1. Lifting the quality of risk control
Monitoring & Review
Lifting the quality of risk control
Ian A Skinner, ORR
UK National Safety Authority

2. What will we cover today?
GB Railways – some background
ORR – who we are, what we do, our purpose
Railway Safety Directorate – our approach
Monitoring and Review – why?
Impact

3. Introduction & context
Rail passenger demand since 1947
Fatal main line train accidents since source RSSB
Picture illustrates one indicator of the railway’s success: increasing passenger numbers, but also the decreasing incidence of fatal accidents on the network.
Total nr of journeys in GB in 2012/13: 1.69 billion, largely concentrated in SE of England. But Scotland 2nd largest region in terms of passenger numbers outside SE, and saw the largest increase on 2011/12 (2.9% year on year)
Rail passenger demand, measured in passenger kilometres travelled, really took off in 1994, around the time that the industry was privatised, and has continued to increase steadily after a period of mixed fortunes.
Britain’s railways are a great success story. The industry has seen sustained rises in demand from passengers and freight customers in the last decade, and has generally seen rising customer satisfaction, against a background of accommodating more trains in the network which is close to capacity in many places (e.g. approaches to Edin from west).
As you know, the mainline railway sector in Great Britain has been vertically separated since the 1990s. There is no state incumbent train operator, although a subject of recent debate has been whether to introduce one, reflecting the success of Dutch, French and German state operators in the British market.
Freight services are completely open access, most passenger services are subject to public sector contracts let to private sector operators through competitive tender, and there is also a very small number of competitively open access passenger operators who receive no subsidy and are not subject to the same service obligations as franchised operators.
Britain has the fastest growing rail sector in Europe, and consistently scores among the highest in key aspects of passenger satisfaction. Though we must robustly guard against complacency, Britain also has one of the very best recent rail safety records in Europe.
With this growth comes safety challenges in managing increased rail traffic, not just in moving more trains, but also ensuring the safety of increasing numbers of passengers as they travel through stations and getting on and off trains.

4. ORR vision and strategic objectives for health and safety
The Health and Safety vision of our corporate strategy remains “zero workforce and industry caused passenger fatalities, with ever decreasing overall safety risk.”
Our approach:
To be sure the industry manages risk adequately, and continuously improves its health and safety performance so far as reasonably practicable.

5. Safety performance
Over the last decade safety on Britain’s mainline railways has improved steadily as passenger numbers have grown considerably. Over the same period Network Rail has increased its efficiency by over 30%. Key drivers of that safety improvement has included regulated safety enhancements, such as train protection, that has helped drive the industry towards continuous improvement in risk management.
Recently published our Health and Safety Report for 2014/15. GB’s railway amongst safest in Europe, particularly for passengers on trains and those at level crossings. The last mainline passenger fatality in a train accident was in 2007, when Mrs Masson from Glasgow died as a result of the derailment at Grayrigg on the West Coast Main Line. That makes it eight years without any train accident related passenger fatalities. There were no passenger train derailments for the second year – a significant achievement. Harm has reduced by a third over the last decade when normalised by growth in passenger numbers.
Of the XX people killed on the railway last year, XX were at level crossings; eight of them pedestrians. None of the events involved any breaches in health and safety law.
But we cannot be complacent. There are indications that improvements we have seen in recent years are beginning to plateau, and the industry is under increasing pressure to deliver ever improving performance & reliability more efficiently. The industry’s level of management maturity showed only gradual improvements, and has some ways to go to achieve excellence in health and safety culture that is central to high reliability organisations.
Our 2014/15 health and safety report highlights that Network Rail must improve its management of the network so that it predicts and prevents problems before they create a safety risk or cause disruption for passengers. They must move from a “find and fix” approach to “predict and prevent”.
The indutry’s pre-cursor risk model provides an indication of changes in risk by tracking incident frequency based on average consequence. It aims to quantify the potential risk from 51 high risk train incident types. Although it covers most mainline risks, it doesn’t include risks to passengers at stations.
The model indicates that train accident risk declines 15% during 2014/15, and risks to passengers declined 16%. At the moment, according to the model, fatal train accident risk for passengers is at the lowest level ever achieved. Public behaviour at level crossings is the biggest element of overall train risk, but most of that risk is to the crossing users themselves. Hence, for example, the on-going NR publicity campaign around level crossing use.
Almost all the safety performance metrics we monitor are backward looking. So it is important we try to look forwards proactively. Otherwise we can over rely on models and their perceived stability to inform our judgements.
We must not forget that each incident had the potential to cause significant harm. For example, similar passenger train derailments may potentially cause a catastrophic incident with multiple fatalities in one set of circumstances, or cause minimal damage and no injuries or harm in another (cf Spanish performance now worst in EU, because of the 2013 high speed derailment at Santiago de Compstela causing 79 deaths and 140 injuries. one Our Risk Management Maturity Model, for example, is designed to help us assess and test the maturity of the industry’s arrangements to manage risk.
Major train accidents are now rare on Britain’s railways, so we require more sophisticated reading of underlying trends. We analyse data from industry’s risk models, accident and incident data, findings from RAIB, results from our own work and expert opinion. We also learn from events in other countries. Moving forwards, we are focusing on three key strategic safety points:
Challenges around managing growth and change: the ever increasing numbers of passengers is putting greater challenge on managing their safe movement through stations, particulate with the planned modifications and upgrades planned.
Maintaining and renewing a safe sustainable mainline infrastructure: Whilst NR has done lots of good work, it has not delivered all its renewals and backlogs can add pressures to maintenance teams.

6. Our approach

7. Effectiveness and assurance
Properly functioning control used? / is it in place
“Adequacy”
Assurance: The level of certainty that the control will function as intended when called upon;
“reliability”
Effectiveness of control / barrier

8. Risk Management Maturity Model RM38

10. Three lines of defence 3rd line: independent challenge and assurance
Independent external audits
Internal audit
2nd line: corporate oversight 
Corporate engineering verification
Detailed reviews of specific topics
Functional topic and management system
1st line: management control
Operations compliance monitoring
Inspections and safety conversations
Management reviews and advisory visits
Self-assessment

11. Targeted intervention
Safety critical maintenance
accuracy of asset information
adequacy of the judgements
quality of the work
Assurance
Project based approach focusing on management of derailment risk
Tactical risk controls – gap between requirement and delivery
Quality of risk control
Role of self assurance and capability to identify gap

12. Results and next steps Greater understanding Willingness
Clearer framework
Balanced indicators
Increased visibility of assurance being considered routinely