Risk management: A critical process for improving railway safety in the UK

SMS specialist Kevin Thompson of the Rail Safety and Standards Board UK was among the speakers at the RISSB Rail Safety 2015 Conference in Melbourne. The conference brought together key personalities in the industry who discussed the critical issues surrounding rail safety and why it remains everyone’s responsibility.

Accountability for risk management

How better to start a talk on risk management than a strong emphasis on how it is everyone’s duty to practice and implement it.

SMS specialist Kevin Thompson of the Rail Safety and Standards Board UK said, “With your Work and Health Safety Act, we’ve got this duty to ensure as far as reasonably practicable the health, safety, and welfare of all our employees.”

Mr. Thompson explained that risk management is not just an essential process but a legal requirement that everyone is responsible for properly managing all the risks that they’re exposed to. The RSSB representative added that under the risk management duty that people have comes the need to implement a suitable and sufficient assessment not just to their own employees but all people that may be affected by the work they do as well.

The scope of the Rail Safety and Standards Board

As an intricate process, the railway industry comes with many different interfaces coming from various organisations with whom the Rail Safety and Standards Board works in close collaboration with. In its pursuit to help the industry advance specifically in terms of innovation, knowledge, standards, and most significantly, safety, the board strongly advocates the critical importance of understanding risk, research, and analysis.

On the national level, the RSSB actively collates data from different sources across the system. The board holds the Safety Management Information System (SMIS), an enormously large database for all the train operating companies, infrastructure, and all railway undertakings. All of these are required by Railway Group Standards to be able to import all safety-related incidents and accidents into the SMIS.

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​A Railway Group Standard (RGS) defines the plan of action required to achieve the technical compatibility across the GB mainline network. These standards determine the technical or process requirements suitable for the infrastructure, vehicles, or transport operators.

All of the board’s accumulated information is used for many different purposes by various users. Duty holders can get their own data after SMIS so they can conduct their own accidents statistics analysis. Manual safety performance reports are distributed yearly that present summaries of relevant events that happened on the national industry scene.

The board likewise manages the Safety Risk Model as well as develops precursor indicators as they help generate different methods of manipulating and presenting information. All of the board’s information are used for planning, developing business plans, and prioritisation as to the best safety investments to make in their decision planning.

The Safety Risk Model

The Rail Safety and Standards Board primarily aims to facilitate the railway industry’s work to ensure uninterrupted improvement in terms of the health and safety performance of Great Britain’s railways and promote the reduction of risk to employees, passengers, and the general public. Getting a good understanding of the general risk profile and the overall risk level of the railway is critical to implement the above facilitation—thus, the Safety Risk Model (SRM) is used.

The SRM is basically a quantitative representation of the potential accidents that may be the result of the GB rail network operation or maintenance. The model is comprised of 121 different types, every type a representation of one hazardous event. The term “hazardous event” is used to refer to an incident that has the potential to result in an injury or a fatality.

In his presentation of fatalities and weighted injuries (FWI) per year, Mr. Thompson showed how the workforce risks consists the lowest percentage of risks compared to passengers and the general affected public whose levels of risk showed about the same levels of risks percentage.

He explained around the idea of whether we should be spending a lot of time looking at and evaluating train accidents, considering that this variant accounts for only a minimal amount every year, instead of putting more resources on slips, trips, and falls. The SMS specialist further suggested that perhaps train accidents are actually a lot worse than what we actually know about and we must instead put in relentless effort into looking at how we should be managing that risk.

The Precursor Indicator Model

Aside from the Safety Risk Model, the RSSB also makes use of the Precursor Indicator Model, which measures the fundamental risks that come from every train accident. The model works by keeping track of the changes in various accident precursors and is normally adjusted and fine-tuned against the Safety Risk Model. The Precursor Indicator Model is a beneficial tool to use as it provides a more predictive evaluation of where risk is actually going in the GB rail. However, it is primarily focused on high-risk train accident risks.

Kevin was proud to announce that with their PIM analysis over the past few years, RSSB was able to successfully halve the risks in the network and things are basically slowing down a bit more recently. He admitted that the board is currently putting a substantial amount of focus on the public behaviour aspect of risk as it is a big challenge for the team.

As for managing risks and monitoring safety, the RSSB suggests undertaking thorough inspection, accurate auditing, objective investigation, factual surveys, reliable data collection and analysis and proper risk assessment. Mr. Thompson recommended that results from all these processes need to be reviewed, filtered, and properly arranged so that the board will be able to design their programs accordingly and deploy the intelligence required to know what action needs to be implemented.

