Select Committee on Environment, Transport and Regional Affairs Memoranda

Annex 2

Report on railway safety by the Transport Sub-Committee



  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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.


  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)


  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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