1 Table 11 presents the risk on the mainline railway broken down by person and accident category. As in the previous section, the table shows that overall risk due to train accidents (HETs) has decreased by 4.6%, largely due to the decrease in estimated frequency of derailments. Movement accidents (HEMs) have seen a 12.4% reduction in risk, whereas nonmovement accidents (HENs) have remained relatively constant. Overall, the total decrease in risk from SRMv7.5 to SRMv8.1 is 5.2%. Version 8.1 - Issue 1.1 - December 2014 13 Total risk on the railway Table 11: Total risk to each person category from each accident category SRMv8.1 Accident category Total FWI/year SRMv7.5 Passenger FWI/year Workforce FWI/year MOP FWI/year Total FWI/year % change from SRMv7.5 to SRMv8.1 HET 7.8 2.8 1.0 4.0 8.2 -4.6% HEM 49.0 11.7 6.0 31.3 55.9 -12.4% HEN 75.2 43.9 19.1 12.2 75.1 +0.1% Total 132.0 58.4 26.1 47.5 139.2 -5.2% Figure 3 presents the total risk profile for passengers, workforce and public. It shows that the bulk of the risk is split between passengers and public, with 44% and 36% respectively — the remaining proportion (20%) is attributed to workforce incidents. Fatalities still dominate risk to public, comprising 90.0%. This is due to public trespass events, contributing 31.3 fatalities per year. Version 8.1 - Issue 1.1 - December 2014 14 Version 7.1 — August 2011 Class 1 minor injuries (11.9%) Class 2 minor injuries (17.1%) Class 1 shock/trauma (5.5%) Class 2 shock/trauma (2.9%) Fatalities (90.0%) Major injuries (8.8%) Class 1 minor injuries (0.8%) Class 1 shock/trauma (0.01%) Passenger (44%) Class 2 minor injuries (10.3%) Class 1 minor injuries (13.8%) Class 2 shock/trauma (1.4%) Class 1 shock/trauma (0.01%) Major injuries (60.3%) Total risk = 132.0 FWI/year Class 2 shock/trauma (0.1%) Fatalities (14.5%) Major injuries (48.1%) Workforce (20%) Members of the public (36%) Fatalities (14.2%) Class 2 minor injuries (0.3%) Total risk on the railway Figure 3: Mainline railway risk profile by person type (% of total mainline FWI/year) 15 Total risk on the railway 4.1.2 Yards, depots and sidings This section presents the overall risk for the nine hazardous events and 40 sub-hazardous events related to YDS, which are considered within the SRM. Risk is presented as: Injury severity by accident category (Table 12) Injury severity by person category (Table 13) Person type injured by accident category (Table 14) The total risk from the 49 HEs for YDS is assessed to be 7.6 FWI/year. This is made up of approximately: 0.7 fatalities per year 47.6 major injuries per year 180 class 1 minor injuries per year 1224 class 2 minor injuries per year 13.4 shock/trauma events per year These total risk estimates are broken down by accident category and injury type in Table 12. Class 1 minor injuries/year Class 2 minor injuries/year 0.17 <0.1 0.72 3.2 2.4 3.3 <0.1 Movement accidents (excl. trespass) 0.64 <0.1 4.0 15 61 <0.1 1.0 Non-movement accidents (excl. trespass) 6.59 0.35 43 161 1160 <0.1 8.8 Trespass 0.21 0.19 0.20 0.21 <0.1 0.12 <0.1 Total 7.61 0.70 47.6 180 1224 3.58 9.80 FWI/ year Class 2 shock/trauma/ year Major injuries/ year Train accidents Accident category Class 1 shock/trauma/ year Fatalities/year Table 12: Total risk by accident category Table 13 shows the risk to each person category on YDS. The majority of the risk on YDS can be attributed to the workforce (96%). The remaining 4% of risk is allocated to members of the public and over-carried passengers. The risk to workforce is now 7.3 FWI/year in comparison to the 7.2 FWI/year in SRM-YDS. The absolute risk to members of the public and over-carried passengers is small and therefore susceptible to large percentage changes in risk from year to year as it is based on relatively few events, as can be seen in Table 13 and Table 14. Version 8.1 - Issue 1.1 - December 2014 16 Total risk on the railway Table 13: Total risk by person category Major injuries/ year Class 1 minor injuries/year Class 2 minor injuries/year Class 2 shock/trauma/ year FWI/year % change from SRM-YDS to SRMv8.1 Passenger <0.1 - <0.1 <0.1 0.27 - <0.1 <0.1 -19.1% Workforce 7.28 0.44 47 178 1220 3.3 8.8 7.2 +1.4% MOP 0.33 0.26 0.57 1.4 3.9 0.25 1.0 0.29 +14.9% Total 7.61 0.70 47.6 180 1224 3.58 9.80 7.47 +1.9% Person category Class 1 shock/trauma/ year Fatalities/year SRM-YDS FWI/year SRMv8.1 YDS Table 14 presents the risk broken down into person category and accident categories. The table shows that overall risk due to train accidents (HETs) has increased by 6% but is still a relatively small absolute risk at 0.2 FWI/year. Movement accidents (HEMs) have seen an increase of 0.14 FWI/year which amounts to a 27.9% increase in risk (this is largely a consequence of having a larger pool of data to analyse for SRMv8). Non-movement accidents (HENs) have remained relatively constant. Overall, the total increase in risk from SRM-YDS to SRMv8.1 is 1.9%. Table 14: Total risk to each person category from each accident category SRMv8.1 YDS Accident category Total FWI/year SRM-YDS Passenger FWI/year Workforce FWI/year MOP FWI/year Total FWI/year % change from SRMYDS to SRMv8.1 HET 0.17 - 0.13 <0.1 0.16 +6.0% HEM 0.64 - 0.60 <0.1 0.50 +27.9% HEN 6.80 <0.1 6.5 0.26 6.8 -0.1% Total 7.61 <0.1 7.27 0.33 7.47 +1.9% Figure 4 presents the total risk profile for the different workforce types on YDS sites10. Risk to engineering staff is the highest of all workforce types at 36% of the total YDS risk. Across all workforce types, major injuries are the highest contributors to workforce risk on YDS. 10 Workforce type groups are detailed in the glossary (section 13.2). Version 8.1 - Issue 1.1 - December 2014 17 Version 8.1 - Issue 1.1 - December 2014 Class 2 minor injuries (12.4%) Class 1 shock/trauma (0.7%) Class 2 shock/trauma (0.1%) Fatalities (5.9%) Major injuries (60.1%) Class 1 minor injuries (12.8%) Class 2 minor injuries (21.1%) Total workforce risk = 7.28 FWI/year C Class 1 minor injuries (12.2%) Major injuries (68.6%) Cleaner/ admin (14%) Infrastructure worker (21%) Major injuries (67.4%) Fatalities (6.0%) Class 1 shock/ trauma (0.2%) Class 1 shock/ trauma (0.0%) Class 2 minor injuries (17.0%) Class 1 minor injuries (12.3%) Fatalities (3.2%) Class 2 shock/ trauma (0.2%) Class 1 shock/ trauma (0.0%) Class 2 minor injuries (15.3%) Class 1 minor injuries (11.3%) Fatalities (8.1%) Class 2 shock/trauma (0.1%) Major injuries (65.0%) Driver/shunter (30%) Engineering Staff (36%) Class 1 shock/ trauma (0.0%) Total risk on the railway Figure 4: YDS risk profile for workforce (% of total workforce FWI/year) 18 Total risk on the railway 4.1.3 Estimation of YDS underreporting There is some evidence for underreporting of incidents across the whole of the railway11. For most areas of risk on the mainline railway this is not currently thought to be a significant issue as: Reporting into SMIS is mandatory. RSSB operates a data quality programme for mainline data reporting. Underreported events tend to be less severe and due to the way in which minor injuries are weighted limits their effect on overall FWI risk. However there are specific problems relating to the quality of YDS data. The reporting of events that occur on YDS into SMIS is not mandatory, and some companies do not report any incidents into SMIS at all. Consequentially there are gaps in the data for events on YDS sites. To attempt to address this issue of underreported YDS events, the scale of underreporting has been estimated based on reporting from all freight companies and train maintenance companies, taking into account the size of each company. Of the freight operators who have agreed to provide event data, there is evidence that up until 2008/09 reporting was not complete. However, incident reporting from April 2009 is considered fairly complete and by looking at the level of reporting since then it is possible to estimate what level of reporting would have occurred pre-April 2009 if there had been no underreporting. In doing so, an increased freight-based rate of reporting was estimated, which in turn increased the freight proportion of the overall risk figure. Using this same method, the gaps for other freight reporting have been filled in and scaled accordingly. Estimates can also be made for train maintenance companies. Discussions were held with three of the four train maintenance companies regarding; the scale of their operations, their injury rates and the types and locations of those injuries. One company has also provided some injury data, which has been used to aid the estimates. Based on these discussions and data an estimate was made of the number of injuries that would have been reported had the companies been doing so. An extrapolation from the data that is available can be made to estimate a figure for the risk associated with the missing data. This gives an increase of around 24% in the overall level of risk on YDS sites. If we assume a similar profile of injury types for this missing data we can extrapolate the total risk by this proportion. This gives an overall risk on YDS sites: Estimated total risk = 9.4 FWI/year This provides an estimate of the overall risk on YDS sites (the equivalent figure calculated for the YDS-SRM was 9.2 FWI/year). Note that there is more uncertainty in this estimate than the base figure of 7.6 FWI/year based on the known dataset. The portion of the extrapolated figure that relates to workforce is 9.0 FWI/year (based on the existing ratio of workforce risk to overall risk). 11 Further information on data quality is given in Chapter 10 of the ASPR 2013-14 Version 8.1 - Issue 1.1 - December 2014 19 Total risk on the railway 4.2 Risk by ASPR hazard categorisation The 131 HEs which make up the SRM have been grouped into the 22 accident groups used in the ASPR [Ref. 6] in Table 26 (Appendix B). Combining the HEs in this manner allows identification of the types of accidents that contribute the greatest proportion of risk. 4.2.1 Risk by annual FWI Figure 5 presents the risk profile in FWI/year and indicates the percentage change in risk between SRMv7.5 and SRMv8.1 for each of the 22 HE categories listed above. The greatest overall risk contribution results from Slips, trips and falls with 39.0 FWI/year, an increase of 6% compared with SRMv7.5+YDS. The next-highest risk contribution results from Trespass with 33.6 FWI/year, which is dominated by fatality risk. The majority of risk from Slips, trips and falls occurs to passengers, contributing 27.2 FWI/year, which represents 47% of the overall risk to passengers. After Slips, trips and falls, the category which contributes most to the overall risk to passengers is Assault and abuse, representing 9.6 FWI/year, followed by Platform edge incidents (both boarding/alighting and nonboarding/alighting). Considered together, these four categories account for over 80% of the risk to passengers. The greatest workforce risk also comes from the Slips, trips and falls category (10.2 FWI/year), with the second-highest contribution coming from Contact with object (5.4 FWI/year). Together these categories represent 47% of the risk to the workforce. A large proportion of the risk to the public results from Trespass (33.5 FWI/year), followed by Struck/crushed by train (not trespass) with 6.5 FWI/year. Together they represent 84% of the risk to MOP. For both Figure 5 and Figure 6 the large percentage change in road traffic accident risk is due to significantly improved reporting of this type of event. The large percentage change in trespass event is mainly due to the reclassification of suicide and trespass events as a result of the SRMv8.1 update. 