The Railways and "Just Culture"

[Economist]

As someone who's soon to start a career on the railways, I thought I'd ask ask about how prevalent the concept of "Just Culture" is. I believe it started off largely as a civil aviation thing but seems to have moved to other industries, one of the main elements being that learning is more important than punishment when investigating mistakes.

Since I received my offer the trap and drag at Hayes and Harlington has become a prosecution and the more recent of the two Merseyrail guard incidents resulting in a prosecution has gained a lot of attention. There was also a well-known trap and drag which it has transpired may have lead to a trainee getting into trouble whilst under instruction, though that was only from a single source on here.

Are companies and regulators becoming more prone to punishing those who make genuine errors and are honest about them?

 

[Bromley boy]

As someone who's soon to start a career on the railways, I thought I'd ask ask about how prevalent the concept of "Just Culture" is. I believe it started off largely as a civil aviation thing but seems to have moved to other industries, one of the main elements being that learning is more important than punishment when investigating mistakes.

Since I received my offer the trap and drag at Hayes and Harlington has become a prosecution and the more recent of the two Merseyrail guard incidents resulting in a prosecution has gained a lot of attention. There was also a well-known trap and drag which it has transpired may have lead to a trainee getting into trouble whilst under instruction, though that was only from a single source on here.

Are companies and regulators becoming more prone to punishing those who make genuine errors and are honest about them?

I've never heard of the phrase "just culture". However I recognise your description of it in the way that the AAIB/RAIB investigate aviation/rail incidents for the sole purposes of establishing cause and learning points rather than apportioning blame.

If you're expecting this commendable approach to extend to TOCs you are in for a rude awakening. SPADs are reported via red and green notices but other types of safety incident are hushed up and not generally discussed. You'll only hear about them through the rumour mill. This is a huge missed opportunity in my view given the "human factors" which contribute to these incidents reoccur time and time again.

Personally when I hear of an incident I try and find out as much as I can via the rumour mill and think about how I can modify my own driving in order to minimise the risk of being involved in a similar incident.

In my experience the culture on the railway is very much "cover your own backside" at every turn. It is a blame culture in which you will be hung out to dry and blamed for any and every mistake. Of course one person's "blame culture" is another person's "culture of accountability" but I get the distinct impression that TOCs would rather apportion blame to staff for incidents than invest in genuine safety improvements.

An example of this is wrong side door releases. For all the big talk about safety there's absolutely no appetite to invest in relatively simple CSDE technology.

 

[lineclear]

It is interesting to read the report into the Ladbroke Grove collision. Lord Cullen felt that a 'no blame' culture led to drivers taking the blame for SPADs rather than blaming the (deficient) infrastructure.

 

[pdeaves]

If you're expecting this commendable approach to extend to TOCs you are in for a rude awakening.

That certainly is not the case for all TOCs.

 

[Bromley boy]

That certainly is not the case for all TOCs.

I should qualify my previous comments to say I only have experience of one TOC.

I think I know which TOC Economist is most concerned about, though.

 

[signallerscot]

Network Rail have recently transitioned to a fair culture model and it has been very successful. A total change from the old days when managers would go straight down the discipline route. Genuine slips, lapses and errors are recognised as such, while only a deliberate violation for personal gain will result in disciplinary action.

 

[W230]

That certainly is not the case for all TOCs.

Nor the case for my TOC. You hold your hands up and they do their best to help you and get you back out. They certainly don't go out to hammer staff for mistakes.

Mind you, we need all the drivers we can get!!

 

[Trog]

Network Rail have recently transitioned to a fair culture model and it has been very successful. A total change from the old days when managers would go straight down the discipline route. Genuine slips, lapses and errors are recognised as such, while only a deliberate violation for personal gain will result in disciplinary action.

Interesting my impression of Network Rail over the last few years was that they were getting harsher.

 

[signallerscot]

Interesting my impression of Network Rail over the last few years was that they were getting harsher.

From inside or outside the tent? Certainly colleagues of mine who have gone through the fair culture system have benefitted from its pragmatic approach.

 

[Trog]

Inside.

 

[ComUtoR]

Personally when I hear of an incident I try and find out as much as I can via the rumour mill and think about how I can modify my own driving in order to minimise the risk of being involved in a similar incident.

Love you xxx.

Keep this up. I also find it very important to learn from other peoples mistakes and try and identify where I am going wrong and try to introduce some kind of mitigation with my driving.

Other than how poor the Red/Green notices are they are there to help others learn and adapt. When we have LADD's it is also an important opportunity to learn more and adapt our driving.

We have lots of resources at our disposal to improve our driving beyond what is taught. Opsweb, Spark, RSSB, etc.

