Written evidence submitted by the Rail Accident Investigation Branch (RAIB) (RLS0005)

Purpose of the paper

1. This paper provides written evidence on behalf of the Rail Accident Investigation Branch (RAIB) to the Transport Select Committee’s inquiry into rail safety.
2. The Committee is interested in the effectiveness of the current system of management, investigation, regulation, enforcement and policing in ensuring the safety of rail passengers, workers and the public and in current issues in railway safety performance.
3. The RAIB is the independent rail accident investigation body for the United Kingdom (UK).  A description of our role, and other information that may be of use to the Committee, is set out below. In particular, this paper describes the purpose and benefits of independent accident investigation in the context of UK rail safety.  It also describes some of the current railway safety issues that concern the RAIB.  It does not address those items in the terms of reference that are not directly relevant to the RAIB’s scope (for example, transport security).

Background information on the RAIB

4. The RAIB is part of the Department for Transport for administrative purposes (resourcing, accommodation, and support services).  However, it operates independently when conducting accident investigations, which are carried out in accordance with its statutory duties and powers set out in UK law.
5. The RAIB started work in 2005.  Four years earlier, the public inquiry into the 1999 Ladbroke Grove accident had recommended that an independent organisation should be established to investigate rail accidents, and that this body should be independent of government, safety regulators, police and all industry parties.
6. The “Railways and Transport Safety Act 2003” implemented this recommendation by establishing the role and powers of the RAIB.  The Railways (Accident Investigation and Reporting) Regulations 2005 give practical force to the Act by detailing the RAIB’s powers and duties, while also establishing the duties of industry to report accidents and to cooperate with RAIB investigations.  The Act and Regulations also implement those parts of the EU Railway Safety Directive (2004/49/EC) which required member states to establish independent accident investigation bodies.
7. The RAIB’s scope includes mainline railways, metros (including London Underground), tramways, and heritage railways.  Geographically, the RAIB covers the whole UK, including the UK part of the Channel Tunnel.
8. Improving railway safety is the sole purpose of RAIB investigations.  The RAIB does not apportion blame or liability, prosecute, or enforce any laws, rules or regulations.  RAIB investigations identify causal factors, and make recommendations to the relevant safety authority and other bodies.  The objective of every recommendation is the improvement of railway safety, either by reducing the likelihood of a recurrence or by mitigating the consequences of a dangerous event.  RAIB’s recommendations have encompassed areas of design, business processes and people management (eg competence and fatigue).
9. The RAIB does not investigate all rail accidents.  Although there are certain types of train accident that the RAIB is obliged to investigate[1], in general the RAIB is given wide discretion when deciding which accidents to investigate.  When making this decision, we consider the following factors:

• the severity of the outcome;
• the potential for the consequences to have been more severe; and
• the potential for new safety learning, and how widely it could be applied.

10. The above consideration is based on a review of the evidence gathered as part of our preliminary examination of the circumstances, often informed by a visit to the site of the accident.  When a full investigation is not justified the RAIB will sometimes publish a short form report, known as a Safety Digest, to disseminate any obvious or repeat safety learning that was identified during the preliminary examination.
11. The RAIB has 43 full time equivalent staff, split between two sites, in Aldershot and Derby.  Working from two locations allows us to deploy quickly to incidents across the country. 

Regulation, investigation and liaison

12. The RAIB does not develop rail safety policy, or play any role in regulation and enforcement.
13. This separation allows the RAIB to consider all contributory factors to an accident or incident, including those related to the actions of any public and regulatory bodies.   Although all of our recommendations are addressed to the safety authority, or another public body, we always identify the organisation(s) that requires to take action; ie we ‘direct’ each recommendation to the intended ‘end-implementer(s)’. When we believe that actions need to be taken by the safety authority to address a gap in the regulatory process we will not hesitate to direct a recommendation to the safety authority itself.
14. The Office of Road and Rail (ORR) has a duty to ensure that each recommendation addressed to it is duly taken into consideration, and where appropriate acted upon.  The RAIB is therefore pleased to note that ORR has facilitated a high level of implementation by rail industry bodies.  
15. Current working relationships with ORR and other industry bodies are effective and positive, although from time to time the RAIB has voiced concerns when the time taken for certain recommendations to be fully implemented is excessive, or when the actions proposed do not meet the recommendation’s real intent. 
16. Through its investigations, the RAIB has regular contact with the industry, and those who work in it.  This includes many different types of organisations, including infrastructure managers (such as Network Rail and London Underground Ltd), train operators, rail freight companies, engineering contractors, rolling stock owners, RSSB and trade unions. 
17. Our investigations process includes consultation with industry to share learning and issues emerging from investigations.  This ensures that the industry is aware of the emerging findings from our investigations; they do not have to wait until the final report is published to find out what we have concluded.  The consultative process also affords the industry the opportunity to provide information to support the accuracy of our work, and take early action to address the issues identified.  We consider this engagement process as integral to the success of safety investigations.  Ultimately, we want relevant organisations to act on our recommendations to the benefit of themselves, passengers, workers and the public. 
18. In addition to individual investigations, the RAIB Annual Report summarises safety themes across a calendar year.  This provides us with an opportunity to highlight important areas of concern, and we further consult with regulators and the industry throughout this process.
19. Levels of deaths and injuries on the UK railway (attributable to the operation of the railway) are historically low.  The RAIB cannot directly link this to effective coordination between different railway parties, but at a system level, existing arrangements appear to deliver a good safety outcome relative to other developed countries.

