Annex 2
Report on railway safety by the Transport
Sub-Committee
HEALTH AND SAFETY EXECUTIVE (HSE) RESPONSE
TO RECOMMENDATIONS TO THE ENVIRONMENT, TRANSPORT AND REGIONAL
AFFAIRS COMMITTEE
RECOMMENDATION 1
Where the causes of incidents which could have
led to serious accidents are attributable to the incompetence
or inadequate site knowledge of staff, Railtrack must take responsibility
for the work of its contractors, and take action against them.
Railtrack also should tighten its procedures for selecting and
training its contractors. The monitoring of the work of contractors
by Railtrack has not been good enough and the system of "cascaded"
safety cases needs to ensure that any sub-contractor is subject
to the same controls as the main contractor. (Para 71)
Response
HSE shares the Committee's views about the need
to manage properly the activities of contractors and sub-contractors
who are employed to maintain the railway infrastructure. In response
to continuing HSE concerns, Railtrack has undertaken a further
review and prepared an action plan to strengthen its management
and monitoring of contractors to ensure that objectives for improvement
are set and that there is a firm commitment by Railtrack and its
contractors. This will be monitored by HM Railway Inspectorate
(HMRI) as part of its 1999-2000 workplan.
RECOMMENDATION 2
The present regulatory system gives Railtrack's
Safety and Standards Directorate too much responsibility. Railtrack's
proposals for separating the Directorate further from the operating
company are not acceptable. The Directorate needs to be free-standing
and should pass to an independent safety authority as already
recommended by the Environment, Transport and Regional Affairs
Committee. (Para 72)
Response
Following a recommendaton contained in last
year's report from the Committee on the Strategic Rail Authority,
HSE is conducting a thorough review of Railtrack's role in setting
and policing railway group standards and its role in the current
safety regime. We expect to produce a report for the Minister
for Transport containing a range of options in the spring. The
review is governed by a number of principles which are that any
changes should:
— minimise conflicts of interest within
the industry;
— enhance the transparency of decision
making;
— not jeopardise current safety standards
nor hinder their further improvement;
— not compromise in any way the aims
and purpose of the Health and Safety Commission and Executive;
— not cut across statutory duties for
health and safety in the railway industry or weaken the railway
companies' obligations to ensure safety;
— not cause, through any transition
to new arrangements, significant disruption to major railway projects.
The findings of the review will also inform
HSC/E's contribution to the Government's recently announced Transport
Safety Review, and our planned evaluation of the Railway (Safety
Case) Regulations.
RECOMMENDATON 3
In view of the problems that have arisen from
the increased use of contractors to maintain the railway, the
HSE should be much more active in monitoring contractors' work.
It should make more unannounced site inspections and levy instant
penalties for any breaches in safety regulation that it finds.
(Para 73)
Response
Like any other employer which uses contractors,
Railtrack itself has the prime responsiblity for managing the
work of those contractors. In particular this means that Railtrack
must ensure that contractors do not import risk on to the railways,
either from the quality of the work they deliver, or the way they
undertake it. HSE's Railway Inspectorate will continue to monitor
Railtrack's own procedures and practice for managing contractors,
and by direct scrutiny, on a sample basis, of the work of individual
contractors. Some are "surprise" inspections, some not:
the practicalities of establishing precisely where contractors
are working, and getting access to the site, sometimes militate
against unannounced visits.
Where HSE finds poor contractor standards it
can and does take direct enforcement action. The recent prosecution
of both Railtrack and its contractors, following a train accident
at Bexley and caused largely by a failure on the part of the contractors,
is a good example. Moreover in the year 1997-98, seven of the
eight prosecutions by the Railway Inspectorate involved contractors
as defendants. HSE is also planing to continue specific inspection
projects to look at the work of contractors and the way that Railtrack
manages them, building on an earlier survey which HSE undertook
in 1996 and on the follow-up activity which is reported in subsequent
HMRI annual reports.
A power to levy instant penalties would require
primary legislation, as no such power exists under the Health
and Safety at Work Act. HSE inspectors do, however, have wide
ranging powers which include the power to take instant action
where an activity involves, or will involve, a risk of serious
personal injury through serving Prohibition Notices which require
that activity to cease immediately or after a specified time period
and not allowing it to be resumed until remedial action has been
taken. Where there is a breach of law, an inspector can serve
an Improvement Notice which requires an employer to take specific
remedial action within a specified time period.