4.2.2 Risk by annual fatalities Figure 6 shows the combined risk by event type in fatalities per year (excluding the contribution from injuries, shock and trauma). Fatality risk is dominated by Trespass accidents, accounting for more than half, with 31.3 fatalities per year down 25% on the SRMv7.5+YDS figure due to the reclassification of a number of suicide/trespass events. The accident type contributing the second-highest number of fatalities is Struck/crushed by train with 8.5 fatalities per year, suggesting these events have remained relatively constant since SRMv7.5+YDS. Together, these two categories account for 72% of all fatalities. The highest contribution to passenger fatalities is Platform edge incidents (not boarding/alighting), which accounts for 3.8 fatalities per year (representing 46% of passenger fatality risk). The most significant contributor to workforce fatalities is Struck/crushed by train, accounting for 1.6 fatalities per year (39% of the workforce fatality risk total). The 31.3 fatalities per year due to MOP Trespass represents 73% of public fatality risk. 4.2.3 Detailed risk profiles More detailed risk profiles for each accident type and person category can be found in the Annual Safety Performance Report 2013/14. Version 8.1 - Issue 1.1 - December 2014 20 6.2 (+9%) Platform edge incidents (not boarding/alighting) Version 8.1 - Issue 1.1 - December 2014 0.40 (-27%) 0.39 (-10%) 0.31 (-9%) Fires and explosions (not involving trains) Lean or fall from train in running Train accidents: other 0.42 (-9%) 0.53 (-19%) Workforce electric shock Contact with person 0.54 (-8%) Train accidents: strikes with objects 1.1 (+10%) Falls from height 1.1 (+7%) 1.2 (+16%) Indirect risk due to suicide Machinery/tool operation 1.2 (+4%) 1.3 (+62%) Road traffic accident Other 1.7 (-8%) 3.5 (-12%) Manual handling/awkward movement Train accidents: collisions and derailments 3.6 (+5%) 6.7 (-4%) Contact with object Train accidents: strikes with road vehicles at level… 6.9 (-4%) On-board injuries 9.0 (+16%) Platform edge incidents (boarding/alighting) 11.8 (+2%) 9.0 (+1%) 10 Struck/crushed by train Assault and abuse Trespass Slips, trips, and falls 0 20 30 Public Workforce Passenger 33.6 (-25%) 39.0 (+6%) 40 Total risk on the railway Figure 5: Risk profile in FWI/year (with % change from SRMv7.5+YDS) 21 Version 8.1 - Issue 1.1 - December 2014 0 0 0 Contact with person Indirect risk due to suicide 0.03 (+10%) 0.06 (-1%) Manual handling/awkward movement On-board injuries Machinery/tool operation 0.16 (-25%) Platform edge incidents (boarding/alighting) 0.29 (-30%) Fires and explosions (not involving trains) 0.17 (-47%) 0.32 (-21%) Workforce electric shock Contact with object 0.32 (-10%) Lean or fall from train in running 0.21 (-5%) 0.32 (-3%) Train accidents: strikes with objects Train accidents: other 0.34 (-3%) 0.62 (+23%) Falls from height Other 0.66 (-67%) 0.87 (+293%) 4 4.3 (+7%) 3.2 (+6%) 2.4 (-13%) 1.4 (-27%) 2 Assault and abuse Road traffic accident Slips, trips, and falls Train accidents: collisions and derailments Train accidents: strikes with road vehicles at level… Platform edge incidents (not boarding/alighting) Struck/crushed by train Trespass 0 6 8 Public Passenger Workforce 8.5 (+1%) 30 31.3 (-25%) 32 Total risk on the railway Figure 6: Risk profile in fatalities/year (with % change from SRMv7.5+YDS 22 Key risk areas 5 Key risk areas Effective safety planning requires a detailed understanding of risk areas – the activities or circumstances where the safety risk profile for passengers, the workforce, and the public is the greatest. This allows resources and effort to be concentrated where they will have the greatest impact. Though it is no longer produced, the SSP [Ref. 7] considered nine key risk areas (KRAs) that have been selected from the original breakdown of the SRM into 15 risk areas. These nine KRAs represent the top 98% of the overall SRM risk (and the percentage has remained the same since SRMv7.5) and are thus considered to be the key to understanding the causes of risk in the rail industry. A complete breakdown of the SRMv8.1 figures into the 15 risk areas is shown in Table 15 and diagrammatically in Figure 7 (the KRAs are indicated in both). These figures do not include YDS risk. Table 15: Grouped risk figures for SRMv8.1, not including YDS risk Risk area group Engineering Risk in FWI/year (% of SRMv8.1) 4.48 (3.4%) Infrastructure 2.47 % of SRMv8.1 risk (excluding YDS) (FWI/yr) 1.87% Level crossing 0.20 Rolling stock Risk areas (key risk areas in bold) SRMv8.1 risk (excluding YDS) (FWI/yr) SRM v7.5 risk (FWI/ yr) Change from SRMv7.5 to SRMv8.1 3.04 -19% 0.15% 0.23 -11% 1.81 1.37% 2.09 -13% Environment 0.23 (0.2%) Adjacent property/land 0.04 0.03% 0.03 +14% Weather 0.19 0.14% 0.18 +5% Passengers 28.0 (21%) In stations 24.7 18.7% 23.1 +7% On trains 3.32 2.52% 3.02 +10% Crime 46.3 35.1% 57.3 -19% General 2.02 1.53% 1.44 +14% 7.26 5.51% 6.80 +7% 3.63 2.75% 3.58 +1% 0.12 0.09% 0.06 +108% Signaller 0.68 0.52% 0.78 -13% Station staff 17.8 13.5% 16.6 +7% Track worker 14.0 10.6% 13.6 +3% Train crew 7.43 5.63% 7.38 +1% Public behaviour Workforce Total 59.3 (44.9%) 40.0 (30%) Pedestrian user Level Road crossings vehicle user Shunter 132.0 Version 8.1 - Issue 1.1 - December 2014 132.0 139.2 23 Key risk areas Figure 7: Breakdown of SRMv8.1 (excluding YDS risk) by risk area Level crossing 0.2% Infrastructure 1.9% Total Risk = 131.95 FWI/year Rolling stock* 1.4% Adjacent property/land 0.03% Weather 0.14% Train crew* 5.6% Track worker* 10.6% Workforce 30.3% Station staff* 13.5% In stations* 18.7% Passengers 21.2% Engineering 3.4% Environment 0.2% On trains* 2.5% Signaller 0.5% Shunter 0.1% Level crossing* RV user + Pedestrian user 8.2% RV user 2.8% Pedestrian user 5.5% General 1.5% Public behaviour 44.9% Crime* 35.1% *Indicates that the risk area was one of the nine KRAs reported in the SSP 2009-2014. The 15 risk areas relate to the sources of risk. For example the Infrastructure worker risk area relates to the risk that arises from infrastructure workers carrying out their activities and their behaviour in doing so, rather than the risk to infrastructure workers in their role. This means that the risk areas relate to the causes of the SRM precursors. In some cases, where a precursor has more than one cause, it has been necessary to assign proportions of the precursor risk between two or more risk areas. Appendix C gives full details of how the figures in Table 15 have been derived – it lists all of the precursors making up each of the risk areas and gives the proportions that have been applied for any precursor split between two or more risk areas. The 15 risk areas can be further grouped into five higher level risk area groups – namely engineering, environment, passenger behaviour, public behaviour and workforce behaviour. These groupings can also be seen in Table 15. Table 15 provides information to the industry regarding the significant causes of HEs. Precursors, by definition, are the main contributors to the HEs that ultimately lead to harm. Targeting the precursors through effective management actions will lead to a reduction in risk for all associated HEs. Version 8.1 - Issue 1.1 - December 2014 24 Key risk areas 5.1 Other risk groupings It is also useful to group the HE and precursor into high level groups that relate to specific causes or areas of risk on the railway. Significant risk groupings include track faults, rolling stock, signals passed at danger (SPADS) and level crossings. Table 16 provides a summary of the top level figures for a variety of groupings concerning these four broad categories. It should be noted that these groupings are not mutually exclusive and the same precursor risk contribution may be counted in more than one group. Table 16: Selected SRMv8.1 risk groupings Group description Track faults - grouped for both passenger and non-passenger trains (outside possession) Passenger train risk (FWI/year) Nonpassenger train risk (FWI/year) Total Risk (FWI/year) - - 1.75 Track faults (including incidents inside possession) 1.67 0.11 1.77 Rolling stock faults 3.32 0.50 3.82 SPADs resulting in collision 0.36 0.24 0.60 SPADs resulting in derailment or level crossing collision 0.06 0.03 0.09 Other SPADs and runaways 0.01 0.27 0.28 - - 11.21 3.19 0.42 3.61 Footpath crossings - - 3.30 Non-footpath level crossings - - 7.60 All level crossings Road vehicles at level crossings To accompany this chapter a detailed breakdown of risk by key risk areas is provided in Table C1, C2 and C3 which are available via the via the RSSB Rail Risk Portal www.safetyriskmodel.co.uk Version 8.1 - Issue 1.1 - December 2014 25 SRM risk vs observed risk SRM risk vs observed risk 6 The level of safety risk estimated by the SRM is often higher than the observed rate of harm. This is because the SRM accounts for rare events and the small contributions from many different types of rare events add up to make an annual average modelled risk that is usually higher than that which is observed. This holds despite the volatility in observed FWI and the multi-year risk smoothing used in the SRM to reduce this volatility. This is particularly the case for passenger risk as shown in Figure 8. This chart is an attempt to show how the total observed passenger risk has changed over the last nine years and over CP4. The blue line represents an annual moving average of all observed FWI normalised by passenger train km. This is calculated using all of the FWI data reported in the ASPR excluding passenger assaults. Risk from passenger assaults has been estimated using BTP data because such events are not well reported in SMIS. This includes all reported injuries in train accidents as well as movement and non-movement related accidents. The green line shows a risk metric that attempts to mimic the modelling of the SRM. This is done by selecting different periods to average the different injury types over. The chart shows fatalities averaged over ten years, major injuries over 2.5 years, class 1 and class 2 minor injuries over four years. This is mostly based on data except, unlike the blue line, the FWI contributions for HETs and passenger assaults are determined from the SRM modelling. This is a significant simplification of the SRM and should be seen as a rough approximation. Figure 8 shows the change in different measures of risk over the past nine years and illustrates the volatility of taking a one-year average of observed risk compared to the relatively less volatile SRM risk. Some key observations are: SRM risk estimation is nearly always higher than that of observed risk. The occurrence of a major accident may temporarily push the rate of observed risk higher than the SRM risk estimation (Grayrigg) or closer to the SRM risk estimation (Ufton Nervet). There has been a long term trend of decreasing risk, which is becoming less pronounced and may now have started to plateau. Because of the difficulty, without hindsight, of differentiating between genuine trends/turning points and short-term statistical variation, and with the