The effect of the result of the EU referendum on the current framework for rail safety and security

20. As explained earlier, the RAIB and its powers were established in accordance with Lord Cullen’s recommendation following his inquiry into the Ladbroke Grove accident of October 1999.  However, the legal framework underpinning its activities also met the requirements placed on member states by European Union Railway Safety Directive 2004/49/EC.  The RAIB is currently reviewing Railway Safety Directive 2016/798, which was passed in May 2016, in order to determine how its requirements could be transposed into an updated version of The Railways (Accident and Investigation Reporting) Regulations 2005.  It is possible that the 2016 Directive will come into force before the United Kingdom’s exit negotiations from the European Union are complete.
21. The RAIB notes that the impact of the new directive on RAIB operations would be limited since the new requirements that are relevant to accident investigation generally reflect good practice, or promote processes that are already adopted by the RAIB.  For that reason, the RAIB considers that the impact of Britain’s exit from the EU on its own operations will be minimal. 
22. The RAIB enjoys good relations with other accident investigation bodies in Europe and other parts of the world (eg United States, Canada, Australia and Japan), and does not expect that to change after exit negotiations have been completed.

Specific safety issues on the operational railway

23. The terms of reference for the Select Committee’s inquiry identify some specific issues that affect safe operation of the railway.  The RAIB is aware of general trends in the identified areas, but through its investigation into individual accidents and incidents can bring some specific insights into factors that affect current safety performance.  Five of the key themes are discussed below, and some summary information about them is included in Annex A.

Level crossing safety

24. The RAIB provided evidence to the Transport Committee’s 2013 Inquiry into level crossings, at which it identified a number of specific concerns in respect of level crossing safety:

• Means of influencing user behaviour, and encouraging them to use crossings safely.
• Deficiencies in industry’s processes for assessing risk at level crossings.
• Consideration of local factors such as usage and layout at individual crossings.
• Design of crossing infrastructure and the lack of engineered safeguards.

25. The RAIB has continued to investigate level crossing accidents on a frequent basis since the 2013 Inquiry.  Ten investigation reports have been published since 2014 and six further investigations (including two safety digests) are currently ongoing.
26. The RAIB notes that industry continues to work to improve level crossing safety. However, each of the four concerns identified above continue to feature in the causal chain of many level crossing accidents investigated by the RAIB. 
27. In order to reduce harm at level crossings, the RAIB considers that industry needs to continue with its programme of level crossing closures and pay particular attention to the way in which engineered solutions can contribute to risk reduction at those crossings which must remain open. 
28. In recent years, the RAIB has become concerned about the contribution made by signaller error to accidents at crossings where it is necessary for the user to telephone the signaller for permission to cross.  The RAIB is currently investigating two such accidents (at Dock Lane crossing near Melton, Suffolk on 14 June 2016 and at Hockham Road crossing near Thetford, Norfolk on 10 April 2016).  In an environment where signal box control areas are becoming larger, and the number of crossings overseen by an individual signaller is increasing, there is a greater scope for signaller error unless the risk can be properly controlled.
29. The RAIB has noted a specific area of risk at user worked crossings where the railway crosses farm land, and the crossing is used intensively for a relatively small period of the year (typically at harvest time).  This year was no exception; the RAIB attended an accident on 10 September 2016 in which a train running on the narrow-gauge Romney, Hythe and Dymchurch Railway struck a tractor, resulting in the steam locomotive overturning.
30. Meticulous attention to detail in level crossing risk assessment and explicit consideration of the layout and signage of the crossing and its usage will also contribute to future risk reduction, providing that the output from those risk assessments leads to the adoption of suitable risk mitigation measures.

