Fair culture investigations

Fair culture principles What’s changing/staying the same The remit TU participation The investigation 10 Incident Factors Fair culture flowchart The report Independent review panel Refresher training Advice and support

What’s changing Fair culture flowchart to be used where an unsafe act is identified All alleged breaches of lifesaving rules to be investigated Revised trade union participation Independent review panels Revised templates

What’s staying the same? Investigate what happened and identify immediate cause Investigate why it happened and identify underlying causes Use the 10 Incident Factors and Investigator Prompts

The remit Essentially the same Simplified template for local investigations New requirement in the general objectives section

The remit – general objectives The investigation team is required to investigate the circumstances of the accident/incident, including the following: identifying the events leading up to the accident/incident, identifying the immediate and underlying causes, including: the relevance of the 10 incident factors (guidance on these is provided in Part 4 of the Investigators’ Handbook), and relevant management issues/processes; identifying the behavioural cause of any unsafe act using the fair culture flowchart; consideration of previous accidents/incidents of a similar nature; consideration of the findings/intelligence from relevant audit/assurance activity (guidance on this is provided in Part 2 of the Investigators’ Handbook); consideration of the specific objectives listed below (as far as they are relevant). January 2012 SLCC

TU participation Much wider participation Focus on role as Safety Reps Move towards participation rather than representation – part of the investigation team Arrange participation through the central contact list on Connect Invite the TU that is appropriate for the grades being interviewed/involved

TU participation A trade union representative should be invited to join the investigation team for the following: Where the investigation team intend to interview staff (they should invite the TU(s) appropriate to the grades involved); An investigation that includes a potential breach of a lifesaving rule; A fatality to any person in a train accident (excl. suspected suicide or trespass); A collision between trains on a running line where there is injury to at least one person or significant damage; the derailment of an ‘in service’ passenger train, except where the derailment occurs at low speed (i.e. less than 20mph); A fatal or life changing injury to a member of the workforce employed by or contracted to Network Rail whilst at work/on duty; Other accidents or incidents where Network Rail and a trade union agree that the participation of a TU observer would be beneficial.

The investigation Investigations that previously would have subject to investigation Follow your training/Investigators’ Handbook Arrange TU participation through contact list on Connect Use the 10 Incident Factors and Investigator Prompts Use the fair culture flowchart to classify any unsafe acts May need to be validated by the Independent Review Panel Investigations where the incident is the breach of the lifesaving rule As above Remember we are investigating the safety incident not the individual January 2012 SLCC

10 Incident Factors The 10 Incident Factors sit at the core of our investigation process Part 4 of the Investigators’ Handbook Investigator prompts help investigators establish what Incident Factors might have been causal or contributory to an accident or incident Part 2 of the Investigators’ Handbook Latest version (2.1)

10 Incident Factors Communications Knowledge, skills and experience The Incident Factors support the investigation of any incident or accident They provide investigators with prompts that can be used to generate potential areas of investigation and to check that all possibilities have been explored Covers 10 key areas which have been identified as common underlying and contributory factors in incidents and accidents Communications Knowledge, skills and experience Practices and processes Supervision and management Information Work environment Workload Personal Equipment Teamwork

An example During Temporary Block Working (TBW) the signaller failed to reach a clear understanding with a handsignaller at the start of TBW, regarding the handsignallers action in relation to a train stood at the signal protecting the TBW section. As a result the handsignaller allowed the train to enter the section believing he had authority from the signaller to do so. This resulted in two trains being in the TBW section at the same time. A review of the conversation revealed that the signaller did not ensure that the handsignaller fully understood what was required in relation to the train that was stood at the signal.

Fair culture flowchart

Fair culture flowchart

Report – revised section A Event summary, conclusions, recommendations and local actions Summary of the accident/incident Immediate cause Behavioural cause (using fair culture flowchart) Underlying cause Other safety related issues identified Recommendations Local actions

Example Behavioural cause (using fair culture flowchart) The IWA was in breach of the Lifesaving Rule: Always have a valid safe system of work in place before going on or near the line. In accordance with the ‘fair culture flowchart’ the investigation team concluded that this was a ‘contravention’ (see section G3 of this report). Local actions The section manager should consider the behavioural cause of the identified breach of the lifesaving rule by the IWA in accordance with the consequences table and take appropriate action (see section A4.1 of this report). The IME should review the behavioural cause of the identified breach of the lifesaving rule with the section manager (as the IWA’s line manager) and take appropriate action in accordance with the consequences table (see section A4.1 of this report).

Does the ‘description’ fit?

Independent review panel Who RSIM, HRBP, Independent senior manager, TU H&S rep Support from Ergonomics, Senior Investigator, Change Consultant as required What Check fair culture flowchart has been used correctly That report supports the decision All investigations where malicious intent/personal benefit identified, sample of others When Sent to Panel by DCP once they are satisfied An interim report may be considered if more time is needed to develop underlying causes and recommendations Where Panel disagrees with report discuss with DCP/Lead and require further investigation

Refresher training Mandatory for those wishing to maintain their Lead Investigator competence To be completed between July 2013 and June 2014 Human factors e-learning One day workshop focusing on: Using the 10 Incident Factors to prepare for interview Effective interview technique Applying the fair culture process

Advice and support Accident Investigation pages on Connect Guide to the 10 Incident Factors Guide to using the Fair Culture flowchart Fair culture FAQ Senior Investigators Change Consultants Accident Investigation Forum Dial in surgeries Fridays at 2pm (June 14, 21, 28) Dial 020 7819 3600 then passcode 97992910 followed by #

A ‘series’ process Safety investigation A remitted accident/incident investigation. TU participation 10 Incident Factors ‘Behavioural cause’ Unsafe acts classified using the flowchart. Underlying causes identified as usual Review Panel All cases of malicious or personal benefit to be verified by Panel. May be returned for further investigation Consequence Coaching, etc tracked as local actions at RRP. Any formal disciplinary to commence after Panel verification