requirement for a data sample large enough to produce robust risk estimates yet relevant to current operations, the SRM estimates will lag during periods when the risk profile is changing. The extent to which they lag is dependent on the time period used in the modelling and this will vary from HE to HE. Version 8.1 - Issue 1.1 - December 2014 26 Version 8.1 - Issue 1.1 - December 2014 Grayrigg SRMv6.7 SRMv8.1 2004 2005 2007 SRM approximation 2006 2009 2010 Observed FWI (moving 12-month average) 2008 2011 SRM results 2012 2013 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 Ufton Nervet SRM risk vs observed risk Figure 8: Passenger observed FWI vs SRM FWI approximation 27 Normalised passenger risk Uncertainty in the SRM risk estimates 7 Uncertainty in the SRM risk estimates 7.1 Introduction The SRM risk estimates represent the underlying level of risk on the GB rail network. They are based on an analysis of data reported to SMIS, which is classified according to the HE and precursor structure of the SRM. The amount of data for each precursor in the SRM can vary quite considerably. In some cases, there is a lot of data to base a precursor estimate on, in other cases there is little or very little, and in some cases there is none. The SRM precursor/HE estimates represent the best estimate of risk based on the available data for that precursor/HE. For cases where there is a lot of data available, there is a high level of confidence in the estimations, however, where there is little data, there is less confidence in the estimate. It has been a long standing aim to quantify this level of uncertainty and to develop a framework that can determine selected confidence intervals around the SRM estimates. This section gives some background to the work that has been undertaken in this area, outline the methodology that is currently being developed and presents some results based on the version 8.1 update. 7.2 Uncertainty methodology In 2003, RSSB commissioned research to investigate quantification of the uncertainty in a risk assessment model, using the SRM as an example. This research formed R&D project T306 [Ref. 8]. While methods investigated apply primarily to the train accident (HET) models (as they are built using fault and event tree models), the principles can be equally applied to the other models of the SRM. The main difference between the HET models and the HEM/HEN models is that in general the HEM/HEN models are based on significant amounts of actual injury-related data, while the HET models are not. This means that the HET uncertainty methodology is mainly aimed at quantifying model uncertainty in conjunction with statistical uncertainty due to the lack of data. The HEM/HEN methodology focus, however, can be aimed more at quantifying statistical uncertainty, as there is ample data. The occurrence of a hazardous event and the consequences associated with it can be regarded as random. This means that there is inherent uncertainty in the SRM estimates, and year to year it could be expected that different event counts and consequences would be observed for a given hazardous event even if the ‘underlying risk’ did not change. The aim of the uncertainty methodology is to quantify this uncertainty and determine relevant confidence intervals within which we would expect the true value of the SRM estimates to lie given a specified level of confidence. The main part of the methodology consists of quantifying the uncertainty in the frequency and in the average consequence estimates for each precursor. This involves constructing distributions (either from data or expert judgement, or a mixture of the two) for each of these factors. Once these have been set, a simulation can be run, where frequency and consequence estimates are sampled from the distributions many thousands of times and combined to give a distribution of the risk estimates for each precursor. Subsequently, these can be sampled to give distributions of the risk at HE level, HEM/HEN level or at the overall SRM system risk level which can be used to determine confidence intervals. Version 8.1 - Issue 1.1 - December 2014 28 Uncertainty in the SRM risk estimates 7.3 SRM uncertainty results The uncertainty methodology currently in development has been applied to the version 8.1 HEM/HEN risk estimates. YDS risk has been included, while HET risk has been excluded from this analysis. Excluding the HET contribution gives an overall SRM combined HEM/HEN risk of 131.6 FWI per year. Comparison between the uncertainty model and the SRM risk estimates are given in Table 17 (values in this table exclude all HET risk). Table 17: Comparison of SRM and uncertainty model risk estimates SRM risk group SRM estimate (FWI/yr) Overall Uncertainty model distribution mean (FWI/yr) 131.6 132.9 HET Not shown Not calculated HEM 49.6 50.0 HEN 82.0 82.8 Passengers 55.6 55.8 Workforce 32.2 32.5 MOPs 43.8 44.5 It should be noted that the uncertainty and confidence intervals in this section are based on statistical uncertainty and do not take into account other potential sources of error such as modelling assumptions (many models implicitly assume that the risk has been relatively stable for the past few years) and data quality, particularly the underreporting of events. Figure 9: Risk distribution for the total SRMv8.1 HEM/HEN risk SRM 125.8 -7.1 Mean Probability density LL 121 132.9 UL 140.6 7.7 95% 123 125 127 129 131 133 135 Risk (FWI/year) 137 139 141 143 145 Figure 9 shows the 95% confidence interval12 around the overall HEM/HEN risk of 131.6 FWI/year. The boxes above the chart show some properties of the distribution of the risk that 12 A confidence interval indicates the range of values an estimate is likely to lie in given a specified level of confidence. In this case a 95% confidence interval means that if we were to rerun (if this was possible) the whole operation of the railway again, as it was over the SRMv8.1 data period, collect the data and calculate a 95% Version 8.1 - Issue 1.1 - December 2014 29 Uncertainty in the SRM risk estimates has been constructed. The central white box gives the mean (average) value of the distribution and it can be seen that this corresponds well with the overall SRM HEM/HEN risk estimate of 131.6 FWI/year13 (see Table 2). The other two white boxes either side show the extent of the 95% confidence interval, with a lower limit (LL) of 125.8 FWI/year and an upper limit (UL) of 140.6 FWI/year. The blue boxes show the absolute risk difference between the LL/UL and the distribution mean. In this case it can be seen that the UL is 7.7 FWI/year above the mean risk, while the LL is 7.1 FWI/year below the mean risk. Note that all charts are drawn to the same scale on the x axis to allow comparisons between them. Figure 10 shows the 95% confidence interval for HEM risk and HEN risk considered separately, while Figure 11 shows the 95% confidence interval for passenger, workforce and public risk considered separately. Figures for the mean risk of each of these distributions along with the LL and UL of the 95% confidence interval can be read from the white and blue boxes as before. Figure 10: Risk distribution for the SRMv8.1 risk for HEM and HEN separately HEM 44.1 -6.0 Mean Probability density LL 38 50.0 UL 56.8 6.8 95% 40 42 44 46 48 50 52 Risk (FWI/year) 54 56 58 60 62 HEN 79.5 -3.3 Mean Probability density LL 70 82.8 UL 86.2 3.4 95% 72 74 76 78 80 82 84 Risk (FWI/year) 86 88 90 92 94 confidence interval for the overall HEM/HEN risk, we would expect in 19 out of 20 occasions (ie 95% of the time) the confidence interval would contain the true underlying level of risk. 13 This is to be expected from the way the HEM/HEN uncertainty model has been constructed. There is a slight overestimate due to the use of lognormal distributions to model the uncertainty in low event counts. Version 8.1 - Issue 1.1 - December 2014 30 Uncertainty in the SRM risk estimates Figure 11: Risk distribution for the SRMv8.1 risk by person type 53.6 Passenger Mean 55.8 -2.1 Probability density LL 44 20 46 48 31.4 50 52 54 56 58 Risk (FWI/year) 33 60 Workforce Mean 32.5 -1.1 2.1 62 UL 64 66 33.6 68 1.1 95% 22 24 38.1 26 28 30 32 34 Risk (FWI/year) 36 Member of Public Mean 44.5 -6.4 Probability density LL 57.9 95% Probability density LL UL 38 UL 40 42 51.9 44 7.4 95% 35 37 39 41 43 45 47 Risk (FWI/year) Version 8.1 - Issue 1.1 - December 2014 49 51 53 55 57 31 Uncertainty in the SRM risk estimates Note that proportionally, there is more uncertainty in the estimate of HEM risk. This is because HEM risk tends to be dominated by a relatively small number of fatalities, whereas HEN risk tends to be dominated by a greater number of lower consequence events. The same reasoning explains why there is more uncertainty in the estimate of public risk than in the estimates of risk to passengers or members of the workforce. 7.4 Uncertainty analysis next steps The work presented in this chapter is on-going and the results should be treated as preliminary findings, however they do illustrate how the results can be presented. The next steps are to finalise the HEN/HEM uncertainty methodology and to continue to develop the HET methodology. The eventual aim of this work is to construct a framework that can be used to assess the uncertainty in the SRM risk estimates at any level that is required and to present the information in a format that is accessible and understandable. This can help inform decisions. For example, when interpreting benefit-cost ratios to determine whether a measure is needed to ensure safety so far as is reasonably practicable, the judgement as to whether the cost is grossly disproportionate to the benefit is informed by an understanding of the level of uncertainty in the estimates of both. Version 8.1 - Issue 1.1 - December 2014 32 Individual fatality risk 8 Individual fatality risk 8.1 Introduction Individual fatality risk is defined as the probability of a fatality to which a category of individual is exposed. Fatality risk is distinct from FWI risk, because it excludes the component of risk relating to injuries and shock/trauma. The industry document Taking Safe Decisions [Ref. 2] clarifies that collective risk (rather than individual fatality risk) is used in the formulation of arguments about whether a particular measure is needed to ensure risk is acceptable. However, individual risk can help a company understand its risk profile and prioritise safety management effort. Note that the comparisons made in the following sections are between the figures reported in the SRM-RPB version 7 (based on SRMv7), the YDS report (based on the SRM-YDS) and the latest figures for SRMv8.1. Changes between versions shown here are due to both modelling changes and the updating of data to 30 September 2013. 