HSC press release C043: 04 - 14 September 2004
The Health and Safety Commission (HSC) today published its third progress report on recommendations made following recent rail Public Inquiries.
The report charts progress on the implementation of recommendations since HSC published its last report in August 2003. Bill Callaghan, HSC Chair said:
"This latest report records considerable progress. The rail Public Inquiries have delivered results because the rail industry has risen to the challenge of delivering the recommendations; this is part of the framework for the continued improvement in railway safety. Of the total of 295 recommendations arising from the three Public Inquiries into rail safety, only 27 now remain to be completed. The end of 2003 saw the successful completion of the train protection and warning system (TPWS) programme. TPWS has already reduced the signal passed at danger risk and there have been several incidents where TPWS has effectively intervened in situations where there was potential for collisions."
He added: "In the recently published White Paper 'The Future of Rail' the Government set out its plans to merge regulatory responsibility for rail safety with the Office of Rail Regulation. That new body must ensure that the process of improving safety culture on the railways continues, and both the Rail Accident Investigation Board and the Rail Safety and Standards Board - two creations of the rail Public Inquiries - will have key roles to play. In the meantime, HSC remains committed to maintaining health and safety on the railways."
Bill Callaghan was speaking as HSC published its third progress report on implementing the 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. Professor Uff and Lord Cullen asked HSC to monitor implementation of the recommendations made in the Public Inquiry reports.
HSC published a first progress report in November 2002 charting progress on all 295 recommendations. The second progress report was published in August 2003 showing progress on the remaining 116 recommendations. This third report tracks progress made on the remaining 79 recommendations.
'The Rail Public Inquiries: HSC report on overall progress as of March 2004 on the remaining recommendations from the rail Public Inquiries' can be found at: http://www.hse.gov.uk/railways/railpublic3.pdf
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. Work on all the recommendations is now regarded as complete.
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, 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. The industry reports that action on 34 recommendations is now complete. Action continues on 5 recommendations, mainly relating to ETCS - the automatic train protection element of the European Rail Traffic Management System (ERTMS). HSC has published separately its work on monitoring progress with this (see http://www.hse.gov.uk/railways/liveissues/tps.htm)
3. The Ladbroke Grove Rail Inquiry Part 1 Report by Lord Cullen 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. Industry reports that action on 86 recommendations is now regarded as complete. Action continues on the remaining 3.
4. The Ladbroke Grove Rail Inquiry Part 2 Report also by Lord Cullen was published on 20 September 2001. It contained 74 recommendations, 1 of which required HSC to publish a report on compliance after six months, and regular reviews thereafter. The recommendations cover: use of contractors; establishing a Rail Accident Investigation Branch (RAIB) and a Rail Safety and Standards Board (RSSB); railway safety cases; HSE; safety leadership and skills; accreditation and licensing. Industry reports that action on 55 recommendations is now regarded as complete. Action continues on 19 recommendations. A summary of progress on all four reports is below.
5. The Health and Safety Executive (HSE) carries out the monitoring work for HSC. As before, the recommendations are grouped under eight themes: safety culture; infrastructure; investigations; organisations and standards; suppliers and contractors; training; train protection, and vehicle integrity. The first report showed that of the 295 recommendations, 179 were considered completed. The second report showed that of the remaining 116 recommendations, 37 were considered completed. This report shows progress on the remaining 79 recommendations, with 52 considered completed. Both the industry and HSE agree that work on 27 is still to be delivered. Of these 27, action on 9 has continued beyond the dates put forward in the Public Inquiry reports, as well as 9 recommendations where no timeline was specified. There is a range of reasons for this, including the complexity of interrelated issues, the need for legislative change, or because industry is taking a broader look than the recommendations strictly require. HSE and industry have discussed and agreed alternative timescales. A summary of progress on the eight themes is below.
6. Where HSC has accepted that adequate action has been taken to regard certain recommendations as completed, it does not mean that industry will not continue to take the issues forward, or indeed that HSE will not continue to monitor the position as part of its ongoing planned inspection work. Earlier progress reports can be found on the HSE website at http://www.hse.gov.uk/railways/information.htm. See also press releases C040-03 dated 5.8.03 and C053-02 dated 28.11.02.
