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

2. 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

3. 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 (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

4. 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

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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. Questions
Paul Appleton