8.2 Fatality risk The predicted individual fatality risk from SRMv8.1 was analysed for each of the person categories listed below: Passengers Workforce, including: Train drivers (eg passenger train (PT) drivers, freight train drivers, driver/shunters) Other train crew Infrastructure workers Other workforce (eg train dispatch and ticket line staff) YDS based staff members (engineering staff and YDS cleaner/admin) Members of the public Fatalities on the railway are dominated by suicide and trespass, together amounting to 56.5% of the total fatality risk. Excluding these types of event, Figure 12 shows the fatality risk for each person category. In the following sections, the individual fatality risk to each person category is discussed and compared with its equivalent value in SRMv7+YDS. To accompany this chapter a detailed breakdown of individual fatality risk by person group and hazardous event is provided in Table D1 which is available from the RSSB Rail Risk Portal www.safetyriskmodel.co.uk. Version 8.1 - Issue 1.1 - December 2014 33 Individual fatality risk Annual fatalities Figure 12: Fatality risk for each person category per year (SRMv8.1) 14 11.61 Fatalities per year 12 8.30 Fatalities 10 per year 8 4.22 Fatalities per year 6 4 2 0 Passenger 8.3 Workforce Public Passengers Of the population of train passengers, regular commuters have the greatest exposure to risk from the railway environment. The individual fatality risk to a commuter is therefore assumed to be indicative of the worst-case for the whole population of train passengers14. Figure 13: Causal breakdown of passenger fatality risk Platform edge incidents (not boarding/alighting) Train accidents: collisions and derailments 45.8% 20.6% Slips, trips, and falls 11.5% Assault and abuse 7.3% Struck/crushed by train 6.4% All other risk categories 8.4% 0 1 2 Annual fatalities 3 4 It is assumed that, on average, each commuter makes 450 journeys per year (two journeys per day, five days per week for 45 weeks per year). SRMv8.1 predicts a probability of fatality of 1 in 403,976 per year for the average passenger (Table 18), which is a reduction of 33.6% compared with the corresponding risk in SRMv7+YDS. This large reduction in individual fatality risk is due in part to the increase in passenger journeys and partially due to a reduction in observed and modelled fatality risk resulting from assaults and passenger train derailments. As assault risk was not recalculated using the SRMv7 data cut-off the reduction in observed fatalities is not directly comparable. 14 Whilst it is logical to do this, analysis has shown that per journey, regular commuters have a lower level of risk than other travellers. This worst case should be seen as a best guess approximation. Version 8.1 - Issue 1.1 - December 2014 34 Individual fatality risk The most significant contributions to passenger individual fatality risk are broken down in Figure 13. Table 18: Total passenger individual fatality risk SRMv8.1 SRMv7+YDS % change v7+YDS to v8.1 Fatality risk per year 8.30 10.44 -20.49% Annual passenger journeys 1,508,403,942 1,259,400,000 Population size (assuming each person undertakes 450 journeys per year) 3,352,009 2,798,667 2.48E-06 3.73E-06 1 in 403,976 1 in 268,169 Individual fatality risk (probability of a fatality per year per passenger) 8.4 19.77% -33.62% Workforce The total workforce fatality risk calculated in SRMv8.1 was distributed into specific workforce types in order to estimate their individual fatality risk.15 Individual and absolute fatality risks are summarised in Figure 14 and Figure 15. Population numbers for each of these workforce types; estimated from Network Rail (NR) timesheet data (infrastructure workers and OTP drivers), and RSSB surveys of NR and each TOC/FOC (all other workforce groups), are presented in Table 19 along with their individual fatality risk. Comparison of Table 18 with Table 19 shows that individual fatality risk to the workforce is an order of magnitude greater than for passengers. This is in line with the workforce’s increased exposure to the railway environment and the hazardous nature of the work carried out in the rail industry. Note that for SRMv7 ‘OTP driver’ risk was grouped with the ‘Other workforce’ risk. This has been separated out here as the OTP driver risk is observed to be significantly higher than risk for the ‘Other workforce’ group. Therefore there are no comparisons between SRMv7 and SRMv8.1 for these workforce groups. A summary of expected annual fatalities by workforce group is given in Table 27 in Appendix C. 15 During this process a number of assumptions were made, which are detailed in Appendix D.1. Version 8.1 - Issue 1.1 - December 2014 35 Version 8.1 - Issue 1.1 - December 2014 YDS cleaner/admin Other train crew 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 YDS cleaner/admin Other train crew YDS engineering staff Passenger train driver Other workforce Freight train driver Infrastructure worker OTP driver Driver (shunter) 3 2.7 2.4 2.1 1.8 1.5 1.2 0.9 0.6 0.3 0 YDS engineering staff Passenger train driver Other workforce Freight train driver Infrastructure worker OTP driver Driver (shunter) Individual fatality risk per 10,000 years Expected annual fatalities Individual fatality risk Figure 14: Expected annual fatalities by workforce role Expected annual fatalities Figure 15: Individual fatality risk by workforce role Individual fatality risk per 10,000 years 36 Individual fatality risk Table 19: Workforce individual fatality risk breakdown Person Type Expected annual fatalities Population v8 Infrastructure workers 2.399 30,500 OTP drivers 0.129 Individual fatality risk (probability of a fatality per year) SRMv7 or SRMv8 % change YDS-SRM 7.86E-05 9.22E-05 1 in 12,716 1 in 10,847 -15% 8.48E-05 1,525 - - 1 in 11,799 Passenger train drivers 0.473 Freight train drivers 0.136 Other PT crew members 0.204 Other workforce 0.594 13,145 3.60E-05 4.22E-05 1 in 27,805 1 in 23,670 5.74E-05 5.43E-05 1 in 17,432 1 in 18,410 1.54E-05 2.34E-05 1 in 65,117 1 in 42,818 2,378 6% 13,284 16,019 -15% -34% 3.71E-05 - - 1 in 26,960 Driver/shunter 0.120 YDS engineering staff 0.146 YDS cleaner/admin 0.022 8.5 8.96E-05 1.30E-04 1 in 11,161 1 in 7,721 2.29E-05 2.43E-05 1 in 43,652 1 in 41,226 1.04E-05 1.01E-05 1 in 95,757 1 in 99,455 1,338 -31% 6,379 2,123 -6% 4% Members of the public In hazardous industries where all operations occur within a discrete, clearly-defined, geographical location, the numbers of exposed members of the public, and therefore individual fatality risk to the public, can be determined. For the GB railway, however, it is only possible to discuss fatality risk to the public population as a whole. The individual fatality risk to members of the public (excluding suicides and trespass) is equivalent to 11.6 fatalities per year. The most significant contributions to MOP individual fatality risk are broken down in Figure 16. Version 8.1 - Issue 1.1 - December 2014 37 Individual fatality risk Figure 16: Causal breakdown of MOP fatality risk Struck/crushed by train 54.7% Train accidents: strikes with road vehicles at level crossings 25.5% Platform edge incidents (not boarding/alighting) 4.3% Slips, trips, and falls 3.9% Falls from height 3.3% All other risk categories 8.4% 0 2 4 Annual fatalities 6 8 The dominant fatality risk to members of the public (non-trespasser) occurs at level crossings, including all events in the struck/crushed by train category. Individual fatality risk to members of the public (non-trespasser) at levels crossings is equivalent to 9.3 fatalities per year, or 80.2% of the non-trespass total fatality risk. Individual fatality risk estimates for regular crossing users have not been given as it has not been possible to calculate reliable values given the uncertainty in usage data and the large variations in crossing types. Version 8.1 - Issue 1.1 - December 2014 38 The F-N curve 9 Multiple fatality risk: the F-N Curve While there are no specific criteria associated with the acceptability of the frequency of train accidents that could potentially lead to multiple fatalities, it is important to understand the vulnerability of the railway to such accidents. Guidance on taking multiple fatality events into account in the decision making process is given in Taking Safe Decisions. 9.1 F-N results Using the event tree structures within SRMv8.1, for all the train accident hazardous events with the potential to lead to multiple fatalities, an overall F-N curve (frequency versus number of fatalities) for train accidents has been produced. This curve is shown in Figure 17. The curve shows that as the number of potential fatalities associated with an event increases, the frequency of occurrence of the event reduces rapidly. Key points on the curve and information on how the rest has changed between SRM versions are given in Table 20 and Table 21. Table 20: Frequency of train-related incidents leading to multiple fatalities Incidents (events/year) affecting passengers, staff and MOP SRMv2 (Jul-99) SRMv3 (Mar-01) SRMv4 (Dec-03) SRMv5 (Dec-05) SRMv6 (Sep-08) SRMv7 (Sep-10) SRMv8.1 (Sep-13) >=5 fatalities 0.700 0.416 0.265 0.189 0.186 0.173 0.144 >=10 fatalities 0.320 0.180 0.127 0.110 0.065 0.055 0.047 >=25 fatalities [not included] [not included] [not included] 0.021 0.020 0.016 0.011 Table 21: Return periods of train-related incidents leading to multiple fatalities Years between incidents affecting passengers, staff and MOP SRMv2 (Jul-99) SRMv3 (Mar-01) SRMv4 (Dec-03) >=5 fatalities 1.4 2.4 3.8 5.3 5.4 5.8 6.9 >=10 fatalities 3.1 5.6 7.9 9.1 15.3 18.3 21.2 >=25 fatalities [not included] [not included] [not included] 48 50 62 87.0 Version 8.1 - Issue 1.1 - December 2014 SRMv5 (Dec-05) SRMv6 (Sep-08) SRMv7 (Sep-10) SRMv8.1 (Sep-13) 39 Version 8.1 - Issue 1.1 - December 2014 1.00E-07 1.00E-06 1.00E-05 1.00E-04 1.00E-03 1.00E-02 1.00E-01 1.00E+00 2 20 Number of passenger, staff and member of public fatalities 200 The F-N curve Figure 17: The F-N Curve – all person and train accident types. 40 Cumulative frequency (events/year) The F-N curve The continued increase in expected time between train-related incidents that lead to multiple fatalities can be seen from SRMv2 to SRMv8.1 (Figure 18). The more recent reductions are due to a generally improving safety performance trend, as reflected in the SRMv8.1 train accident model results. The reasons for these reductions include many steps that the industry has taken to reduce the likelihood of accidents occurring (eg the introduction of TPWS) and to reduce the consequences if accidents do happen (eg the overall improvement in train vehicle crash-worthiness due to the removal of Mark 1 slam-door rolling stock). There is also likely to be some effect from enhancements to the train accident models over successive SRM versions. Figure 18: Estimated frequency of train accident-related fatality events 0.8 0.7 v2, Jul-99 Frequency (events/year) >=5 fatalities >=10 fatalities 0.6 0.5 v3, Mar-01 0.4 0.3 v4, Dec-03 0.2 v5, Dec-05 v6, Sep-08 v7, Sep-10 v8, Sep-13 0.1 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Figure 19 shows the F-N curve for the three main categories of train accident: collisions, derailments and level crossing accidents. This chart shows that multi-fatality derailment events generally occur more frequently for all severity levels and level crossing events least frequently. Note that these three categories do not cover the entirety of the train accident HEs in the SRM. Figure 20 shows the contribution of key hazardous events to the F-N curve. It is apparent that the majority of events with fewer than 100 fatalities are HET-12 (passenger train derailments) events, whilst the majority of events with 100 or more fatalities (which are estimated to occur very infrequently at a rate of less than 1 per 7500 years) result from HET-13 (non-passenger train derailments) events as a result