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ISSUE 60 Sept/ Oct 2016

CONFIDENTIAL REPORTING FOR SAFETY

5 Editor's note

6 Vulnerable road users

10 Solutions shared workshops -

fatigue

11 Reports being processed

14 Membership update

CIRAS UPDATES

4-5 Contractor

7 Bus

8-9 Train operator

12 Network Rail

13 Train operator

3 Member viewpoint - ScotRail

REPORTS

GUEST ARTICLES

Greg Morse, Operational Feedback

Specialist looks at how CIRAS came

into being. It's hard to believe it's

been twenty years. Originally created

as a confidential reporting and

analysis system for railways, it was

led in those days by a team from

Strathclyde University.

Several British Rail-managed

operators in Scotland expressed an

interest and joined voluntarily in the

run-up to privatisation. Around the

same time, Scotrail commissioned a

report that highlighted the important

role of human factors both in rail, and

the off-shore oil, nuclear, aviation and

marine industries. Existing internal

reporting procedures, whilst fully

established, were often associated

with blame and disciplinary action.

The relationships between

management and staff were often

characterised by mutual mistrust,

a culture that still exists in some

organisations today. However, in

1999 the rail industry suffered one

of its most serious accidents: 31

people losing their lives at Ladbroke

Grove, near Paddington. Accidents

almost always bring change, and this

one (inter alia) was a catalyst for the

industry increasing its understanding

of 'culture'.

So what happened at Ladbroke

Grove? Just after eight in the morning

on 5 October 1999, a commuter

service left Paddington for Wiltshire.

From the terminus to Ladbroke Grove

Junction, the lines were signalled

to allow trains to travel in either

direction. Beyond Ladbroke Grove,

the main line switched to the more

conventional layout of two lines in

CIRAS - 20 years of

confidential reporting

"Until rail and other industries truly change the very core of their existence from blame and

retribution to openness and genuinely doing the right thing, CIRAS is going to remain a

vital and imperative part of the structure." - Pam Warren, Ladbroke Grove survivor

© Alamy

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