1. 1 “How to make cheese – Cheddar takes longer to mature than Emmental” Amanda Mumford-Rudd HM Inspector of Railways

2. 2 Overview Regulator in Britain – a short history to set the scene What is the Railway Safety Directorate? Britains national rail network Infrastructure Manager Developments in ORR’s approach to proactive inspections and audit and their contribution to securing improved management of the asset by the Infrastructure Manager Accidents New ways of working Effect

3. 3 Hatfield 17 October 2000

4. 4 Potters Bar 10 May 2002

5. 5 Southall East 24 November 2002

6. 6 Grayrigg 23 February 2007

7. 7 Common Themes All TRACK failures All maintenance failures All systemic failures Regulatory intervention?

8. 8 Industry and Regulatory structure Bristol Plain York Glasgow Birmingham London

9. 9 Our response – Project based inspection Restructuring of maintenance delivery by IM Supporting paperwork and briefing Time bound Clear questions put to ORR inspectors HQ review and analysis Outcome

10. 10 Our response – Project based inspection & audit Maintenance Delivery Unit Inspection Project SMS audit & 6 topic verifications How do we ensure consistency? ORR internal challenges External challenges

11. 11 What effect have we had? The bigger picture - Grayrigg What has the Infrastructure Manager done?

12. 12 Next steps Practical application of bow tie analysis Change imports risk Ongoing internal challenges

13. 13 Our vision amanda mumfold-rudd@orr.gsi.gov.uk