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Contents

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Executive Summary Chairman's Welcome and Introduction Keynote Address Operational Safety Performance & the Changing Risk Profile National OPSRAM Implementation ­ One Year On RAIB Eight Months On Managing Precursors Engineering Reduced Operational Risk RSSB Research and Development Programme Managing Risk - A Train Operator's Perspective Discussion Closing Remarks Summary of Key Issues to Consider Presentation slides Abbreviations Conference Agenda Delegate List 1 8 10 13 16 19 22 24 28 30 32 42 44 47 67 69 70

Executive Summary

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Executive Summary

Halcrow facilitated the 10th National SPAD Conference on behalf of the industry on 11th July at the headquarters of the Institution of Civil Engineers in London. This year, whilst still maintaining a focus on SPADs, the theme was broadened to address wider operational risks. The main themes emerging from the day are outlined below, and are distilled into some key messages and action points at the end of this brief overview. Elsewhere in this digest a summary of each presentation and the presentation slides can be found, together with details of the discussions and other event material. 1.1 SPAD Risk reduced by 87% - but we must not show complacency It was evident that significant progress has been made towards reducing the industry's SPAD risk, achieving a reduction of 87% since March 2001. Putting this into context, SPAD risk now represents just 4% of the total train accident risk profile. However, speakers were keen to point out that we can't afford to be complacent with respect to SPADs, as there is still a residual SPAD risk, despite technologies such as TPWS, and the consequences of just one SPAD can be severe. Indeed, TPWS had brought its own risk issues most notably the `reset and continue' SPAD issue. Also, SPAD risk still exists where TPWS is not provided such as at plain line signals and shunting signals, and during engineering work and under degraded mode operation. Key initiatives highlighted included the review of the case for TPWS at plain line signals and at platform starting signals where speeds are 20mph or less. It was noted that there are no significant technical solutions coming in the immediate future to further address SPAD risk, the next major technical solution being ERTMS which is many years away. Therefore, to maintain the good progress made and continue to drive SPAD risk down, TPWS must be looked on as a longer term technology, increasing its role and growing its reliability. The industry must also continue to share good practice in SPAD management, paying attention to the management of key personnel, incident investigations, safety critical communications; and training and competence. Many examples of good practice were both seen at the event and cited in presentations, and SPADWEB was commended as a vehicle for sharing good practice. 1.2 The Changing Risk Profile The Conference heard for the first time at this event, an overview of the wider operational risk existing in the railway. 83% of all train accident risk arises as a result of operating the railway. Significantly, level crossing risk, mainly from abuse and misuse by road users, accounts for nearly half of all operational risk and irregular working accounts for nearly a third. Further, over the past 5 years SPAD risk had reduced by a factor of 10 whilst level crossing risk had remained constant and irregular working risk had risen by 50%.

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Executive Summary

1.3 Level Crossing Risk Noting that level crossing risk in particular is mostly externally generated, Network Rail is expending much effort in addressing this through its National Level Crossing Safety Campaign, by raising awareness of road users to the risks and highlighting unacceptable behaviour, and in engaging with relevant external bodies by developing road rail partnership groups. In addition, Network Rail outlined technology improvements for level crossings being developed, such as obstacle detectors; wig-wag improvements with LEDs; and level crossing predictors which provide a constant warning time for road users irrespective of approaching train speed. It was considered that further elimination of level crossings could also be progressed and a challenge has been set by Network Rail for industry to develop an affordable modular bridge to aid this. 1.4 Irregular Working Risk Further efforts are also being made within the industry to address irregular working, defined as irregularities likely to affect the safe operation of trains, staff, passengers or the public. Key initiatives include challenging rules and procedures for robustness when such events occur; improved training and competency (including simulation); and improved safety critical communication monitoring. Operating within engineering possessions is of particular concern and the complexity of the current rules for taking possessions was noted as a possible cause. It was also pointed out that the number of road-rail vehicles operating in possessions in modern times was significant, and that train control technology, such as signalling and TPWS, is not used within possessions removing a vital control function. 1.5 Systems' design centred around the user The integration of engineering and operations into one group was discussed by Network Rail, in response to the need to take a more holistic view of the railway as a system, together with future systems' design being centred around the user. Attention has recently been focused on driver and signaller workload metrics to support system design balancing automation with manual tasks, and including ergonomics and human factors throughout the design and operating processes. This approach will increasingly be seen within signalling renewals where design objectives will include designing out operational risk and seeking input from train operators. 1.6 Addressing Precursor Events Several speakers referred to the need to be more reactive in reporting and investigating precursor events. Conventional wisdom points to a direct link between precursor events (e.g.

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Executive Summary

near misses) and actual incidents arising. Southern Railway presented their process for this, which was already achieving benefits in reduced operational incidents and improved staff relationships. Their reactive approach involves a robust root cause determination and common cause analysis, and devolves ownership to depot level enabling local action plans to be developed. Their proactive approach includes a care and support system for drivers and a fatigue management system linked to rosters. 1.7 The changing role of the industry Changes in the structure of the industry and its regulation were noted, including changing roles for HMRI in approvals, and the restructuring of RSSB's strategic safety direction and initiative groups to recognise the wider operational risks and a more focused national/local split. Delegates heard about the success of the OPSRAM groups, which had now been running for 12 months, and the benefits being seen from broadening the previous SPADRAM concept to address the wider operational risks. However, caution was expressed to make sure OPSRAMs remained focused on local operational risk issues rather than being steered by national issues. 1.8 General finding of RAIB - 8 months on Delegates also heard about the first 8 months of RAIB's existence and the general findings so far. As noted in other presentations, the main issue emerging from 45 RAIB investigations so far, identified level crossings as the most significant area. Three other emerging areas were staff struck by rail vehicles, SPADs and derailments. Significant findings were, recognising that the number of investigations to date did not form a statistical base: the failure to use the emergency brake; unplanned division of freight trains; bridge strikes; the mindset of accepting compliance with standards as sufficient and a lack of challenge to these; and a desire to reduce the duplication of investigations. 1.9 Industry Research RSSB outlined the aims of their research and development work, with particular reference to human performance research and consideration of human factors throughout all research. Research has been broadened to the wider operational risks and research outputs as usable `products' was a theme they were promoting. A number of strands were relevant to operational risk, including the Human Factors Good Practice Guide, the review of driver selection and compliance with safety critical rules. 1.10 Changes to Driver Management and potential risk of Franchise Change First Group (FGW) outlined their approach to separating driver line management from competence management, which in many ways was returning to the general British Rail position

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Executive Summary

some years ago. They had initially experimented with this and found the benefits worthwhile, citing the ability for managers to move away from the `jack of all trades' position to a more focused role amongst other benefits. The profile of train operator risk was also noted as being wider than the national picture outlined in other presentations, as specific train operator risks included incidents in depots and yards and train dispatch issues. It was also noted that precursor events and operational risk was seen to increase on the run up to and changeover of a Franchise, and the causes of this needed to be determined 2. Summary of key issues: a) There was some concern within the industry about broadening the focus of the Halcrow National SPAD Conference to the wider aspect of operational risk, however, this was the right decision to make and it is important for the industry to now focus its attention on addressing the wider aspect of operational risk which represents 83% of train accident risk. b) The significant commitment from all parties within the industry to address SPADs had delivered a tremendous success. Recorded SPAD numbers and SPAD risk have fallen to an all time low. SPAD risk has reduced to 87% compared with the 2001 baseline. However despite this improvement, the industry cannot afford to be complacent as residual SPAD risk remains and the consequences from a SPAD can still be very severe. c) Managing level crossing risk is one of the highest priorities as misuse/abuse by the road user accounts for 46% of all railway operational risk, and has remained constant in real terms over the past 5 years. d) Focus is also being directed at the operational risk generated in irregular working, including in possessions, which accounts for another 29% of all railway operational risk, this figure increasing by 50% over the past 5 years. e) Some technology based changes are happening to reduce operational risk, such as the rollout of GSM-R communications and the upgrade of GPL and main line signals with LED technology. Equipment to detect obstacles on level crossings will be trialled and consideration is being given to the use of GSM-R communication in possessions. f) Train operators are subject to other operational risks, including in depots and yards off Network Rail controlled infrastructure and during train dispatch at stations. Further, evidence suggests that Franchise changes can lead to increases in operational risks for which the industry needs an understanding of the reasons. g) TPWS has played a key role in delivering the reduction in SPAD risk and must now be looked on as a longer term control measure than originally envisaged. Further installations

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Executive Summary

are being considered, attention to fitments at PSRs and buffer stops is in hand and reliability is being grown. However, the `reset and continue' issue is of significant concern. h) The industry needs to be aware of a possible cultural change where drivers over-rely on train protection systems such as TPWS to control risk. i) To drive down SPAD risk further the industry must continue to manage human factors, training and competence, safety critical communication and safety management, as no significant technical solutions are on the immediate horizon. j) The concept of OPSRAM has been successful, it is important to further enhance the process with continued co-operation by all parties, by focusing on key risk areas and more sharing of good practice between OPSRAM Groups. k) The National Initiatives Groups are being restructured and the new arrangements are designed to address the wider aspect of operational risk. l) Operation in possessions is over-complex and has grown from 100+ years of reactive rules application. 3. Key issues requiring consideration: The following provides a summary of key issues where it would be beneficial for companies to consider as part of their SPAD and operational risk strategies. It is acknowledged that existing work streams and company initiatives may already be adequately addressing these. However, industry working groups and individual companies are encouraged to review the list to identify outstanding issues, to share examples of good practice and to determine if further industry support is required and how best to communicate progress in addressing these points. a) The Train Operating Companies and Network Rail should ensure that its focus on risk encompasses all elements of Operational Risk whilst continuing to direct proportionate resources to the management of SPADs. b) Train Operating Companies should exploit the full potential within SMIS and the Safety Risk Model to gain an individual company baseline for Operational Risk and the precursors, this should form the basis of any specific company or joint initiatives. c) To move forward to a philosophy of protecting trains and customers from operational risk at level crossings, it is important for Train Operators and Network Rail, through drivers, signallers and other operational / track personnel, to improve the reporting of persons who violate the rail infrastructure such as the misuse of level crossings. This includes improving procedures for reporting, investigation, analysis and response to precursors such as near misses, particularly at level crossings.

