HSC publishes progress report on rail public enquiries

HSE Press Release C053:02 - 28 November 2002

The Health and Safety Commission (HSC) today published a report on the rail industry's progress with implementing 295 recommendations made by Professor John Uff and Lord Cullen in their reports on the Southall and Ladbroke Grove rail crashes and their Inquiry into train protection systems.

HSC was asked by Professor Uff and Lord Cullen to monitor implementation of the recommendations and has made its findings public in seven progress reports on the individual Inquiries. This report is the first to bring together progress on the recommendations from all four Public Inquiry reports.

Bill Callaghan, Chair of HSC, said:

"Publication of today's report shows that this follow-up process has been beneficial. The Commission's overall conclusion from this review is that there are promising signs: the industry is now tackling some longstanding issues. The trends in this year's safety statistics are also positive in most areas.

"However, it is still too early to say if all the old problems are being dealt with effectively. HSE's safety case and inspection work also continues to find evidence of failures to effectively assess risks and manage day-to-day issues, such as track maintenance. I believe we are still short of the step change in culture that is necessary.

"I am particularly concerned that parts of the industry still appear to find it difficult to make the links between delivery of effective overall performance and good health and safety practice. Many other high hazard industries and other transport sectors see good health and safety, commercial performance and customer satisfaction as inextricably linked. I share that view. The Commission and Executive will maintain a close dialogue with the industry. Our goal, which we share with Ministers and the industry, is to see a modern and safe railway fit for the 21st century."

The new report groups the 295 recommendations together under eight themes: culture; infrastructure; investigations; organisations and standards; suppliers and contractors; training; train protection; and vehicle integrity. HSC believes this will help everyone involved to gain a better appreciation of the overall safety benefits being delivered, as well as sharpening the focus on key issues.

The 25 recommendations under the culture theme are aimed at securing improvements in: the safety auditing processes; fault reporting and maintenance; risk assessment; application of the railway safety case regime; and safety leadership and communication in companies. There are encouraging developments, with 16 recommendations implemented, but the evidence of an improved culture is still patchy. However, cultural change is a long process and this issue will need to be continually reviewed by both industry and HSE.

The 27 infrastructure recommendations are aimed at improving signal sighting and signalling systems. There is positive progress to report here, with industry generally tackling the issues in a clear and methodical way. Work is complete on 24 recommendations and HSC is particularly encouraged to see a continuous decline in the rate of signals passed at danger (SPADs).

The 43 recommendations on investigations are designed to achieve: establishment of the Rail Accident Investigation Branch (RAIB); improved arrangements for investigating major and other serious incidents; and better monitoring and implementation of post-investigation recommendations. Work is progressing well, with 27 recommendations completed, though establishing RAIB will require legislation.

The 56 recommendations on organisations and standards are aimed at establishing the new Rail Industry Safety Body (RISB) and reforming or reviewing existing bodies; safety-related research and development; revising standards; the work of system authorities; emergency planning; the operation of safety cases and the role of HSE and HSC's Railway Industry Advisory Committee. Some work has been completed - 27 recommendations have been implemented - but at the heart of this theme is the creation of RISB and its subsequent conduct. It is currently expected that RISB will be created in Spring 2003.

The 13 recommendations on suppliers and contractors are aimed at delivering improvements in managing the supply chain; contractor management; and training for contractors and sub-contractors. The scale and complexity of the problem, plus complications introduced by general organisational and funding decisions, has slowed down the Cullen timetable. Seven recommendations have been completed, however, and there have been advances, especially at the level of 'superstructure' and management systems, e.g. Railtrack's high-level maintenance strategy, changes to its safety case arrangements and improvements to the Sentinel work recording system. However, both the Hatfield and Potters Bar crashes involved aspects of track work and, it must be concluded that 'lower level' delivery of the intent of Lord Cullen's recommendations on contractors still appears uncertain. This remains a key area that HSE will keep under close scrutiny.

The 41 training recommendations are aimed at securing improvements in driver and signaller competence; understanding of human factors and behaviour as they relate to train driving and signalling; and staff instructions, e.g. responses to SPADs and fault reporting. Delivering these recommendations will make a major contribution to safety on the network by improving the quality of training given to drivers and signallers, leading to greater competence. Work on 30 has been completed.

The 45 recommendations on train protection are aimed at improving the effectiveness of protection systems and other operating arrangements. Delivery of these recommendations has a major bearing on public confidence in the rail industry and its safety performance, following the two crashes - Southall and Ladbroke Grove - that could have been prevented by automatic train protection (ATP).

Good progress is being made fitting the Train Protection and Warning System (TPWS), which greatly reduces the risk of collisions resulting from SPADs, by the December 2003 deadline. The timescales for the European automatic train protection system envisaged by the Joint Inquiry (ERTMS) may not now be achievable, but there remains a commitment to develop a national fitment plan, in line with European interoperability requirements. HSC has commissioned independent scrutiny of the industry's analysis of economic and technological issues and will advise Ministers of its conclusions in Spring 2003.