of train accidents involving trains carrying hazardous materials. Version 8.1 - Issue 1.1 - December 2014 41 Version 8.1 - Issue 1.1 - December 2014 1.00E-09 1.00E-08 1.00E-07 1.00E-06 1.00E-05 1.00E-04 1.00E-03 1.00E-02 1.00E-01 1.00E+00 2 Collisions Derailments 20 Level crossing RV strikes Number of passenger, staff and member of public fatalities 200 The F-N curve Figure 19: F-N curve – plotted separately for three categories of train accidents 42 Cumulative frequency (events/year) The F-N curve Figure 20: Contribution of key hazardous events to the F-N curve 100% Percentage contribution to F-N Curve 90% 80% HET-01 70% HET-02 60% HET-10 50% HET-12 40% HET-13 30% HET-17 20% 10% 0% 2 5 10 30 100 300 Fatalities per event 9.2 F-N modelling approach Only the train accident models have been considered in the F-N curve calculation as these are the main contributors to multiple fatality events. Previous F-N figures have included all HEs, however the contribution for non-train accidents with two or more fatalities to these figures is minimal. SRMv3 F-N results were presented in two versions — with and without the effects of TPWS. For comparison in this section the without TPWS figures have been used, as SRMv3 was produced during the transition period before TPWS had been fully implemented. As in previous SRM versions, the basic F-N analysis suggests that the frequency of accidents leading to 25 fatalities has reduced. However, even though the event trees within the SRM break down the HEs into a large number of different potential outcomes, each consequence estimate still only represents a single average consequence for that outcome. In reality a greater spread of consequences might actually be possible. This is the case, for example, with public fatalities in models involving the spillage of hazardous goods, where the possibility for very high consequence events exists, albeit with a very low frequency. Consequently, while the average risk associated with such outcomes is accurately modelled within the SRM, the full range of higher and lower consequence outcomes that make up this average is not always explicitly modelled. The F-N analysis has been adjusted for high-fatality public events. The adjusted results have been calculated by redistributing the high-fatality portion of public fatality events whilst maintaining the overall level of risk. As a result of the correction, the frequencies of higher fatality events are now considered to be more realistically represented on the F-N curve in SRMv6, SRMv7 and SRMv8.1. Version 8.1 - Issue 1.1 - December 2014 43 Risk at the PTI Remodelling risk at the platform-train interface 10 The update process to SRMv8 has involved the remodelling of several hazardous events that together cover hazards at the platform-train-interface (PTI). The new structure provides more granular information to improve understanding of PTI risk and the assessment of PTI hazards. The following five passenger hazardous events and one member of public (non-trespasser) hazardous event have been remodelled. These are: HEM-05 and HEM-43 (train door closes on passenger/MOP incidents), remodelled to single out ‘trap and drag’ incidents and train movement. HEM-09 and part of HEM-06 (boarding and alighting incidents), restructured and new precursors defined to detail train motion at the time of the event. HEM-06, HEM-08, and HEM-10 (fall from platform and/or struck by train incidents), restructured and new precursors defined to detail train motion at the time of the event. The following sections describe the changes in more detail and explain further some of the motivating factors behind the remodelling. 10.1 Background and objectives High-profile accidents, including at James St in 2011, have focused attention on accidents at the PTI involving train dispatch. Consequently there has been considerable interest in improving the management of the PTI with discussions being held at an Industry Safety Meeting in February 2013 and the ORR/RSSB industry workshop in April 2013. The rail industry has established a PTI Strategy Group which is developing a PTI Strategy focused on optimising safety, capacity and performance issues. To support the work of this group and industry efforts to manage the risk there is a need to better understand risk at the PTI, which this remodelling aims to facilitate. Changes to the PTI model permit more detailed, immediate insight into PTI hazards than has been the case for past SRM versions. 10.2 The remodelling process 10.2.1 Scope of changes The hazardous events considered in this remodelling are all hazardous events which relate specifically to passenger and member of public PTI risk. These hazardous events are given in Table 22. Version 8.1 - Issue 1.1 - December 2014 44 Risk at the PTI Table 22: Remodelled PTI HE descriptions 10.2.2 HE Code Description HEM-05 Train door closes on passenger HEM-06 Passenger falls between stationary train and platform HEM-08 Passenger fall from platform and struck by train HEM-09 Passenger injury while boarding/alighting a train (platform side) HEM-10 Passenger struck by/contact with moving train while on platform HEM-43 Train door closes on MOP (non-trespasser) Remodelling steps The remodelling process can be seen as a compromise between creating a highly detailed model and being able to reliably quantify it using the available accident and incident data. In order to create the new PTI accident models the available accident dataset was analysed with an emphasis on finding what useful information could be reliably extracted from incident narratives. The conclusions of this investigation were then used to decide on a consistent and quantifiable way to restructure the models that would benefit the PTI strategy. The datasets have all been recoded to the new structure and the model was analysed in this new format for SRM v8. 10.2.3 PTI structural changes Table 23 summarises the new model structure for each affected hazardous event. Version 8.1 - Issue 1.1 - December 2014 45 Risk at the PTI Table 23: Remodelled PTIHEs. Summary of changes HE code Description Summary of changes HEM-05 Train door closes on passenger Remodelled to isolate 'trap and drag’ incidents. Now distinguishes between events where the train door has closed on a passenger, and where the train has or has not subsequently moved with the passenger remaining trapped. HEM-06 Passenger fall between train and platform Expanded to segregate three train movement scenarios that are connected to a passenger fall between a train and platform. There are now three sub-hazardous events covering passenger falls involving a stationary train, a moving train and a stationary train which subsequently moves. HEM-08 Passenger fall from platform and struck by train Remodelled so that events are grouped according to the motion of the train (arriving at, departing from, or travelling through the station) at the time of accident. HEM-09 Passenger injury while boarding and alighting Existing boarding and alighting sub-hazardous events have been duplicated to distinguish between events involving stationary and moving trains. Passenger struck by/contact with moving train while on platform This event has been more rigorously defined so it is restricted to events where a passenger has made contact with a moving train while on the platform and has remained entirely on the platform. Events that no longer fit this definition were moved to newly created sub-hazardous events for the other PTI HEMs. HEM-10 A new sub-hazardous event for passenger alighting not at platform has been added. Precursors restructured to separate events according to train motion (arriving at, departing from, or travelling through the station) at the time of accident. HEM-43 10.3 Train door closes on MOP (non-trespasser) This hazardous event is the MOP (non-trespasser) equivalent of HEM-05. Similarly it has been remodelled to isolate 'trap and drag’ incidents. Impact on the risk profile These changes led to some events being re-categorised (for example, moving from HEM-08 or HEM-10 to HEM-06). Table 24 summarizes the hazardous events affected along with the overall change in the modelled risk for version 6.6 to version 6.7 (an equivalent comparison between SRMv7 and SRMv8.1 cannot be provided as results were not computed using the new PTI structure for SRMv7). This table shows that overall risk at the PTI has remained relatively the same but it has shifted between HEs significantly as a result of the remodelling. Version 8.1 - Issue 1.1 - December 2014 46 Risk at the PTI Table 24: Summary of the changes in risk for PTI hazardous events HE HE description HEM-05 Risk (FWI/year) v6.6 v6.7 Train door closes on passenger 0.57 0.66 HEM-06 Passenger fall between stationary train and platform 1.55 2.80 HEM-08 Passenger fall from platform and struck by train 2.19 1.50 HEM-09 Passenger injury while boarding/alighting a train (platform side) 3.35 3.14 HEM-10 Passenger struck by/contact with moving train while on platform 1.32 0.68 HEM-43 Train door closes on MOP (nontrespasser) 0.0021 0.0044 8.99 8.79 Total Version 8.1 - Issue 1.1 - December 2014 47 SRM governance and RPB updates 11 SRM governance and RPB updates 11.1 Data and Risk Strategy Group The Safety Risk Model (SRM) and related tools such as the SRM Risk Profile Tool are now under the remit of the DRSG. This group is a subgroup of the SSRG. Full details of the scope and remit of DRSG can be found on the RSSB website16. 11.1.1 SRM Practitioners Working Group Throughout control period 4, including the production of SRMv8, SRM-PWG was the industry governance body of the SRM. It was set up to facilitate a structured process for eliciting the industry’s views on the development and use of the SRM. The SRM-PWG provided governance for changes to the SRM. The SRM-PWG was formed under the authority of the industry’s Safety Policy Group (SPG) the predecessor to the current System Safety Review Group (SSRG). SRM-PWG’s remit was to engage stakeholders in the development and control of future versions of the SRM and its related outputs. These outputs include the SRM-RPB and SRM-RPT. The modelling changes implemented as part of the update of the SRM to version 8 have been endorsed by SRM-PWG. The re-revised version 6 figures (SRMv6.7) and the SRMv8 figures were presented to the group in March 2014 and recommended for approval by SSRG, which took on responsibility after SPG was disbanded and before DRSG was formed. Following this meeting the results were then presented to SSRG and approved in March 2014. 11.2 Update history Since version 1 in 2001, the SRM-RPB has been updated regularly so that the risk profile remains as current as is reasonably practicable. Since version 2, the SRM-RPB has been issued approximately every 18–24 months. The last SRM-RPB update was for version 7 which was issued August 2011. Since then there have been two shorter versions of the Risk Profile Bulletin, Risk Profile Reports (RPRs) which were: Version 7.5, detailing the SRM v7.5 partial update, The Yards, Depots and Siding Risk Profile Report detailing the development and calculation of the YDS-SRM This RPB version 8.1 is the ninth Bulletin (eleventh including Risk Profile Reports) release and covers SRMv6.7, SRM-YDS and SRMv8.1. The update history up to and including this version is shown in Table 25 below. 