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Executive Summary

d) Train Operators should evaluate the benefits of providing `front-end' cameras on trains as these would pay dividends in enabling the proper investigation of accidents and gaining a better understanding of incident black spots. This may best be taken forward as a national project or research. e) Network Rail and Train Operators should continue to work together to further raise public awareness of risk associated with level crossings, including strategies to eliminate risk such as reducing the number of level crossings. f) In addition to reducing the overall risk profile, train operators need to review their company specific risk profile and implement suitable controls ­ for example depot risk, train dispatch, station overruns etc. g) Taking into account the long life expectancy of TPWS as a train protection system, it is important for train operators to improve the design and function of the TPWS cab display equipment to reduce the potential of further TPWS reset and continue incidents. In the meantime, briefing of drivers should continue on this issue. h) The industry should continue, through OPSRAM, to identify locations where fitment of TPWS may reduce SPAD risk further, and continue to improve reliability of the system. i) Train operators should continue to take steps to understand and mitigate the potential for operational risks to increase during Franchise changes. j) Network Rail should take the lead in ensuring that OPSRAM share initiatives and good practices between each other and seek to improve contribution of all participating parties - a joint approach is essential. k) Companies should provide feedback to RSSB as to whether the emphasis on research `products' is correct and where RSSB should be concentrating their research efforts. l) The industry should actively challenge rules and procedures following incidents rather than just accept compliance as the answer.

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Welcome and Introduction

by Charles Horton

Conference Chairman

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Welcome and Introduction

By Charles Horton ­ Conference Chairman

Charles introduced himself as Chairman of the 10th National SPAD Conference, being run by Halcrow on behalf of the National SPAD Focus Group (NSFG), and Managing Director of Southeastern Railway. He reminded delegates that the annual SPAD Conference had been set up in 1997 by Halcrow, through concern that the industry might lose its' focus on managing SPADs. It has been successful in doing just that, providing delegates an opportunity to share good practice and acting as a catalyst for decisions on what changes to make in their own companies. Charles felt passionately that there was truth in the saying that if everyone took away and implemented just one idea emerging from the speakers, the exhibitions or the discussions, then the conference would be a great success. He noted that guest speakers would be identifying the success we have had as an industry in managing SPAD risk and cited this as proof that these conferences, and the supporting workshops, had played a key role in retaining, and even enhancing, the industry's focus on SPADs. That said, Charles reminded delegates that SPADs still have the potential for tragedy and recounted a very serious low adhesion related SPAD on Southern Railway last Autumn which, but for the professionalism of the drivers concerned, would have resulted in a major collision. For him, this was a stark reminder that however well we have done so far we must continue to address and drive down SPAD risk, from both a legal and moral duty. Charles explained the changes to this year's Conference, which had been made as a result of feedback from last year. Firstly the location had been changed to provide a larger venue to enable more displays from suppliers and train companies, secondly the content had been broadened to include the wider railway operational risk issues as well as SPADs, and lastly more time had been given to open forum sessions. He welcomed the guest speakers, themselves key players in the industry, to the event who he knew would make a very valuable contribution to the discussion. He was also pleased to welcome delegates from train operators, Network Rail, infrastructure companies, as well as from HMRI; RSSB and RAIB. This was an excellent opportunity for such important bodies to discuss these issues with senior managers and to take back initiatives and good practice and apply these in our own companies to reduce operational risk. The objectives of the day were: · To improve understanding of rail operation risk and SPAD risk in the context of the overall risk profile · To enable the sharing and understanding of good practice to enable companies to identify measures to improve their own risk profile.

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Keynote Address

by Linda Williams

Chief Inspector of Railways Office of the Rail Regulation

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Keynote Address

By Linda Williams, Chief Inspector of Railways, ORR

Linda opened her keynote address by outlining the challenges facing the railway in operational risk terms, first and foremost the need to avoid becoming complacent in the light of recent successes in SPAD management, seeing an 87% reduction in risk compared to 2001. She noted that SPADs still have catastrophic risk potential and we should not be moving to a position of relying on the Train Protection & Warning System (TPWS). There is a need to refocus our efforts on risk management and share good practice. She also noted that there are no new technology leaps imminent and hence we should be nibbling away at the detail to get things right. Linda felt the industry needs to increase its effort in taking a co-ordinated approach to risk management. This would become even more important when legislative changes removed HMRI's approval role, with responsibility for ensuring safe design of new and changed equipment resting with the industry and its safety management systems. Management of the interfaces was essential and this was an area that HMRI would be looking at in particular. Human factors analysis was another significant opportunity for the industry, the more we know about human behaviour and why people do what they do then the better our ability to prevent errors and violations. Along with this, Linda felt employee health was also an important factor, not only from a safety perspective but also from an efficiency perspective. This was another area that HMRI would be looking closely at. Another challenge facing the industry was delivering value for money against the ORR's long term strategy for the railway, which will state what is expected, and the HLOS (High Level Output Statements - the railway services that the government wants). Linda had no doubt that these would require a continual improvement in health and safety, which would mirror requirements of European health & safety legislation. She also felt that public perceptions about railway safety would be a continual challenge for the railway but the reality was rail transport was one of the safest forms of transport. Level crossing safety and irregular working are it's the industry's greatest risks. To illustrate this, Linda showed the trends in various risk categories (shown overleaf).

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Keynote Address

TPWS was a success story in Linda's view, the Railway Safety Regulations 1999 had achieved what they set out to and, no doubt, TPWS had prevented some serious accidents. However, Linda recognised the `reset and continue' post-SPAD issue as a significant area of concern. Professional driving was also an area she felt well worthwhile. Turning to what ORR are doing, Linda identified that work on human factors is progressing in conjunction with industry, and they had recently published `managing fatigue' guidelines. A strategy for railway operational incident risk was being developed and guidance on what So Far As Is Reasonably Practical (SFAIRP) means will be provided, and ORR's enforcement policy will be reviewed. Looking to the future, Linda suggested we have to make the best use of what we've got, particularly TPWS which was now likely to be a much longer term system than planned now that ERTMS is many years further away than originally expected. ORR did not see any significant national engineering solutions approaching but considered that small, local engineering solutions might be a solution in some cases. What was now needed was a proportionate, risk-based approach, the fostering of an effective safety culture through commitment from the top, demonstration of leadership, competence, cooperation, communication and effective control. Linda concluded by re-stating the need for the industry as a whole to avoid complacency, seek cost-effective areas for improvement and continue to work together.

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Operational Safety Performance and the Changing Risk Profile

By

Wallace Weatherill Head of Operations Principles & Standards Network Rail

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Operational Safety Performance & the Changing Risk Profile

By Wallace Weatherill ­ Head of Operations Principles & Standards, Network Rail

Wallace opened his presentation by depicting the current operational risk profile. He noted that the profile had changed over recent years since the focus on SPAD management and the introduction of TPWS. Wallace noted that operational risk accounts for 83% of all train accident risk. The chart, shown right, illustrated the sources of current operational risk, and clearly showed that `level crossing' risk and `irregular working' risk, account for the lion's share of overall operational risk, and SPAD risk had been driven down to just 4%. This clearly justified the wider focus now being taken on managing operational risk, yet maintaining the drive to reduce SPADs. Further, Wallace pointed out that, whilst SPAD risk had reduced by a factor of 10 over the past 5 years, level crossing risk had remained constant and irregular working risk had increased by 50%. Looking firstly at level crossing risk, Wallace noted the public perceptions from the high profile accident at Ufton Nervet and the death of two young girls at Elsenham station in 2005, had highlighted the risk. However, from the railway's perspective, level crossing risk was 96% due to abuse and misuse by the public and hence the key risk control factors were with external parties. Key initiatives to address this include powers within the Road Safety Bill that will permit the Secretary of State to mandate requirements on Highway Authorities, for example the ability to put up red light infringement cameras; Road Rail Partnerships are being set up to allow railway people to discuss rail issues with road planners; and OPSRAM groups will include level crossing safety within their remit. Wallace also commended the national level crossing safety campaign, which includes powerful advertising on television and in other media, and is aimed at influencing road user behaviour. This was being backed up by visits to non-railway events to get the message across. Wallace encouraged train companies to help with this issue by increasing their vigilance and reporting of incidents of misuse and abuse. Turning to irregular working, Wallace first defined what that meant and gave examples of the sorts of issues, including infringements of isolations, possessions, rules

National Operational Risk Conference 2006

Level crossing misuse (incl. near miss) 46% Irregular working 29%

2005 Proportion of train accident by precursor group (from PIM)

SPAD 4% Objects on the line 4%

Trains & rolling stock 5%

Infrastructure failures 12%

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Operational Safety Performance & the Changing Risk Profile

and instructions etc. He showed some pictures illustrating the results, including derailed vehicles, collisions and obstructions on the line. He stated that, unlike level crossing risk, irregular working was completely within the railway's control. Key initiatives in addressing irregular working risk include changing the structure of the RSSB initiative groups to address operational risk; improving SMIS to permit a proper categorisation of operational risk; challenge to rules and instructions which have been in existing for many years and don't necessarily reflect the modern railway; developing a culture of intolerance to poor operating practices; improved training and competence management including using simulators; and a general improvement in safety critical communications. That said, Wallace was clear that SPAD risk has not gone away and cited cases where TPWS provides no protection, for example at plain line signals, shunting signals, during engineering work and degraded operations. He stated that despite a much reduced scope for signal specific mitigation due to TPWS' effectiveness, Network Rail still applies rugged processes to determine if further work or equipment can be justified. Key initiatives to address this further included a review of the case for TPWS at platform signals where speeds were 20mph or less, a review of the fitment of TPWS at plain line signals by OPSRAM groups, and review of route knowledge DVDs in Scotland Route. Wallace identified the key issues going forward as whether we have minimised the likelihood of a SPAD occurring by our driver training and competence assessment systems, our professional driving policies and MSS briefings. He questioned whether we have locked in the many lessons learnt since 1999. He concluded with some key messages: · · · 83% of train accident risk comes from operating the railway; Level crossings and irregular working are the key areas that need addressing; Have we done enough as an industry? As individual companies? As individuals?

