Health and safety across the rail sector: the regulator's view

Railway operators

Our inspection teams have continued to focus their inspection activity using sector specific teams (specialising in either passenger TOCs, freight operators, heritage and light rail operators or Transport for London’s rail businesses) to ensure in depth assessment and analysis of health and safety management. This structure has enabled us to take an overview of performance in each sector.

In many cases we were pleased to identify good health and safety management arrangements although there are some specific topics where we made recommendations for improvements. We have used the evidence we obtained to extend the application of the railway management maturity model to each mainline operator and London Underground Ltd.

Mainline train operating companies and freight operating companies

Overview:

• The industry shows high levels of commitment to effective management of rolling stock maintenance and driver competence.
• Some challenging management issues still to be tackled including low adhesion, TPWS and SPADs caused by distraction.

What ORR found:

• Low adhesion remains a significant concern and we are not convinced that the industry has a reliable strategy both for existing rolling stock and the specification for new rolling stock. We found a worrying lack of understanding over the need for efficient and reliable sanding which manifested itself in a number of extremely serious runaways. Signals past at danger (SPADs) have again increased this year primarily due to the poor performance of train operating companies to mitigate the effects of low adhesion. Many European operators fit electromagnetic track brakes to their trains which are capable of stopping independent of adhesion between the wheels and the rails. We are examining all aspects of low adhesion and the practicability of introducing best European practice.
• Train Protection and Warning System (TPWS). Implementation of standard self monitoring TPWS continues to be of concern. We perceived reluctance within the industry to develop a coherent strategy for upgrading the onboard equipment and ensuring continuing reliability for a safety system that is no longer a short term measure but something that will be fitted to the network for many years.  We will be seeking assurance from dutyholders that the proper risk analysis for their fleets has been completed and appropriate controls implemented.
• Driver management and competence. All of the companies inspected were able to demonstrate a high level of commitment to the need to effectively manage this high risk area. As well as this commitment to safety we found examples of strong leadership in the pursuit of continual improvement. We found examples where companies were moving to a more risk based approach and had a desire to adopt best practice and to learn from others both inside and external to the rail industry.
• Loss of concentration/distraction issues now account for the majority of operational incidents and we investigated a number of incidents due to lack of concentration. We believe this to be an industry wide issue and we urge operators to consider further work to identify solutions. 
• Train operating companies’ liaison on emergency planning with other members of the railway group, the emergency services and other interested parties was found to be patchy. Although there were some examples of regular engagement there were also examples where this was not properly managed. Station emergency plans were generally well managed, although testing appeared to be patchy with some operators performing regular emergency exercises, including some multi-agency events, with others limiting their testing to evacuation drills.
• Freight operations on third party sites were found to have safety management arrangements that were less than adequate to deliver good conditions for train operation. In some cases there was reluctance, or more frequently, a lack of awareness by staff to report site conditions which reflected a weakness in the safety culture. We also believe that the reluctance of freight operators to push for better standards on site is a reflection of the climate in which freight currently operates. 
• Maintenance of rolling stock is a key activity for train and freight operators, and all of the companies inspected were able to demonstrate a high level of commitment to effectively manage this high risk area. In the main there was a good performance in respect of the standard of maintenance. We concluded, from an extensive inspection of sites around the country, that with the appropriate controls in place, wagons can be safely maintained away from a workshop. There were issues with some of the companies but overall the picture is a positive one.
• Rolling stock failure. There were a number of notable incidents with rolling stock, the causes of which are as yet inconclusive; gearbox and axle failure on a class 222 ‘Meridian’ and cardan shaft failures on class 142 ‘Pacers’.  More rolling stock is being used beyond its intended design life and we have devoted an increasing amount of time monitoring the safety performance and maintenance of older rolling stock to verify that procedures are in place to ensure ongoing safe operation.  We are particularly concerned about the ongoing use of Pacers beyond their intended design life and we will be scrutinising the industry’s plans for ensuring they can continue to be used safely..
• Occupational health. There was varied commitment to the management of occupational health issues and although there were some examples of good practice it is clear there is more the industry needs to do to effectively manage these risks. In particular there is a need to have clear occupational health policies, understand the issues that lead to work-related ill health and have arrangements for controlling and reducing health risks. We found some evidence of good practice in dealing with work-related stress and employee well-being. We were concerned to find that compliance with the control of Substances Hazardous to Health Regulation (COSHH) was not always good with risk assessments often failing to consider the way hazardous materials were being used.