7. On 15 July 2004 the Secretary of State for Transport (SoS) published a White Paper, The Future of Rail, with outcomes from the Rail Review that he announced in January 2004. HSC published its response to the White Paper on the same day - see press release C032-04. The SoS decided that the responsibility for rail safety regulation should be transferred from HSE to the new Office of Rail Regulation (ORR). A date for the merger has not been proposed but since primary legislation is required there will be a transitional period in which the statutory responsibilities for health and safety on the railways remain with HSE. During the transitional period, and before the merger takes place, HSE will discuss with the ORR how future progress on the rail Public Inquiry recommendations should be reported.
8. The report refers to Railtrack PLC (Railtrack) as the owner and operator of the network and infrastructure. Railtrack PLC was acquired by Network Rail Holdco Ltd and is known as Network Rail. All references in the report to what Railtrack is expected to do in the future should be construed as referring to Network Rail. It also refers to Railway Safety as the rail industry's own safety body. Railway Safety's functions are now the responsibility of the Rail Safety and Standards Board (RSSB), established on 1 April 2003. All references in this report to what Railway Safety is expected to do in the future should be construed as referring to RSSB.
9. Rail Public Inquiries Progress September 2004
Update on the remaining recommendations
| Public inquiry | Total number of recommendations | Completed to date | Continuing |
|---|---|---|---|
| Southall | 93 | 93 | 0 |
| Joint Inquiry | 39 | 34 | 5 |
| LGRI 1 | 89 | 86 | 3 |
| LGRI 2 | 74 | 55 | 19 |
| Totals | 295 | 268 | 27 |
Recommendations that have not been implemented by the date put forward in the Inquiry reports:
Joint Inquiry 5 continuing:
Ladbroke Grove 1 3 continuing
Ladbroke Grove 2 19 continuing:
10. Summary of progress on the themed recommendations September 2004
We are now satisfied that each individual organisation has delivered the full scope of each recommendation as written. Safety culture is an issue that goes far beyond the recommendations made by Lord Cullen. Implementing these recommendations will make a significant contribution to improving safety culture as he envisaged. This is the first step in the long process of developing a positive safety culture.
The remaining 3 recommendations have all been implemented, all aimed at improving signal sighting and signalling systems.
There are 15 remaining recommendations included in this report. The Rail Accident Investigation Branch (RAIB) has been established and further legislation is expected shortly to set out its framework.
Of the 12 remaining recommendations included in this report, a further 10 have been completed. Action continues on the other two. A real challenge remains for the industry to ensure that the Rail Safety and Standards Board (RSSB) succeeds in filling the leadership and standards development role that Lord Cullen has set for it.
6 remaining recommendations are covered in this report; a further 5 recommendations aimed at improving the management of contractors have been completed. Work continues on the recommendation on the accreditation of safety critical suppliers.
Of the remaining 6 recommendations included in this report, a further 3 have been completed. Action continues on the remaining 3.
Of the remaining 21 recommendations included here, a further 16 recommendations have been completed since the last progress report. Work is continuing on the remaining 5. The end of 2003 saw the successful completion of the TPWS fitment programme across the network as required by the Railway Safety Regulations 1999. HSE has granted exemptions from these Regulations where the industry produced good evidence to show that the costs were high and risks were low. In 2003, exemptions were granted for TPWS fitment at Permanent Speed Restrictions (PSRs) at diverging junctions and Temporary Speed Restrictions (TSRs). In granting the exemptions, HSE accepted that evidence suggests that TPWS is much less effective and suitable for mitigating overspeed risk than anticipated when developing the Regulations. HSE is seeking additional information on this from the rail industry to use in an early review of this aspect of the Regulations. The National European Rail Traffic Management (ERTMS) Programme (NEP) 2nd year progress report, published on 18 May 2004, reports good progress being made across the industry in a number of areas in the development of ERTMS.
Of the remaining 12 recommendations, a further 11 have been completed. Work is continuing on 1 recommendation. Train operators have introduced improved arrangements for emergency evacuation, safety information and signage, training of staff, and provision of equipment. Additional standardised information for passengers will also help. A substantial programme of research and investigation is continuing. This is progressing more slowly than the Inquiries recommended, because the industry is taking a broader look at the issue than the strict terms of the recommendations demand, which appears a sensible approach for the longer term. The future development of European Technical Standards for Interoperability will influence and eventually determine standards in many of these areas.
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