Rail accident history

Rail accident history

Inquiries into many major accidents - Herald of Free Enterprise (1987), King’s Cross (1988), Clapham Junction (1989), Piper Alpha (1990), Southall (1997), Ladbroke Grove (1999), Longford Explosion (2000), BP Texas oil refinery (2007) - have found faults in organisational structures, safety management systems and prevailing cultures, throwing the importance of safety culture and the management of human factor (ie. people) risks into the spotlight.

The Southall and Ladbroke Grove train crashes, in September 1997 and October 1999 respectively, led to three separate public inquiry reports: one for each crash and a report on Automatic Train Protection. The inquiries took a fundamental look at the generic issues surrounding safety in the British Railway Industry. A principle conclusion focused on the improvement of safety management, specifically safety culture:

“Achievement of an improved safety culture on the railways is at the core of the whole programme of change initiated by Lord Cullen’s Inquiries . . . if an organisation has the right culture in place it will find the right people and the right technology to deliver safe and effective performance.”

“…the need for a positive safety culture is the most fundamental thought before the inquiry.”

The reports resulted in 295 recommendations, setting 'a necessary and challenging criteria to change the state of the railways’. A section of the recommendations fell under the title ‘Culture, Safety Leadership and Health and Safety Management’ which presented twenty-five recommendations relating to the internal structures of companies, safety culture, and the management of health and safety. The recommendations were aimed at securing improvements in the following areas:

• Safety auditing processes
• Fault reporting and maintenance
• Risk assessment
• Application of a railway safety case regime
• Safety leadership and communication in companies

Driven by increased understanding of human performance capabilities and limitations, and lessons learned from major accidents, expectations for organisations’ safety performance continues to increase. Public scrutiny of corporate accountability is becoming ever more intense, but, when major safety incidents do occur, despite the efforts that have been made, it is often ‘culture’ that is invoked as one of the root causes. This has led many companies to want to measure their safety culture.