Greg Morse
RHSS Editor and Operational Feedback Lead, RSSB
‘Those who cannot remember the past are condemned to repeat it,’ said the philosopher George Santayana. The trouble is, you can’t ‘remember’ what you weren’t alive to witness.
Someone born in 2000 will be in their mid-twenties now. So, they won’t know about any of the accidents that go back to the turn of the century.
Yet the lessons we learnt from those accidents, and many others, help turn compliance into competence. And they help prevent changes being brought in that weaken our safety defences—which they will if the person making the change doesn’t know why it’s unwise to make it.
Debt to safety
We don’t only owe a debt to safety to keep these lessons alive. We also owe it to everyone who lost their life, was injured or affected by an accident, to keep on being vigilant. And vigilance is particularly important in a time of organisational change.
‘When you reorganise, you bleed,’ wrote rail manager Gerry Fiennes in 1967. He was quoting his trainer of 20 years before. His trainer was quoting Roman senator Petronius, which suggests that we humans have never been very good at handling change.
But on the railway, we did it at nationalisation in 1948, when four companies became one, and at privatisation in 1994, when one became more than 100. The trains kept rolling. And yet it soon became clear that maybe we had not been that good at it after all.
Past, present, and future
In October 1999, a commuter train passed a red signal near Ladbroke Grove, West London, and struck an incoming express; 31 people were killed. The causes ranged from changes made to training, to electrifying without considering how that might obscure some signals from the cab.
The following year, a passenger train derailed on a rail that shattered near Hatfield, Hertfordshire, killing four passengers.
The investigations revealed that track maintenance and renewal had been downsized for economic reasons, and that contractors were not being adequately monitored by the infrastructure manager.
Organisational change was a key part of this loss of assessment and control. But the loss of knowledge and experience—a type of corporate memory—that comes naturally with the cycle of retirement and recruitment is heightened at times of reorganisation.
Accidents help explain why things are the way they are. As we transition to a new structure, understanding the reasons for what we do and the way we do it becomes more and more vital. You could argue, in fact, that the rail industry’s past has never been more important to its present, nor its imminent future.
At RSSB we’re building a user-friendly archive of material on how accidents have informed the development of standards and safety guidance. For more information about how our unique approach to risk and decision-making supports a better, safer railway, click the links in the Related Resources section to give you a start.