Oversight of Network Rail and others - implementation of safety reports.

[whole diary]

[grahame]

From the RMT^▸ (National Union of Rail, Maritime & Transport Workers)

RAIL UNION RMT is calling for the establishment of a new body to oversee the Rail Accident Investigation Branch's recommendations in the wake of publication of their report into the Margam Rail tragedy in which two union members were killed.

On the morning of Wednesday 3 July 2019, the two track workers were struck and fatally injured by a passenger train at Margam East Junction on the South Wales main line. A third track worker came very close to being struck. The three workers, who were part of a group of six staff, were carrying out a maintenance task on a set of points.

The union has written the Chief Executives of Network Rail, RSSB^▸ (Rail Safety and Standards Board), RDG^‡(resolve) and to HM Chief Inspector of Railways at ORR^» (Office of Rail and Road formerly Office of Rail Regulation - about) calling for a group to be formed to oversee the rail industry response to the tragedy.

We have an awful lot of bodies in the rail industry already ... BUT ... where does the responsibility for evaluating and implementing recommendations of the RIAB lie?   Does it fall on a variety of organisations, split so that it can fall between stools / areas of responsibility?   Should there be ONE body who's job it is to "make sure this never happens again"?  Does that body need to be a new one to make 110% sure that it's independent of all possible bodies that the RIAB might find issue with?   And for goodness sake, should such a body be responsible for all RIAB recommendations - and not just this tragedy - not a special case, but a. system learning from this case amongst others??

With Network Rail becoming every more powerful, are the wider checks and balances we have and will have into the future adequate?   We may have excellent people at the helm at present - but does the system need strengthening in case we have people who need the guidance of more checks and balances in the future, or indeed if we have them in pockets today?

I'm not really taking a view here - I'm asking questions about an area that most of us "just a passenger"s find murky and complex - and perhaps with too many bodies already?

[CyclingSid]

Who is going to oversee the Government's response to Grenfell, Covid, etc?

Or is it us at every election?

[Electric train]

From the RMT^▸ (National Union of Rail, Maritime & Transport Workers)

We have an awful lot of bodies in the rail industry already ... BUT ... where does the responsibility for evaluating and implementing recommendations of the RIAB lie?   Does it fall on a variety of organisations, split so that it can fall between stools / areas of responsibility?   Should there be ONE body who's job it is to "make sure this never happens again"?  Does that body need to be a new one to make 110% sure that it's independent of all possible bodies that the RIAB might find issue with?   And for goodness sake, should such a body be responsible for all RIAB recommendations - and not just this tragedy - not a special case, but a. system learning from this case amongst others??

With Network Rail becoming every more powerful, are the wider checks and balances we have and will have into the future adequate?   We may have excellent people at the helm at present - but does the system need strengthening in case we have people who need the guidance of more checks and balances in the future, or indeed if we have them in pockets today?

I'm not really taking a view here - I'm asking questions about an area that most of us "just a passenger"s find murky and complex - and perhaps with too many bodies already?

The ORR^» (Office of Rail and Road formerly Office of Rail Regulation - about) took on the powers, duties etc of Her Majesties Inspectorate of Railways.  The ORR have the same legal powers as the HSE^▸ (Health and Safety Executive).  The RIAB perform a different but related function

The statement on the ORR website regarding RIAB recommendations is

We have a policy for considering and following up RAIB^▸ (Rail Accident Investigation Branch)'s recommendations.

We ensure that recommendations are duly considered and where appropriate acted upon.
We assess the action taken by those to whom we have directed the recommendations to against clear criteria, using both technical and other experts, to decide our view on the responses and decide what further action we may need to take.
We report to RAIB in accordance with the regulations and the Memorandum of Understanding between us. We have a separate Memorandum of Understanding for Scotland. We report back to RAIB details of any implementation measures, or the reasons why no implementation measures are being taken.
In assessing the status of recommendations we make reference to a status definition list which has been agreed with RAIB. To assist those asked to consider RAIB recommendations we have also produced a glossary of commonly used terms within RAIB recommendations, along with our interpretation of what actions an organisation needs to deliver in order demonstrate that the requirements of a recommendation have been satisfied.   

I suspect it is more about the time it takes for the industry to implement many of the recommendations the RMT has an issue with.

I a member of a number of groups working on changes to procedures, instructions, training, working practices in electrification, some of the changes are driven by recommendations 10 or mores old, however most of them this old are minor recommendations.

Changes driven by the report recommendations fall into a number actions - modification / replacement to equipment, changes to working practices / human factors (culture), provision of PPE and signage

The first has a cost in both terms of money and time but does get done within the determination the ORR / DfT^» (Department for Transport - about) gives NR^» (Network Rail - home page) and can take a number of Control Periods to implement.  (Note a number of equipment changes that will improve safety, all be it of a minor nature, will be deferred as part of the ?1b cut to NR CP6^▸ (Control Period 6 - The five year period between 2019 and 2024) plan)

The second can take time, but often it is the human factors that are perhaps the most difficult to deal with.  The ToC, NR and the Trade Unions do work closely on changing this aspect both the sides have the same desire and interest. 

Carrying out a culture change is possible the most difficult of all, and if you look back at the majority of accidents it is the human factors at the root of it

PPE and signage is always seen as the last resort although this is done first as it is quick to provide

[eightonedee]

Firstly (with apologies for a bit of pedantry in the festive season) it should be Oversight not "oversite". The latter is I think (but happy to be further corrected) a construction industry term for works to form a slab at or just above ground or foundation level.

Secondly, sadly, Electric Train's comments about the human factors being the most difficult to deal with is borne out by what I have been told on more than one occasion by directors with safety responsibilities in the construction industry. Here at least it seems management and unions are on the same side.

