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When the simple becomes complicated
by David Shirres

In my ten years working on track safety initiatives, it became increasingly clear to me that track safety requirements could be safer; they were both inefficient and over complicated as they did not consider the practicalities of those who work on track in difficult conditions. This puzzled me as I had a high regard for the competence of those responsible for track safety. Looking back since my retirement in 2009, it is now apparent to me that it is organisational and cultural issues that prevent individuals - however competent - from changing things for the better.

As, with the exception of the Death by Health and Safety website, little is said in public about track safety issues, I decided to take advantage of my retirement to give a presentation entitled 'Do rules keep track workers safe?' to the Institution of Occupational Health & Safety’s Rail Conference. This presentation (2.7MB) and a supporting paper (852kB) are available by clicking the red text.

Feedback on the content of this paper from the 51 rail safety professionals present was -

Poor 0% Adequate 12% Good 52% Excellent 36%

This is a fair indication that most rail safety professionals share my concerns about track safety even though they are not able to say so in public.

Since presenting my paper, things seem to be getting worse as the reality of the new Rule Book and the revised approach to RIMINI is becoming apparent. The Rule Book claims to achieve simplicity but does so by removing items which then have to be specified in other standards and it is not clear how track workers are expected to know about these removed items. An example of this is the omission of the requirement to leave a gap to provide access to a position of safety when erecting safety fencing. This disjointed approach is further illustrated by the Rule Book abolishing red and green zones which remain in Network Rail standards.

To ensure RIMINI plans are correct the COSS now has to check - and in effect duplicate - the work of the RIMINI planner. A better approach would be to understand why plans are not right first time. For example, since RIMINI was introduced in 2001 there has been no effective process to provide Network Rail employees and contractors with the required information, e.g. location of signals. This is a breach of Network Rail’s duties as client under the CDM Regulations.

So why are things so bad? It is unlikely that track safety arrangements will improve unless the following underlying issues are addressed.


Before anything can be improved it must be first admitted that there is a problem. If the organisational culture discourages bad news being passed up the management chain, nothing will improve. A good example of this is Network Rail’s under-reporting of accidents exposed by the UNITE union and the Office of the Rail Regulation (ORR). All safety professionals know that there will be many more minor accidents than major ones - roughly a 10:1 ratio, although this is not a precise science.

(Above) Workforce accident graph for 2007/8 & 2008/9, as featured on Network Rail's website

So how is it possible that accident graphs showing a roughly equal number of minor and major accidents have been widely circulated within Network Rail since 2005? From a safety professional’s perspective, this is the equivalent of the little boy being the only person who would admit to seeing that the king had no clothes. Network Rail has now acknowledged this under-reporting but has the culture that led to it changed?

Another aspect of culture is the industry’s strong attitude towards rules compliance. This is a great strength but can result in a blame culture with someone making a genuine mistake being considered to be solely responsible for an incident. The HSE publication 'Reducing error and influencing behaviour' states “Many accidents are blamed on the actions or omissions of an individual who was directly involved in operational or maintenance work. This typical but short-sighted response ignores the fundamental failures that led to the accident. These are usually rooted deeper in the organisation’s design, management and decision-making functions”. This needs to be understood by all involved in track safety incidents to ensure that lessons are learnt from them.

Consequences of poor track safety arrangements not understood

It is perhaps a tribute to those working on the track that they are able to keep themselves safe despite current arrangements. Unfortunately this has the effect of hiding track safety deficiencies. One issue is that the risk to track safety personnel is not understood. RSSB has a risk model which shows that the probability of an individual track worker being killed by a train is 1 in 15,850. According to HSE criteria, this is tolerable but close to its upper limit. It is however only an average figure and doesn’t consider the risk to particular types of track workers.

The table below shows all track fatalities from failure of the Safe System of Work (SSoW) between 1994 and 2009.
Safe system Total COSS/
Lookout Protection
Possession 5 1 4
Setting-up possession 2 2
Open line alongside green zone 3 3
Static red zone 6 2 4
Mobile red zone 7 4 3
None 2 1 1
Total 25 5 5 2 1 12

This shows that -

  • 32% (8 of the 25) fatalities were those providing the SSoW
  • when used, lookouts account for more than half the fatalities - 5 of the 9 (6 at static sites plus 3 in mobile sites requiring lookouts)
  • 16% of fatalities (4 of the 25) were working alone in a mobile site despite this being quite a small percentage of the total work done on track.