Platform/train interface

31. To date, the RAIB has published 16 investigations into accidents at the platform/train interface.  Of particular concern in recent investigations have been:

• The need to review the designs of certain types of train doors to reduce the risk of passengers becoming trapped in doors and then dragged by the departing train.  For example, this was a feature in an accident at West Wickham station on 10 April 2015 (RAIB report 03/2016, published February 2016).
• A widespread misunderstanding about the sensitivity of train door control systems to the presence of trapped objects.  This has led some staff to conclude that the presence of objects such as hands between the leaves of closed doors will always be detected. For example, this was a feature in an accident at Hayes & Harlington station on 25 July 2015 (RAIB report, 12/2016 published June 2016).
• The need for a better understanding of the ways in which passengers interact with train doors.

32. In the first two examples above, the RAIB issued urgent safety advice to the railway industry in order that action could be taken to address the identified hazards before the RAIB published its investigation report.  That advice also emphasised the importance of any member of staff involved in dispatching trains making a final safety check after the doors have been closed.  More broadly, the RAIB has made a number of recommendations following our reports, intended to address the risk at the platform/train interface.
33. The RAIB considers that safety at the platform/train interface can be managed effectively by focusing on:

• the provision of suitable equipment for the dispatch method used (eg cameras and CCTV monitors);
• the person responsible for dispatch being able to observe the platform for longest possible time (whether directly or via equipment (above bullet)) and to have the ability to stop the train directly;
• rigorous compliance with safety rules by trained operating staff; and
• effective management of risk at stations, particularly where visibility is poor or platforms are crowded.

34. A reduction in the gap between trains and platforms can also make a significant contribution to safety at the interface for some types of accident, but this is likely to be a longer term solution, since it would require modifications to trains and/or station platforms.

Structures and earthworks

35. As the United Kingdom continues to experience occasional episodes of very heavy rainfall, so there will be a corresponding need to focus on the management of structures and earthworks.
36. After a relatively benign period for accidents and incidents associated with structures and earthworks, the RAIB is currently investigating:

• one serious incident involving the failure of the viaduct at Lamington on 31 December 2015, which closed the west coast main line for seven weeks, and acted as a reminder that damage to structures at times of heavy rainfall can pose a serious risk to trains; and
• the derailment of a train near the north portal of Watford tunnel on 16 September 2016 following a period of heavy rain and a landslip, and its subsequent collision with another train in the tunnel.

37. Both accidents focus a spotlight on processes for assessing the risk to structures, cuttings and embankments from extreme weather, and the measures adopted for eliminating or mitigating that risk, ranging from design solutions through to procedural measures such as monitoring by watchmen.
38. Often forgotten, but arguably as important in controlling risk, is effective drainage.  The RAIB has investigated a number of accidents where poor drainage was in the causal chain, for example the high-speed derailment of a freight train at Gloucester on 15 October 2013 (RAIB report 20/2014, published October 2014) and the derailment of a freight train at Heworth (between Sunderland and Newcastle) on 23 October 2014 (RAIB report 16/2015, published September 2015).  Those accidents serve to emphasise the importance of infrastructure owners managing all aspects of the assets they control.

Safety of track workers

39. The safety of track workers continues to be a major concern for the RAIB.  In 2015, the RAIB published five investigation reports concerning the safety of track workers.  It also conducted a ‘class investigation’ (reviewing a number of incidents rather than a single incident or accident) into irregularities associated with the protection of engineering activities on the operating railway.
40. Although the last year has not seen any major track worker accidents, the high level of near-misses indicates that the risk is not under control.  When a near-miss occurs, it is frequently a matter of luck that a serious accident did not happen.  The RAIB is therefore currently undertaking a further class investigation, this time focusing specifically on the safety of staff whose work takes them onto the track when normal train services are operating. The class investigation will describe some near-misses in greater detail, but a recent example that was subject  to a full investigation was the near-miss at Hest Bank in Lancashire on 22 September 2014 when a train travelling at 98 mph approached a group of nine track workers without warning.  The last member of the group to clear the track did so around one second before the train passed (RAIB report 08/2015, published July 2015).
41. The RAIB’s investigations have identified three overriding areas of concern:

• the need for high standards of safety leadership of those undertaking track works;
• the attitudes and behaviours within track maintenance teams, which can see workers feeling unable or unwilling to challenge unsafe working practices; and
• the incorrect planning, or execution, of work which can result in unsafe practices being adopted.

