USA Banner

Official US Government Icon

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure Site Icon

Secure .gov websites use HTTPS
A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

U.S. Department of Transportation U.S. Department of Transportation Icon United States Department of Transportation United States Department of Transportation

Confidential Reporting: the UK Rail Experience

Document Series:
Publications
Author:
  • Aidan Nelson
Subject:
Risk Reduction Program
Keywords:
C3RS
Document
closecalls_nelson.pptx (428.58 KB)
Workshop: Improving Railroad Safety through Understanding Close Calls
Aidan Nelson Presentation:
Confidential reporting: the UK rail experience

 

Slide 1
Rail Safety & Standards Board

 

Slide 2
Confidential reporting: the UK rail experience Aiden Nelson Director Policy amd Stadards 23 April 2003

 

Slide 3
History or reality today? [illustration of dual railroad tracks]

 

Slide 4
Has anything changed? &##39;&##39;Engine drivers constantly complain .... of the way in which signalls are placed; but it is only in rare cases or after an accident has actually occurred .... that improvements are introduced&##39;&##39; &##39;&##39;On several occasions the author has examined signals where drivers have made mistakes, and in every case has found the true cause was the defective state or position of the signal&##39;&##39;

 

Slide 5
Company or the individual? &##39;&##39;Accidents constantly occur through the defective system of working adopted by the companies, but .... whatever the system, when the accident causes the death of a person, the railway servants are liable to a charge of manslaughter&##39;&##39;

 

Slide 6
Blame them not us? &##39;&##39;It has always been the custom, whenever an accident happens, for the companies to .... try to place all the blame on some servant, in order that he may be punished, and the responsible officers who are really to blame for neglecting to provide proper appliances may escape scot free&##39;&##39;

 

Slide 7
Source: Safe Railway Working by Clement Stretton Published: 1893

 

Slide 8
Experiment to national system [illustration of video consoles in a rail control facility]

 

Slide 9
Rapid change in level of commitment * Summer 1999 A growing level of volunteer company interest Industry conference - support in principal but funding generally not in business plan * Autumn 1999 Cataastrophic rail accident Parliamentary interest All Railway Group now committed

 

Slide 10
Developing the national system Broadly based industry steering group led and facilitated by RSSB predecessors managed the process Concerns as to cost led to engagement of &##39;&##39;newcomers&##39; being conditional on there being a competitive procurement strategy Core service provider contracted nationally, regional centres funded by a levy on number of staff enrolled

 

Slide 11
Some problems on the way The transition from academically provided to commercially provided service was not without pain IPR issues led us to a new taxonomy and reverse fitting historic data to it Issues of trust and confidentiality led to the creation of a trust to own the taxonomy, the data itself and to license use of system Creative counting of staff to be enrolled

 

Slide 12
Commitment has to be underpinned Railway Group Safety Plan Railway Group Standard directly mandates enrolment of safety critical staff employed by Network Rail and train operators (The Railway Group) Supply chain to Railway Group members has to be handled within contractual framework

 

Slide 13
But we have an open safety culture Some organisations still feel they don’t need CIRAS However the nature of the reports into the system illustrates that there is still a widely held concern that &##39;&##39;blame&##39;&##39; is alive and well in management thinking Watch for local managers keeping the supply of CIRAS forms under surveillance

 

Slide 14
Why report to CIRAS? Quite a few early reports are to test the system, in particular that it really is confidential Because when I reported an issue openly nothing was done and we know that the CIRAS system guarantees a response CIRAS operates across organisational boundaries

 

Slide 15
Quality of response Too often the managerial response to a CIRAS report is defensive This often reflects that the responding manager feels that self justification is necessary within the organisation Independent peer review of responses raises quality considerably

 

Slide 16
Our role in CIRAS [illustration of bus, passenger car, and pedestrians at rail grade crossing with train approaching]

 

Slide 17
Governance We facilitate, fund and act as managing agent for the CIRAS Trust Our nominated trustee chairs the Trust We facilitate the independently chaired industry steering group on which we have membership We fund the independent chair of the industry steering group

 

Slide 18
Management We fund the core CIRAS facility and recover the costs from the general funding of RSSB We provide procurement services We undertake the annual census of enrolled staff We undertake research to review the effectiveness of the system ?e.g. CIRAS journals

 

Slide 19
We too are members of CIRAS All our staff are within the scope of the system We also provide the lead managerial response on issues related to ambiguity in and /or the interpretation of the Rule Book and other Railway Group Standards

 

Slide 20
RSSB CIRAS Committee (1) Newly formed, operates in the context of our safety leadership role within the rail industry Works principally from CIRAS national report cross referenced with wider industry safety performance data and intelligence Will request additional analysis from the CIRAS core facility as requires

 

Slide 21
RSSB CIRAS Committee (2) Determines necessary RSSB action: Identify issues for further research Key issues monitored within quarterly and annual safety performance reports or generates a requirement for special topic reporting Influence Railway Group Safety Plan, national initiatives and standards Identify sources of risk for discussion at the RSSB risk review forum Initiate topic based workshops Monitors progress / close out of actions

 

Slide 22
In conclusion: [illustration of rail worker on railroad tracks]

 

Slide 23
In short Don’t underestimate the management challenges in creating a high integrity confidential reporting system Don’t see it as a &##39;&##39;bolt on&##39;&##39;, rather See it as an integral component of your wider human error management programme Champion and lead development from within the industry to create ownership and minimise scepticism

 

Slide 24
Rail Safety & Standards Board

DOT is committed to ensuring that information is available in appropriate alternative formats to meet the requirements of persons who have a disability. If you require an alternative version of files provided on this page, please contact FRADevOps@dot.gov.
Last updated: Wednesday, April 23, 2003