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Set up to fail
The writer of this article has asked us not to publish their name

A report into the disregard of good health and safety practises during line blockages without additional protection and the persecution of signallers who fall foul of the traps set.

On 4th December 2010, the RSSB issued new line blockage rules which, in many circumstances, eliminated the need for workers to place additional protection on the track. This placed the onus for the safety of those workers with the signaller. These rules demand that the signaller uses reminder appliances only to protect staff working on the line, even if a safer method is easily available, thus relying on the supposed infallibility of the signaller to protect several teams of workers. This method takes no account of human factors or ergonomic principles, and sets up the signaller to fail.

We all make errors

By making a busy signaller - who has a myriad of different duties - the guardian of trackworkers’ safety, the RSSB and Network Rail have put those workers at risk and the signaller under stress. This method of relying on someone not making a mistake is totally rejected by the HSE.

We all make errors irrespective of how much training and experience we possess or how motivated we are to do it right. Failures are more serious for jobs where the consequences of errors are not protected. However, errors can occur in all tasks, not just those which are called safety-critical.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)

Isn’t it just about people taking more care?

The RSSB, when challenged about the safety of line blockages without additional protection stated, “If the line blockage is correctly applied using the specified protocols on each occasion then it cannot be considered as dangerous.” This is patently nonsense and the HSE knows this.

It is quite wrong to believe that telling people to take more care is the answer to these problems. While it is reasonable to expect people to pay attention and take care at work, relying on this is not enough to control risks.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)

Consideration of human factors is a key ingredient of effective health and safety management

Using additional protection will considerably reduce the chances of a train entering a line blockage and will help protect the signaller from persecution for making a mistake. Line blockages using a disconnection must be made easier and have more respect for the signallers’ workload. When challenged about no additional protection, the RSSB stated, “Also you may be taking the view that additional protection should be applied for all line blockages purely to protect trackworkers, when this is not the case.” All precautions should be taken to ensure safety according to the HSE.

Adequate workplace precautions have to be provided and maintained to prevent harm to the people at risk. These precautions include: procedures and warnings, safe systems of work, controls on equipment, alarms, safety instructions, communications arrangements, and machine guards. All of these need to be designed with the human in mind to make sure that they are used correctly and reliably. Ergonomic changes to the task and the working environment also help to reduce risks and can improve the physical and mental well-being of the workforce.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)
Without additional protection, when trying to look after several groups of workers as well as running hundreds of trains, the signaller is totally exposed to errors.

Through a failure a person can directly cause an accident. However, people tend not to make errors deliberately. We are often ‘set up to fail’ by the way our brain processes information, by our training, through the design of equipment and procedures and even through the culture of the organisation we work for.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)

Blame the individual

It is wrong and shameful to downgrade or sack a signaller who has been let down by poor working practises, poor planning and a fundamentally unsafe method of work, especially when there is a safe method of work readily available.

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 which led to the accident. These are usually rooted deeper in the organisation’s design, management and decision-making functions.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)
Network Rail and the RSSB seem to have buried their heads in the sand as they don’t investigate these incidents properly, nor do they take any meaningful steps to avoid them happening again. I hope this isn’t so that they can avoid admitting they were wrong in the first place.

After an accident involving human failure there may be an investigation into the causes and contributing factors. Very often, little attempt is made to understand why the human failures occurred. However, finding out both the immediate and the underlying causes of an accident is the key to preventing similar accidents through the design of effective control measures.

Slips and lapses are the errors which are made by even the most experienced, well-trained and highly-motivated people. They often result in omitted steps in repair, maintenance, calibration or testing tasks. We need to be aware of these types of errors and try to design equipment and tasks to avoid or reduce their occurrence. We can also try to increase the opportunities to detect and correct such errors. It can be useful to make everyone aware that slips and lapses exist and to consider them during accident investigation.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)
In fact, Network Rail seems to want to ignore all of the HSE guidelines about human factors, by introducing a computer matrix to decide when a signaller can cope with more line blockages.

Tasks should be designed in accordance with ergonomic principles to take into account limitations and strengths in human performance.

Organisation and management factors -

· poor work planning, leading to high work pressure

· lack of safety systems and barriers

· inadequate responses to previous incidents

· poor management of health and safety

· poor health and safety culture.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)

Key messages

Everyone can make errors no matter how well trained and motivated they are. Sometimes we are ‘set up’ by the system to fail. The challenge is to develop error-tolerant systems and to prevent errors from occurring.

Failures arising from people other than those directly involved in operational or maintenance activities are important. Managers’ and designers’ failures may lie hidden until they are triggered at some time in the future.

There are two main types of human failure: errors and violations. Controls will be more effective if the types are identified and addressed separately.

Reducing human error involves far more than taking disciplinary action against an individual. There are a range of measures which are more effective controls including design of the job and equipment, procedures, and training.

Paying attention to individual attitudes and motivations, design features of the job and the organisation will help to reduce violations.

Source: Reducing error and influencing behaviour (HSE, second edition, 1999)

Network Rail and the RSSB have set up signallers to fail and are refusing to change or learn from past mistakes.

Story added 1st October 2012

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