In 2002 Arthur D Little produced a comprehensive report on the 'Root Cause Analysis of Red Zone Working'. This also concluded that fatalities mainly involved staff working alone or as lookouts. As this is not considered by the RSSB risk model, there is an urgent requirement to assess the level of risk to which such staff are exposed as it is possible that the risk to certain types of trackworkers may be unacceptable according to HSE criteria.

Fundamental changes in the way possessions are managed have been considered since the late 90s yet, despite various trials and initiatives, there have been no significant changes. This is perhaps surprising as, for some time, Network Rail has recognised that possession utilisation efficiency is low (e.g. 2003 Annual Report) and the need to improve it to achieve the seven day railway is a key part of the company’s business plan. 

Two examples of unnecessary inefficiencies from current rules are excessively slow speed in possession worksites where no-one is working on-track and unnecessarily complex communications which delays the start of work in possessions. It is essential that the industry makes the best use of possessions so there is often a requirement to undertake a large amount of work in an Engineering Supervisor’s worksite. Although this can be done safely if suitable arrangements are in place, the Rule Book does not address the requirements of complex worksites and, where it does, it is often impracticable and confusing. It is therefore perhaps not surprising that a recent efficiency assessment by the ORR concluded that Network Rail’s infrastructure work is 34-40% less efficient than European railways; one reason for this being the way possessions are carried out.

Lack of focus

Network Rail is effectively the employer of all who work on track so it is legally accountable for all track safety arrangements. However, as already mentioned, the relationship between track safety rules produced by RSSB and Network Rail standards is not clear. A cohesive approach is needed. This requires NR to specify all track safety arrangements. Track safety is a key safety and productivity issue for which urgent and effective action is required. Unfortunately the company has not been able to deliver worthwhile track safety initiatives such as Lookout Operated Warning Systems - which have been bought but are rarely used - and Track Occupancy Permits. Perhaps one reason for this is lack of ownership of track safety at Director level.

Unfortunately the company has not been able to deliver worthwhile track safety initiatives...


There are many in the industry for whom ‘quality’ is a dirty word due to poorly implemented quality systems with excessive paperwork. Quality is like any tool - it can be used or abused. Done properly it gives clear concise procedures that take account of the way work actually has to be done. This can only be achieved with the active involvement of the workforce. In my experience, railway traction and rolling stock depots show how quality management should be applied within the rail industry. For example, at Polmadie Depot the time to install air conditioning units on Pendolinos has been halved using quality techniques involving the workforce.

Despite the internationally recognised benefits of effective quality management, Network Rail is perhaps the only significant part of the industry that does not have accreditation to the ISO9001 Quality Standard, nor does it have a Quality policy. Network Rail does however demand this from its contractors.

So what’s to be done?

There are many competent folk within Network Rail and its contractors who could improve things if NR gave sufficient priority to improving track safety arrangements and took full ownership of all associated issues.

One area that does need immediate action is the Rule Book. Although most of the track safety rules are sound, many are poorly presented and some issues are not addressed. With the ‘new approach’ to the Rule Book making matters worse, the Rule Book is a lost cause. The solution is for Network Rail to produce its own definitive guides to work in possessions and work on open lines as a first step to taking full ownership of track safety arrangements. Such guides could present all necessary instructions (including issues not addressed in the Rule Book) in a clear comprehensible manner that is wholly compliant with current rules. Given the popularity of the PTS and now-defunct COSS handbooks, it is likely that such guides would be well received.

My presentation to the IOSH Rail Conference demonstrates that many track safety arrangements are not fit for purpose and result in unnecessary risk and costs. If things are to improve, the first step is an honest acceptance of this problem with a high level commitment to ensure that effective action is taken. Unless this is done it is likely that the risk to track workers will remain at the upper limit of tolerability and track safety arrangements will continue to reduce productivity unnecessarily. This is a situation that should not be allowed to continue.

Story added 1st February 2011

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