16http://www.rssb.co.uk/groups-and-committees/rssb-board/safety/system-safety-risk-group/data-and-risk- strategy-group Version 8.1 - Issue 1.1 - December 2014 48 SRM governance and RPB updates Table 25: SRM update history Version Issue date Data cut-off Major change (from previous version) 1 January 2001 July 1999 First version 2 July 2001 July 1999 Re-release of SRMv1 3 February 2003 March 2001 4 January 2005 December 2003 Full data update and model enhancements Inclusion of TPWS Full data update and model enhancements Full data update and model enhancements 5 August 2006 December 2005 Removal of Mk1 slam-door rolling stock from models Inclusion of OTP risk model Interim partial data update 5.5 May 2008 October 2007 6 June 2009 September 2008 Full data update and model enhancements CP4 HLOS benchmark version 6.5 January 2011 September 2008 Enhanced version 6 7 June 2011 September 2010 Full data update YDS November 2012 September 2011 Introduction and calculation of yards, depots and sidings risk profile 6.6 March 2013 September 2008 Enhanced version 6.5 (required for HLOS comparisons) 7.1 March 2013 September 2010 Enhanced version 7 (required for HLOS comparisons) 7.5 March 2013 June 2012 Interim partial data update 6.7 March 2014 September 2008 Change in FWI weightings Enhanced version 6.6 (required for HLOS comparisons). Model enhancements to allow like for like comparisons with v8. Full data update and model enhancements. 8 March 2014 September 2013 Full incorporation of YDS–SRM into main SRM model. Final CP4 HLOS benchmarking. 8.1 May 2014 September 2013 Version 8.1 - Issue 1.1 - December 2014 Update of suicide and trespass risk models due to improved data accuracy resulting from improved data sharing with BTP. 49 SRM governance and RPB updates 11.3 Updates to the SRM during CP4 Version 8 is the final full update of the SRM required for HLOS metric comparisons across CP4 using SRMv6 figures as benchmarks. Figure 21 illustrates the timeline of SRM updates during CP4. Figure 21: Timeline of updates of the SRM and RPB that occurred in CP4 Version 6 Mar 2009 (risk figures) Jun 2009 (RPB) 2009 Version 7 Mar 2011 (risk figures) Jun 2011 (RPB) 2010 2011 Version 7.5 Dec 2012 (risk figures) Mar 2013 (RPR) 2012 CP4 11.4 2013 Version 8 Mar 2014 (risk figures) Aug 2014 (RPB) 2014 2015 CP5 Future updates during CP5 Moving into CP5 there is no longer the requirement to use the SRM to track industry progress against HLOS targets. SRM-PWG has been disbanded with DRSG taking its place. As a result of this, future plans for the development of the SRM are being discussed and a strategy is currently being developed. Version 8.1 - Issue 1.1 - December 2014 50 Contributors 12 Contributors Details of the preparation and approval of the SRM and SRM-RPB are given below: Prepared by: Carol Bloxsome Steven Burke Stuart Carpenter Marcus Dacre Joanna Evans Alex Gilchrist Ben Gilmartin Jonathan Gregory Chris Harrison Alex Healy Jay Heavisides Matthew Hunt Rachael Johnson Albert Law Reuben McDonald Paul Murray Kevin Thompson Reviewed by: George Bearfield Marcus Dacre Chris Harrison SRMv8 and SRMv6.7 scope and update changes were endorsed by the SRM Practitioners Working Group on behalf of the SSRG. Approved by: George Bearfield Release date: August 2014 Correspondence may be sent to: RSSB Block 2, Angel Square 1 Torrens St London EC1V 1NY UK Or: risk@rssb.co.uk Version 8.1 - Issue 1.1 - December 2014 51 Acronyms and glossary 13 Acronyms and glossary 13.1 Acronyms ABCL Automatic barrier level crossing, locally-monitored AHB Automatic half-barrier (level crossing) ALCRM All Level Crossing Risk Model AOCL+B Automatic open level crossing, locally-monitored (with half barrier) ASPR Annual Safety Performance Report BTP British Transport Police CP4/CP5 Control period 4/5 CSM RA Common Safety Method on Risk Evaluation and Assessment DfT Department for Transport DRSG Data and Risk Strategy Group FP Footpath level crossing FWI Fatalities and weighted injuries GB Great Britain HE Hazardous event HLOS High-level output specification HSE Health and Safety Executive KRA Key risk area LC Level crossing LUL London Underground Ltd MCB Manually-controlled barrier level crossing MCB+OD Manually-controlled barrier level crossing with obstacle detector MCG Manually-controlled gate level crossing MOP Members of the public NR Network Rail OC Open level crossing ORR Office of Rail Regulation POS Inside possession PTI Platform-train interface RGS Railway Group Standards RIDDOR The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 RMF Risk Management Forum Version 8.1 - Issue 1.1 - December 2014 52 Acronyms and glossary RSSB Rail Safety and Standards Board SMIS Safety Management Information System SPAD Signal passed at danger SPG Safety Policy Group SRM Safety Risk Model SRM-PWG Safety Risk Model Practitioners Working Group SRM-RPB Safety Risk Model: Risk Profile Bulletin SRM-RPT Safety Risk Model: Risk Profile Tool SSP Strategic Safety Plan SSRG System Safety Risk Group TABS Track Access Billing System TfL Transport for London TPWS Train Protection and Warning System UWC(+T) User-worked level crossing (+telephone) VPF Value of preventing a fatality YDS Yards, depots and sidings 13.2 Glossary The following list describes terms as they are used in the SRM. acceptable level of risk The CSM RA defines risk acceptance principle to mean: “the rules used in order to arrive at the conclusion whether or not the risk related to one or more specific hazards is acceptable”. It also defines safety measures to mean: “a set of actions either reducing the frequency of occurrence of a hazard or mitigating its consequences in order to achieve and/or maintain an acceptable level of risk”. The risk acceptance principles are explained in detail in Taking Safe Decisions [Ref. 2] ACTRAFF A database for recording actual traffic movement across the network. assault SMIS records incidents in which ‘in circumstances related to their work, a member of staff is assaulted, threatened or abused, thereby affecting their safety or welfare’. BTP records and categorises criminal assaults in accordance with Home Office rules. For the majority of RSSB’s work, BTP crime codes have been grouped into higher level categories to facilitate analyses and comparisons with SMIS records. Version 8.1 - Issue 1.1 - December 2014 53 Acronyms and glossary awkward movement An injury caused by an unusual body movement, eg twisting or stretching, which is received in the course of carrying out normal everyday activities. It excludes any injuries received from lifting or carrying objects which are classified under manual handling. child A person aged 15 years or below. cleaner/admin staff All those workers who are not engineering and maintenance staff, and who are not involved in shunting/driving activities. It is specifically directed at those engaged in cleaning and train servicing activities that do not actually involve any physical maintenance work, plus those supervisors and administration staff who are occasionally on the shop floor or in the yard. collective risk The aggregate risk, possibly for a range of different groups, associated with their exposure to a particular scenario or hazardous event. The SRM calculates collective risk as the average number of fatalities, or FWI/year that would be expected to occur from a hazardous event, or group of hazardous events. When undertaking an assessment of whether or not a measure is necessary to reduce risk to a level that is acceptable, the change in risk associated with the measure is a collective risk estimate. consequence The amount of safety harm directly caused by a hazardous event. This is quantified in terms of fatalities, injuries and occurrences of shock and trauma. control measure Any means to reduce the frequency of a hazardous event and/or minimise the consequence following its occurrence. Control measures may be physical devices, procedures, or a system of both. driver/shunter Drivers of trains undertaking shunting manoeuvres (and entering/exiting the site) on YDS sites, and the shunters that assist in those manoeuvres on the ground. engineering staff All workers who are undertaking engineering and maintenance work (including maintenance during train servicing) on trains and train-related components on a YDS site. This also includes fitters and machine operators, loading workers (freight) and other workers on the site involved in operational rail activities that do not fit into other categories. Version 8.1 - Issue 1.1 - December 2014 54 Acronyms and glossary escalation factor Any failure which significantly increases, or ‘escalates’, the consequence of a hazardous event. For instance, a train derailment (the hazardous event) could escalate into a bridge collapse onto the train, a fire or release of hazardous goods. An escalation factor may be a system failure, sub-system failure, component failure, human error, physical effect or operational condition. It may occur individually, or in combination with other escalation factors. fatalities and weighted injuries (FWI) The aggregate amount of safety harm. One FWI is equivalent to: one fatality, or 10 major injuries, or 200 Class 1 minor injuries, or 200 Class 1 shock/trauma events, or 1,000 Class 2 minor injuries, or 1,000 Class 2 shock/trauma events. fatality Death occurs within one year of the accident. frequency The rate of occurrence (eg the number of events per year). hazardous event (HE) An incident that has the potential to be the direct cause of safety harm. HLOS A key feature of the access charges review. Under Schedule 4 of the 2005 Railways Act, the Secretary of State for Transport (for England and Wales) and Scottish Ministers (for Scotland) are obliged to send to ORR a high level output specification (HLOS) and a statement of funds available, to ensure the railway industry has clear and timely information about the strategic outputs that Governments want the railway to deliver for the public funds they are prepared to make available. ORR must then determine the outputs that Network Rail must deliver to achieve the HLOS, the cost of delivering them in the most efficient way, and the implications for the charges payable by train operators to Network Rail for using the railway network. individual fatality risk The probability of fatality per year to which an individual is exposed from the operation of the railway. Individual risk is a useful notion when organisations are seeking to benchmark their risk profile and to prioritise safety management effort. The ORR categorises individual risk as ‘unacceptable’, ‘tolerable’ and ‘broadly acceptable’ for the purposes of prioritising its enforcement activity. Version 8.1 - Issue 1.1 - December 2014 55 Acronyms and glossary infrastructure worker A member of the workforce whose responsibilities include engineering or technical activities on or about the track. This includes track maintenance, civil structure inspection, signalling and telecommunications renewal/upgrade, engineering supervision, acting as a controller of site safety, hand signaller or lookout and machine operation. level crossing A junction between a road, footpath, bridleway etc and the railway, where both are at ground-level. mainline railway Any location that is connected to the running lines but is not a YDS site major injury Injuries to passengers, staff or MOP as defined in Schedule 1 of RIDDOR. This includes losing consciousness, most fractures, major dislocations, loss of sight (temporary or permanent) and other injuries that resulted in hospital attendance for more than 24 hours. 