1. 1 Achieving Excellence: The ORR Railway Management Maturity Model Neil Anderson – HM Inspector of Railways

2. Have you really assessed your risks?

3. Have you really weighed the options?

4. Are the controls effective?

5. 5 Do we always see the bigger picture?

6. 6 Challenger Rule based decision to launch Cultural understandings, rules, procedures that had worked before failed Organisational acceptance of deviance – wrong safety critical designation Problems in reporting systems for issues Asked the wrong question – why is it unsafe to launch?

7. 7 Haddon – Cave Nimrod report The Loss of RAF Nimrod XV 230 – Afghanistan 2006 A Failure of Leadership, Culture and Priorities  The Nimrod Safety Case process was fatally undermined by a general malaise: a widespread assumption by those involved that the Nimrod was ‘safe anyway’ (because it had successfully flown for 40 years) and the task of drawing up the Safety Case became essentially a paperwork and ‘tick-box’ exercise.

8. 8 “Auditors have tended to chase ‘paper trails’ rather than check what is actually taking place on the ground.”

9. 9 “Reviews and inspections tend to focus on confirming whether relevant processes are in place, rather than.. …whether the processes are, in fact, having the desired effect

10. 10 Haddon – Cave Nimrod report The lessons to the learned from the loss of Nimrod XV230 are profound and wide-ranging. Many of the lessons to be learned are not new. The organisational causes of the loss of Nimrod XV230 echo other major accident cases, in particular the loss of the Space Shuttles Challenger and Columbia, and cases such as the Herald of Free Enterprise, the King’s Cross Fire, the Marchioness Disaster and BP Texas City.

11. Olympic Park London – the real legacy 11 Leadership Worker Involvement Culture Change Communication Systems Contracts and Procurement Risk Management Monitoring Assurance All key to the safe delivery of the Olympic park project

12. 12 ‘If you can’t describe what you’re doing as a system you don’t know what you are doing’ W Edwards Denning

13. ‘Take care of the process and the outcomes will take care of themselves’ - Dave Brailsford, Head Coach UK Cycling and Team Sky

14. Strategy

15. Ever decreasing safety risk Excellence in risk control Excellent Safety Culture Management System Organisational Culture Safety Management System Inspection Safety Climate Surveys (Industry led) Risk control system / workplace precautions Inspection Our Corporate Strategy

16. Inspection of a work siteManagement system inspection Observation of conditions Documents Interviewing people 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Observation Documents Interviewing Observation Documents Interviewing

18. What excellence looks like Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit

19. Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit Policies are forward-thinking are based on solid evidence of what is achievable. promote a consistent approach at all levels. Leaders at all levels set and communicate clear direction reinforces a consistent approach reinforce the values, ethics and culture needed to meet objectives. Governance arrangements ensure the organisation remains accountable for the health and safety of its workers and members of the public affected by their work. What excellence looks like

20. Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit Excellent organisations: are structured to aid implementation of the organisation’s policies into practice as efficiently as possible. provide highly effective communications up, down and across the organisation. ensure there is a clear understanding of how each person’s targets achieves the overall business objectives. provide the framework for using people, plant and processes successfully. What excellence looks like

21. Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit Excellent organisations ensure that: the competencies (knowledge, skills, experience and abilities) needed to work effectively, efficiently and safely are understood by the organisation. employees are actively involved in developing processes and making the business successful and safe. recruitment, selection, training and continued development focus on meeting the organisation’s objectives. What excellence looks like

22. Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit Excellent organisations ensure the systematic implementation of processes to make sure that the plant, people and processes are continually improving their effectiveness and efficiency to achieve the organisation’s objectives safely. What excellence looks like

23. Governance, Policy and Leadership; Organising for delivery of control and communication; Cooperation, competence and development of employees at all levels; Planning and implementing risk controls Monitoring, review and audit Excellent organisations: Fully understand the risks of the organisation Monitor, audit and review the risk controls, based on the criticality and vulnerability of them Use appropriate monitoring at all levels Recruitment, selection, training and continued development focus on meeting the organisation’s objectives Review variations from expected outcomes Seek good practice from inside and outside of the organisation What excellence looks like

24. 24 RM3 – Time to get involved

25. 25 SP3 – Board Governance Defining your tolerance to risk Defining and communicating your health and safety goals and performance measures Establishing business structure and workflows to meet those goals Developing and communicating policies to guide actions of employees Making sure the responsibilities and activities of each parts of the organisation work together to control health and safety risk Monitoring the workflows of different parts of the organisation and how those parts relate to each other

26. 26 RM3 - Over to you Criteria for the various levels of performance for SP3 “Board Governance” follow… How do you think you’re doing as a Board? What’s the evidence for your view?

27. 27 RM3 – SP3 – Board Governance Level 1 – Ad Hoc The Board shows little or no consideration of health and safety Level 2 – Managed Executive management bring activities in line with the organisation’s goals. They approve, measure and manage the business activities of the organisation’s individual parts Board is not as thorough as possible in reviewing the effectiveness of risk controls within the organisation Little difference between the role of the board and the role of the executive

28. 28 RM3 – SP3 – Board Governance Level 3 – Standardised The board and executive show a clear, wide ranging understanding of the business as a system It is clear how responsibilities relating to health and safety are defined both between the board and the executive management Level 4 – Predictable Non execs have strong, independent role in challenging safety issues H&S recognised as part of organisation’s overall risk Appropriate training is provided to board members (esp. non execs) so they understand the business risk of the organisation

29. 29 RM3 – SP3 – Board Governance Level 5 – Excellence Board shows a balanced approach to continuous improvement, looking for examples of good practice from outside the organisation that add value Execs show commitment to identifying areas for improvement and actively manage these Non-execs are ready, able and encouraged to test strategies put forward by execs Organisation knows about and regularly measures its activities against recognised good practice Board conducts formal and extensive evaluation of its own performance against H&S objectives

31. conversation