The 45 recommendations on vehicle integrity are aimed at securing improvements including: fire prevention and crashworthiness; escape and evacuation; information to passengers and communication systems on trains. The delivery of these recommendations will help to ensure the safety of passengers and train crew in the event of an incident. Work on 26 recommendations is complete. Train operators have introduced improved arrangements for emergency evacuation, safety information and signs, staff training and equipment provision. A substantial research programme is also underway. Progress is slower than the Inquiries recommended because the industry is taking a broader, more holistic, look at the issues than the terms of the recommendations strictly demand.

The report, 'The Rail Public Inquiries: HSC report on overall progress as of July 2002 on all recommendations from the Rail Public Inquiries', is accessible on the HSE website at: http://www.hse.gov.uk/railway/railpublic.pdf

Notes to editors

1. The Southall Rail Accident Inquiry Report by Professor John Uff QC FR Eng was published on 24 February 2000. It contained 93 recommendations on: driver training; operating rules; fault reporting; maintenance; regulation; vehicle design; research and development; automatic train protection; accident investigation and post-accident procedures. Since the report was published almost three years ago significant progress has been made. Examples include: amended operating rules for drivers using the Automatic Warning System (AWS); improved arrangements for driver training and better maintenance procedures. The industry reports that work on 90 of the recommendations is now regarded as complete, with action continuing on the remaining three. Many of the issues raised in the report will be taken forward in recommendations in the Ladbroke Grove Rail Inquiry reports.

2. The Joint Inquiry into Train Protection Systems was established shortly after the Ladbroke Grove crash and during the Southall Inquiry. It was not concerned with the facts of either crash, however, but with broader questions relating to train protection systems. The report, by Professor Uff and Lord Cullen, was published on 29 March 2001. It contained 39 recommendations covering: implementation of TPWS; introduction of the European Train Control System (ETCS); and further action to reduce the number of SPADS through defensive driving techniques and other management initiatives.In the 20 months since the report was published, measures have been introduced to reduce the number of SPADs and fitment of TPWS is almost complete. The industry reports action on 15 recommendations is now complete. Action continues on 25 recommendations, mainly relating to ETCS - the automatic train protection element of the European Rail Traffic Management System (ERTMS).

3. The Ladbroke Grove Rail Inquiry Part 1 Report was published on 19 June 2001. It contained 89 recommendations drawing lessons from the causes of the train crash. The recommendations cover driver management and training, signalling systems and signal sighting, crashworthiness and passenger protection, evacuation and escape. In the 17 months since the report was published most of the changes to signalling systems and signal sighting have been introduced, which has played a part in further reductions in the number of SPADs. Many recommendations on driver and signaller training have been completed, as have most of those dealing with passenger protection, evacuation and escape. Industry reports that action on 61 recommendations is now regarded as complete. Action continues on 25 recommendations.

4. The Ladbroke Grove Rail Inquiry Part 2 Report by Lord Cullen was published on 20 September 2001. It contained 74 recommendations, one of which required HSC to publish a report on compliance after six months, and regular reviews thereafter. The recommendations cover: use of contractors; the structure of HSE; establishing a Rail Accident Investigation Body (RAIB) and a Rail Industry Safety Body (RISB); railway safety cases; safety leadership and skills; accreditation and licensing.

5. 14 months since the report was published, work on most of the recommendations continues. Many of them deal with safety culture and institutional change, and have long timescales. Work is underway on the measures needed to set up RAIB, but as Parliamentary time is needed for this, it will not be in place to the timescale suggested by Lord Cullen. RISB should be in place in the first half of 2003. Individual companies have reviewed their internal systems to make improvements, and provide increased safety leadership.

6. HSC will continue to publish progress reports covering all 295 Public Inquiry recommendations (i.e. the remainder from Southall, the Joint Inquiry into Train Protection Systems and the two Ladbroke Grove Reports), under the eight themes. HSE will continue to track action on each recommendation to ensure that none are overlooked. Earlier reports are accessible on the HSE website at: http://www.hse.gov.uk/railway/rihome.htm

7. The report refers to Railtrack PLC (Railtrack) as the owner and operators of the network and infrastructure. Railtrack PLC has now been acquired by Network Rail Holdco Ltd and will be known as Network Rail. All references in the report to expected future action by Railtrack should be construed as referring to Network Rail.

8. A summary ofprogress on the reports is below:

Update on recommendations

*Completed - action holders report completion, HSE accepts. These recommendations will not be covered in future progress reports.

*Action holder reports completion - action holder believes it has done enough to meet the intent of the recommendation, but HSE is not yet able to endorse this view and will continue to report on progress.

Continuing recommendations

Southall
3 continuing
2 were due February 2001
1 was due August 2000

Joint Inquiry
23 continuing
8 had no timeline specified - includes 1 'not yet endorsed'
7 were due in 2001/02
8 are due in 2003/04

Ladbroke Grove 1
28 continuing
4 had no timeline specified
20 were due 2001/2002 - includes 2 'not yet endorsed'
4 are due 2003

Ladbroke Grove 2
51 continuing
23 had no timeline specified - includes 3 'not yet endorsed'
13 were due in 2002 - includes 5 'not yet endorsed'
23 are due in 2004

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