The Ladbroke Grove Rail Inquiry Part 2 Report The Rt Hon Lord Cullen PC The Ladbroke Grove Rail Inquiry Part 2 Report The Rt Hon Lord Cullen PC © Crown copyright 2001 Applications for reproduction should be made in writing to: Copyright Unit, Her Majesty’s Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ First published 2001 ISBN 0 7176 2107 3 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. 1 Front cover: Taken from a photograph supplied by Milepost 92 /2 ii Contents Chapters 1 Executive summary 3 2 The Inquiry 11 3 The rail industry and its regulation 19 4 The implications of privatisation 39 5 The management and culture of safety 59 6 Railway Group Standards 79 7 Safety cases, accreditation and licensing 85 8 Railtrack and Railway Safety 109 9 The safety regulator 123 10 A rail industry safety body 155 11 An accident investigation body 161 12 Summary of recommendations 169 Appendices 1 Parties and their representatives 181 2 Witnesses 183 3 Principal documents 185 4 The relevant accidents 189 5 The models proposed by parties to the Inquiry 195 6 Safety regulation and accident investigation in aviation 203 7 Joint statement of experts on risk management 207 8 Abbreviations 215 Inquiry team 217 1 2 Chapter 1 Executive summary 1.1 As I explain in Chapter 2, this report relates to Part 2 of the Inquiry which was concerned, in regard to the railways, with the management of safety and the regulatory regime. 1.2 The chapter outlines my approach to Part 2, the preparations for the Inquiry, and the procedures which were followed. It concludes with some observations about the scope for recommendations. 1.3 In Chapter 3 I provide, as a background to the following chapters, a general overview of the organisation of the rail industry and its regulation. The chapter includes an outline of the arrangements which govern the relationship between the different members of the industry, the functions and duties of the Rail Regulator and the Strategic Rail Authority (SRA), legislation for the regulation of safety and the responsibilities of the safety regulator. 1.4 In Chapter 4 I explore the safety implications of the disaggregation of the rail industry which was brought about by privatisation. While there has been a gradual increase in overall safety levels, there is a perception that there has been a decrease in safety. Within the workforce there is a perception that emphasis on performance has affected attitudes to safety. Safety consultants have found a pre-eminent culture of focus on train performance in terms of delays. The disparity in sanctions between those for failures in performance and those for failures in safety may well have conveyed to the industry that performance was of top priority. 1.5 The Inquiry heard evidence that fragmentation of the industry has engendered defensive or insular attitudes which hinder the identification of the underlying causes of accidents and the learning of lessons from them. Within the industry differences of culture and ways of working have developed, skills and experience have tended to become compartmentalised, the breadth of training has suffered and there has been a shortage of properly trained and competent personnel. 1.6 The Inquiry heard evidence about two areas which lie beyond the ability of any one member of the industry to deal with, namely: (i) the use of system authorities for large scale projects; and (ii) research and development, especially in regard to matters of strategic importance. I discuss the problems and possible ways forward. 1.7 The evidence in regard to the use of contractors, most notably by Railtrack, was a source of considerable concern. I find, first, that the current process for the award of contracts was not being operated with due regard to the amount of training and 3 preparation of the contract workforce. Secondly, the controls in place for the management of the work of contractors and sub-contractors were inadequate. Thirdly, there is a need for an immediate and sustained improvement by the industry in the manner in which the employees of contractors and sub-contractors are controlled. Fourthly, the argument for reduction in the number of contractors is well founded. Further, it is clear that contractors should work to exactly the same safety standards as those directly employed. Competence is of vital importance. 1.8 The chapter concludes with a discussion of the role of trade unions. I emphasise that it is the responsibility of management to ensure that the elected representatives of employees, whether they are union officials or not, have a significant role in the management of safety. 1.9 Chapter 5 is concerned with a consideration of essential elements for the management of safety on Britain’s railways. The evidence indicated that a high proportion of accidents, incidents and near misses followed unsafe actions resulting from underlying deficiencies in the management of safety. 1.10 A key factor in the industry is the prevailing culture, of which safety culture is an integral part. There is a clear link between good safety and good business. 1.11 Recognising that the first priority for a successful safety culture is leadership, I find that the fragmentation of the rail industry has made it difficult to provide leadership to the industry and for it to take united action on safety, although there are signs of improvement. I identify the need for an industry body which, with the support of the members of the industry, can take the leading role in the promotion of safety across the industry. 1.12 As regards leadership within individual companies, the evidence made it plain that it is essential that the safety commitment of senior management should be continuously visible at the working level. Much can be achieved by management undertaking regular walkabout visits. Every company should have a strategic safety management leadership team, which is led from the top and devoted to health and safety issues. 1.13 A key task for leadership is the communication of safety goals and objectives. However, if communication is to be an effective instrument in the management of safety, it has to be a two-way process, involving the workforce and giving them the sense that they are able to make a worthwhile contribution. It is not clear from the evidence to what extent safety policies play an active part in influencing safety performance. There was evidence of lack of clarity and effectiveness in rules and long-standing practice, and a variability in the effectiveness of safety meetings. A confidential reporting system such as the Confidential Incident Reporting and Analysis System (CIRAS) yields useful information, but the fact that such a system has been found to be necessary is eloquent of the lack of open communication within railway organisations. 1.14 Conflicting views were expressed about the state of morale in the rail industry, but there was general agreement that it can and must improve. Improvement in the culture of safety should bring a rise in morale. Initiatives such as reward and recognition programmes can play a significant part. 4 1.15 The evidence clearly demonstrated that the rail industry needs to develop its ability to behave as a learning organisation. I identify a number of areas of importance. First, identifying unsafe acts and conditions and taking prompt steps to deal with them. Secondly, applying and disseminating the lessons of accidents and incidents (including near misses). Here the evidence showed that the process was inhibited by the “blame culture”, and the lack of a co-ordinated system for the collation of recommendations and ensuring that they were followed up. Thirdly, using risk assessment in order to drive improvements in safety. Fourthly, gaining benefit from the process of auditing. This has been less than fully effective. Fifthly, using data and analytical tools. The evidence showed there were weaknesses in the industry’s use of these materials. Sixthly, training, with particular reference to refresher courses, into which greater effort requires to be put. 1.16 Finally, I direct attention to the desirability of the industry developing a culture in which there is a progressive movement from a situation of dependency, where management make the rules and tell employees what to do, to a situation where individuals can contribute ideas and effort, while complying with the rules and procedures, through to a position where there is a committed, dedicated team approach, with a high degree of interdependency between teams and across company boundaries. 1.17 In Chapter 6 I set out the way in which Railway Group Standards are used and developed for system safety and safe interworking, along with non-safety matters which are of concern to the rail industry. They represent a key element in the control of risk, without exhausting what has to be done in order to meet the requirements imposed by health and safety legislation. 1.18 Chapter 7 is primarily concerned with safety cases. I am satisfied that there is a need for the framework provided by the Safety Case Regulations, within which the duty holder demonstrates, and by reference to which it operates, its arrangements and procedures for the management of safety in a consistent and effective manner. I discuss what should be done in order to clarify the responsibilities for the control of risk at sites shared by different railway operators and at the interfaces between them. 1.19 I set out an outline of the evidence before the Inquiry about the content, preparation and uses of safety cases.