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A very real fear

Cheryl Cole lecturing on particle physics; Sir Alex Fergusson extolling a referee; turkeys voting for Christmas. All these things will never happen. And yet this month I find myself - deep breath, uncomfortable shuffle - commending RSSB. Not the organisation in general; specifically its ‘independent’ review into RIDDOR reporting within Network Rail and its contractors. The organisation’s four big guns - Jack, Dennis, Gibson and Pitman - seem to have squirted their water pistols in broadly the right direction, causing the elephant in the board room - Network Rail’s questionable safety culture - to trample through the directors’ complacency.

Back in April 2010, the ORR made known its concerns about the unsustainably low number of lost-time RIDDOR injuries that were being reported by Network Rail and the contracting fraternity, compared with major injuries. Its belief was that around 500 of these annually were simply going missing. Unite’s Railway Officer, Bob Rixham, compiled a dossier which revealed what he called “a mix of incompetence, obfuscation and, sadly, the conscious choice of a perverse policy.” This ultimately prompted Rick Haythornthwaite, Network Rail’s chairman, to bring in RSSB in an effort to establish the truth. It did so…ish…through confidential interviews with senior executives, staff and contractors, as well as analysis of SMIS (Safety Management Information System) data and other documentation.

Published on 25th January, the review’s conclusions do not make easy reading, although they are tempered by RSSB’s characteristically subdued language. It doesn’t like to offend anyone.

Over the five years from 2005/6, the level of under-reporting was estimated to range between 37-42% - that’s 500-600 incidents - within Infrastructure Projects and Maintenance. This is based on a ratio of 3:1 between lost-time and major injuries. I won’t burden you with the many reasons why this assumption is suspect, other than to point out that the Scottish part of the West Coast Route Modernisation programme - involving around five million man-hours of work - returned a ratio of 8.5:1. On that basis, it’s likely that the real number of incidents is much closer to that calculated by the ORR.

The under-reporting drivers were changes “in both the culture of Network Rail and its relationship with its contractors.” This was reflected through “real and perceived pressure and, in some cases, fear felt by Network Rail staff and contractors if they report accidents or incidents.” Safety targets and league tables linked to RIDDOR reports, frequent reorganisations and a cost-focussed procurement strategy all contributed to that sense of threat - the latter resulting in contractors making much greater use of ‘zero hours’ temporary staff.

Some evidence was found of misunderstandings amongst directors and managers around the requirements of RIDDOR but the failures were mostly attributed to deliberate violation: front-line reporting being discouraged through management “incentives” and the unwritten policies of contractors. Whatever their cause, the consequence was a falling Accident Frequency Rate (AFR) for which Network Rail’s top brass were quick to congratulate themselves. This improvement could only be down to their actions in implementing new equipment, work practices and the supposedly “motivational aspects” of safety league tables…couldn’t it? They had not considered a more disturbing reality, which says much about the culture within the organisation. And its senior safety professionals don’t exactly emerge smelling of roses. Questions had first been asked by the ORR in 2008 - why didn’t they recognise this as an emerging issue and make representations upstairs? Incompetence? Ignorance? A fear of communicating bad news?

Having examined bonus arrangements within Network Rail, RSSB determined that safety performance targets did not directly impact on the level of an individual’s bonus award but it did recognise an indirect link through the deliberations of the company’s Remuneration Committee and some managerial performance assessments. No evidence was found of senior people instructing or encouraging those lower down not to report RIDDOR incidents or interpret the regulations incorrectly. That doesn’t of course mean that this categorically did not happen. (That’s my statement, not RSSB’s.)

So what do these conclusions prompt the review panel to recommend? “A more open and just safety reporting culture” is apparently what’s needed, supported by better high-level relationships with staff and “a partnering approach” with contractors. Phrases like “open dialogue” and “effective industry learning” are scattered about. The removal of AFR and FWI (Fatalities & Weighted Injuries) as targets is advocated, as well as the cutting of any links between these and the bonus scheme.

Worthy of full reading is Appendix B - this is a record of discussions at a Railway Industry Contractors Association (RICA) meeting on 7th December. (Click here to download the review (1MB) - Appendix B is on page 95 of the PDF which, helpfully, is page 93 of the report!) It features comments made by RICA members on the relationship between safety performance and contract awards. One states that “the norm on a Monday morning is of a route director ringing up the contractor’s MD and yelling at them if they have had a RIDDOR over the weekend” whilst another comments that “the whole process came across as more interested in clearing up the reporting than learning from the event and exploring underlying causes so they are not repeated.” Track renewals companies are “all scared of having any RIDDORs on their sites”, asserts a delegate.
Track renewals companies are “all scared of having any RIDDORs on their sites”...

It would be fair to suggest that the review doesn’t really reveal much we didn’t already know from personal or anecdotal evidence. Many of us have been involved in incidents we chose to keep quiet through fear of retribution. But seeing it all in black and white from an ‘official’ (if operationally detached) source takes it to a higher level. If you cut through RSSB’s fluff, you gain some insight into Network Rail’s conflicting internal priorities and the difficulties they give rise to. (That’s explored in part of David Shirres' contribution this month - available by clicking here.)

And what of the firm’s response to publication? Encouragingly, it reflects the shifting tone that has accompanied Haythornthwaite’s arrival and Coucher’s departure to his Scottish retreat. Less grating now is Network Rail’s arrogance; the instinct to blindly dismiss criticism. It does not yet feel the need to apologise for everything - a habit the BBC has fallen into - but its chairman’s recognition that the house needs putting in order does come over as genuine.

As we all know though, words are one thing, acceptance is another. But affecting real change in an organisation with such ingrained flaws is a challenge that will not easily be met. The new man in charge, CEO David Higgins, has a serious job on his hands. We can only hope he has the commitment to tackle it with some zeal.

Next month I will spend £239 on one of East Coast’s Standard Open Returns between Wakefield and King’s Cross. Or perhaps not.

Story added 1st February 2011
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