Heritage railways

Overview:

• Good overall safety performance is encouraging.
• The industry needs to improve maintenance of pressure systems and overall competence management.

What ORR found:

• Safety performance of the UK heritage railways has remained good with the number of incidents slightly higher than last year, which remains the lowest on record. 
• Competence Management Systems. We are concerned at the lack of awareness within the heritage railways of the importance of a robust Competence Management System, being the primary control measure that underpins all activities. All of the railways inspected this year were found to be deficient in some aspects of their management system, including some of the larger railways. We commend to all railways ORR’s Railway Safety Publication No. 1: Developing and maintaining staff competence, published on the ORR website. 
• Boiler repairs and inspection remain of concern and we found examples of poor workmanship, use of incorrect materials, lack of material traceability and worse of all we found some workshops that still have a make do and mend culture. This culture has no place in the maintenance of high pressure steam systems. Good work has however continued with the Heritage Railway Association (HRA) to develop industry codes of practice for the maintenance and repair of boilers. The agreed codes of practice are published on the HRA website. 

Tramways

Overview:

• Good overall safety performance is encouraging.
• The sector needs to improve its management of change.

What ORR found:

• Safety performance of the tramways remains very good and comparable to the best performing European systems. We found a high standard of safety culture and implementation of robust safety management systems.
• Change management was found to be inconsistent and the tramway industry has struggled with the implementation of appropriate safety verification systems for new works. We found a number of failings in works and systems that were subject to safety verification and we are concerned about the lack of a holistic approach to system safety and the application of inappropriate heavy rail technology in the design of the new UK tramways.

London Underground and other TfL companies

Overview:

• Safety performance of London Underground, London Overground and Docklands Light Railway remains high and, in terms of worker safety, better than the mainline railway.
• Challenging economic circumstances have demanded careful scrutiny of proposals for change.

What ORR found:

LUL

• Economic pressures on LUL have led to some significant changes in staffing and, in some cases, we are challenging LUL's risk analysis and change management processes.
• Railway operations. We carried out inspections of a range of operational risk control measures including the use of safety critical communications and route knowledge for uncommon moves. In general we were satisfied that safety critical communications are taken seriously but there are still occasions where standards are not as good as they should be, for example poor ‘repeat-back’ and inadequate confirmation of understanding. On route knowledge we found that the system for ensuring drivers undertake uncommon moves works reasonably well, with a good variety of training techniques used.
• Preparation for the Olympic Games 2012. LUL has taken this challenge seriously and has looked in detail at plans for maintenance during the games and ensuring sufficient resilience of the service. We will continue to seek assurance as the start of the games approaches.
• Construction (LUL and Tube Lines Ltd). We found evidence of poor practice in health and safety management e.g. risks of work at height and welfare provision, on site although Tube Lines’ assessments and management of exposure to dusts and hand-arm vibration risks were good.
• Asbestos. We carried out a number of visits to assess LUL’s and Tube Lines’ management arrangements and made recommendations for improvement to management arrangements in LUL.
• Rolling stock. Our inspections of management of rolling stock assets led to a range of recommendations regarding both existing, and in some cases ageing, stock, and design and operational issues relating to the new stock .
• Worker safety. Our inspection topics included electrical safety, depot protection and track worker protection in traffic hours. In general these risks were effectively managed although we made a number of recommendations regarding monitoring of safe systems of work.

Other TfL dutyholders (LOROL and DLR)

• We discussed preparation for the Olympic Games and these discussions will continue throughout 2011/12. Other inspection activity included driver management arrangements and risk assessment. We found generally good standards of management in these areas.

Network Rail

Overview:

• A disappointing year with clear evidence of a poor safety culture, patchy implementation of procedures and slow progress on some key risks, often requiring formal enforcement.
• Encouraging changes originating from new management and commitments which now must be translated into reality.

What ORR found:

During the year, we were pleased to note a much more constructive and positive engagement by senior Network Rail managers on health and safety issues. We noted in particular some positive steps to start using ORR’s rail management maturity model (RM3) in the company. We welcomed the recognition that our earlier assessment of the company health and safety management system, as reflected in the Investment Projects division, was broadly accurate, leaving considerable scope for improvement.

Similarly, while originating from the extremely adverse picture that emerged on culture in RSSB’s review of RIDDOR non-compliance, Network Rail’s leadership and safety culture programme is a vital step in making future improvements.