RECOMMENDATION 4
Train Operating Companies should be pressed
to improve their own safety standards and practices. Their safety
records should be one of the factors taken into account when franchises
are renewed. (Para 74)
Response
HSE's HMRI already takes action to ensure that
Train Operating Companies (TOCs) have appropriate safety standards,
including liaison at senior level with TOC management; monitoring
of Railtrack's auditing of TOC's compliance with safety case commitments;
and where necessary the provision of advice and the taking of
enforcement action. The question of franchise renewal is largely
for the Office of Passenger Rail Franchising (OPRAF) but safety
is certainly an element which could be considered (and on which
HSE would advise) in the decision whether or not to renew an individual
TOC franchise. HSE reported on a "TOC benchmarking"
project in paragraphs 52 and 53 of its most recently published
Annual Report on Railway Safety for 1997-98.
RECOMMENDATION 5
In view of the risk of accidents involving Mark
1 rolling stock resulting in increases in deaths and serious injuries
it must be replaced, rebodied or modified for use on franchised
services by 1 January 2003, as recommended by the Health and Safety
Commission. (Para 75)
Response
We agree. A full-scale test of crashworthiness
modifications took place on 8 December which confirmed their effectiveness,
and a second test is planned for 10 February. Following the first
successful test, the HSC Chairman has written to the Deputy Prime
Minister proposing new railway safety Regulations which would,
among other things, require the withdrawal of unmodified Mark
1 rolling stock by 1 January 2003.
RECOMMENDATION 6
The "doomsday" problem of the HSC's
proposals, if implemented, resulting in a severe shortage of rolling
stock cannot be allowed to happen. Close consultation must take
place between the HSE, the Office of Passenger Rail Franchising
or the Strategic Rail Authority, and the Train Operating Companies
to ensure that sufficient new or rebodied/modified rolling stock
is in service after the deadline for withdrawing Mark 1 carriages
in their current form has passed. The failure in the first franchising
round to secure the withdrawal of Mark 1 stock must not be repeated.
(Para 76)
Response
HSE accepts the Committee's recommendation.
During the consultation phase of the HSC proposals on Mark 1 rolling
stock, HSE held meetings with OPRAF and with train operators and
rolling stock leasing companies to discuss the industry's response
and possible impact of our proposals. We will continue to liaise
closely with OPRAF on issues of mutual concern and envisage close
liaison arrangements with the Strategic Rail Authority.
RECOMMENDATION 7
Once the benefits of the Train Protection Strategy
(especially the Train Protection and Warning System) are checked
and found to be clear, then the strategy must be implemented to
a clear timetable. The HSE must monitor Railtrack's progress against
the timetable and act to enforce it if necessary. Any incompatibilities
between the different elements of the Strategy must be addressed
before they are installed and the wasteful duplication of schemes
must be avoided. The HSE should not become wedded to the introduction
of particular signalling systems as long as its objective remains
clear. (Para 77)
Response
As HSE stated in its oral evidence to the Committee,
we are not wedded to one particular signalling system. This means
that we would expect those lines which have installed Automatic
Train Protection (ATP) to continue using it and for the West Coast
Mainline modernisation to be equipped with the proposed transmission
based signalling system.
We propose to require train operators and infrastructure
controllers to install a train protection system by 1 January
2004, to a programme agreed with HSE. We expect in practice that
the Train Protection and Warning System (TPWS) will become the
principal single system of train protection installed on the majority
of the network. TPWS is not compatible with the ATP systems currently
in use and with the transmission based system envisaged for the
West Coast Mainline but we will seek to ensure that dual fitting
of track or trains is kept to a minimum, consistent with the objectives
of our proposals on train protection.
RECOMMENDATION 8
The railway industry is not doing enough to
combat vandalism which is a very serious and growing threat to
railway safety. In order to reduce both vandalism and trespass
a three year programme to clear lineside debris and repair all
boundary fences on the network should be implemented. A vandalism
and trespass hotline should be established by the British Transport
Police and Railtrack, so that incidents can be reported and responded
to more quickly. A reduction in the number of police officers
and staff on station platforms and on trains leads directly to
a decline in the safety of passengers. A more visible staff and
police presence is needed, and is in the commercial interest of
the Train Operating Companies and Railtrack. (Para 78)
Response
HSE's experience has been that while the railway
industry has been keen to tackle problems posed by trespass and
vandalism, there has been little co-ordination of activities until
recently. To facilitate this process, the Railway Industry Advisory
Committee, which advises the HSC on railway health and safety
matters, issued on 3 December last year a publication "Prevention
of Trespass and Vandalism on Railways—A Good Practice Guide".
