Do we need the Rule Book?

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Written by Colin Wheeler

I am indebted to those readers who contacted me following the publication of my July track safety article.

Last month the number of incidents and their implications meant that I was unable to comment fully. I will try to do so now.

Lord Cullen got it right ten years ago

During a recess in the Ladbroke Grove Inquiry I met two graduate engineers and was horrified to discover that they had left jobs with rail consultant engineers to join a London Solicitors’ and be trained as lawyers themselves. They made it clear to me that they had done so due to the increased earnings potential.

They were philosophical about their new employer who had targeted them so as to better position himself for future rail incident litigation. Another facet of the “ambulance chasing” philosophy of lawyers!

The Inquiry Report Part 2 was published ten years ago! Re-reading the Executive Summary reveals how even back then it identified the importance of improving our safety culture and commitment.

I quote from the report:

“Improvement in the culture of safety should bring a rise in morale”.

“The first priority for a successful safety culture is leadership.”

“If communication is to be effective 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.”

“Much can be achieved by management undertaking regular walkabout visits.”

The importance of Site Visits

As I reported last month the COSS (Controller of Site Safety) who was attempting to earth the wrong track at Westbourne Park, narrowly escaped being hit by a train. He had not visited the site of work before the weekend.

I have received correspondence from other multi-sponsored contract COSS’s who have expressed fears on this.

Late alterations to planned work doesn’t help, but surely the risks are such that arranging and perhaps more importantly paying the COSS to undertake a site visit before the shift should be mandated unless the individual worked there last weekend? Surely we don’t need a new rule for the lawyers to be paid to fight over.

Motivation, actual and perceived

Conversely the Track Manager, his assistant and others who were working at Stoats’ Nest Junction Purley (where he was struck by a train and seriously injured) were very familiar with the area, maybe even too familiar?

The job went wrong when the selected closure rail was found to be too short. I hope the investigation report doesn’t make too much of the risk assessments, method statements and task briefing sheets which some office bound safety ‘professional’ might think needed to be re-written before the work was completed.

I suggest that the more likely root cause was the individual’s concentration on getting the job done and the track restored to traffic.

If leadership is the top priority for a successful safety culture, and safety comes first even before getting the job done, then such accidents and incidents should not occur.

The selection of individuals needs to look for individuals who put their own and their team’s safety first even when things go wrong.

The need for experience, training and guidance?

The hired Rail Grinding Train weighing some 37 tonnes which ran away last August on London Underground was the subject of the recent Rail Accident Investigation Branch’s (RAIB) Report. The machine reached 35 mph during the 16 minute runaway and travelled around four miles going through six stations before it came to rest.

The report commends the Service Manager, Control Room staff, and Drivers for their actions which prevented what could easily have been a catastrophic collision. However, it also adds a criticism by saying that no-one in the Control Room had, “experience, training or guidance” in how to deal with such a situation. A good thing too I suggest.

The actions taken under pressure in just those few minutes were essentially correct, and dealt effectively with the situation. I hope all the Drivers and those who work in the Control Room have been fully briefed on what occurred.

Surely the actions taken by all those involved demonstrated that none of them needed further training? The lack of written procedures or guidance meant that no time was lost in searching for archived information.

The Runaway near Inverness last July

On the subject of runaways, on 11th July the RAIB published its report on the accident that occurred near Inverness on 20th July 2010. The machine that ran away was a High Ride Road Rail Vehicle (RRV) pictured above.

The work had been arranged at short notice. The roles of Person in Charge of Possession (PICOP), COSS, Engineering Supervisor (ES), and Machine Controller (MC) were all being fulfilled by the one man.

The Road Rail Access Point near Drumrosach Farm was used to get the machine on track. The access point was fully timbered to both the six-foot and the two four-foots with the cesses timbered by two side by side timber sleepers each.

Possession was taken at around 2336 hours and the Machine Operator began to on-track his machine before the return of the PICOP/COSS /ES/MC. The machine was initially set down on the timbers rather than the rail.