Some TOCs, like mine, do have a blame culture but its important to remember that mess room gossip might not reflect what is happening in reality. We have 3 licence withdrawals on going at the moment but when you look at the Drivers history you begin to understand why. Managers certainly see a different picture and have parts that we don't see in the mess room and the Drivers aren't always honest about their incident or incident history (as I found out recently)

 

[Economist]

This is a huge missed opportunity in my view given the "human factors" which contribute to these incidents reoccur time and time again.

Keep this up. I also find it very important to learn from other peoples mistakes and try and identify where I am going wrong and try to introduce some kind of mitigation with my driving.

In the aviation world they have something called CHIRP (Confidential Human Factors Incident Reporting) https://www.chirp.co.uk/. Basically, pilots can send confidential reports in and there is a newsletter which some of the reports are included in. AFAIK it's been going for over a decade now and the Maritime industries have been getting involved too. I don't know what involvement the airlines have in it but it seems to be fairly popular amongst pilots.

 

[pdeaves]

In the aviation world they have something called CHIRP (Confidential Human Factors Incident Reporting)

Sounds like the railway's CIRAS system.

 

[Trog]

Was never all that impressed with CIRAS as the answer to almost every problem people reported was be more careful in future, rather than the company involved doing anything to solve the problem for good. Although that said I have not seen one of their news letters in years, as they just seemed to stop coming round.

 

[nom de guerre]

Network Rail have recently transitioned to a fair culture model and it has been very successful. A total change from the old days when managers would go straight down the discipline route.Genuine slips, lapses and errors are recognised as such, while only a deliberate violation for personal gain will result in disciplinary action.

Your route must be run rather differently to mine, then.

Around here, if you make a serious error - however 'accidental' - you will be disciplined for it. Personally, I think that's fair.

 

[Phil.]

Your route must be run rather differently to mine, then.

Around here, if you make a serious error - however 'accidental' - you will be disciplined for it. Personally, I think that's fair.

Ah but one person's serious error is another person's trivial mistake. The real skill is knowing how to interpret it.

 

[Bromley boy]

Around here, if you make a serious error - however 'accidental' - you will be disciplined for it. Personally, I think that's fair.

But then you are just penalising people for being human beings and not robots.

Unfortunately this kind of attitude just perpetuates the blame culture. People will try to cover up mistakes to avoid disciplinary action. No one will want to share information. As a result the opportunity to learn from previous mishaps is missed and everyone ends up worse off as a result.

Surely it's better to take a grown up approach, work out what has led to the error and work together to identify strategies to stop it happening again. Discipline should be reserved for deliberate transgressions, cutting corners, dishonesty etc.

It's a shame the railway (in some quarters at least) is still to learn this lesson.

 

[LBSCR Times]

Having been in the operations side of the industry for more years than I can remember, my attitude towards my staff depends on how I view the severity of the incident.
They either get a b*llocking and told not to do it again, and hope they learn by their error, or they get disciplined. However, some of those above me take the attitude that you discipline them irrespective, and given half a chance, would sack them too!
I personally fail to understand that mentality.
There is still too much blame culture rather than learning in parts of the industry.

 

[al78]

But then you are just penalising people for being human beings and not robots.

Unfortunately this kind of attitude just perpetuates the blame culture. People will try to cover up mistakes to avoid disciplinary action. No one will want to share information. As a result the opportunity to learn from previous mishaps is missed and everyone ends up worse off as a result.

Surely it's better to take a grown up approach, work out what has led to the error and work together to identify strategies to stop it happening again. Discipline should be reserved for deliberate transgressions, cutting corners, dishonesty etc.

It's a shame the railway (in some quarters at least) is still to learn this lesson.

You ideally need to do both. If someone makes an error which enhances the probability of, or results in death or serious injury, then they should be held accountable for that error. Otherwise, what is to stop people becoming lackadaisical if there are no consequences to actions? We have this already on the roads where drivers will try to pull off dangerous manoevures and someone else suffers the consequence, the driver just pleads accident and my life will be unbearable if I lose my license, and they get off with some small fine and that's it, no wonder we have thousands of deaths and injuries on the roads. We also need to look at the system in general and try to engineer it in such a way that the consequences of careless are minimised.

 

[godfreycomplex]

Network Rail have recently transitioned to a fair culture model and it has been very successful. A total change from the old days when managers would go straight down the discipline route. Genuine slips, lapses and errors are recognised as such, while only a deliberate violation for personal gain will result in disciplinary action.

Certainly the case in my neck of the woods; at least in the signalling grades. Maintenance however is still largely in the bad old days of finger pointing I gather.

 

[godfreycomplex]

Your route must be run rather differently to mine, then.