1 FWI is equivalent to 10 major injuries. minor injury Class 1: Injuries to passengers, staff or MOP, which are neither a fatality nor a major injury, and: For passengers or MOPs, result in the injured person being taken to hospital from the scene of the accident (as defined as reportable in RIDDOR 1995 amended April 2012). For workforce, result in the injured person being incapacitated for their normal duties for more than three consecutive calendar days, not including the day of the injury. Class 2: All other physical injuries that are not Class 1, but must still be reported in SMIS for compliance with GE/RT8047 [Ref. 9] 1 FWI is equivalent to 200 Class 1 minor injuries, or 1000 Class 2 minor injuries. movement accident (HEM) An accident causing injury to people, involving trains (in motion or stationary) but excluding injuries sustained in train accidents, which occurs within the scope of the SRM. non-movement accident (HEN) An accident causing injury to people, unconnected with the movement of trains, which occurs within the scope of the SRM. operational incident An irregularity affecting, or with the potential to affect, the safe operation of trains or the safety and health of persons. The term operational incident applies to a disparate set of human actions involving an infringement of relevant rules, regulations or instructions. Version 8.1 - Issue 1.1 - December 2014 56 Acronyms and glossary operational railway All railway lines for which the infrastructure manager has been granted a safety authorisation, and the railway undertaking has been granted a safety certificate by the ORR (under European Safety Directive 2004/49/EC [Ref. 5]). This provides evidence that there is a suitable safety management system (SMS) in place, and that operations are being conducted in accordance with that SMS. Ovenstone criteria An explicit set of criteria, adapted for the railway, which provides an objective assessment of suicide if a coroner’s verdict is not available. The criteria are based on the findings of a 1970 research project into rail suicides and cover aspects such as the presence (or not) of a suicide note, the clear intent to commit suicide, behavioural patterns, previous suicide attempts, prolonged bouts of depression and instability levels [Ref. 10]. outcomes The range of scenarios that could arise following the occurrence of a hazardous event. passenger A person on railway infrastructure, who either intends to travel on a train, is travelling on a train or has travelled on a train or has been over carried to a YDS site after a train has been taken out of service. This does not include passengers who are trespassing or who commit suicide — they are included in the SRM as MOP. possession (POS) The complete stoppage of all normal train movements on a running line or siding for engineering purposes. This includes protection as defined by the Rule Book (GE/RT8000) [Ref. 9]. precursor 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. probability The likelihood of an event occurring on demand. public, members of (MOP) Persons other than passengers or workforce members. This includes passengers who are trespassing (eg when crossing tracks between platforms), or attempting to commit suicide. Any authorised visitors to a YDS site, except those who work for, or are under contract to, the company who manages the site, are considered to be MOP. Version 8.1 - Issue 1.1 - December 2014 57 Acronyms and glossary railway infrastructure All structures within the boundaries of Network Rail’s operational railway, including the permanent way, land within the lineside fence and plant used for signalling or exclusively for supplying electricity for railway operations. It does not include stations or YDS that are owned by, or leased to, other parties. It does, however, include the permanent way at stations and plant within these locations. residual risk The level of risk remaining with the current risk control measures in place and with their current degree of effectiveness. RIDDOR The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 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. (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) risk Risk is the potential for a known hazard or incident to cause loss or harm; it is a combination of the probability and the consequence for that event. Safety Management Information System (SMIS) 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 131 individual models, each representing a type of hazardous event. shock/trauma Class 1: Shock or trauma results from being involved in, or witnessing, events that have serious potential of a fatal outcome, eg train accidents such as collisions and derailments, or personal accidents such as being struck by a train. Class 2: Shock or trauma results from other causes, such as verbal abuse, near misses, or personal accidents of a typically non-fatal outcome. 1 FWI is equivalent to 200 Class 1 S/T injuries, or 1000 Class 2 S/T injuries. Version 8.1 - Issue 1.1 - December 2014 58 Acronyms and glossary signal passed at danger (SPAD) 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. Full definitions are available from GO/RT3119 [Ref. 9]. Strategic Safety Plan (SSP) This is a joint statement by the companies responsible for Britain’s mainline rail network setting out and agreed industry approach to managing safety. The 2009-2014 plan was developed by bringing together commitments made by individual companies in their own individual safety plans, thus creating a link with the duty holder planning process. In the plan, trajectories have been developed which describe the industry’s ambitions in nine key risk areas and identify actions that are being undertaken to achieve them [Ref. 7]. suicide and suspected suicide A fatality is classified as a suicide according to a coroner’s verdict. 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 the Ovenstone criteria. The consequences of suicide events are split into direct risk (injuries to the suicidal person) and indirect risk (injuries to persons who observe the event or are injured in any associated accident). train Any self-powered vehicle, or vehicles hauled by a selfpowered vehicle, with flanged wheels on guided rails. train accident (HET) Reportable train accidents as defined in RIDDOR. The main criterion is that the accident must be on or affect the running line. There are additional criteria for different types of accident, and these may depend on whether the accident involves a passenger train. Train Protection and Warning System (TPWS) 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. trespass An occurrence of a person entering a location where they are never authorised to be. This is distinct from a person behaving inappropriately at a place where they are allowed to be under certain conditions (eg level crossing violations/errors). workforce Persons working for the industry on railway operations, either as direct employees or under contract. Version 8.1 - Issue 1.1 - December 2014 59 Acronyms and glossary YDS site Any location that is connected to but away from the running lines, where train maintenance, stabling, marshalling and/or servicing (including refuelling) takes place. Version 8.1 - Issue 1.1 - December 2014 60 References 14 References [Ref. 1] HLOS Safety Metrics – baseline and progress metrics following completion of the update of the SRM to version 8. Report delivered to SRM-PWG 27th March 2013. [Ref. 2] RSSB (2014) Taking Safe Decisions — How Britain’s railways take decisions that affect safety. http://www.rssb.co.uk/Library/risk-analysis-and-safetyreporting/2014-guidance-taking-safe-decisions.pdf [Ref. 3] Network Rail (2012) Strategic Business Plans 2014-2019. http://www.networkrail.co.uk/publications/strategic-business-plan-for-cp5/ [Ref. 4] RSSB (2012) Yards, Depots & Sidings Risk Profile Report, version 1. www.safetyriskmodel.co.uk [Ref. 5] European Railway Safety Directive 2004/49/EC. http://www.dft.gov.uk/pgr/rail/Safety/ersd [Ref. 6] RSSB (2014) Annual Safety Performance Report 2013/14. [Ref. 7] RSSB (2009) The Railway Strategic Safety Plan 2009–2014. http://www.rssb.co.uk/safety/Pages/default.aspx [Ref. 8] Cheng D., 2009, Uncertainty Analysis of Large Risk Assessment Models with Applications to the Rail Safety & Standards Board Safety Risk Model. Glasgow: Strathclyde University. http://strathprints.strath.ac.uk/13400/ [Ref. 9] Information on railway group standards, guidance notes and similar is available at: http://www.rgsonline.co.uk [Ref. 10] Ovenstone, I.M. (1973) A psychiatric approach to the diagnosis on suicide. British Journal of Psychiatry, 123 (572), pp15–21. Version 8.1 - Issue 1.1 - December 2014 61 Appendices Appendix A. SRM outputs The outputs from the Safety Risk Model are available via the RSSB Rail Risk Portal www.safetyriskmodel.co.uk. The following tables of results are available: Table A1 which gives a breakdown of risk at the sub-hazardous event level. Table B1 which provides the most detailed breakdown of risk to the precursor level. Table A2 which gives reasons for the changes in risk from version 7 to version 8/8.1. Table C1 which contains the full breakdown of the SRM at precursor level into the Key Risk Areas as summarised in Table 15. Tables C2 and C3 which contain the breakdown of the SRM by Key Risk Grouping as summarised in Table 16. Table D1 which details individual fatality risk by person group and hazardous event summarised in Chapter 8. Table E1 details the normalisation data used in the calculation of SRMv8.1, the sources of that data and an explanation of changes from v7 normalisers. Tables are provided as .xls files, other formats are available on request. Version 8.1 - Issue 1.1 - December 2014 62 Appendices Appendix B. ASPR hazardous event groupings Table 26: Accident groups used within the ASPR Accident grouping Description of the types of event contained within grouping Hazardous events Assault and abuse All types of assault, verbal abuse and threat. Also includes unlawful killing. HEN-64, HEN-65, HEN-66 Contact with object Any injury involving contact with objects, not covered by another category. HEM-20, HEM-32, HEM-42, HEM-45, HEN-21, HEN-23, HEN-26, HEN-44, HEN-55, HEN-56, HEN-59, HEN-76, HEN-79, HEN-80 Contact with person Injuries due to bumping into, or being bumped into by, other people. Excludes assaults. HEN-55, HEN-56 Falls from height Generally speaking, falls of more than 2m. Excludes falls down stairs and escalators. HEN-15, HEN-25, HEN-45, HEN-78 Fires and explosions (not involving trains) Fires or explosions in stations, lineside or other in scope locations. HEN-01, HEN-02, HEN-03, HEN-04, HEN-05, HEN-48, HEN-49 Indirect risk due to suicide Second party injuries arising from suicide, suspected suicide and attempted suicide. HEM-31, HEN-77 Lean or fall from train in running Injuries resulting from accidental falls from trains, or from leaning from trains. HEM-03, HEM-07, HEM-15, HEM-17 Machinery/tool operation Injuries from power tools, being trapped in machinery, or track maintenance equipment. Does not include injuries due to arcing. Does