Learning from near misses Paul Appleton Deputy Chief Inspector of Railways 1 November 2018

History Learning from accidents is inextricably linked to the history of the railways 1889: Armagh Train Crash Overloaded passenger train runs away 80 killed, 260 injured- mainly children 1889: Regulation of Railways Act Lock, Block & Brake- key principles that still apply today

Regulation of the rail industry Following a series of major accidents the way the industry was regulated was changed in 2006 The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) The health and safety performance of GB’s railway industry is the best in Europe This has come about due to a seismic shift in attitudes by the entire industry One of the key changes has been that we use the “minor” incidents to see what they can tell us

Office of Rail and Road Rail Accident Investigation Branch Learning from accidents/incidents is built into the UK’s legislation RAIB independently investigates accidents in a blame-free manner with a view to improving railway safety, and informing the industry and the public. ORR investigates accidents with a view to ensuring compliance with Health & Safety legislation and if necessary takes formal enforcement action Part of ORR’s role is to take RAIB’s recommendations to the railway industry to get the recommendation implemented by industry within the H&S legal framework advise RAIB what has been done

Do we always realise how close we came? See the whole board…. 5 5

Near misses and the Swiss cheese model Every control measure has flaws Risk assessment seeks to identify flaws proactively Near misses point us towards those flaws before the holes line up to deliver an incident This is key information in an industry that suffers from low frequency high consequence events such as train collisions We must take every opportunity to learn James Reason

Learning from near misses changes organisational culture Safety is not the sole responsibility of managers, but every body’s responsibility But to enable that learning you have to have a fair culture It empowers everyone and enables two way information flow Every near miss should be treated as an opportunity to learn NOT a person to be told off Learning outwardly demonstrates management’s commitment to the work force and increases employee engagement

Learning enables Continuous Improvement We are the safest large railway in Europe, but there is more we can do Other nations ask us “how has your railway brought about the change?” We learnt the hard way, learning shouldn’t have to involve death and injury There are many pressures on the rail system we need to ensure they are managed and risk is controlled. We need to look after our people, they are ultimately the last line of defence Technological developments offer opportunities to improve, but we must manage their introduction carefully, particularly human interaction and changes to embedded working practice.

Communication is key to organisational learning An organisation can be the world’s best at ‘fixing’ near misses but if you don’t tell anyone else the organisation isn’t learning Creating an environment of mutual trust enables a two way conversation that promotes the reporting of issues and tells people what has been done and promotes learning Feeding back on near miss reports builds such trust

Risk Management Maturity Model (RM3) RM3 allows to you take disparate data to build a picture of an organisations maturity We use lots of information sources to tell us about an organisation Some pieces will be narrow and negative some will be broader and lack depth, some will be targeted and deep All the pieces of the puzzle tell us something – the more we know the better the picture

for the Evaluation of Management Systems Risk Management Maturity Investigation Inspection Techniques for the Evaluation of Management Systems Risk Management Maturity Model Audit EVERYTHING WE DO – should tell us something about an organisation, some will be narrow and negative some will be broader and lack depth, some will be targeted and deep. All the pieces of the puzzle tell us something – the more we know the better the picture. 11

What have we learnt History is useful it tells us what went wrong But it will only take you so far We are in a low frequency high consequence industry – what hasn’t happened yet? Use the near misses to identify the flaws in your control systems Learning from every information source is key to achieving excellence To learn you have to build trust across your organisation To earn trust you have to communicate

Questions Paul Appleton