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National OPSRAM Implementation One Year On

By Dyan Crowther

Route Director, LNE Network Rail

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National OPSRAM Implementation ­ One Year on

By Dyan Crowther ­ Route Director LNE, Network Rail

Dyan opened her presentation by outlining the role and purpose of OPSRAM Groups. She highlighted that OPSRAMs were not about historical rule book changes, they are not `town hall' meetings, knitting circles or bun fights, and are not boring or long winded. What they are about is a means for managing operational safety risk, jointly on the railway. They are an opportunity to share good practice and have an ability to identify, solve, predict and prevent risk by looking forward. Finally, they are positive, dynamic and collaborative. In essence the OPSRAM should be a high performing team ­ of all players in the industry. However, she expressed concern that many senior managers still did not know what OPSRAM was for and how it worked, so her presentation today was partly to address that concern. To find out whether the OPSRAM was working one year on, a survey was conducted using a simple questionnaire, with 7 questions, eliciting 26 responses from OPSRAM members. The responses overwhelmingly concluded that attendees benefited from the meetings; ideas had been taken away from the groups and implemented; and the focus on operational risk and SPADs had been improved and widened through OPSRAM. Some of the benefits stated by respondents included: "much better now... allows more topics to be covered and genuine actions to be delivered" and "a noticeable improvement in the speed at which issues are resolved." The top 3 areas of good practice taken away from the OPSRAM meetings were cited as · · · good practice in SPAD management including human factors, return from annual leave and seasonal briefing a direct link to the communications review group generic route risk assessment

Regarding SPAD management, Dyan noted that a lot of examples of good practice were available, including the summer SPAD risk magazine, mid-platform signal risk DVD and an initiative by WAGN to send drivers a postcard on their return from leave to remind them of the risks of SPADs. On the subject of communications, Dyan advised that this is a standing agenda item, and the Communications Review Group (CRG) would migrate to be a national group in September 2006, aligned with the SAF 6 programme. Also, communications' monitoring will be

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National OPSRAM Implementation ­ One Year on

standardised providing a national benchmark over time. The output will be league tables by Routes, Operator specific results (TOCs, FOCs and OTM operators) and signal box specific results (both before and after SAF 6). The third area was the introduction of generic route risk assessments. Feedback at OPSRAM had identified the difficulties for train operators and OTM operators in addressing the sheer volume of routes, as well as the unnecessary multiplication of effort. The method will allow a joint understanding of all route risks, it will be owned by OPSRAM and as well as identifying hazards, will suggest mitigation measures. Only one version will be produced. Dyan then referred to other areas of good practice mentioned in the survey response including investigation techniques, driver training, competence assessment, human factors studies and `Baissez Panto' operations. Dyan also quoted respondents view's as to why it's important to have an OPSRAM. They considered its about risk reduction in the industry and doing that in one co-ordinated way, educating people and carrying on in a mature and professional manner, solving problems and helping reduce costs as well. With respect to the future, the survey

What do you believe should be the priority areas for OPSRAM

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respondents identified their priorities on a scale from 1 to 10 as shown on the adjacent chart. Possession irregularity, SPADs and perturbed working came out as the top 3.

Peturbed Risks

Standards Review

External Factors

Training

Possession Irregularity

Human Factors

how OPSRAM could be improved and answers included more attendance from Network Rail's

senior managers and less from `bag carriers'; increased sharing of good practice between TOCs and FOCs and between OPSRAM Groups; smaller group sizes; more looking forward; include suppliers such as renewals contractors and celebrate achievements. In concluding, Dyan made the point we must maintain focus and move forward with joint contributions, use data wisely to focus on key risks and we will achieve joint success. In summary, Dyan noted that it has been the right thing to do to broaden the scope of SPADRAM to OPSRAM. She said the priority items must now be set by you, the operators and Network Rail, and we must share more as it's a big opportunity for us all.

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LX Risk

Station Risk

SPaD

AFR

The final area of questioning wanted to know

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The Rail Accident Investigation Branch - Eight Months On

by Andy Savage

Deputy Chief Inspector Rail Accident Investigation Branch

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RAIB Eight Months On

By Andy Savage ­ Deputy Chief Inspector, RAIB

Andy opened his presentation by explaining the role of RAIB, reporting to the Secretary of State for Transport, as the independent rail accident investigation organisation, with the objective of improving safety on the railway but not apportioning blame or undertaking enforcement. RAIB sit alongside the long established air and marine equivalents, and take the lead at accident investigations where evidence supports there being no criminal action as the cause. It was a new organisation set up in 2003 with a permanent team now in place. To date, RAIB had investigated 45 incidents and accidents out of 55 mobilisations. The biggest category of investigations (10) were passenger train derailments, half of which were not on NRCI. Other main categories of investigations were with freight train derailments (8), collisions (4) and train door incidents (2) all seeing mainly minor injuries. However, they had investigated serious accidents on level crossings (8) which had led to 5 fatalities and 2 serious injuries. 2 incidents of staff coming into contact with rail vehicles, one leading to a fatality, were investigated and 3 runway vehicles. In the main, these involved passenger and freight train operators on NRCI, but a few involved tram lines, heritage railways, London Underground and Northern Ireland Railways. In terms of reports and recommendations, Andy advised that RAIB had now published 6 reports (3 light rail systems and 3 on main lines). A further 8 reports had completed consultation, with 2 under consultation and a further 4 ready to go for consultation. Recommendations had been made to main line TOCs regarding operations, to Network Rail, to light rail operators and to light rail infrastructure controllers. The areas covered by recommendations to the heavy rail side of the industry included wheel slip, Traincrew fatigue, wagon maintenance, yard operations, wicket gates at level crossings, and management of track gauge in tunnels. Looking at risk categories, Andy first of all warned that 45 investigations does not constitute a statistical base, and RAIB's view was the RSSB SRM was the best tool available for this. However, there were patterns emerging with the top risk areas as measured by fatalities level crossing risk, staff struck by trains, SPADs and SPASs, and derailments. Level crossings were RAIB's biggest single category of work and risk, with one train driver fatality at the Rhomney, Hythe and Dymchurch Railway during shadow running, and 5 public fatalities and 2 amputations investigated since October 2005. He stated that these were personal tragedies for all involved. Two particular areas being looked at are wicket gates and conspicuity of miniature red/green warning lights.

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RAIB Eight Months On

Turning to staff struck by trains, Andy advised that this was usually a binary event; if you come into contact with a train it's fatal, stay out of its way and you survive. There had been one staff fatality investigated since RAIB went live, but there were 2 contractor and one staff fatality whilst RAIB were in shadow running. Also, in both shadow running and since going live, there have been a number of very near misses in this category. He added that the rules appear appropriate but are not always complied with. This is as a Traincrew issue as well as one for infrastructure staff. On the SPAD/SPAS side, RAIB were soon to publish findings and recommendations following low adhesion related SPADs in November 2005. There had been several SPADs resulting in derailments, which was leading RAIB to think about whether we should be considering the use of TPWS instead of catch points to reduce the risk of damage and injury. On light rail operations, investigations had led to concerns over the conspicuity of signals, the lack of SPAS indicators at some places, and how drivers use their hazard lights and whether there is a case for overlaps on some signals. Andy also noted the SPAD issues with London Underground which was very well protected, as a fully fitted train stop railway with sufficient safety overlap for line speed, but suffers the largest number of SPADs of any operator, indeed more than all the SPADs in the rest of the industry Looking at derailments, Andy identified that 6 had been rolling stock related, 2 with passenger trains in tunnels, 5 due to track defects, 3 due to bank slips and 1 due to operational error. Andy offered some thoughts on operational risk as a result of the outcome of RAIB's first 8 months. Several times incidents had been noted without the driver using the emergency brake. It had not so far made a material difference so far but RAIB were concerned at why this was so frequent. The unplanned division of freight trains had been a more or less a weekly event and RAIB had looked into this with EWS which had however, been able to demonstrate a continuing improvement in this trend over some years. RAIB also noted the increasing number of bridge strikes, albeit with little consequence so far, and had discussed this with Network Rail as the consequence could be catastrophic. RAIB were also concerned about a general mindset that provided things comply with minimum standards then that's alright. However, we must be prepared to exceed the minimum and challenge standards in managing risk. Finally, Andy said that RAIB wanted to work with the industry to reduce the duplicated effort in investigations. He stated that they were working with RSSB, Network Rail and ATOC on this, but noted that RAIB would need access to the findings as soon as possible if they were to rely on industry investigations.