not include injuries due to being struck by things thrown up by tools or from carrying tools/equipment. HEN-22, HEN-27, HEN-56 Manual handling/awkward movement Strains and sprains due to lifting or moving objects, or awkward movement. Excludes injuries due to dropping items being carried, which are classed under contact with objects. HEN-73, HEN-74, HEN-82, HEN-83 On-board injuries All injuries on trains, excluding train accidents, assaults, and those occurring during boarding or alighting, or whilst leaning from trains. HEM-38, HEM-39, HEM-48, HEN-62, HEN-63 Platform edge incidents (not boarding/alighting) Accidents that involve falls from the platform (with or without trains being present) or contact with trains or traction supplies at the platform edge. Excludes accidents that take place during boarding or alighting. HEM-05, HEM-06, HEM-09, HEM-16, HEM-21, HEM-22, HEM-23, HEM-43, HEN-84 Platform-train interface (boarding/alighting) Accidents occurring whilst getting on or off trains. Includes falls between train and platform where it is not known if the person is boarding or alighting. HEM-06, HEM-08, HEM-10, HEM-21, HEM-40, HEM-41, HEM-49, HEN-09, HEN-10, HEN-13, HEN-52, HEN-67 Version 8.1 - Issue 1.1 - December 2014 63 Appendices Accident grouping Description of the types of event contained within grouping Hazardous events Road traffic accident All accidents directly resulting from road traffic accidents, apart from road vehicle incursions not at LC. HEN-35 Slips, trips, and falls Generally speaking, falls of less than 2m at any in scope location (except on trains), and falls of any height down stairs and escalators. HEN-14, HEN-16, HEN-24, HEN-25, HEN-46, HEN-68, HEN-78, HEN-80 Struck/crushed by train All incidents involving pedestrians struck/crushed by trains, excluding trespass, platform edge and boarding and alighting accidents. HEM-11, HEM-14, HEM-19, HEM-27, HEM-45 Train accidents: collisions and derailments Collisions between trains, buffer stop strikes and derailments (excluding those caused by striking road vehicles at level crossings). HET-01, HET-02NP, HET-02P, HET-03, HET-06, HET-09, HET-12, HET-13, HET-26, HET-27 Train accidents: other Train divisions, train fires, train explosions, structural damage affecting trains. HET-17, HET-20, HET-21, HET-22, HET-23, HET-24, HET-25 Train accidents: striking objects Train striking an object, including road vehicles not at level crossings and trains hit by missiles. Excludes derailments. HET-04 Train accidents: striking road vehicles at level crossings Includes derailments. HET-10, HET-11 Trespass First-party injuries resulting from people engaging in behaviour involving access of prohibited areas of the railway, where that access was the result of deliberate or risk-taking behaviour. Errors and violations at level crossings are not included in this category. HEM-12, HEM-25, HEM-30, HEM-44, HEM-46, HEN-36, HEN-37, HEN-38, HEN-39, HEN-40, HEN-41, HEN-42, HEN-43, HEN-71, HEN-72, HEN-81 Workforce electric shock Electric shock involving third rail, OLE, or non-traction supply. Includes burns from electrical short circuits. Does not include injuries due to arcing, which are classed under ‘other’. HEN-27, HEN-30, HEN-31, HEN-32 Any other event not covered by the categories above. HEM-01, HEM-50, HEN-07, HEN-08, HEN-11, HEN-27, HEN-28, HEN-29, HEN-33, HEN-50, HEN-51, HEN-53, HEN-54, HEN-57, HEN-58, HEN-60, HEN-61, HEN-70, HEN-75, HEN-79 Other Note that the risk from some HEs has been split across two or more accident types based on precursor level risk estimates. Version 8.1 - Issue 1.1 - December 2014 64 Version 8.1 - Issue 1.1 - December 2014 0.006 - 0.008 0.002 6.3E-04 - - - 0.002 0.200 0.004 0.874 0.056 1.628 0.395 0.061 0.057 0.317 0.022 0.002 0.059 4.223 - 0.144 0.146 0.027 - - - 0.005 0.012 0.015 - 0.037 0.029 - 0.011 - 0.120 0.002 - - - 0.043 0.007 0.027 - 0.029 0.007 0.001 0.003 - 0.002 0.002 Total annual fatalities 0.059 YDS cleaner/ admin - YDS engineering staff 0.185 Driver (shunter) 0.009 Other workforce 4.1E-04 0.594 0.020 - - - 0.135 0.022 0.211 5.1E-04 0.060 - - 0.042 0.047 0.047 OTP driver 0.164 0.129 - 0.004 5.1E-04 0.083 0.009 - - - - - 0.032 - - 0.001 Infrastructure worker 2.399 0.240 - - - 1.295 0.010 0.511 5.1E-04 0.051 0.021 0.034 0.003 0.133 0.102 1.8E-04 0.204 - 0.001 0.011 0.047 0.025 0.002 0.025 0.002 0.007 - 0.072 - - 0.002 0.008 Other train crew - 0.136 0.002 0.049 0.006 0.060 0.010 - 0.007 Fires and explosions (not involving trains) Machinery/tool operation Slips, trips, and falls Train accidents: striking road vehicles at level crossings Train accidents: collisions and derailments 0.473 Total annual fatalities 0.025 Workforce electric shock 0.004 Train accidents: other 0.044 0.205 0.105 Struck/crushed by train - 0.071 Road traffic accident Platform edge incidents (boarding/alighting) 0.011 Other - 0.002 Lean or fall from train in running - 0.004 Falls from height 8.6E-05 9.2E-04 9.8E-04 - 0.002 - 4.1E-04 5.7E-05 6.3E-04 Contact with object 8.6E-05 9.3E-04 Assault and abuse FT driver 0.011 PT driver 4.4E-05 2.6E-05 6.6E-05 NB – the shading in this table indicates the relative magnitude of the figures. The more green the box is the higher the risk figure. 0.021 Appendices Appendix C. Individual fatality risk summary Table 27: Workforce group individual fatality risk by cause classification. 65 Appendices Appendix D. Modelling approach D.1. Key assumptions Table 28 describes the main assumptions used in the analysis for SRMv8. Assumptions for individual models are available on request. Table 28: Key modelling assumptions in the SRM Assumptions 1. Train accident (HET) event frequencies are calculated based on all recorded incidents, irrespective of injury, whereas movement and non-movement (HEM and HEN) event frequencies are only based on incidents that resulted in an injury to a person. 2. An average day has been divided into: Night: 0000–0600 hrs Peak: 0700–1000 and 1600–1900 hrs Off-peak: 0600–0700, 1000–1600 and 1900–0000 hrs 25% of peak trains are assumed to be crush loaded. 3. Average train distributions: Night: 0.6 PTs Peak: 5 PTs Off-peak: 2 PTs 4. and and and 0.4 NPTs per hour 0.05 NPTs per hour 0.38 NPTs per hour Consequences are based on a five car train with average passenger loadings per train: Night-loaded train: 2 passengers per carriage: Peak-loaded train: 50 passengers per carriage: Off-peak-loaded train: 10 passengers per carriage: Crush-loaded train: 90 passengers per carriage: 5. 10 passengers per train 250 passengers per train 50 passengers per train 450 passengers per train Average passenger train loadings are calculated using assumptions 2 and 3, as well as an assumed proportion of passenger loadings at each time of day: 11% of all PTs are night loaded 63% of all PTs are off-peak loaded 19.5% of all PTs are peak loaded 6.5% of all PTs are crush loaded 6. Average train crew: Passenger trains: Freight, ECS & parcels trains: OTMs/RRVs: Shunting manoeuvres: 1 driver and 1 guard 1 driver 2 operators 1 driver (shunter) 7. The frequency of train accidents at stations and in tunnels is based upon their respective proportions of overall length compared with total track kilometres. The length of each platform is assumed to be 200m. 8. It is assumed that there is complete and correct reporting of injury events. Version 8.1 - Issue 1.1 - December 2014 66 Appendices D.2. Hazardous event definitions Full descriptions of all HEs and precursors used in the SRM are available via the RSSB Rail Risk Portal www.safetyriskmodel.co.uk. D.3. Normalisation data The values used to normalise data in SRMv8.1 along with equivalent values from past versions of the SRM are provided in Table E1 available via the RSSB Rail Risk Portal www.safetyriskmodel.co.uk D.4. Significant modelling changes for SRMv8 D.4.1. Inclusion of YDS-SRM risk Risk previously modelled in the YDS-SRM has been fully incorporated into this version of the SRM. D.4.2. Remodelling of risk at the PTI The platform-train interface risk models and precursor structure have be remodelled in order to better understand risk at the PTI. Full details are given in Chapter 10. D.4.3. Inclusion of MCB+OD and AOCL+B crossing types Two new crossing types, MCBs with obstacle detection and AOCL with half barriers, have been introduced. All level crossing models (HET-10, HET-11, HEM-11, HEM-27, HEN-44, HEN-46 and HEN-75) have been extended to explicitly calculate the risk at these crossing types. D.4.4. New approach to assault data analysis For this version a change has been made to the assault modelling. Algorithms have been written and automated to match BTP recorded assault data with SMIS recorded assault data in order to provide a larger, richer dataset. In previous updates this was done manually and so only a subset of the data was analysed then scaled up. This has resulted in more reliable assault risk modelling. Version 8.1 - Issue 1.1 - December 2014 67 Appendices Appendix E. Railway lines in SRM scope The SRM only includes railway lines which are managed and/or operated by Network Rail. Table 29 contains examples of some commonly-queried lines (and sections of lines), along with the reason for their inclusion or exclusion. Table 29: Railway lines in and out of scope of the SRM about the track/at PTI The Cambrian line18 The entire line, including St Pancras, is managed, operated and maintained by NR. Owned and managed by NR. In Stations High Speed 117 Notes In In In In In In In In Out In NR Managed? Line / Section In/Out of Scope NR operated signalling? Criteria Heathrow Express: Paddington to Heathrow Central NR-owned infrastructure. Heathrow Express: Heathrow Central to Terminals 4 and 5 Nexus — Tyne and Wear Metro: Fellgate to South Hylton Owned by BAA but maintained on their behalf by NR. Nexus — Tyne and Wear Metro: All sections apart from Fellgate to South Hylton LUL Metropolitan Line: Chiltern services between Harrow-on-the-Hill and Amersham LUL District Line: Gunnersbury to Richmond Neither managed by NR, nor is the signalling controlled by NR. Out Out This section is owned and operated by LUL and its subsidiaries / operators. Out Out19 Out In Out Out Out In Out Out In In LUL District Line: East Putney to Southfields LUL Bakerloo Line: Services north of Queens Park Island Line on the Isle of Wight East London Line Owned and managed by NR. This section was a joint operation with Silverlink Metro, for which NR is now responsible. LUL owns the infrastructure. NR owns the signals, but the signalling is operated by LUL. Track managed by NR, who also operates the signalling. The service is wholly operated and managed under a franchise to South West Trains. TfL owns and maintains the track, but NR operates the signalling. 17 The risk from High Speed 1 train operations is modelled in the same way as all other lines, ie as an average railway, rather than explicit modelling of High Speed 1 characteristics. The contribution of Eurostar services to HEM/HEN risk is included. 18 The risk from the Cambrian line is modelled in the same way as all other lines, ie, as an average railway rather than modelling explicit ERTMS characteristics. This is under investigation for future versions of the SRM. 19 PTI and on-board injuries on these Chiltern services are in scope, injuries on or about the track are out of scope. Version 8.1 - Issue 1.1 - December 2014 68