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Suffer in silence

Spleen venting can be quite cathartic. I certainly find it so; hence the monthly rants on this website. And it’s clear from the feedback I get that many of them prompt thought and debate. That’s also a good thing, and personally very satisfying. What’s less clear is how much tangible benefit ensues: do they bring any closer a resolution to the issues highlighted? Probably not. For that, you need to have the sympathetic ear of someone with influence.

The Rule Book’s failings are apparent to all but the dead, and practitioners suffer their consequences. The volume and communication of rule changes have now plumbed such depths that three train operating companies feel the need to collaborate on an official appendix to capture them all. There is no point highlighting problems to RSSB, the Rule Book’s custodian, as it just swats them away, such is its arrogance.

The Rule Book’s failings are apparent to all but the dead...

So on 10th September, I wrote a letter - reproduced below - to Ian Prosser, Safety Director at the Office of Rail Regulation. It offers an overview of three broad areas where difficulties are currently encountered and illustrates them with examples. My hope is that some enforcement pressure might be brought to bear, resulting in a programme of improvements. No reply as yet - if one is eventually forthcoming, I’ll let you know what it says. One thing is for certain: the ongoing shambles is neither helpful nor sustainable. The unwillingness to tackle it suggests that the industry’s hierarchy does not regard it as important, which says much about the culture of those involved.


Dear Mr Prosser

Rule Book concerns

My first regular engagement on the railway came in 1998 when I was contracted to produce workforce safety briefing materials for Railtrack Safety & Standards Directorate. The work involved spending a couple of days a week on-track which gave me a useful insight into trackworker culture. I also sat on the Track Safety Strategy Group and played a leading role in its Rules Simplification Subgroup. It became clear to me that there was a disconnect between the development of the railway’s Rule Book at safety professional level and the needs of the workforce in terms of clarity, structure and user-friendliness.

Judging by the size of my email Inbox, concerns over the Rule Book’s shortcomings - and the associated safety implications - are shared by many friends and colleagues. The implementation of RSSB’s New Approach has prompted the number of messages received to increase as both general and specific problems are identified. I am aware that some people have contacted RSSB directly about these but, as one put it, “You are treated with contempt for having the audacity to question them.”

You will be aware that many inquiry reports cite problems with the rules - or the misunderstanding thereof - as contributory factors in incidents and accidents. As safety regulator, I am keen to gauge the ORR’s perspective on three related themes:

State of flux

The foundations for most people’s rules knowledge are laid at the relevant competency’s initial training course. These are built upon through subsequent practical experience, resulting in correct application of the rules becoming instinctive. When rules are changed, this inevitably presents a challenge to the individual, requiring them to invest time and effort modifying their behaviour.

Unlike that initial training, changes are not generally communicated in person: perhaps a package of papers is left in a pigeonhole or posted to home. Rarely do they form part of a structured programme in which the effects are put into context and an opportunity provided to seek clarification. Even if the individual has been sufficiently motivated to read the material, their understanding of it is not usually tested.

Currently, rule changes are implemented either via the Periodical Operating Notice or consolidated into larger tranches in June and December. Over time, this drip-feed serves to undermine inherent rules knowledge. The number of changes therefore needs to be minimised, whilst recognising that the industry has an obligation to take action on the basis of inquiry findings and to improve efficiency. Revisions/additions on these grounds are reasonable - providing they are proportionate, not knee-jerk - but they need to be right first time.

Unfortunately, many changes are actually driven by omissions, errors and inconsistencies resulting from failures in process: in other words, a rule that had been written, examined, approved and implemented is later found to be flawed or have unforeseen consequential impacts. A couple of examples -

  • When Issue 1 of Handbook 9 (IWA/COSS setting up safe systems of work within possessions) came into force, it stated that an IWA could not sign-in with the PICOP in order to rely on a 40mph speed restriction if working outside a worksite, although they could previously do this under the requirements of module T7. RSSB told me that “This has been recognised to be an error” and was corrected in Issue 2 of Handbook 9. But for a period of several months, IWAs were denied the opportunity of using a preferable method of protection when working in possessions.

  • When Issue 1 of Handbook 8 (IWA, COSS or PC blocking a line) was implemented, it required the IWA/COSS to sign the Line Blockage Form held by the PC whereas they could previously agree arrangements over the phone. This was inconsistent with the comparable relationship between ESs and PICOPs, and potentially required IWA/COSSs to travel many miles to visit the PC, reducing productivity. This was often impractical and drove the adoption of less appropriate arrangements. Again it has been amended in Issue 2.

More worrying are procedural black holes, such as the one identified in RAIB’s inquiry into near misses at Clapham Junction and Earlsfield on 11th March 2011. Here a COSS found himself in a situation for which there were no applicable rules. “In the circumstances, it would not have been possible for COSS A to establish a safe system of work for work in a possession but outside a work site that was compliant with the Rule Book…”, the inquiry report states.

It should be recognised that the Rule Book and any changes made to it are the focus of a lengthy process that culminates in approval by Subject Committees. However, whilst the COSS at Clapham Junction found himself the subject of scrutiny, audit and sanction after a situation arose that was beyond the scope of the Rules, those who made safety-critical errors in developing and endorsing a flawed Rule Book are not held accountable for their failings. This is clearly unjust.

There needs to be a concerted effort to reduce the number of rule changes by ensuring that proposals are proved to be robust prior to implementation.

Disjointed structure

The workforce is told that the Rule Book is the definitive point of reference on procedural matters and that compliance with it is obligatory. This position has been engrained in the culture of the railway.