And the comprehensive review of how the company manages risks at level crossings will play a key part in tackling level crossing risk - a stubbornly large proportion of overall system risk. That review was triggered by ORR’s intervention on various aspects of level crossing management. We still see poor quality inspection and risk decisions, and the company must now take real action to implement the changes identified.

Our inspections and RM3 audits found in most cases that suitable written procedures and processes were in place but often poorly implemented in practice. We found some non-compliance with the procedures and processes across all of the Network Rail functions we inspected, including Maintenance, Operations and Infrastructure Projects. Network Rail uses the written procedures and processes (the ‘company standards’) to manage health and safety and other aspects of its business.

The level of non-compliance found during our inspection work has led us to start a discussion about the complexity and suitability of the current standards approach, particularly in the Maintenance function.  Overly complex standards that are not readily understood by those who have to implement requirements, or which drive a bureaucracy that hinders staff engagement, do not deliver safety.

We found increasing evidence that Network Rail’s internal assurance processes to assess health and safety compliance are not effective. Too often, our inspection activity revealed significant issues that came as a surprise to the company. An effective assurance regime would have found these beforehand and led to corrective action. The company cannot rely on ORR to do that which should be at the core of effective safety management.

We have been disappointed that stated commitments to improve health and safety are not reliably translated into action – especially when enforcement action had already covered the issue. We found, for example, workers exposed to risks from moving trains despite an improvement notice issued in Scotland in 2009, and poor management of track drainage despite an improvement notice in Anglia, again in 2009. In addition, a lack of resource slowed progress on the collection and analysis of data to identify accident precursors at switches and crossings, a key requirement following the Grayrigg derailment in 2007.

Asset Safety

We found evidence of missing or incomplete data in the three asset areas inspected (structures, track drainage and track). We welcome the appointment of a Director of Asset Information and the direction he has set. We now expect to see pace maintained in this area to deliver safety improvements.

• Structures: we inspected the management of structures, particularly looking at the implementation of risk-based maintenance examination arrangements; whether critical defects are adequately identified during routine inspections and how hidden components are addressed. We found a significant backlog with all types of examination (visual, detailed, additional and underwater) and consequently served a national improvement notice. Separately, from an investigation of a culvert that collapsed below the track, we found weaknesses in the quality of examinations and with the management of the inspection process, and we served a separate improvement notice.
• Drainage: we inspected management of track drainage maintenance and renewal in three routes finding similar failings, including: incomplete asset registers, missed inspections and a poor reporting on the results of drainage inspection. In one delivery unit, the overwhelming majority of planned drainage inspection was postponed. This was particularly disappointing because track drainage had been the subject of an improvement notice in January 2009 in Anglia after a freight derailment directly linked to poor drainage management.
• Track: we continued our focus on how the company manages track inspection – issues that were highlighted by the Grayrigg derailment. The relevant company standards have been revised and improved. We found better levels of compliance than in 2009/10 but with some inconsistencies and areas of non-implementation that undermine the company’s systems approach to managing risk. The failure of the track inspection process to consistently take account of previous findings, to identify trends in track condition was of particular concern. From a national perspective, the individual gaps seen in isolation did not constitute risk, but taken together they may align to do so. However, in one depot, we found non-standard procedures dating from before 2004 that indicated a greater failing and we served two improvement notices.
  
  Our inspection looking at the role of section managers in the track inspection process found they had a better understanding of their responsibilities compared to 2009/10 inspections and a better awareness about the importance of key track measurements.  But, we also found some evidence that section managers were delegating switch and crossing inspections to their assistants, to a point where they may be unable to maintain a good working knowledge of the asset condition.

Managing maintenance at a local level

Our scrutiny of Network Rail’s maintenance restructuring (known as phase 2b2c) found some lack of competency in the section planner and section administrator roles. Section planners and administrators are key support roles for the section manager. Our inspections found issues with the competency in the section planner posts that resulted in poor quality safe systems of work. We found difficulties with planners accessing relevant documents and with their local knowledge. This results in additional work for the section manager and the potential for fatigue. We found variable levels of compliance with the method for monitoring section manager hours of work.

While not a consequence of this change, the implementation of 2b2c highlighted gaps in how the company manages staff competence. It is to the company’s credit that its change management procedures discovered the issue and led to plans for correction without the regulator becoming involved.