The key messages from the guide, which was produced in partnership
with the industry, the British Transport Police, the Central Rail
Users Consultative Committee and Crime Concern, are that there
is a sound business case for organisations in the railway industry
to take action in this area, and that there is a need for the
industry to work in partnership with others to address this problem
and for greater evaluation of the effectiveness of any intitiatives
to take place. HSE intends to launch in the Spring/Summer this
year, in conjunction with the industry and other interested parties,
a publicity campaign aimed at reducing the risk from trespass
and vandalism on the railway.
HSE would welcome the other initiatives which
the Committee has proposed such as a campaign to clear away lineside
debris (which is already part of the focus of Railway Inspectors'
field activities) and to introduce a dedicated hotline.
RECOMMENDATION 9
We recommend that Railtrack and the Train Operating
Companies investigate urgently the introduction of the Confidential
Incident Reporting and Analysis System as a national scheme, which
includes infrastructure maintenance workers. (Para 79)
Response
HSE welcomes the introduction of confidential
incident reporting schemes, currently in operation across a range
of industries, as being a useful adjunct to any statutory accident
or dangerous occurrence schemes, such as the Reporting of Injuries,
Diseases and Dangerous Occurrence Regulations, which exist. They
can play a useful role in pointing up near-miss incidents etc
which means that corrective action can be taken before a serious
incident occurs. HSE was one of the original sponsors of the Confidential
Incident Reporting and Analysis System in Scotland and continues
to support it. We would be happy to see this or a broadly similar
scheme being expanded across Great Britain.
RECOMMENDATION 10
There is considerable concern at the delays
to accident inquiries or the publication of their findings caused
by the pursuit of criminal investigations into railway accidents.
We recommend that the Government, as a matter of urgency, should
investigate what procedures should be put in place to expedite
criminal proceedings, to ensure that accident inquiries may be
held as swiftly as possible. (Para 80)
Response
HSC/E share the Committee's concerns about the
delays to accident inquiries, particularly Public Inquiries, caused
by either actual or impending criminal proceedings. The attached
letter from the Chairman of the Commission to the Deputy Prime
Minister makes clear the views of HSC and HSE.
We are pleased that the Transport Safety Review
will address this issue as part of its work and look forward to
participating in it.
RECOMMENDATION 11
The HSE must undertake research in order better
to understand how safety management systems work in practice,
and must encourage a safety culture within the railway industry
that is not merely a form-filling exercise, but is shared by all
those within it. It should consider including information about
safety management in its annual report. (Para 81)
Response
We agree that safety management and safety cultures
are vital. They have featured in HSE's research programmes for
some time and continue to do so. HSE's very firm view is that
managing health and safety is fundamental to the effective control
of risks. For that reason, it is at the core of the safety case
regime which HSE introduced successfully on the railways in 1994.
Health and safety needs to be managed as an integral part of the
business process, not as an add-on or as a mere "form-filling
exercise". HSE has advocated such a view for many years and
in 1991 published the guidance document "Successful Health
and Safety Management" (HSG 65). A second, updated edition
was published in 1997. The document has been one of HSE's best-selling
publications. It provides practical guidance on the principles
and management practices to underpin effective health and safety
management and promote a positive health and safety culture. The
health and safety management system described in HSG 65 is consistent
with those advocated for quality and environmental management.
A guidance standard developed by BSI on occupational health and
safety management systems (BS8800), which HSE helped to prepare,
is also consistent with HSG 65.
As a matter of course, HSE inspectors look at
how health and safety is managed when they are visiting companies—focusing
not just on the adequacy of the systems in place but, as importantly,
on how well they are delivered in practice.
A report by the Commission's then Advisory Committee
on the Safety of Nuclear Installations' (now Nuclear Safety Advisory
Committee) Human Factors Group on "Organising for Safety"
and published by HSE in 1993 is recognised as a definitive text
on safety culture. Since then, HSE has also developed a safety
culture "climate survey tool". Using specially-designed
questionnaires and software, companies can confidentially collect
employees' views on some of the important health and safety issues
within their organisations. The tool helps raise the profile of
health and safety in an organisation and promotes employee involvement,
a key component of a positive health and safety culture, by stimulating
debate on particular problems and issues arising from the questionnaire
and their solutions. It can also be used to complement the monitoring
and auditing of health and safety performance. Very recently the
railway industry has also developed its own "climate"
tool, based on research done by AEA Technology.
Finally the recommendation suggests that HSE
should consider including information about safety management
in its annual report. The last two annual reports from HSE on
Railway Safety have included such chapters—specifically
chapter 17 of the 1996-97 report, and chapter 16 of the 1997-98
report. We will keep the issue of safety management and safety
culture on the railways under review and will commission relevant
research if necessary.
Health and Safety Executive
January 1999
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