1. Annual Occupational Health Railway Conference 2008 The Work of the RAIB; emerging safety themes Carolyn Griffiths Chief Inspector Rail Accident investigation Branch UK

2. Part 1: What is the Rail Accident Investigation Branch UK?  Why was the RAIB established?  How was it established?  Organisation  The investigation process Part 2: The story so far Some case history

4. What is the RAIB?  The independent railway accident investigation organisation for the UK  Reports to Secretary of State for Transport  Sole purpose to improve safety of railways and prevent further occurrences. Does not apportion blame or liability, nor enforce law or carry out prosecutions  Lead Party  in rail accident investigations where there is no evidence that serious criminal action is the cause  Operational for two and a half years

5. What is the RAIB?  Scope of responsibility  Geography  Types of railway  Types of Accidents and Incidents

6. RAIB’s geographical area

7. Which railways are covered by the RAIB?  The RAIB will investigate accidents and incidents on… Mainline All operations by passenger and freight train operating companies Metros Including London Underground, Tyne and Wear Metro, Docklands Light Railway, Strathclyde Metropolitan Railway Tramways in England, Wales and Northern Ireland Heritage Railways with a gauge above 350mm Cable-hauled Systems of 1km or longer

8.  Derailments or collisions which result in or could result in… The death of at least one person Serious injury to five or more people Extensive damage to rolling stock, infrastructure or the environment Or any other accident which, under slightly different circumstances, could have the same consequence Discretion, to investigate other accidents or near misses based on:  How serious the incident is; and  The likely safety lessons to be learned What type of accidents will be investigated?

9.  The RAIB will not investigate… Worker accidents / near misses unless involving train movements Trespass or suicide

10. Why was the RAIB established?

11. Major accident (Ladbroke Grove) 1999 ; 31 fatalities, 400 injured Public Inquiry recommended establishment of national rail accident organisation, independent of:  Government  Safety Regulators  Prosecutors incl. police  All industry parties Then…in 2004 European Rail Safety Directive Required Member states to establish an independent accident investigation by April 2006

12. Organisation design, recruitment and training

13. Dukes Court, Woking, Surrey The Wharf, Derby

15. How we investigate: Working with other parties

16. Other parallel investigations: The need for clear and sharing of evidence RAIB Safety Investigation HMRI, DRDNI, Duty Holder Enforcement of safety legislation Police Criminal Prosecution & Sudden Death Investigation

17. RAIB leads the investigation unless: How does this work? There is evidence that a criminal act caused the accident/incident Criminal investigation normally will take precedence (eg terrorist incident or vandalism) Police and the RAIB are required to agree if the Police investigation is to take precedence The RAIB will still have access to the site and evidence, and may still conduct a safety investigation

18. RAIB recommendations formulated with industry input RAIB is advised by the Safety Authority of industry parties intent The industry parties notify the Safety Authority their intent to implement. The Railway Industry has a duty to consider the recommendations Safety Authority ensures ALL relevant industry parties are informed of the recommendations. RAIB publishes report, sends to those involved How do RAIB’s recommendations affect the industry?    

19. Experience so far…..

22. Largest investigation so far

23. 86 Completed; 33 Current Investigations 37 % : Train Derailments 13.25 %: Level Crossings 13.25 %: collision (with a train/or other object) 10.25 %: staff hit by trains/near misses 5.75 % involve runaway incidents 4.25 % unauthorised train movement 4% train door incidents 3.5 % involve Spads 2.5 % fire on Rolling stock 2.5 % train defects 2.25 % involve Unsafe loads 0.75 % involve Possession Issues 0.75 % electrocution

24. So why DO accidents happen? Examples….  Brentingby, 09.02.06: Driver fatigue  Runaway trolleys/road rail vehicle

25. Brentingby: 09.02.06

26. Brentingby: 09.02.06.  Cause: Driver had microsleep(s) and passed signal at danger  2 early shifts (shortened sleep?); rest day ( consumed 5-6 pints of beer) ; night shift- accident after 22 hrs awake.  Main task in 2 nd half of shift  Arrived early for work  No check for fitness on signing on  Briefing on fatigue did not deal with first night shift issues

27. Brentingby: 09.02.06. Recommendations:  Operator to consider planned napping +facilities- if shift pattern requires  Research most effective sleep pattern when changing from day to night shift. (Aware of research carried out in the USA)  Investigate feasibility of screening for sleep disorders  Guidance for drivers on lifestyle to suit shift working incl.preparation for first night shift. Include families where possible  Review checking for fitness for duty when ‘signing on’

28. Larkhall

29. Brakes - Larkhall

30. Notting Hill Gate

32. Brentwood

33. Risks…….  Trolleys are not wheel barrows – can carry 2T of rail  Incident of one laden trolley runaway onto running rail-  by luck operated track circuits and stopped approaching trains  Road rail vehicles can present risk even though they should operate at slow speed (walking pace in possession)  One road rail ran 7 miles, 3miles out of possession,

34. Runaway trolleys/road rail vehicles  Lack of gradient information in risk assessing the work  2 trolley incidents,  2 road rail incidents  Loss of adhesion due to contamination  1 Trolley incident  1 road rail incident  No adequate on-site functional test  2 trolley incidents  Speed of operation  1 trolley incident  1 road rail incident  Unauthorised alterations  brake blocks - Larkhall  brake linkage Notting Hill Gate  tyre pressure- 2 road rail incidents  Approvals process  All road rail and trolley incidents?

35. Are we making a difference?…. 120 investigations; 86 published  83 investigations on Mainline network (2 in the Channel Tunnel)  16 on LRT/trams  14 on Heritage systems  7 on Metro Systems  497 recommendations  Circa 95% acceptance

36. How do we measure up? Survey of stakeholders incl.:  those we investigate and those we might investigate  @ senior level  @ working level  unions  other investigators such as the police and safety regulator Positive outcome  Quality of investigations and reports  Interface with industry  Highly rated organisation w.r.t. selected similar organisations in UK But we are constantly trying to develop our capability further………

37. What’s on the RAIB website? www.raib.gov.uk Accident Notification What to notify: How to notify: Forms and Guidance About Us History: Formation: Organisation: Powers: Contact Publications Investigations register: Reports: Safety Advice News Media notices released by the RAIB: Media contact details Library Downloadable leaflets and information on legal framework

38. ‘People need to know that accidents have been thoroughly investigated and that actions have been take so they don’t happen again That’s what we do…’

39. Thank you