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Managing Precursors

by Chris Burchell

Managing Director Southern Railway

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Managing Precursors

By Chris Burchell ­ Managing Director, Southern Railway

Chris opened his presentation by stating his personal conviction that addressing precursor events will lead to a reduction of risk. He defined the term `precursor' as something that precedes or indicates something to come, and explained why in his view we needed to take note of precursors, referring to a wide range of views in academia about the ratio of `near misses' to actual events. What all of this had shown is that there is a direct relationship between the causes of near misses and the causes of accidents, so addressing the near misses will reduce accidents. This was known as `common cause hypothesis'. Further, work had been completed to look at 21 railway specific accident causes which had concluded that 18 of these causes shared similar consequences, meaning that errors made leading to near misses and minor injuries will be the same causes that lead to SPADs and the like. Hence if we can identify the cause of the minor errors then we can help prevent the major incidents and accidents occurring. Chris explained that Southern took a two-pronged approach to this, a `reactive approach' and a `proactive approach'. The objective of the reactive approach was to understand better the causes and trends of minor incidents that may act as precursors. The method employed is to start with a robust, but appropriate, investigation of all near misses and minor incidents leading to a root cause coding, balancing speed, efficiency and quality. A common factors analysis is then conducted where there is a trend that shows a need. Chris continued by explaining the philosophy of ownership of the data and the actions, which Southern believed should be devolved to those who own it, i.e. at depot level. This gets local managers to focus on the detail and is easier to communicate to those affected by it. The local teams can then identify specific and targeted actions appropriate to their part of the business. One of the benefits of this approach was to allow senior managers to see the performance across the business and create

0.12 0.10

Selhurst Depot - Events per Driver (normalised)

company plans from the individual plans. Chris showed an example of normalised operational risk

0.08 0.06 0.04 0.02

performance at one driver depot, each being monitored on a monthly basis.

0.00

P1 P3 P5 P7 P9 3 P2 P4 1 P6 P8 0 2 P1 P1 P1 P1 06 P1 /0 7

He also displayed an analysis sheet for TPWS incidents at red signals which they found helpful to identify trends either by driver, train or infrastructure. The outcome of this had shown TPWS activations at below the declared set speed and locations where repetitive problems were

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Managing Precursors

occurring such as at Barnham. The approach had also shown Crystal Palace as the top location where wrong routes are most likely to be offered and taken. Finally, the process had shown distraction as an issue and Human Engineering had been engaged to help provide drivers with an understanding of why they can get distracted. One further benefit seen was a more consistent approach to investigations. Overall, the approach had led to a better understanding of common factors, depots and individuals, and had led to better action plans. Turning to their proactive approach, Chris remarked that this was a bit like crystal ball gazing, and the objective is to identify the circumstances which may assist an individual to make uncharacteristic errors that may be a precursor. The main methods were a care and support system for drivers and fatigue management in safety critical work rosters. The care and support system allows traincrew to come forward to their manager in strict confidence, to discuss the issue and develop an action plan. Chris stressed the confidential nature of this which, despite being on the CASS register, the detail resides only between the local manager and the individual and is not disclosed to anyone else. There is a wide range of actions available to managers. This is not a Specially Monitored Driver system, its separate in order to encourage drivers to come forward without being given points on an SMD system. Their fatigue management system requires all rosters to be assessed for fatigue and this is done in conjunction with Union colleagues. This encourages good debate for both current diagrams and future timetable changes being planned. Chris emphasised the benefits of both approaches in both preventing incidents occurring and improving management/staff relationships. It has also improved people's understanding of the Safety Management System and why we must have one. Incidences of fatigue had dropped dramatically as well. Southern had also introduced an operations safety group, a cross section of the operations spectrum including Network Rail, which was sub-ordinate to OPSRAM. The actions identified are put together to create an annual SPAD and operational risk management plan. Southern also work closely with South West Trains and Southeastern as they have some similar issues such as new rolling stock, third rail operation and many new drivers. Chris concluded with a chart showing Southern's improving trend in reducing operational risk which he attributed a large slice to their precursor management programme.

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Engineering Reduced Operational Risk

by Andrew McNaughton

Chief Engineer Network Rail

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Engineering Reduced Operational Risk

By Andrew McNaughton ­ Chief Engineer, Network Rail

Andrew opened his presentation with a brief overview of current post-TPWS engineering initiatives ongoing to address operational risk, including the roll-out of GSM-R train radio, which will improve communications between signallers and driver; the upgrade of GPL signals with LED units and the introduction of LED main running signals, improving visibility and reliability. He then extolled the fact that the railway is a system and hence engineering and operations go hand-in-hand and should not be separate entities. The railway is an engineering beast run by operators. To this end, he announced that Network Rail has just taken the step to bring operations principles and standards together with engineering under one leadership. He reminded delegates that the complex railway is operated and maintained by humans. Andrew then looked to the future and noted that today's railway has to change to match the expectations and rising demand from the public. It has to be an `on time' railway, operating 7day per week, with a low maintenance demand, lower energy demand and at a lower cost. He also noted that the real cost of skilled workforce is increasing as demand rises and supply falls. Movement principles will also need to change to optimise train running. Andrew considered there were only really 3 states for the railway in the future: trains running with a working control system; trains running with a degraded control system and trains not running with the infrastructure being maintained. He believed we need to rethink each of these if we are to remain competitive and grow the railway. What was clear to Andrew was that if we are to achieve this then the design must be centred around the user. The science of ergonomics, whether hard physical design in the work place, information handling, human psychology and behaviour or general human factors, must be understood to enable designers to address this at the design stage. There needs to be a balance between automation of repetitive tasks and manual control of out of course and unusual events. Andrew showed an example of poor design from the users perspective in information handling. Andrew advised that Network Rail are currently gathering the workload metrics for signallers such that future design can be centred around these. They have also worked with train operators to determine how much information drivers can absorb.

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Engineering Reduced Operational Risk

Looking at collision risk, Andrew remarked that TPWS has been installed and tweaked with TPWS+, TPWS-, and will be further tweaked at PSRs and buffer stops. He noted that reliability is improving and the maxim of gradual improvement through attention to detail was key. However, he noted risks still exist and complacency must be avoided. TPWS has also changed the case for ATP as much of the available safety benefits have be claimed. In the future, ERTMS brings in-cab signalling, an opportunity to reduce maintenance costs by removing lineside equipment and increasing capacity by allowing trains to run closer together. He was keen that this should not be seen as just another signalling system as it was a fundamental change to the operating concept with information presented in the cab and not at the lineside. Andrew noted that the business case for ERTMS is a challenge due to retrofit costs and hence it is being aligned to renewal schemes which will be spread over decades. However, the roll-out of GSM-R has started which will provide the foundation of the communications between train and control. The trial on Cambrian Lines will allow us to determine how the railway will operate under an ERTMS regime. Turning to level crossing risk, Andrew identified that Network Rail wanted to address this risk quickly. He noted that the best risk reduction method was to eliminate the crossing and Network Rail would be working hard to do this. He had challenged his engineers to develop a low cost modular road bridge. Improvement to wig-wags were being undertaken with LEDs and new level crossing predictor technology was to be introduced which would detect the speed of approaching trains and allow a constant warning time to be given to road users, reducing frustration and abuse of the crossings. Network Rail will also trial obstacle detectors, in use in Japan amongst other countries. Network Rail's signalling renewals programme over the next 40 years is soon to be signed off by the Regulator, based on route based renewals providing the best operational advantage. Route strategy planning groups have been set up to ensure the train operators' needs are considered and there are great opportunities to design out risk. Finally, on possession management, Andrew felt the current arrangements are over-complex having grown up over 100+years. It now takes too long to obtain a possession and we remove vital technical safeguards in so doing. There were just 16 road-rail vehicles in use in 1994 compared to just over 1000 currently, bringing operators with little or no experience in rail operation to the railway. He felt it was time to radically re-think possession management.

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RSSB's Research & Development Programme

by Andrew Sharpe

Head of Research & Development Rail Safety & Standards Board

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RSSB's Research & Development Programme

By Andrew Sharpe ­ Head of Research & Development, RSSB

Andrew opened his presentation by explaining the background to the R&D programme which had been born to resurrect industry research following privatisation. The objective of the programme is to address research that will improve not only safety but also capacity and availability, reducing costs and improving overall performance. He outlined the range of research and development, picking out that which delivers good practice and promulgating it. On the subject of human factors, Andrew identified that there is no longer a separate activity called `human factors' as the topic, human performance, is addressed in all strands of research and development. However, there is now an increasing focus on delivering products that builds on research. He noted that research has had a major contribution to SPAD risk reduction in the past, but has more recently been broadened to the wider operational risk areas. Andrew then gave some examples of where research is helping to improve human performance. The first of these was the HF Good Practice Guide which had spawned from many individuals and companies asking questions like "why do people break rules?", "why do people make mistakes?". The second example was a review of driver selection, citing a request from train operators for an independent review of the current process. The research showed that some selection methods are much better predictors than others, and this is continuing to be developed within an industry working group. The third example quoted was research into compliance with safety critical rules, i.e. why do people break the rules and can anything be done about it? Some early research on the first part was done and it showed that it was more extensive than thought and under-reported. From this a paper-based guide was produced which led to the follow on interactive product on CD ROM. This tool helps the user work out why the rule was broken with separate layers of issues being guided through. The tool can also be used as a proactive tool, and has a set of solutions. Looking at future research, Andrew identified that there is a research life-cycle that needed to be followed, translating research into products, training materials, tools and advice. Making use of research was key, as examples such as DRA have shown. In reviewing research, the question "why do drivers lose concentration?" had not be answered directly and this was an area now being looked at, as well as development of ways to improve driver's situational awareness Andrew concluded that research would provide simple and practical outputs in support of existing initiatives, the key audience being drivers and their managers. He was also keen to know whether the focus on `products' was right and where they should be directing the effort.

