Summarising the recommendations from all analyses in this way provides an indication of the human factors interventions that have the potential to have the greatest impact on incidents involving contact with a live conductor.
From what was found out about the sample of incidents reviewed, it would seem that safety observation schemes, greater emphasis on supervisory checks, safety communication training and more methodical checks of the planning process are the four interventions that would prove most fruitful in reducing incidents. In addition, it is felt that further analyses of the incident reports to find out how effective they have been in reducing the occurrence of incidents in electrified areas is undertaken. The information presented in the Formal Inquiry Reports lacked in detail and consistency.
6.6.1 Implement Safety Observation Schemes
Safety observation schemes are designed to aid behavioural change by using the principles of providing feedback to reinforce the required behaviours. They revolve around management or employee observations of work areas to identify both safe and unsafe behaviours taking place. The concept then is to provide positive reinforcement for the desired (i.e. safe) behaviour whenever it is observed. The idea is that workers get to know that behaving safely brings recognition and will therefore tend to join in. When an undesired behaviour is observed, rather than punishing the individual, the concept is to sit down with the individual and get them to:
(a) explain what they did (b) explain why they did it
(c) describe what the consequences could have been (what’s the worst that could happen) (d) come up with the suggestions for how to do the same job more safely the next time.
The aim should be to get the individual committed to doing the job more safely next time.
This process has two objectives – the first is to provide positive feedback on the desired behaviour to reinforce that behaviour. The second is to engage the individual in coming up with a better way of doing that task, to gain their buy-in and commitment to change.
We recommend that the concept of Safety Observation Schemes be further researched under Phase 2 of this Project.
Benefits
In terms of the common causes identified in the previous section, this recommendation would help to identify situations where perceived time pressure is a particular influence, and allow managers and supervisors to re-define their expectations. It would also identify situations where personnel work unsafely due to lack of a formal method statement, risk assessment, or procedure, and allow workers and supervisors the opportunity to define solutions for such cases. It would highlight situations where workers seek the approval of colleagues and managers, allowing the setting of more helpful expectations and examples. Finally, it could provide the opportunity to identify cases where workers are required to implement makeshift adaptations to equipment due to a lack of suitability of the original equipment, and for the workers themselves to highlight any problems.
However, this should not be seen as a replacement to sound human factors engineering involvement in the procurement and design of equipment to ensure suitability and usability.
The introduction of schemes of this nature will not be easy in today’s disaggregated railway; this
performance. Organisations could be encouraged to do this by inclusions in The Railway Group Safety Plan (RGSP) and through acceptance of Contractor’s Assurance Cases.
6.6.2 Greater Emphasis on Supervisory Checks
Related to the previous recommendation, the evidence emanating from a number of the formal investigation reports seemed to suggest that the frequency of supervisory checks of worksites tended to be very low, and that when they did occur they were not very thorough. Organisations should be required to place a greater emphasis on supervisory checking, which should be used to check that work is being done according to plan and the prescribed procedures, but also helps to raise the level of visibility of the supervisors.
Benefits
Several of the common causes identified in the previous section would benefit from improved supervisory practices. For example, supervisors would be able to check that suitable method statements and risk assessments were in place and would be in a position to make sure that workers were sufficiently aware of the risks to which they would be exposed. It would also be possible for supervisors to demonstrate commitment to getting the job done safely, and hence help to avoid workers gaining the impression that they are under time pressure. More checks by supervisors would also have the effect of helping to set management expectations in terms of safety and getting the job done. This would help to reduce the number of instances where workers behave unsafely because they think they will get some from of reward for getting the job done, even though it was not a safe way of doing so.
6.6.3 Introduce Safety Communications Training
A number of incidents seemed to involve incomplete or ambiguous information being passed between team members. A great deal of work has been conducted in the recent past to develop guidelines for workers on how best to communicate safety information to make sure that the relevant information is correctly understood.
A number of principles to do with giving a good handover are applicable to safety communications in general. These include:
Communicating face-to-face whenever possible
Using positive statements relating to safety issues (i.e. do not say, “The lever is not in the correct position” because if the middle part of that message were drowned out by noise the recipient might think that the lever was in the correct position. Do say, “The lever is in the wrong position”).
Summarise the main points of the communication at the beginning.
Where possible, supplement verbal information with written or another form of visual information so that there is redundancy of information to help avoid mistakes.
Check that the other person has fully understood, do not take it for granted.
Summarise main points at the end of the communication.
Person you are communicating with should be actively listening, asking questions and confirming understanding, not just nodding their head.
Safety communication training should not be classroom-based, it should provide delegates with the opportunity to practice these skills and go away a better communicator.
Benefits
This would help to tackle the issue of poor risk awareness by helping to ensure that critical information relating to hazards and risks is effectively communicated. However, it would not address the whole issue, and would need to be supplemented with a hazard awareness training and training effectiveness monitoring scheme. This training would need to raise awareness of the conditions under which complacency can impair safety performance, such as ongoing maintenance activities, as this complacency was another of the common causes listed in the previous section.
This recommendation would also help to address another common cause, ineffective briefings.
6.6.4 Checking the Planning Process
On a number of occasions, there were failures in the planning process that contributed in some way to the incidents. For example, providing the wrong map of underground services, planning work for red-zone working when there is a T3 possession the following week, having work areas and isolations with different limits, etc.
A checking (or auditing) process is required to identify these problems early when they arise, and try to find a safer alternative. There are clear barriers to be overcome – at present, there appears to be a culture in the rail industry that encourages a focus on keeping trains running and avoiding delay. A system that asked for all electrified area working to take place during a T3 possession would not fit within this culture. Some form of step-change is required, similar to the change that was initiated in the offshore industry following the Piper Alpha disaster. The petrochemical industry is living proof that this can be achieved, and the documentation that discusses how to go about ‘changing minds’ is available from the Step Change website (http://step.steel-ci.org/publications/main_publications_fs.htm).
A parallel to the change that is required can be drawn from the implementation of the RIMINI approach for protection of lineside workers. Rather than determine what work can be done under live conditions have a hierarchical approach that looks at the safest possible option first.
6.6.5 Recommended Further Analysis
It would be useful at some later date to perform an analysis of the recommendations generated by the incident reports to find out how effective they have been in reducing the occurrence of incidents in electrified areas. This should involve making contact with the organisations involved in the incidents and finding out how well the recommendations were received, and whether they have been implemented. This would also provide the opportunity to perform a reality-check of the recommendations from this report with these organisations, and obtain impressions of the value added by human factors analysis.
The Railway Group Safety Plan (RGSP) already contains a recommendation for Railway Group members to assess safety culture. Reviewing these incidents suggests that to some extent behaviours of workers are being influenced by a ‘can-do’ culture that seems prevalent within the rail industry. This is resulting in workers taking risks in the belief that they will gain acceptance from their colleagues and managers for getting the job done. It would therefore seem that the RGSP recommendation is much needed, and that the assessment of safety culture within the rail industry should be heartily encouraged.
An obstacle in the preparation of this report has been the availability and inconsistency of information contained within Formal Inquiry Reports. It is recommended that a review of Standards covering this requirement is undertaken.