Construction safety

Our inspection activity looked at recognised safety risks on railway construction sites, including work at height, lifting operations, segregation of people from moving plant, use of road rail vehicles (RRVs) and on-track plant, manual handling, management of fatigue, control of lineside scrap and control of contractors.

Planning and management of construction activity was variable; we found good and poor practice. We found some scaffolds and other workplaces without the necessary edge protection; poor access and egress particularly relating to escape from fire on sites storing flammable materials; fall arrest equipment with out-of-date inspection records; poor site access controls and poor use of personal protective equipment. These are all basic, well understood safety requirements, but ORR inspectors were particularly concerned because some of the sites visited had also been audited by Network Rail and its contractors without identifying the failings.

We found Network Rail repeatedly missed opportunities to specify health and safety standards as part of the contractual arrangements when acting as a client or sponsor.

We found numerous instances of failures by contractors to manage fatigue risks linked to the combination of travel and site working hours, resulting in enforcement action against several contractors. In some cases, the long work and travel times were made more difficult to manage because of complex sub-contracting arrangements. There were examples of recording excessive travel times in site access logs and site managers taking no action. Good practice by some contractors in one part of the country was not promulgated more widely.

It was disappointing to find (with a few notable exceptions) generic rather than task-specific risk controls, often presented in a format that was difficult to use, stating the safety aim but not how to achieve it. To compensate we found some site supervisors and crane controllers devising their own safe systems of work on the hoof.

We are concerned that site briefings are often poorly targeted, repetitive and ineffective. Information is given without effectively checking understanding.
Road rail vehicles (RRVs) were involved in a number of serious incidents, including runaways, overturns, and injuries incurred when working in close proximity.  We welcome the work to improve braking performance but are concerned that it took another machine runaway before initiating this. We found it necessary to issue a national improvement notice to secure interim control measures while engineering changes to improve braking are rolled out..

Audit of occupational health at bridge refurbishments. We audited Network Rail’s management of bridge refurbishment, particularly focussing on health risks arising from exposure to lead and isocyanates. Formal enforcement was required because some workers were exposed to significant risks to their health. Following our enforcement, we found the management of health risks improved because Network Rail, in its role as client, was clearer about its expectations to its contractors. We concluded that managing occupational health risks is not properly core to related standards and procedures.

Worker safety

Following our work last year to highlight RIDDOR under-reporting, improvements were made to better reflect the actual number of injuries occurring and this resulted in a higher than target accident frequency rate (AFR). The fatality and weighted injuries (FWI) is also higher than the target and this is of more concern because this measure reflects numbers of major injury accidents, which were not under-reported and which remain unacceptably high.
Network Rail has made a number of significant changes that affect track worker safety and we welcome the increase in green zone working, (when there is no direct risk from moving trains). But we still found some examples where workers were at risk of being hit by trains, requiring immediate enforcement. We consider there is still scope for a further shift away from red zone working, particularly in high risk areas such as crossovers.

While much has been done to better understand the key interpersonal and behavioural skills required by critical staff, we are concerned at the delays in applying better selection criteria to existing staff.

Electrical safety remains of concern. Risks from the overhead line equipment and electrified ‘third rail’ system have been demonstrated in several incidents that came close to killing workers. We had to enforce improvements in the management of insulated tools but note the positive changes for better equipment to test whether rails are live. We believe isolation and permit to work arrangements should be strengthened.

Level crossings

We welcome the increased focus on level crossing risk in 2010/11, including establishing a national level crossing lead and a fundamental review of risk assessment and control. One key finding was that too many people are involved in the overall risk control processes, with questions about competence and the priority they give to level crossings. Site specific risk assessment, distinct from the prioritisation provided by the industry’s All level Crossings Risk Model (ALCRM), remains a worry. The company has set ambitious targets for reducing risk before the end of the current control period, with more planned in CP5.

We welcome the moves now underway to target risks at crossings in long signal sections, such as that involved in a serious collision in Anglia. Similarly, the programme of work to improve passive crossings with compromised sighting is a positive recognition of a risk that had previously not been tackled. Network Rail has started to consider less expensive technical solutions to control risk. This is a positive development and we expect to see trials at a number of Automatic Open Crossings, in the next few months.

Our inspection work found continuing weaknesses with the maintenance of level crossings. We found issues with vegetation, road surfaces, signage and communication with regular users of user-worked crossings, some of which merited enforcement action.

Last updated: July 2011

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