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The targeted risk tools

Among the actions that will be implemented by the Rail Safety and Standards Board with the recommendations from the results of using the Precursor Indicator Model include a detailed examination into more specific risk tools such as the following:

• SPAD Risk Ranking, which provides a deeper understanding of potential consequences of SPADs or Signals Passed at Danger
• Signal Sighting
• Signal Over-run Risk Assessment, which provides a better understanding of the risk for every signal
• Level Crossing Risk Assessment
• Passenger Train Interface Risk Assessment, which is a web-based risk monitoring tool
• Platform Aerodynamics Risk Assessment offers an excellent evaluation tool for working on the effects of passing trains, high speeds, passengers on platforms, etc.
• Buffer Stop Collision
• Provision of Fixed Lineside Telephones is the evaluation for the need to provide fixed lineside telephones when a radio system is put in place
• Musculoskeletal Disorder Risk Assessment (e.g., evaluation of the driver for injuries after a train accident)

Mr. Thompson pointed out how combining everyone’s efforts and resources together can significantly improve the chances of actually producing these critical tools for the industry.

On Safety Performance Indicators

Safety Performance Indicators or SPIs are measurements that reflect the effectiveness of risk control arrangements. They are normally used to determine whether or not trends appear in safety performance. When used properly, SPIs can be used to evaluate whether the trends that we are looking at are on the right track.

• Activity Indicators – also known as leading indicators, which measure whether a risk control system is currently in place
• Outcome Indicators – also known as lagging indicators that measure events/accidents after their occurrence

Mr. Thompson mentioned that as an industry, they are more experienced about using outcome indicators and are not too mindful about looking at activity indicators. The whole program of work was focused toward achieving a balanced set of performance indicators. While SPIs are normally referred to leading or lagging indicators, the distinction is not clearly defined and therefore people tend to identify the two as a continuum from the activity up to the outcome.

Here, the various SPI categories are likened to the Swiss cheese accident causation model where the slices of cheese are the risk control systems (activity indicators) and the holes on the cheese are the results of the inspections or audits (outcome indicators).

In the case of the Ladbroke Grove rail crash, the risk control systems or factors that contributed to the crash can include the driver’s training, his knowledge on the route, his sight problems in the past, and the infrastructure fitted to the train for automatic protection.  When all these issues line up, they will lead to the collision with all those fatalities. But all of these could be easily prevented by putting activity indicators in place that will accurately measure the suitability of the different risk control systems.

Are you using the right Safety Performance Indicators?

Kevin proposed the use of the Bow Tie Approach or the Fishbone Diagram to easily go about identifying the safety indicators you should be examining and implementing.

The Bow Tie Model or the Fishbone Diagram will help you map out the risk control measures that you’re employing to prevent particular hazards from occurring and assessing them for criticality and vulnerability. The former being the extent to which a failure of the risk control system could readily result in a loss or an accident; the latter being the risk control element susceptible to deterioration, unreliability, or uncertainty.

With all the information you have at hand, you can now create a matrix that will help determine your priorities, which you will need to generally put more focus on and particularly develop performance measures for.

Conclusion

Mr. Kevin Thompson concluded his talk on “Risk Management: An Essential Process for Improving Railway Safety in the UK” by enumerating in chronological order the steps by which things may develop in terms of risk management processes:

1. The occurrence of accidents in the past (qualitative)
2. The occurrence of a series of accidents (quantitative)
3. Auditing/assessment (looking into activities and risk controls in place)
4. Scored order (risk management maturity model-scored audit system)
5. Safety risk modelling (outcomes and quantification of risks)
6. Bow tie modelling (focusing on risk controls; qualitative level)

Again, Mr. Thompson emphasised on how important the Safety Risk Model is as it helps us understand the volume of risk one is dealing with and identify the priorities that has to be met. The safety model is likewise vital to use when making investment decisions. Mr. Thompson also identified the need to put great focus on risk controls particularly using Bow Tie models, MSPs, etc. Finally, he saw that there is great necessity to make that shift towards measuring risk management activities rather than focus on the outcome of our risk management process.

To close, Mr. Thompson shared a story Professor Andrew Hopkins, who introduced the concept of having the “chronic sense of unease” that “everyone should be having and be actually using risk management processes to understand where the next instant might be coming from, for us to be always alert to what’s happening in our environment and within those risk controls that we’re responsible for.”