Dave Bennett describes how the rail industry has worked to eradicate a blame culture and replace it with one that is just and positive in promoting good health and safety behaviours.
The Ladbroke Grove train crash on 5 October 1999, and the subsequent inquiry by Lord Cullen,1 marked a watershed for the rail industry with regard to the promotion of a positive health and safety culture.
The UK Railway Safety and Standards Board (RSSB) defines human factors as “the discipline of optimising human performance in the workplace by combining a wealth of knowledge, primarily from the disciplines of psychology and ergonomics. It considers the working environment from a human-centred viewpoint, looking at the whole system and its influence on the way people behave and interact with the railway.”2
During the Ladbroke Grove inquiry, all parties in the rail industry agreed, for the first time, that issues such as safety culture and a holistic approach to safety had to be explored in the aftermath of incidents. Prior to Ladbroke Grove, the industry had tended to treat accidents as the fault of the person who was the last link in the causal chain of events.
An example was the case of driver Bob Morgan, who was involved in the Purley train crash on 4 March 1989. The incident, which resulted in five fatalities and left nearly 90 injured, led to Mr Morgan’s conviction, on 3 September 1990, on two counts of manslaughter. He was sentenced to 18 months in prison, of which 12 months were suspended, after he admitted passing a signal while it was red – an event that contributed to the crash.
However, the original conviction did not take into proper account underlying factors, not least that this signal had been previously passed at danger on four occasions between 16 October 1984 and the time of the Purley tragedy, while another similar event occurred on 6 June 1991.
In January 2008, the Court of Appeal quashed his conviction, on account of new evidence being presented, relating to the signal having previously been passed at danger on several occasions. It is this recognition – that conditions outside the control of the individual can act as underlying causes of incidents – that changed in the wake of Ladbroke Grove.
The substitution question
One innovation of the Cullen Inquiry was to set up small groups to examine specific issues, and which then fed into the main report. I represented train drivers’ union ASLEF at an inquiry seminar on “developing an effective safety culture”, during which an HSE document, ‘Reducing error and influencing behaviour’, was discussed.3
Based on many of the ideas of human-factors expert Professor James Reason, the document states: “Everyone can make errors no matter how well trained and motivated they are. Sometimes, we are ‘set up’ by the system to fail. The challenge is to develop error-tolerant systems and to prevent errors from occurring.”
Commenting in relation to the first report into Ladbroke Grove, the then Chief Inspector of the Railway Inspectorate, Vic Coleman, said on 8 October 1999: “There are many other factors involved. This is primarily a system failure. The person most at risk when a danger signal is passed is the driver himself. I do not believe drivers set out deliberately, or carelessly to make mistakes.”4
Posed the question of how to tell the difference between a deliberate act and a mistake, Reason argued for the use of a “substitution test”.5 The test states that, in order to determine how a particular person reacted in an incident, they could be substituted with an individual from the same domain of activity possessing comparable qualifications and experience.
The question is then asked: “In the light of how events unfolded and were perceived by those involved, is it likely that this new individual would have behaved any differently?” If the answer is “probably not”, then apportioning blame has no material role to play and it is likely to obscure systematic deficiencies.
Moving to a “no-blame culture”
During the Cullen inquiry, the concept of a “no-blame culture” was raised. It became clear that some acts are not acceptable in a safety-critical industry such as rail. If a person deliberately and wilfully acts in an unsafe manner, then they can and should be held responsible.
The issue arising out of the inquiry was how to actually implement the lessons learnt in the real world of the railway industry. By 2005, train drivers involved in ‘safety of the line’ incidents were dealt with by Railway Group Standards (RGS) and supporting industry guidance on specially monitored drivers (SMDs). The standards promoted the allocation of points following incidents (similar to road-traffic offences), which could ultimately result in a train driver being removed from normal driving duties.
However, ASLEF had significant issues with the policy of managing drivers through the SMD system. Key problems included:
Competence and development
The next task was to produce a good-practice document on how to deal with ‘safety of the line’ incidents, so that the union’s full-time officers could use it as a basis for negotiation with each train and freight-operating firm.
To deliver this, ASLEF worked with representatives from National Express Group rail companies and sought specialist consultancy advice from an ex-British Rail manager. The first task was to change the title from the Specially Monitored Drivers (SMD) procedure to Competence Development Process (CDP), as this emphasised that development was the main issue, not punishment.
In April 2009, after reaching agreement with ASLEF, Northern Rail (a joint venture between Serco Group plc and Abellio, a subsidiary of NS Dutch Railways) introduced Drivers’ Development Plans (DDPs).
A crucial ingredient for the success of DDPs was the training of both staff representatives and management in how the new system would work. This covered a number of issues, such as: understanding how human factors can play a part in accident/incident causation; interviewing skills; the reason for the change; and the principles of applying the new process. A key part of this was implementing competence development programmes with drivers, who would ultimately take ownership of them. These were also intended to satisfy legal obligations under railway safety legislation and guidance for managing competence of safety-critical staff.
Review
The consultant undertook a review of the application of the CDP policy across the then National Express East Anglia (NEEA) franchise (now Greater Anglia) in 2011. The review found that since the implementation of the revised process in 2008, there had been a 50-per-cent reduction in the number of drivers within the system when compared to the previous points-based system. Furthermore, there was evidence of improved safety performance during 2010, with the company experiencing its lowest level of signals passed at danger (SPADs).
Other rail companies, such as Northern Rail, have also seen fewer staff caught up in the system, as well as less time spent with each member of staff, as development plans became more focused. More than 95 per cent of the UK train companies with which ASLEF has agreements have now implemented the CDP policy.
What can other industries learn?
So, what can other industries learn from the rail sector’s experience? Firstly, it is a slow, continuous process – ASLEF has been working since 2005 to get where it is today.
Secondly, there exists a fundamental need to seek and gain “buy in” from both staff and managers. Training is imperative, and companies such as Northern Rail have further developed the concept, with greater emphasis now being placed on the application of softer, non-technical skills associated with human performance.
Non-technical skills are described as “generic skills that underpin and enhance technical tasks and improve safety by helping people anticipate, identify and mitigate against errors”.6 Examples include conscientiousness, communication, rule compliance and workload management.
Northern Rail’s efforts in this area have involved joint training of managers and ASLEF representatives. This has resulted in the production of development plans that are more targeted and individual-oriented, through better identification of the underlying causes of an investigation.
References
1 The Rt Hon Lord Cullen PC (2000): The Ladbroke Grove Rail Inquiry Report, Part 1, HMSO ISBN 0 7176 2056
2 www.rssb.co.uk/expertise/hf/pages/whatishumanfactors.aspx
3 HSE (1998): Reducing error and influencing behaviour (HSG 48), HSE Books ISBN 0 7176 2452 8
4 HSE (1999): Train accident at Ladbroke Grove Junction, 5 October 1999, First HSE interim report
5 Reason, J (1997): Managing the risks of organisational accidents, Ashgate, ISBN
1 84014 105 0
6 Rail Safety and Standards Board (2012): T869 Project Non-technical skills for rail: development, piloting and evaluation of a training course
Dave Bennett is health and safety advisor at the Associated Society of Locomotive Engineers and Firemen (ASLEF). This article is based on a speech he gave at the IOSH Rail Conference in November 2012.
The Safety Conversation with SHP (previously the Safety and Health Podcast) aims to bring you the latest news, insights and legislation updates in the form of interviews, discussions and panel debates from leading figures within the profession.
Find us on Apple Podcasts, Spotify and Google Podcasts, subscribe and join the conversation today!