When the modular Rule Book was first introduced in 2003, RSSB’s stated intention was to reissue any module to which amendments were made. The Board has subsequently reneged on this commitment, instead publishing changes via the Amendments Module. The June 2012 issue comprised 202 substantive pages. However, as neither this document nor the Rule Book modules/handbooks come in loose-leaf form, one cannot be used to update the other - they have to remain separate. It should also be noted that not every Rule Book holder is issued with the Amendments Module or its associated briefing/explanatory notes.

As a result, end users can no longer pick up a current Rule Book module/handbook and be confident that it contains the current rules. For example -

  • Issue 2 of module TW3 (Preparation and movement of locomotive-hauled trains) has been in force since February 2005 but changes to it have subsequently been made in Issues 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 of the Amendments Module.

  • Issue 3 of module S5 (Passing a signal at danger) details four situations when a driver can pass a signal at danger under his own authority, yet two of these were removed in Issue 13 of the Amendments Module.

A cross-referencing process has to be undertaken between the relevant module/handbook and every issue of the Amendments Module published since it came into force, as well as consulting more recent PONs. This is neither practical nor desirable, giving rise to uncertainty or error, and is untenable given the Rule Book’s safety-critical status.

It should be recognised that most people consult the Rule Book prior to a competence assessment, before implementing a procedure of which they have little real-world experience, or in situations of abnormal/degraded working when urgent clarification is needed. Misinterpreting the requirements in any of these situations has obvious potential consequences.

Given the industry’s assertion that cost never comes before safety, RSSB’s insistence that some changes “do not justify reissue for the module concerned” is untenable. It is basic common sense that the current issue of any Rule Book module/handbook must be up-to-date and its contents definitive.

Procedural voids

Although it is reassuring to see RSSB acknowledge some of the Rule Book’s weaknesses through the instigation of its New Approach project, there is a view that it actually exacerbates some of the existing problems as a result of the stated objectives.

What the end-user needs is a single, authoritative document that imparts all that is required of them. This should be presented in a form that best fits the audience profile, recognising that drivers, signallers and trackworkers all have different skillsets. This will impact on the layout, the language and the use of visuals. The procedural progression should follow a logical path.

But RSSB’s focus seems to revolve largely around “significantly rationalising its content”. Whilst there is certainly scope for simplification and a reduction in wordage, this must not be at the expense of ‘hiding’ live rules. The big issue is quality, not quantity. Many instructions have been designated as ‘training and assessment’, with responsibility for communicating them devolved to Network Rail. In reality, some of these instructions now exist only in the ether - still in force but not written down anywhere for reference by the practitioner. This might have allowed RSSB to make claims about the Rule Book’s lower page count, but to whose benefit? If a trackworker is expected to apply a rule that is only communicated on an initial training course, how is he expected to refresh his memory of it months down the line?

For example -

  • Clauses T2.3.5 and T2.8.3 collectively described the arrangements to be made when a line blockage with TCOD (formerly T2A) was taken of a platform line on which a train was stabled. The procedure is used overnight at many terminus stations. But this does not appear in Handbook 8; instead it is now a local instruction which will be invisible to the likes of a visiting subcontract COSS.

  • Clause T7.9.3 confirmed the need for an IWA/COSS, if working on an open line, to speak first with the signaller to confirm whether single line working was in operation or any wrong-direction movements were to be made. This instruction was excluded from Handbook 7 because it forms “part of training and competence”.  But no mention of it is made in Network Rail’s keypoint card for IWA/COSSs.

On the other hand, although they are clearly not rules, Handbook 7 does include five bullet points that describe what ‘an approaching train’ is.

The holder of a competency must now make reference to the relevant Rule Book modules/handbooks, keypoint cards and local instructions, and even then will not gain a complete picture of what they need to know. So this disaggregation compromises that competency holder. It does little to make the remaining rules “more portable for those working in an outdoor environment” or ensure they are communicated in a manner that is “clear, concise and precise” - two aims of the New Approach.

The perceived importance and relevance of the Rule Book has diminished over time. This is due in part to the industry’s shifting culture, as career railwaymen make way for a more transient workforce. But it is also a function of the Rule Book’s tone, structure and contents becoming misaligned with the needs of the workforce. This has had real consequences over the past few years, as evidenced by inquiry findings. It is ultimately unsustainable and needs to be rectified.

As one of my industry associates wrote in an email yesterday, “Amongst my colleagues the Rule Book is losing credibility as a result of the constant fiddling and there is a view now that it has become the play thing of a politically correct Quango. This is on top of the problem that continual change to the rules is bringing about a very real and dangerous disconnect between the ‘coal face’ workers and the rules that are supposed to keep us safe”.

I would be interested to know whether you believe regulatory influence could/should be exerted to address some of the Rule Book’s more fundamental weakness and thus restore its reputation, bringing a much-needed improvement in understanding and compliance at operational level.

Yours sincerely

Graeme Bickerdike

Back in the real world, a potentially life-threatening irregularity took place in central Scotland on 28th October. An overnight possession had been taken of the 15-mile section of two-track railway between Stirling Station and Blackford signal box, allowing a number of maintenance activities to be carried out.

North of Dunblane, one of the sites accommodated drainage work on the Up line, with seven staff involved together with a road-rail excavator and trailer. When the work was complete, the Engineering Supervisor tried to contact the PICOP to inform him that the RRV and the workgroup were clear of the line. Unable to make contact, the ES decided to call the signaller at Blackford. He reported that the PICOP had given the possession up an hour earlier and the line had been open to traffic ever since. So the worksite, with its manpower and machinery, had been completely unprotected from trains although, fortunately, none was scheduled to run during this time.

An investigation has been launched by RAIB.

Story added December 2012
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