The Operator then set down the other set of rail wheels but when he lifted his jib the machine began to run away. The Operator soon discovered that none of the rail wheels could be braked. (Their braking relies on the squashing force between these wheels and the rubber tyres of the machine.)

The machine ran down the 1 in 60 gradient towards Inverness for about 1.4 kilometres before it ran into the back of a stationary freight train at between 50 and 60 mph. The Machine Driver was thrown from his cab onto the rearmost freight wagon and suffered serious injuries.

The problems in getting the machine onto the rails at the access point and the “single point failure of the control system” resulting in the wheels being on track with no braking were the direct causes. The report refers to the lack of any prescribed Safety Integrity Level for the electrical control systems. A level 4 system as required for signalling of trains would be appropriate. After all it was selected some years ago as the right level for automatic track warning systems.

July accidents

Two recent incidents are under investigation by RAIB. At 1755 on 18th July a tamper was on the Down Northampton Line near Althorpe Park. Its driver saw a flapping panel on the approaching container train.

He stopped his machine and ducked away from the adjacent line before his side window was smashed by one of two metal panels measuring 2.5 metres by 1 metre wide which dropped from the freight train as it passed. The RAIB advice says that there is evidence of “loose and missing screws”.

The derailment of an empty passenger train as it passed over Princes Street Gardens Junction between Haymarket and Waverley in Edinburgh at 1751 on July 27th is also under investigation. The train ran on for some 90 metres before being brought to a halt causing damage to both the track and the underside of the train.

The RAIB says that the left hand switch rail of 167B points over which the wheel flange climbed was “heavily worn”. I will be surprised if inspection and management responsibilities don’t feature in the final report!

The necessary length of a PICOP’s arms!

What has all this got to do with the Rule Book and the need for simplifying our hand books etc.? If I start with the PICOP etc. at the Drumrosach Track Access Point, he was fulfilling four different roles according to the Rule Book but they were all on the same relatively straight forward job.

Apart from proving that his arms were long enough for all the armlets he needed to wear and needing understanding of a number of Rule Book rules, do we really need so many titles etc?

Are they of real use for safety and efficient working or are they only useful to investigators, and heaven forbid the lawyers when things go wrong?

Turning to the incidents this July I expect to read that there were instructions and rules which diluted or removed personal responsibility and accountability from individuals who would normally ensure that screws were tightened and switch rails replaced when worn.

Doing away with the Rule Book

A review of the RAIB reports shows just how many recommendations indicate rule or procedure changes. I can just remember the days when inclement weather meant a disciplined reading out loud of the Rule Book in gang cabins all over the West Riding District of British Rail. A long and arduous task even then.

We did it using the old black Rule Book which easily fitted into the pocket of the heavy black macs with which we were issued. Now we have modules, lots of them and expect those who work with shovels, bars and picks to know and understand them.

Time for realism which would improve our track safety I suggest. We do not need a Rule change following every accident and incident.

If we retain the Rule Book for the lawyers and licensors of safety cases etc., then let’s restrict its use to them and only update it when it becomes imperative for us to do so, perhaps every three or five years. (My apologies to the printers, nothing personal you understand!)

Next put together in a 10mm thick booklet as an aide memoire for trackmen, another for supervisors etc. When every five years these are revised, we need to take out at least as much as we add in! It means trusting competent people, and about time too say I.

I write as the saga of News International, and the involvement of the police and politicians grinds onwards. Is there a lesson for our railways? Maybe!

If remote leaders pressurise their people for results without listening to their concerns and local knowledge, wrong actions can easily result. Balancing strategic management with adequate delegation to trusted frontline people is a challenge.

They need empowering to interpret the objectives in the best way for themselves. Getting the balance right is the underlying problem to be tackled.

In my experience an open, receptive and motivating management style fuelled by enthusiasm is the best way for everyone.

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