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Read About It Belatedly

Whether he’s conscious of it or not, the day-to-day activities of every on-track worker are controlled by a snugly fitting harness of rules and regulations. They define those unlikely circumstances in which be might be granted a blockage of the line; the inspection frequency for all equipment under his care; the Pantone colour of his hardhat; the paperwork he’s compelled to sign. His knowledge of relevant standards will be tested periodically and his compliance with them measured in the event of cock-up.

Everyone’s working life is, to some extent, governed either by written instruction or verbal edict from above. Some organisations carve every operational nuance into stone tablets; for others, they are carved for them. Of course, there’s a world of difference between knowing your obligations and actually discharging them.

On 17th October 2005, responsibility for the independent investigation of serious railway incidents was deposited on the shoulders of four principal inspections and 24 enquiring underlings within the Rail Accident Investigation Branch. To reinforce the gravity of their work, their powers and functions were set out in the Railways (Accident Investigation and Reporting) Regulations 2005 which, in turn, satisfied the requirements of the European Railway Safety Directive (2004/49/EC).

Tucked away in the depths of those AI&R regs is clause 11(2)(a) which obliges RAIB to complete and publish its reports “in the shortest time possible and normally not later than 12 months after the date of the occurrence”. Although inclusion of the word ‘normally’ does give this generous deadline some elasticity, it’s reasonable to expect that all exceedances are supported by valid reasoning. It’s not a catch-all get-out-of-jail card.

Late in December 2008, RAIB published its Annual Report….for 2007! Spin doctors must now be on the payroll. Page 15 considers the Branch’s compliance with regulation 11(2)(a) by skillfully moulding facts into a distorted reality.

 “For investigations started in 2006 and published in 2007, the average time from the date of the incident to publication was 12 months” it states. Note the word ‘average’ - don’t be fooled into thinking that the 12-month deadline was ‘normally’ met. “For investigations started and published in 2007, the average time from the incident date to publication was 6½ months”. Of the 37 inquiries triggered in ’07, only 11 fell into this category. Not surprisingly, no mention is made of the 2005 probe which also surfaced during that year.

May 2008 saw the causes revealed of a derailment dating back to the autumn of 2006 - a 20-month turnaround - and, as we welcomed in 2009, no fewer than five reports from ’07 were still lost in RAIB’s black hole.

What’s more telling is to look at the Branch’s recent record in relation to ‘heavy rail’ events - those occurring on Network Rail infrastructure. Of its last 18 such inquiries, only half of them have emerged within the set timeframe. Four of those relied on the skin of their teeth.

Derailment at Ely
19 months
West Lodge Crossing fatality
12 months
Fatal accident on Moor Lane foot crossing
8 months
Near miss near Bishop’s Stortford
11 months
SPAD at Didcot North Junction
15 months
Overspeeding in ESR at Ty Mawr crossing
14 months
Accident east of Reading Station
11 months
Derailment at Grayrigg
20 months
Accident at Leatherhead
14 months
Collision with footbridge at Barrow-upon-Soar
7 months
Derailment at Duddlestone Junction
11½ months
Two trains in same section at Aylesbury
9½ months
Runaway wagons in Camden Rd Tunnel
10 months
Derailment at Croxton Level Crossing
20 months
Runaway and collision at Armathwaite
15 months
Derailment at Kemble
14½ months
Derailment in Hooley Cutting
13½ months
Trackworker fatality at Ruscombe Jnc
10 months

This is more than just a tick-box issue. It is vital that the wider industry is able to learn lessons from serious incidents - quickly and effectively - to ensure that safety improvement is delivered. Any responsible company will have systems in place to review the findings of inquiries and determine whether they raise issues relevant to its business. Hopefully they never bring to light any gaping managerial holes; they might though highlight an area where positive, proactive change could further enhance safety. Thus, RAIB's protracted timescales could potentially delay lower-level safety benefits which offer real value to those staff exposed to high levels of risk.

I put these concerns to the European Railway Agency which convenes the network of investigation bodies established under Directive 2004/49/EC. The “substantial delays” in the completion of RAIB’s inquiry reports are not news to the head of its Safety Unit - in fact the ERA has established a reminder procedure for investigation bodies and is working with them to generally advance the quality of reporting. In respect of the 12-month deadline, he made it clear that “there should be justified reasons if it is not met”.

RAIB informed me that it issues Urgent Safety Advice if, during the course of an inquiry, it unearths an issue which could compromise safety. It also claimed to delve deeper into the technical causes of an accident than was previously the case - efforts which inevitably impact on timescales. But in citing the exceptional accident at Grayrigg as an example, the impression was created of an organisation erecting a façade behind which it could hide broader failings.

...the impression was created of an organisation erecting a façade behind which it could hide broader failings.

I have since asked whether the Branch regards the 12-month deadline as “unreasonable or unrealistic” and, if not, how it intends to improve compliance with it. As yet, no response has been forthcoming.

If RAIB is hopeful that I will be satisfied by its silence, it has a lesson of its own to learn.

Story added 1st February 2009
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