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Managing Risk A Train Operator's Perspective

by Keith Harding

Head of Operational Support First Capital Connect

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Managing Risk ­ A Train Operator's Perspective

By Keith Harding ­ Head of Operations Support, First Capital Connect

Keith opened his presentation with an overview of an initiative put in place at First Great Western Link, whereby the responsibility for line management of drivers was separated from competence management. In essence, he said, this put back the clock to how it used to be, but it differed in a number of ways because it was people orientated, had single accountability at one level, developed relationships between managers and drivers but made sure drivers knew who was in charge. Competence management was now a specialist role independent of the line role, lowered `fraternal risk', enabled a larger resource allocation of about 1 to 40 compared to 1 to 25 and, importantly, was not `office bound'. Looking at the benefits for line management, Keith cited the avoidance of the `jack of all trades' situation and the ability to develop managers to be more focused in the necessary key skills. It had shown a considerable improvement in non-competence driver performance and improved relations at local level. It also aided bringing out underlying issues and put people first. There were also financial benefits arising, as the level of delay minutes had dropped due to local ownership and liaison with drivers. A closer link had been established with the finance department to enable better budget control. Also sickness management had improved through a closer relationship with Human Resources and doctors. Similar benefits had been achieved for the competence management personnel, but in addition it was possible to make better use of company wide resource usage, although lately this had returned to local resources, and helped move driver development onwards. However, Keith explained that there were some potential downsides in this approach, citing a risk of `silo mentality', `fiefdoms' can be created unless led by professional team, flexibility can be lost if the split is taken too far, and finally, there is a risk of the parties not talking to each other to share information. Keith then moved on to discuss the TOC changing risk profile. He recognised the need to work together with Network Rail to reduce the overall risk profile, but noted that TOCs had some specific risks such as derailment and collision risk in yards and depots, platform/train interface risk including train dispatch, station overruns and `failed to call' incidents, and TPWS activations. Human factors was still the primary issue in this. Keith concluded by outlining the risks in Franchise changes as experienced recently with the First Capital Connect change. Precursor events and SPADs increased on the run up to and during the change, and he believed work was needed to understand the underlying reasons.

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Discussion

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Discussion

Session 1

Due to problems with the sound recording system at the Conference, not all questions and answers were recorded and hence the following is not a complete record of the event. Session 1 The following discussion took place following the Introduction, Keynote Address and presentations by Wallace Weatherill and Dyan Crowther. Panel Members: Charles Horton, Conference Chairman Linda Williams, Chief Inspector of Railways, HMRI Wallace Weatherill, Head of Operations Principles & Standards, Network Rail Dyan Crowther, Route Director LNE, Network Rail Aidan Nelson, Director Policy & Strategic Initiatives, RSSB Steve Bence, Director Production Support, ATOC Kevin Kearney (Carillion Rail) queried whether risk was factored into the re-distribution of infrastructure renewals work around the network in April this year? Dyan Crowther (Network Rail) responded believing that the procurement process in Network Rail and the contractor's bidding processes should consider this. She recognised that one of these risks was OTM driver route knowledge and this had been identified by one contractor on LNE OPSRAM. Wallace Weatherill (Network Rail) added that there are always potential risks when contracts change and these are assessed and managed. The example quoted in the question was no different, in his opinion, to the risks existing with a Franchise change which must also be managed. Chris Gibb (Virgin Cross Country) referred to the picture of a large animal on the line shown in one presentation and reminded delegates of the dangers to rail operations these pose. He noted that a new fencing standard was soon to be issued by Network Rail, which he commended, but was concerned at the length of time it would take to bring existing fencing up to that standard.

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Discussion

Wallace Weatherill (Network Rail) responded accepting that it would take time to renew fencing as part of the natural cycle of renewal. However, he stated that the standard does require the identification and priority action at high risk `hot spots'. Mike Sadler (EWS) asked how the industry structure would now manage national operational risk initiatives? Wallace Weatherill (Network Rail) responded by stating that industry needs a steer on this subject. The national initiatives regime is being restructured to focus at a strategic level what the railway needs to do to meet its objectives, and topic groups below that get on with the work, such as has been done by SCCFG and NSFG. But he felt there was still an important link missing between the OPSRAM Groups and the strategic level issues. That said he recognised the need to balance this with the local needs of OPSRAM. Charles Horton (Conference Chairman) undertook a straw poll to determine, of those delegates who attend OPSRAM Groups, how many felt a national lead was needed or more local control and leadership was needed. The overwhelming view was that OPSRAM Groups should be left under local control, leadership and steer. Dyan Crowther (Network Rail) added that LNE OPSRAM took a decision to follow key risks applicable to their route rather than national issues which they felt was the best direction. This had been critical in ensuring that the team felt engaged and could see benefits as it would materially affect their operations and not just address national issues. Aidan Nelson (RSSB) also responded by explaining what RSSB were doing with their structure and how that affected the industry strategic safety issues. He noted that specific issues around local problems were best managed locally, but what the local teams need is a source of good practice to apply to these problems. RSSB were soon to consult industry on a new structure which proposes to set direction at strategic cross-industry level, supported at national level by task focused groups addressing different aspects of operational safety. These would also take on the national level issues around occupational health and safety which are not best left to individual duty holders. RSSB are also looking with Network Rail to transition some elements like Track Safety Strategy Group to Network Rail. He added that NSFG would probably be concluded this year. A steer is also needed on the structure of company and national safety plans, with an aim this year for qualitative objectives followed in the next year by quantified objectives. OPSRAM would be critical in delivering much of this. Steve Bence (ATOC) asked whether delegates thought the industry was doing enough to address the TPWS `reset and continue' SPAD issue as it was a subject that still concerned him greatly?

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Discussion

Charles Horton (Conference Chairman) recounted his time in London Underground and noted a similar issue in LUL in the 1950s, as reported in the book `Red for Danger', where the reset of trip cocks and continue by the driver led to a rear end collision and a number of fatalities. Wallace Weatherill (Network Rail) added that the industry was addressing the issues around unnecessary buffer stop and PSR interventions, and HMRI were soon to consult on an industry Exemption request to remove fitments at a number of PSRs. He felt that this would contribute to reducing the risks but would not address the trainborne equipment human interface issues being reviewed by RSSB on behalf of the industry. He also praised TOCs/FOCs for the excellent briefing process on this which led to a long period of no reset and continue events, but unfortunately, two further events have occurred over recent months. Aidan Nelson (RSSB) added further that TPWS is now being looked on as a much longer term control measure than originally planned and hence, whilst the case may not be positive in pure value per fatality terms, the expenditure required to modify the cab equipment is a relatively small proportion of the total cost of TPWS so far. He also said that we need to understand why there has been a 13 month gap with no events followed by two events in close succession. Aidan also noted that the briefing campaign Wallace had referred to was many months ago and we have not carried that on over in recent times and questioned whether this should be a continual briefing and assessment item. Steve Bence (ATOC) agreed with Aidan that we must make good use of the information we have to brief drivers.

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Discussion

Session 2

The following discussion took place after presentations by Andy Savage and Chris Burchell. Panel Members: Charles Horton, Conference Chairman Andy Savage, Deputy Chief Inspector, RAIB Chris Burchell, Managing Director, Southern Railway Steve Bence, Director Production Support, ATOC Aidan Nelson, Director Policy & Strategic Initiatives, RSSB John Bendon, Chairman of Driver Management Liaison Group Patrick Hallgate, Route Director Sussex, Network Rail Wallace Weatherill, Head of Operations Principles & Standards, Network Rail Chris Walters (Network Rail) enquired what work went into the driver management side to ensure consistent delivery of the precursor management initiatives in Southern? Chris Burchell (Southern Railway) responded by recognising the importance of that aspect, and advised that consistency amongst the skills of the driver management team differed. So Southern decided to take staged approaches, one was a re-organisation at all levels and the other was an 18 month period of development training for driver managers, addressing core skills and broader management skills. This is regularly reviewed with the managers and has shown significant improvements in all skill bases. Stephen Poole (HMRI) referred to the fatigue management approach and queried whether we should be measuring fatigue against actual hours worked rather than just rostered hours? Chris Burchell (Southern Railway) replied in the affirmative recognising the rostered hours is the starting point but there is a need to monitor this in reality. Andy Byfleet (Southern Railway) posed a question to RAIB about industry concerns raised about the number of agencies on site at an accident and the potential for confusion of roles. Andy Savage (RAIB) replied that the first potential for this was at an incident at Liverpool where RAIB inspectors arrived and were signalled straight through to site. He was delighted with the response by all parties and felt the transition had worked well. Aidan Nelson (RSSB) added it is only now that industry has visibility of the protocols of the various agencies and these should give comfort to the industry. Andy Savage (RAIB) added that RAIB hoped to issue a summary of those protocols to industry to further their understanding.