42. RAIB is aware that Network Rail and its contractors remain determined to address track worker safety issues. In recent years, the industry has focused on addressing the behaviours and attitudes of track workers while also developing the leadership skills of supervisors and managers. 2015 saw a shift of focus towards implementation of a major track safety initiative, ‘Planning and Delivery of Safe Work’ (PDSW). This is designed to ensure that every task is correctly planned, and subsequently documented in a ‘permit to work’, similar to those used in other industries.  Execution of the plan that is documented by the permit is then to be implemented by a specially selected and trained individual, designated the ‘Safe Work Leader’ (SWL). It is planned that the SWL will be responsible for both the work activity, and the safety of the team.
43. If implemented as intended by Network Rail, the PDSW scheme should help to address a number of particular issues that have been raised by RAIB over recent years. These include:

• the extent to which the person in charge of site safety is able to exercise effective control of work groups that may include their supervisor or manager;
• the need for a properly documented plan that includes a diagram showing all relevant features, and identifying particular hazards; and
• the need for structure and discipline in the way that planned works are implemented.

44. RAIB is also encouraged by the current work that is being undertaken to examine the role of improved technology in reducing the risk to track workers.
45. While supporting the objectives that the industry has set itself, RAIB is concerned about the slow progress that is being made with the implementation of PDSW.  We are also anxious that Network Rail does not lose sight of the need to address the attitudes and behaviours within teams of track workers, and their managers, which can lead to unsafe practices and non-compliance with the safety management schemes put in place.

Fatigue

46. Since becoming operational in 2005, the RAIB has investigated 15 accidents and incidents where fatigue was found to be a causal factor.  Although nine of those investigations involved train driver fatigue, the RAIB has also investigated events where fatigue affecting track workers, signallers and freight yard staff was found to be a cause of the accident.
47. In recent years, the RAIB has highlighted specific issues in relation to freight train drivers working long overnight shifts, with little opportunity to take effective rest at any point during their shift (eg two signal passed at danger incidents, at Reading on 28 March 2015, and Ruscombe Junction on 3 November 2015 (RAIB report 18/2016, published September 2016) and uncontrolled freight train run-back, Shap Summit on 17 August 2010, RAIB report 15/2011, published August 2011).  It is apparent that the industry still has a problem in relation to staff not reporting fatigue, often because they do not want to let their colleagues or employer down by not turning up for work.
48. The RAIB recognises that this is a difficult problem for employers to manage, and that part of the answer lies in a cultural change that encourages open and honest ‘no-blame’ reporting of fatigue-related events, so that the specific contributors (work-related and personal) can be more clearly identified.  However, the RAIB has also identified other practical steps that can be taken to improve the industry’s understanding of fatigue and promote better mitigation of the risk through design of rosters and shorter working hours for night duties.

Other areas of concern

49. In addition to the areas of concern highlighted above, other emerging themes identified in our last annual report include issues relating to poor freight train condition; weaknesses in safety validation of the design of on-track plant; and the variable extent to which the Entities in Charge of Maintenance (for freight rolling stock) are fulfilling the legal duties that were recently placed upon them.
50. Although the concerns raised above are in the context of a relatively safe railway overall, a concerning feature of our 2015 annual report is the number of events where only luck prevented an accident involving multiple fatalities. Examples include the incidents at Hest Bank (RAIB report 08/2015), Froxfield (RAIB report 02/2016), and Wootton Bassett Junction (RAIB report 08/2016). 

Conclusion

51. The RAIB’s core function is the independent investigation of railway accidents to improve safety and inform the railway industry and the public. During the time the RAIB have been active, railway safety has improved. While our contribution to this improvement cannot be separated from the efforts of the industry and its regulators, we are proud to have played our role by undertaking expert and independent investigation of railway accidents, identifying gaps in existing safety defences, and recommending actions needed to address them.

October 2016

Summary table of numbers of accidents investigated by the RAIB in five key areas and current themes

NOTE

The type of accident most frequently investigated by the RAIB to date has been train derailments, which account for 79 (23.2%) of investigations completed to date.  This figure is split fairly evenly between freight and passenger train derailments.