Around here, if you make a serious error - however 'accidental' - you will be disciplined for it. Personally, I think that's fair.

Remind me never to get a job on your route!
A wise person once said "The hang 'em high and shoot 'em brigade do nothing for safety"

 

[Economist]

I suppose one man's "just culture" is another man's "blame culture" and vice versa.

Recently, the difference between errors and violations was highlighted to me, most people believe that violations should usually result in some form of disciplinary action, however it's the errors which cause controversy.

How many are allowed and of what type? Every circumstance is different yet consistency must be seen to be applied by management. I've always been in favour of investigation without blame and susbsequent coaching and development where this is possible.

 

[Moonshot]

I suppose one man's "just culture" is another man's "blame culture" and vice versa.

Recently, the difference between errors and violations was highlighted to me, most people believe that violations should usually result in some form of disciplinary action, however it's the errors which cause controversy.

How many are allowed and of what type? Every circumstance is different yet consistency must be seen to be applied by management. I've always been in favour of investigation without blame and susbsequent coaching and development where this is possible.

This topic came up in a briefing I attended the other week ( I work on the railway ). In a nutshell , an error is caused by someone doing the wrong thing but believing it to be right. This is a very common trait in the human species, it will never change. A violation is a deliberate action.

There was an interesting incident not so long back involving a driver who accidentally " reset and go " - this type of incident would be classed as a violation ( its a deliberate driver action ).....however the driver who did this accidentally was actually in a " perfect storm " situation. Not going to try and explain the nuts and bolts of it as it would take too long, but it certainly was an eye opener.

 

[D1009]

This topic came up in a briefing I attended the other week ( I work on the railway ). In a nutshell , an error is caused by someone doing the wrong thing but believing it to be right. This is a very common trait in the human species, it will never change. A violation is a deliberate action.

There was an interesting incident not so long back involving a driver who accidentally " reset and go " - this type of incident would be classed as a violation ( its a deliberate driver action ).....however the driver who did this accidentally was actually in a " perfect storm " situation. Not going to try and explain the nuts and bolts of it as it would take too long, but it certainly was an eye opener.

Was that the incident on the Bletchley - Bedford line which was recreated to make a safety video?

 

[ComUtoR]

Was that the incident on the Bletchley - Bedford line which was recreated to make a safety video?

It sounds like the one at Spa Road

 

[Moonshot]

Was that the incident on the Bletchley - Bedford line which was recreated to make a safety video?

No it was up here in northern land.....obviously it can happen anywhere but is very rare.

 

[Bromley boy]

In a nutshell , an error is caused by someone doing the wrong thing but believing it to be right. This is a very common trait in the human species, it will never change. A violation is a deliberate action.

That hits the nail squarely on the head.

This is why threats of the disciplinary action however severe, or even physical injury, will never prevent mistakes from happening.

We have to accept that mistakes will occur. All we can do is minimise them and build systems to mitigate the damage caused. The DRA and TPWS are excellent ways of achieving both of these objectives on the railway. The first reduces the likelihood of a mistake (a SPAD), the second mitigates the consequences if it still occurs.

A culture where factors leading to mistakes can be openly and honestly discussed is vital to this.

 

[ComUtoR]

We have to accept that mistakes will occur. All we can do is minimise them and build systems to mitigate the damage caused.

Why 'minimise'. Why not eliminate ?

I often find it odd that we have a target for SPADS. Surely that target should be zero. Its the same with incidents. We have targets and acceptable risks. Why can't we build systems and put procedures in place that serve to eliminate incidents instead ?

 

[Bromley boy]

Why 'minimise'. Why not eliminate ?

I often find it odd that we have a target for SPADS. Surely that target should be zero. Its the same with incidents. We have targets and acceptable risks. Why can't we build systems and put procedures in place that serve to eliminate incidents instead ?

We would all want to eliminate incidents, but driving trains is fundamentally error prone. Although nobody goes to work intending to have an incident, and despite measures such as the DRA, professional driving policy etc. incidents still happen.

I imagine these targets are a way of measuring how effective preventative strategies are. If a given TOC has 100 SPADs a year, introduced commentary driving and this went down to 20, this would be considered a success. If the figure started creeping up again they'd start asking why.

That said, at my place, there's an unhealthy obsession with statistics!

 

[ComUtoR]

I see your point and raise you another.

What if there was a way to prevent a specific incident. And I mean pretty much eliminate it altogether. Would you still mitigate and reduce the incident or eliminate it ?

At what cost ? Because, there is and always will be a cost. (not always financially either)

Keeping it within the realm of being on topic. At what point does it becomes the TOC's responsibility ?

Not to specifically blame the TOC but surely a portion of the responsibility must be down to the TOC policies, procedures, practices, training etc.