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Discussion

Mike Sadler (EWS) noted the young state of RAIB and wondered how personally satisfied RAIB senior managers were with the performance and appropriateness of the investigations to date? Andy Savage (RAIB) replied that there is always scope for improvement and cited one investigation that in hindsight they might not have done. However, he was largely satisfied but would welcome any views on this from delegates. John Bendon (ATOC DMLG) replied in response to a question, that ATOC DMLG is trying to get together as much TOC/FOC best practice as possible as one workstream. DMLG had also formed a driver training sub-group and a simulator sub-group, details of which were on display in the main hall. Steve Bence (ATOC) added that the only barrier he saw to progress with these groups was that perhaps the groups are not asking for enough from industry, they were not loud enough. Charles Horton (Conference Chairman) agreed with Steve Bence and remarked that ATOC Operations Council had also noted at times that perhaps not enough demand for resources had been forthcoming and encouraged those in these groups to do so. Danny Fox (First Transpennine Express) questioned the panel on what analysis of the causes of wrong routes being offered is underway as his route has shown up as one of the highest likely routes for this to occur on. Patrick Hallgate (Network Rail) replied stating that the classification of wrong routing is a problem as well as classification of operating irregularities. He felt that the next 12 months n OPSRAM would be to understand the causes of wrong routing. Aidan Nelson (RSSB) added that there were issues about the response of signallers to drivers challenging wrong routes and issues about driver knowledge of unusual routes as opposed to wrong routes. Chris Burchell (Southern Railway) added that they had seen some changes in Southern following joint initiatives including positioning of train describer screens and simplifier clarity. One particular area where the TOC has helped has been to change the odd rogue train head codes to ensure they all go down the same route.

Session 3

The following discussion took place following presentations by Andrew McNaughton, Andrew Sharpe and Keith Harding, and also from the final Open Forum Session.

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Discussion

Panel Members: Charles Horton, Conference Chairman Andrew McNaughton, Chief Engineer, Network Rail Keith Harding, Head of Operations Support, First Capital Connect Andrew Sharpe, Head of Research & Development, RSSB Aidan Nelson, Director Policy & Strategic Initiatives, RSSB Mike Sadler, Head of Operational Safety, EWS Railway Steve Bence, Director Production Support, ATOC A question from the floor raised a frustration that signal design was following pure signal engineering rules and operators were not asked to comment upon what would become a riskier section of line depending on the design. Andrew McNaughton (Network Rail) stated that train operators must be engaged at the design stage to be of benefit in the process. He also added that Network Rail were introducing some rational design tools to aid the design process. Charles Horton (Conference Chairman) asked the audience for a show of hands as to who, as operators, had been invited to scrutinise signal designs and whether they had been successful in influencing the design. The show of hands indicated a pretty high level of involvement and success rate. David Marriott (Network Rail) queried how we would avoid maintenance and interface issues when moving signalling onto trains, recounting some maintenance nightmares that had been designed in to trackside signalling systems in the past? Andrew McNaughton (Network Rail) replied noting that we current expect electronic equipment operating at low voltages and currents to be located and maintained in the harshest environment, at risk of attack from rodents and people, and hence bringing it inside the rail vehicle would improve the maintenance situation and hopefully improve reliability. The main issue was doing this with existing trains. Chris Gibb (Virgin Cross Country) referred to the various level crossing initiatives and queried how train operators could actively help in this? Aidan Nelson (RSSB) replied by stating that train operators can help by encouraging the reporting of abuse and misuse, and by fitting front-end cameras to their trains to help aid vigilance. Other actions such as platform usage could also cut down on the number of times people have to cross the track to get to the platform.

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Discussion

Mike Sadler (EWS) noted that there is an opportunity to engage the Traincrew to stop just shrugging their shoulders because it always happens at that location, but to actively report this so that steps can be taken and reliable data gathered. Charles Horton (Conference Chairman) added that to make that work, the response the driver gets to reporting the issue needs to be positive otherwise he won't bother reporting again. Andrew McNaughton (Network Rail) reinforced the point made about front-end cameras as these are fitted to the New Measurement Train and these have shown the work force the amount of time at risk when a train approaches. He also noted that if we want to move to a philosophy of protecting our railway then there will be a societal debate needed about what we protect on the crossing. The obstacle detectors can be set to detect small obstacles such as dogs, or larger obstacles such as cars and vans. A balance would be needed to run a reliable railway. Andy Savage (RAIB) supported the use of front-end cameras and noted that a number of operators use these. They help tremendously in incident investigations. Charles Horton (Conference Chairman) commented that he was also an advocate of front-end cameras but noted that they were difficult for a TOC to justify financially and the case may be better made as a national industry project. Tim Shoveller (Virgin West Coast) wondered whether the advent of new technology, notably ERTMS, would lead to a position in say 30 years time where we did not need a driver? Andrew McNaughton (Network Rail) felt that the capability might exist for the system to operate itself, but 30 years is too short probably for this as it's the sort of life time for a fleet. Dave Bennett (ASLEF) noted that the Army Royal Engineers are capable of erecting bridges in just a few hours so there may be some lessons there. Regarding obstacle detectors, he stated that there was a debate needed on the level of detection but the starting point must be to protect the train, as they do, he believed, in Germany. He also supported the use of forwardfacing cameras and supported the RSSB research programme. Dave further noted an increase in SPADs recently due to drivers not being able to rest properly in the hot weather, and felt that precursor monitoring and analysis should also consider cab design and issues of adding to existing protection systems such as AWS as found in the RSSB research work. In summary, he thought the day had been productive and ASLEF would support this work. Chris Walters (Network Rail) raised the TPWS reset and continue work that had been undertaken and was concerned that the events had arisen again. He firmly believed that we

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Discussion

should move forward with this work and deal with the problem once and for all. The initial design and fitment of the equipment in the cab was poor and needs to be addressed. Aidan Nelson (RSSB) replied that he was going to raise this issue at the National SPAD Steering Group this month as a result of this Conference, and ask what we are going to do as an industry to bring back the focus. This should include dealing with the equipment in the cab. Mike Sadler (EWS) added that, as one of his train drivers was responsible for the last such event, he noted that the traction involved had the equipment positioned in the optimum place but the driver had so many cues from other events. Mike was concerned that it doesn't have an audible indication and felt that briefing alone is not the answer. Keith Harding (First Capital Connect) added that no driver deliberately has a SPAD or, even worse, continues after having a SPAD knowing they are entering a danger area. He was not aware of the reasons why these events occur. Anne Mills (RSSB) replied that the RSSB human factors research into this issue had identified that the events are split roughly evenly between errors associated with poor cab equipment design and installation, and violations influenced by too many unnecessary interventions. Both of these issues need to be addressed. David Morris (HMRI) believed there was a possibility that the introduction of TPWS could lead to drivers believing that TPWS, rather than their own driving skills, manages SPAD risk for them. He also had some concerns about the maintenance of TPWS equipment to ensure that it's always available to do its job when needed. Wallace Weatherill (Network Rail) responded by referring back to the pie chart of operational risk and reminded delegates that SPAD risk was 4% and TPWS reset and continue a fraction of that. He was keen that we keep the issue in context whilst addressing the broader risk issues. Andy Mooney (Freightliner Heavy Haul) stated that his company had been briefing their drivers to challenge sub-standard protection in possessions. Incidents don't just have a safety dimension but also tie up resources for days during investigations. Mike Sadler (EWS) replied that they had made a number of improvements to reduce SPADs going into possessions but still have a problem with trains coming out of possessions. He personally felt there were 3 things to do: firstly we should be making more use of the existing signalling system, i.e. taking and giving up possessions around a train; secondly there should be an open-channel radio system; and thirdly we should have some simple rules, including making the PICOP an operator.

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Closing Remarks

By

Charles Horton

Conference Chairman

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Closing Remarks

Charles Horton ­ Conference Chairman

In closing the Conference, Charles thanked the guest speakers for their presentations, which covered a wide range of subjects in order to meet the objectives of the day, and the panel of experts and the delegates for their contributions. He also thanked NSFG for inviting him to chair the Conference and praised the Institution of Civil Engineers for the facilities and service provided. He also gave thanks on behalf of everyone to the exhibitors and to Andy Waters and the other Halcrow support team for their significant contribution in making the day possible and successful. He noted the commitment and passion with which the everyone in the industry involved with operations were giving to the SPAD problem and the wider operational risk issue, as demonstrated here today. Today had been a demonstration of the industry working together. Charles noted that there had been some concern raised about broadening the scope of the conference in its run up, but it was clear to him following the breadth of issues raised and discussed today, that it was the right decision to make. He noted from Wallace Weatherill's presentation that 83% of train accident risk comes from operational issues and felt we should all remember that and put risk areas into context. He had picked up on a number of key themes through the day: firstly from Linda Williams was a clear message not to become complacent and to address the little things to keep on top; from Wallace Weatherill he noted that we have a tour-de-force on operational risk; from Dyan Crowther we heard how well the OPSRAM Groups are adjusting to their new role to create a dynamic and collaborative team; Andy Savage helped us understand that we can learn from other parts of the wider industry; Chris Burchell spelled out the importance of recognising and managing precursors; Andrew McNaughton reminded us of the importance of thinking about the human being as part of the system and designing the system to support the human; Andrew Sharpe explained the role of RSSB's research and development programme and the practical application of that research; and finally Keith Harding gave us an insight into how we might think about changing our management approach and the risks facing train operators. Charles concluded by restating his earlier view that we must take away at least one initiative from today and apply it for the betterment of our companies and the industry as a whole. He stated that his one action will be to engage his next stakeholder advisory board meeting, who often get into debates with customer facing concerns, and further the debate about operating risk such as level crossing risk, and he will look forward especially to receiving an input from those people from their perspective.

