Corporate memory - how to keep learning

The pandemic has been dreadful for everyone and there cannot be anyone in Britain not affected directly by it. Lives were taken, families destroyed, and some were left with the challenges of living with the after effects of long Covid. We all know that we could never have come through it as far as we have without the NHS. For its part, the railway kept going to help make sure key staff and vital supplies got to the right place at the right time.

Coming out of a long period of pandemic-related restrictions is perhaps a good time to reflect on what happened and what we learned. RSSB does this regularly anyway, one of the things we noticed was that while some risks had gone up during the lockdown (assaults on staff, for example), the traditional railway risks like signals passed at danger (SPAD) and low adhesion never went away.

This was brought home on 31 October 2021, when a passenger train passed a signal at danger, experienced wheelslide and struck another service at Salisbury Tunnel Junction, on the immediate approach to Fisherton Tunnel. Thirteen passengers and one member of staff were injured. It was brought home too during 2022 when the Rail Accident Investigation Branch report on the fatal accident at Carmont was published. A couple of months later saw the 20th anniversary of the fatal derailment at Potters Bar, which—like Carmont—emphasised the issue of asset integrity.

But Potters Bar also emphasised something else—that risk can rise when something changes. In that specific case, the change was to a design of pointwork. In many cases—Clapham (1988), Ladbroke Grove (1999) and Hatfield (2000) to list three—the management of organisational change can be a factor. The rail industry is entering another period of change right now, and this means it has never been more important to keep monitoring risk and safety intelligence.

On the surface, risk and safety intelligence give us numbers. The failure to monitor wrongside failure numbers was in the causal chain of Clapham, and that accident took 35 lives. We saw much bigger numbers than this every day at the height of the pandemic and we must never forget that each one was a real person, with families, friends, and loved ones. This fact—and the need to remember the lessons of the past—is why we also consider what we call Learning from Operational Experience (LOE).

LOE, on one level, involves adding context to the statistics. It is easier for a safety practitioner to remain focused on preventing track worker fatalities if the names of those killed recently—such as Tyler Byrne, killed at Surbiton in February 2021, and Gareth Delbridge and Michael Lewis, both killed at Margam in July 2019 - can be recalled. Putting the name to the number helps us remember. But that does not mean that learning is always easy.

In fact, learning can be difficult enough on a personal basis, especially if there are a lot of plates to be kept spinning. In a company it can be even harder—companies comprise different and disparate memories that don’t always fit together. When you expand the idea to a complete industry like rail, it becomes even more complicated—especially as people move on or move in from elsewhere all the time. And when someone with 30 years’ experience retires, they don’t just take 30 years’ experience and knowledge with them—you have to add what they picked up from those who retired soon after they started, and that’ll make it more like 50-60 years, possibly more.

What can be done? RSSB has a number of products and services that can help. First, the quarterly update on progress against the Leading Health and Safety on Britain’s Railway (LHSBR) strategy is so much more than just another book of numbers. Rather, it allows trends to be monitored; not only from SMIS, but also the daily incident logs and other information sources like British Transport Police and the ORR. It provides too a forum for updates on the work being done to address risk areas highlighted by these indicators, and by investigation reports, and so on.

Aside from this, we provide learning direct to the front line with our RED series of safety films and Right Track magazine. The former has just opened the lid on asset integrity, what it means and why it is important; the latter has just enjoyed its tenth anniversary—that’s ten years of telling safety stories in an engaging way to keep the lessons of the past, and the present, alive in the minds of the audience.

We also track overseas rail incidents through our monthly Rail Accident and Incident News and Rail Investigation Summary documents. Both are available on our website, and both have a wider purpose. The relevant incidents and report findings from each are added to the regular risk papers that we provide for the cross-industry risk groups. These cover everything from train accidents to level crossings, station safety to the specific world of freight operation. Usually, we find that the overseas situation has been seen in Britain before, and that our mitigation methods are adequate. But as the runaway, derailment and fire that occurred in Quebec in 2013 showed, we can never afford to be complacent, and never stop checking ourselves against other railways. Could Quebec have happened in Britain? If the circumstances had allowed it, then yes of course it could.

Rail Safety Review is in effect the safety manager and director version of Right Track; indeed there is often a crossover between both publications. The point about Rail Safety Review, however, is that it helps those who have an overview of safety consider the points the publication raises in light of their own safety management system arrangements. And we do not limit the content to rail (either GB or overseas): there is much that can be learned from other industries, and we have covered the Nimrod air crash of 2006 and the Deepwater Horizon oil rig explosion of 2010. More recently, we’ve considered the 737 MAX incident of 2019, as there were many lessons to be learned about software integrity, something which is becoming increasingly relevant to GB rail operations – you only have to read RAIB’s report on the loss of speed restrictions on the Cambrian line to appreciate that.

You can find out about all these services and resources—and more—by signing up to our monthly Safety News publication, which provides links to everything safety related to help keep you informed.

All RSSB member duty holders have access to the tools I’ve mentioned here, so if you’re an RSSB member, make sure you’re getting the most out of them. They’re all on the website, so please use them, share them in your organisations and let us know how you get on.

In July we will be publishing the Annual Health and Safety Report for Britain’s railways. This is a key output from the Leading Health and Safety on Britain’s Railways strategy. Look out for our videos and publications!