[grahame]

Thank you both - especially Electric Train - for that thorough answer.    Really good to have the questions and issues aired and perhaps a little better understood. 

In the early days of railways, there were far fewer (if any) protections in the system against human error, the humans themselves did not have the same professional reliability all of the time, and in the aftermath of an accident, analysis and implementation of changes to make sure it "never happens again" were rare.    It took countless SPADs^▸ (Signal Passed At Danger) (Signal passed at danger)s to improve systems for alerting drivers, and applying brakes automatically. It took a number of accidents leading up to Armargh for continuous, fail safe brakes to be required on passenger trains. There was a pattern of trains on the same line when they should not have been - at Ais Gill and Abermule and it took a number of those to get the lesson learned, repeatedly, the hard way.   The number of people cooked alive after collisions that had not killed them due to gas lights burning was frightful.  Thank goodness we have got so many things right that any accidents - let alone any accident in which people are killed by trains - are mercifully rare..    We do - still - have an issue with "person hit by train" ... one yesterday, between Swindon and Gloucester ...

On dangerous ground, I will separate "person hit by train" into three groups.  The first two overlap - Margham, which indirectly triggered this thread, is the first and I believe smallest group, where something goes wrong with systems that should provide protection and safeguards, and others such as where something goes wrong in the wider environment - a car goes over a bridge onto the track, someone goes onto the track to call back their dog.  The third group is those who intentionally get themselves killed.   All this highly awkward to write - how you categories and deal with the person who faints as the train comes in .... and because there are so many backgrounds, there's no magic wand.  For these reasons, the systems and schemes written about by Electric trains, and re-assurances that such things are on the radar and being acted on are useful (more than useful) and important (and more than important) ...

No magic wand - I wish there was.   Big "thank you" to the folks who work hard behind the scenes to make the railway safer and safer year on year, but with one necessary eye on ensuring that the system can still operate with all the safety elements in place.

[Electric train]

Thank you both - especially Electric Train - for that thorough answer.    Really good to have the questions and issues aired and perhaps a little better understood. 

In the early days of railways, there were far fewer (if any) protections in the system against human error, the humans themselves did not have the same professional reliability all of the time, and in the aftermath of an accident, analysis and implementation of changes to make sure it "never happens again" were rare.    It took countless SPADs^▸ (Signal Passed At Danger) (Signal passed at danger)s to improve systems for alerting drivers, and applying brakes automatically. It took a number of accidents leading up to Armargh for continuous, fail safe brakes to be required on passenger trains. There was a pattern of trains on the same line when they should not have been - at Ais Gill and Abermule and it took a number of those to get the lesson learned, repeatedly, the hard way.   The number of people cooked alive after collisions that had not killed them due to gas lights burning was frightful.  Thank goodness we have got so many things right that any accidents - let alone any accident in which people are killed by trains - are mercifully rare..    We do - still - have an issue with "person hit by train" ... one yesterday, between Swindon and Gloucester ...

On dangerous ground, I will separate "person hit by train" into three groups.  The first two overlap - Margham, which indirectly triggered this thread, is the first and I believe smallest group, where something goes wrong with systems that should provide protection and safeguards, and others such as where something goes wrong in the wider environment - a car goes over a bridge onto the track, someone goes onto the track to call back their dog.  The third group is those who intentionally get themselves killed.   All this highly awkward to write - how you categories and deal with the person who faints as the train comes in .... and because there are so many backgrounds, there's no magic wand.  For these reasons, the systems and schemes written about by Electric trains, and re-assurances that such things are on the radar and being acted on are useful (more than useful) and important (and more than important) ...

No magic wand - I wish there was.   Big "thank you" to the folks who work hard behind the scenes to make the railway safer and safer year on year, but with one necessary eye on ensuring that the system can still operate with all the safety elements in place.

Track worker safety is one of the key issues being focused on by the ORR^» (Office of Rail and Road formerly Office of Rail Regulation - about) in CP6^▸ (Control Period 6 - The five year period between 2019 and 2024).  There reduction and where possible the elimination of Red Zone working with unassisted Lookouts (that's people working on a line open to traffic with a person with a flag and horn to protect them).  The downside to this is more staff working nights in possessions with the inherent hazards of working at night and shift working; disturbance to neighbours and the early cessation of train services in the late evening

Technology is of course being deployed where it can for inspection and recording condition of equipment, but there are things that have to have the human touch.

Staff coming into contact with electricity is another area of focus and its not just the third rail areas where accidents happen

[grahame]

We do - still - have an issue with "person hit by train" ... one yesterday, between Swindon and Gloucester ...

From Wilthsire 999

A man and his dog were killed when they were hit by a train in Gloucestershire yesterday.

The pre-Christmas tragedy struck when the dog walker, whose age is unknown, attempted to cross the railway line with his pet at the Ebley Level Crossing, Stroud, at around 9.30am.

According to The ABC Railway Guide, Ebley Level Crossing ? for use by vehicles and pedestrians ? is rated D (with A being the highest risk and M being the lowest), meaning it?s believed to poses a high risk to individual users.

Whilst the cause of the collision is not yet known, the British Transport Police (BTP^▸ (British Transport Police)) have classed it as ?non-suspicious?. This means there is not likely to be a criminal element. It?s thought the man?s death was accidental, rather than suicide.

[IndustryInsider]

An accidental death can be more difficult for the crew to deal mentally than a suicide.

[Oxonhutch]

An accidental death can be more difficult for the crew to deal mentally than a suicide.

I didn't want to 'Like' this because the subject for me is not likeable, but I agree wholeheartedly with your comment.