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Summary of Key Issues to Consider

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Summary of Key Issues to Consider

The following provides a summary of the key issues which it would be beneficial for companies to consider as part of their SPAD and operational risk strategies. It is acknowledged that existing work streams and company initiatives may already be adequately addressing these. However, industry working groups and individual companies are encouraged to review the list to identify outstanding issues, to share examples of good practice and to determine if further industry support is required and how best to communicate progress in addressing these points. 1. The Train Operating Companies and Network Rail should ensure that its focus on risk encompasses all elements of operational risk whilst continuing to direct proportionate resources to the management of SPADs. 2. Train Operating Companies should exploit the full potential within SMIS and the Safety Risk Model to gain an individual company baseline for Operational Risk and the precursors, this should form the basis of any specific company or joint initiatives. 3. To move forward to a philosophy of protecting trains and customers from operational risk at level crossings, it is important for Train Operators and Network Rail, through drivers, signallers and other operational / track personnel, to improve the reporting of persons who violate the rail infrastructure such as the misuse of level crossings. This includes improving procedures for reporting, investigation, analysis and response to precursors such as near misses, particularly at level crossings. 4. Train Operators should evaluate the benefits of providing `front-end' cameras on trains as these would pay dividends in enabling the proper investigation of accidents and gaining a better understanding of incident black spots. This may best be taken forward as a national project or research. 5. Network Rail and Train Operators should continue to work together to further raise public awareness of risk associated with level crossings, including strategies to eliminate risk such as reducing the number of level crossings. 6. In addition to reducing the overall risk profile, train operators need to review their company specific risk profile and implement suitable controls ­ for example depot risk, train dispatch, station overruns etc. 7. Taking into account the long life expectancy of TPWS as a train protection system, it is important for train operators to improve the design and function of the TPWS cab display equipment to reduce the potential of further TPWS reset and continue incidents. In the meantime, drivers should continue to be briefed on this issue.

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Summary of Key Issues to Consider

8. The industry should continue, through OPSRAM to identify locations where fitment of additional TPWS may reduce SPAD risk further, and continue to improve reliability of the system. 9. Train operators should continue to take steps to understand and mitigate the potential for operational risks to increase during Franchise changes. 10. Network Rail should take the lead in ensuring that OPSRAM share initiatives and good practices between each other and seek to improve contribution of all participating parties - a joint approach is essential. 11. Companies should provide feedback to RSSB as to whether the emphasis on research `products' is correct and where RSSB should be concentrating their research efforts. 12. The industry should actively challenge rules and procedures following incidents rather than just accept compliance as the answer.

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Presentation Slides

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Keynote Address

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Keynote Address

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Operational Safety Performance & The Changing Risk Profile

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Operational Safety Performance & The Changing Risk Profile

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Operational Safety Performance & The Changing Risk Profile

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National OPSRAM Implementation ­ One Year On

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National OPSRAM Implementation ­ One Year On

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National OPSRAM Implementation ­ One Year On

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RAIB Eight Months On

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RAIB Eight Months On

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RAIB Eight Months On

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Managing Precursors

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Managing Precursors

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Engineering Reduced Operational Risk

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Engineering Reduced Operational Risk

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Engineering Reduced Operational Risk

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RSSB's Research & Development Programme

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RSSB's Research & Development Programme

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RSSB's Research & Development Programme

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Delegate List

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Managing Risk ­ A Train Operator's Perspective

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Abbreviations

AFR ASLEF ATOC ATP CASS CRG ERTMS FOC FTC GPL GSM-R HLOS HMRI LED LUL MSS NRCI NSFG OPSRAM ORR OTM RAIB RSSB SCCFG SFAIRP SMD SMIS SMS SPAD SPAS SPADRAM TOC TPWS Accident Frequency Rate Association of Locomotive Engineers & Firemen Association of Train Operating Companies Automatic Train Protection Care And Support System Communications Review Group European Rail Traffic Management System Freight Operating Company Failed To Call Ground Position Light Global System for Mobile communication - Railways High Level Output Statement Her Majesty's Railway Inspectorate Light Emitting Diode London Underground Limited Multiple-SPADed Signals Network Rail Controlled Infrastructure National SPAD Focus Group Operational Safety risk Reduction and Mitigation ??? Office of the Rail Regulator On Track Machine Rail Accident Investigation Board Rail Safety & Standards Board Safety Critical Communications Focus Group So Far As Is Reasonably Practicable Specially Monitored Driver Safety Management Information System Safety Management System Signal Passed at Danger Signal Passed at Stop SPAD Reduction and Mitigation Train Operating Company Train Protection and Warning System

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Agenda

National SPAD and Operational Risk Conference 11th July, 2006: London

The Institution of Civil Engineers, One Great George Street, London Conference Objectives:

· · To improve understanding of rail operation risk and SPAD risk in the context of the overall risk profile To enable the sharing and understanding of good practice to enable companies to identify measures to improve their own risk profile

08.00 09.30

Registration and coffee Opening remarks from the conference chairperson ­ Charles Horton, Managing Director, Southeastern Railway

10.20

Presentation National OPSRAM implementation ­ one year on Speaker: Dyan Crowther, Route Director, LNE

· · · · Success and outputs of OPSRAM ­ are they delivering? The benefits of sharing good practice and initiatives emerging from OPSRAM What should be the priority areas of OPSRAM? Maintaining the momentum and forward strategy

Keynote Speech

09.40 Speaker: Linda Williams, HM Chief Inspector of Railways

· · · · · Challenges facing the industry Societal concern versus actual risk Practical application of reasonable practicability TPWS What ORR is doing

10.40

Open Forum Key discussion points:

1. Is it appropriate to consider operational risk in the way it is being presented and what are the advantages/disadvantages? Is the industry's understanding of operational risk adequate and if not, what action is required to address this? Is the focus on operational risk taking industry attention away from the residual risk of SPADs? If so, what action needs to be taken and why? OPSRAM - the way forward?

Session 1 The changing safety risk profile

Session objectives: To present and discuss the changing risk profile and identify how the industry can improve safety performance efficiently by maintaining SPADs at a low level yet safeguarding against the potential `one off' high consequence accident - which may not necessarily be a SPAD.

2.

3.

4.

Panelists:

Linda Williams, ORR Aidan Nelson, RSSB Wallace Weatherill, Network Rail Dyan Crowther, Network Rail Steve Bence, ATOC

10.00

Presentation Operational safety performance and the changing risk profile Speaker: Wallace Weatherill Head of Operational Safety, Network Rail

· · · · · · Overview of SPAD and operational risk Understanding the changing safety risk profile at national and route level Key areas of concern and current priorities such as irregular working Changing the structure of NSFG and other national groups The barriers to improvements

11.20

Refreshment break

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National SPAD and Operational Risk Conference 11th July, 2006: London

Session 2 Role of the RAIB and developments in industry good practice and initiatives in SPAD and operational risk management

Session objectives: · To provide the RAIB perspective of operational risk · To provide an opportunity for a train operator to outline examples of initiatives and developments in good practice within the industry since the 2005 conference

Industry developments and forward strategy

Session objectives: To provide an update on industry developments and research to reduce SPAD and operational risk and to discuss the forward strategy for the industry

Presentation: Network Rail Future engineering contributions to managing operational safety risk Andrew McNaughton, Chief Engineer, Network Rail

· · · · · Network Rail moving Engineering and Operations closer together Human Centred Controls Managing train protection now and in the future Signalling design and renewals opportunities Improvements in Possession Operations

RAIB perspective of operational risk Andy Savage, Deputy Chief Inspector, RAIB

· The Rail Accident Investigation Branch - eight months on

Presentation Managing SPAD risk and precursor events and the promotion of good practice Chris Burchell Managing Director, Southern

· · · Managing the residual risk of SPADs Tracking and reviewing causal information at the lowest possible level Developing a positive safety culture and getting the best from care and support systems

Presentation RSSB RSSB research and reducing the risk of human behaviour Speaker: Andrew Sharpe, Head of Research and Development, RSSB

· · · · The R&D programme: Background and Aims Types of R&D and topics covered "Human Performance" R&D Focus on "products" ­ implementing R&D

Open forum Key discussion points

1. Based on the number and type of accidents investigated by the RAIB since it became operational, can we be satisfied the correct accidents and incidents have been selected for investigation? Which precursor events should duty holders focus their attention on and why? Whilst ATOC Driver Management is an effective method of sharing and developing good practice, what are barriers to this process and what actions are required to make the process more effective?

Presentation First Capital Connect A Train Operator's Perspective Speaker: Keith Harding, Head of Operational Support, First Capital Connect

· · Developments in Driver Management Key areas of operational risk

2. 3.

Open Forum Key discussion points

1. As the timetable for implementation of ERTMs is potentially 30 years away, what further action is required to reduce the operational risk at signals not fitted with TPWS? Within the last 12 months a number of significant operational incidents have occurred within engineering possessions. What should be the industry's key priorities to minimise this risk? Is the emphasis on RSSB research `products' right and where should we be concentrating our efforts in future? Today's conference has focused significantly on the changing risk profile of the industry. What are you going to do differently as a result of today's conference and what key areas do you consider the industry should focus their attention on?

2.

Panelists:

Andy Savage, RAIB Chris Burchell, Southern Wallace Weatherill or OPSRAM Chair Steve Bence, ATOC John Bendon, Chair ATOC Driver Management Group Aidan Nelson, RSSB

3. 4.

Panellists:

Aidan Nelson, RSSB Andrew McNaughton, Network Rail Andrew Sharpe, RSSB Mike Sadler, EWS Keith Harding, FCC

Lunch and view displays

Closing remarks

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Delegate List

Name Mark Croucher Barry Osgood Peter Hoare John Linge John Gribble Derek Marshall Tim Bell Chris Didio Dean Katchi Russ Evans Dave Bennett Steve Bence Mick Rayner Tony Small Brian Taylor Drew McCall Kevin Kearney Paul Owen Paul Frost Daniel Healey Richard MacLennan Keith Grafton Richard Mackinnon Norman Egglestone John McGuinness Jeff Marshall Nico Kuijper Graham Pears Jon Chilton Ian Verrinder Keith West Nick Edwards Mike Sadler John Protheroe Carl Farrar Tony Culverwell Ian Duncan Keith Harding Nigel Holness Daniel Williams Barry Minall John Shields Kevin Gale Steve Bailey Andy Moore Iain Stewart Dave Smart

Position Trainer Assessor Head of Health, Safety & Environment Driver Competency Assessor Driver Standards Manager Rail Operations Assurance Manager Operations Director Head of Safety Operations Compliance Manager Operations Standards Manager Safety Adviser Director, Production Support Managing Director Director, Assurance & Safety Operations Manager Route Learning Manager Driving Standards Manager Ops Standards Verification Managers Head of Safety Ops Standards Verification Managers Operations Director Operations Standards Manager Driver Standards Manager Professional Head of Operations Senior Operations Support Manager Operations Director Senior Inspector Driver Manager Head of UK Operations Driver Standards Manager Area Manager London South Operations Standards Office Operations Standards Manager Freight Director Freight Operations Manager On Track Plant Director Train Services Director Head of Operational Support Operations and Safety Director Train Service Director Acting Driver Manager Driver Standards Manager Trains Director Traincrew Manager Central Region Head of Competence Group Competence Manager Operations Standards Manager 71

Representing AMEC Rail AMEC Rail AMEC Rail AMEC Rail AMEY Infrastructure Services AMEY Infrastructure Services Arriva Trains Wales Arriva Trains Wales Arriva Trains Wales Arriva Trains Wales ASLEF ATOC Balfour Beatty Rail Plant Balfour Beatty Rail Plant Balfour Beatty Rail Plant Carillion Rail Carillion Rail Central Trains Central Trains Central Trains Chiltern Railway Co. Chiltern Railway Co. Chiltern Railway Co Direct Rail Services Direct Rail Services Direct Rail Services Dutch Rail Inspectorate Eurostar (UK) Eurostar (UK) Eurostar (UK) EWS Railway EWS Railway EWS Railway Fastline Fastline Fastline First Capital Connect First Capital Connect First Capital Connect First Capital Connect First Capital Connect First Engineering First Great Western First Great Western First Great Western First Great Western First Great Western

National Operational Risk Conference 2006

Delegate List

Name Mike Ball John Williams Alan Price Seamus Scallon Steve Montgomery Allan Brown Robert Plant Douglas McEwen Danny Fox Michael Powell Barry Cook Chris Hewitt Alan Tebay Andy Mooney Paul Atherfold Marc Vince John Smith Ward Simpson Steve Simpson Ali Southan Brian Batch Paul Boyle Chris Drewery Adrian Fairburn Neal Fussey Steve Gear Ray Smith Michelle Tyler Rob Thrower Peter Roche Jim Meade Kevin Corkery Steve Charlick Mark Hopwood James Adeshiyan Susie Homan Huw Bridges Ray Wadey Steve Wright Steve Tyler Claire Brown Paul Harding Lesley Cusick Andy Heath Alex Mcgregor Roger Walton Andrew McNaughton Derek Holmes Position Operations Compliance Manager Operations Training Manager Driver Manager Head of Safety Operations and Safety Director Divisional Operating Manager Operational Standards Manager Route Manager Operations Director Strategy Reporter Area Driver Manager Assistant Ops Standards Manager Group Head of Train Operations Standards Manager Driver Standards Manage Operations Manager Managing Director Operations Director Head of Operations Safety Manager Driver Manager South Driving Standards Manager Driver Team Manager Driver Training Manager Competence & Standards Manager Operations Manager Assistant Operations Manager Control Centre Manager Head of Drivers District Manager District Manager Chief District Traction Executive Head of Technical Services Managing Director Operations Director Head of Operations Services Head of Safety Operations Standards Manager Head of Operations Training Operations Manager Operations Manager Operations Manager Safety Director Operations Director Operations Standards Manager Safety Director Chief Engineer Head of Operations Services 72 Representing First Great Western First Great Western First Great Western First Group First ScotRail First ScotRail First ScotRail First ScotRail First TransPennine Express First TransPennine Express First TransPennine Express First TransPennine Express Freightliner Freightliner Heavy Haul Gatwick Express Gatwick Express GB Railfreight GB Railfreight GB Railfreight GB Railfreight GNER GNER GNER GrantRail GrantRail Harsco Track Technologies Harsco Track Technologies Harsco Track Technologies Heathrow Express Irish Rail Irish Rail Irish Rail London Underground Limited London Lines London Lines London Lines London Lines London Lines London Lines (LL) Silverlink County (LL) Silverlink (LL) c2c Rail Merseyrail Merseyrail Midland Mainline Midland Mainline Network Rail Network Rail

National Operational Risk Conference 2006

Delegate List

Name Wallace Weatherill Mike Carr Warrick Dent Gilbert Fraser Richard Bassett Garth Ratcliffe Chris Walters Dave Fenner Ian Fazakerley David Marriott Jon Wiseman Tim Leighton Dyan Crowther Christopher Willey Jo Kaye Gary Openshaw Andrew Skidmore David Dickson Patrick Hallgate Dick Whitwell David Pape Ian Chambers Mark Langman Andrew Munden Mick Carbro John Kear Steve Pugh Sheldon Hicks Chris Nutton Steve Smithies Linda Williams David Morris Stephen Poole Michael Jampel Perry Ramsey Mark Phillips Stewart Player Andy Sanders Justin Willett Alastair Fyfe Andy Savage Phillip Dee Aidan Nelson Mick Stormouth Susan Cassidy Gary Portsmouth Lesley Hodsdon Ann Mills Position Head of Operational Safety Policy Head of Accident Investigation Operations Safety Support Manager Operations Risk Control Specialist Train Operations Standards Specialist Chief Trains Operations Manager National ERTMS Application Engineer Development Manager Senior Signal M&D Engineer Route Director Area Operations Manager Route Director Operations Safety Manager Area General Manager Area General Manager Area General Manager Area General Manager Route Director Route Operations Manager Route Director Operations Safety Manager Area General Manager Route Director Operations Director Operations Safety Manager Operations Standards Manager Area Operations Manager Performance Strategy Manager Area Operations Manager HM Chief Inspector Deputy Chief Inspector Topic Strategist Head of Strategy Route Director West Anglia Operations Director Operation Standards Manager Head of Safety Head of Driver Training Inspector Deputy Chief Inspector Safety Adviser Director, Policy & Strategic Initiatives Project Manager National Initiatives SCCFG Project Manager Operations Specialist Senior Workforce Development Principal Human Factors Specialist 73 Representing Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Network Rail Anglia Network Rail Anglia Network Rail LNE Network Rail LNE Network Rail LNW Network Rail LNW Network Rail LNW Network Rail Scotland East Network Rail Sussex Network Rail Sussex Network Rail Wessex Network Rail Western Network Rail Western Network Rail Kent NEXUS NEXUS Northern Northern Northern Northern Office of Rail Regulations Office of Rail Regulations Office of Rail Regulations Office of Rail Regulations `one' Railway `one' Railway `one' Railway `one' Railway `one' Railway RAIB RAIB RMT RSSB RSSB RSSB RSSB RSSB RSSB

National Operational Risk Conference 2006

Delegate List

Name Irene Grabowska John Peters Mike Downes Chris Exley Andrew Sharpe Mark Medley Roger Badger Andrew Beddows Stuart Comer Jason Rogers Chris Burchell Andy Byford Oscar Sowerby Charles Horton Michael Hodson John Thompson Colin Caller Andrew Coulthurst Ken Skilton James Burt Brian Cook Sharon Maguire Bob Silk Gary Cooley Chris Gibb Phil Bearpark Andrew Oakey John Wardale Paul Williams Charles Belcher Tim Shoveller Martin Berwick John Bendon Alan MacDonald Ray Metcalfe Andy Waters Nico Kuijper Position Senior Safety Intelligence Advisor Research Manager Safety Intelligence Advisor Operations Specialist Andrew Sharpe, Head R & D Head of Standards Safety Intelligence Analyst Driver Team Manager Driver Manager Managing Director Operations Director Assist Operations Standards Manager Managing Director (Chair) Operations & Safety Director Head of Operations GM, Metro Operations GM, Mainline Operations Operations Safety Manager Operations Director Head of Operational Standards Head of Drivers Driver Depot Manager Traction Manager Managing Director Production Director Head of Drivers Operations Standards Manager ATOC DMLG Driver Training Group Managing Director Operations Director Operations Standards Manager Chair of ATOC DMLG Project Manager Principal Consultant Senior Consultant Senior Inspector Representing RSSB RSSB RSSB RSSB RSSB RSSB RSSB Serco Rail Operations Serco Rail Operations Serco Rail Operations Southern Railway Southern Railway Southern Railway Southeastern Railway Southeastern Railway Southeastern Railway Southeastern Railway Southeastern Railway Southeastern Railway South West Trains South West Trains South West Trains South West Trains Translink Northern Ireland Virgin Cross Country Virgin Cross Country Virgin Cross Country Virgin Cross Country Virgin Cross Country Virgin West Coast Virgin West Coast Virgin West Coast Virgin West Coast SPADWEB Halcrow Halcrow Dutch Rail Inspectorate

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