4 What’s changingFair culture flowchart to be used where an unsafe act is identifiedAll alleged breaches of lifesaving rules to be investigatedRevised trade union participationIndependent review panelsRevised templates
5 What’s staying the same? Investigate what happened and identify immediate causeInvestigate why it happened and identify underlying causesUse the 10 Incident Factors and Investigator Prompts
6 The remit Essentially the same Simplified template for local investigationsNew requirement in the general objectives section
7 The remit – general objectives The investigation team is required to investigate the circumstances of the accident/incident, including the following:identifying the events leading up to the accident/incident,identifying the immediate and underlying causes, including:the relevance of the 10 incident factors (guidance on these is provided in Part 4 of the Investigators’ Handbook), andrelevant management issues/processes;identifying the behavioural cause of any unsafe act using the fair culture flowchart;consideration of previous accidents/incidents of a similar nature;consideration of the findings/intelligence from relevant audit/assurance activity (guidance on this is provided in Part 2 of the Investigators’ Handbook);consideration of the specific objectives listed below (as far as they are relevant).January SLCC
8 TU participation Much wider participation Focus on role as Safety Reps Move towards participation rather than representation – part of the investigation teamArrange participation through the central contact list on ConnectInvite the TU that is appropriate for the grades being interviewed/involved
9 TU participationA trade union representative should be invited to join the investigation team for the following:Where the investigation team intend to interview staff (they should invite the TU(s) appropriate to the grades involved);An investigation that includes a potential breach of a lifesaving rule;A fatality to any person in a train accident (excl. suspected suicide or trespass);A collision between trains on a running line where there is injury to at least one person or significant damage;the derailment of an ‘in service’ passenger train, except where the derailment occurs at low speed (i.e. less than 20mph);A fatal or life changing injury to a member of the workforce employed by or contracted to Network Rail whilst at work/on duty;Other accidents or incidents where Network Rail and a trade union agree that the participation of a TU observer would be beneficial.
10 The investigationInvestigations that previously would have subject to investigationFollow your training/Investigators’ HandbookArrange TU participation through contact list on ConnectUse the 10 Incident Factors and Investigator PromptsUse the fair culture flowchart to classify any unsafe actsMay need to be validated by the Independent Review PanelInvestigations where the incident is the breach of the lifesaving ruleAs aboveRemember we are investigating the safety incident not the individualJanuary SLCC
11 10 Incident FactorsThe 10 Incident Factors sit at the core of our investigation processPart 4 of the Investigators’ HandbookInvestigator promptshelp investigators establish what Incident Factors might have been causal or contributory to an accident or incidentPart 2 of the Investigators’ HandbookLatest version (2.1)
12 10 Incident Factors Communications Knowledge, skills and experience The Incident Factors support the investigation of any incident or accidentThey provide investigators with prompts that can be used to generate potential areas of investigation and to check that all possibilities have been exploredCovers 10 key areas which have been identified as common underlying and contributory factors in incidents and accidentsCommunicationsKnowledge, skills and experiencePractices and processesSupervision and managementInformationWork environmentWorkloadPersonalEquipmentTeamwork
13 An exampleDuring Temporary Block Working (TBW) the signaller failed to reach a clear understanding with a handsignaller at the start of TBW, regarding the handsignallers action in relation to a train stood at the signal protecting the TBW section.As a result the handsignaller allowed the train to enter the section believing he had authority from the signaller to do so. This resulted in two trains being in the TBW section at the same time.A review of the conversation revealed that the signaller did not ensure that the handsignaller fully understood what was required in relation to the train that was stood at the signal.
16 Report – revised section A Event summary, conclusions, recommendations and local actionsSummary of the accident/incidentImmediate causeBehavioural cause (using fair culture flowchart)Underlying causeOther safety related issues identifiedRecommendationsLocal actions
17 Example Behavioural cause (using fair culture flowchart) The IWA was in breach of the Lifesaving Rule: Always have a valid safe system of work in place before going on or near the line. In accordance with the ‘fair culture flowchart’ the investigation team concluded that this was a ‘contravention’ (see section G3 of this report).Local actionsThe section manager should consider the behavioural cause of the identified breach of the lifesaving rule by the IWA in accordance with the consequences table and take appropriate action (see section A4.1 of this report).The IME should review the behavioural cause of the identified breach of the lifesaving rule with the section manager (as the IWA’s line manager) and take appropriate action in accordance with the consequences table (see section A4.1 of this report).
19 Independent review panel WhoRSIM, HRBP, Independent senior manager, TU H&S repSupport from Ergonomics, Senior Investigator, Change Consultant as requiredWhatCheck fair culture flowchart has been used correctlyThat report supports the decisionAll investigations where malicious intent/personal benefit identified, sample of othersWhenSent to Panel by DCP once they are satisfiedAn interim report may be considered if more time is needed to develop underlying causes and recommendationsWhere Panel disagrees with report discuss with DCP/Lead and require further investigation
20 Refresher trainingMandatory for those wishing to maintain their Lead Investigator competenceTo be completed between July 2013 and June 2014Human factors e-learningOne day workshop focusing on:Using the 10 Incident Factors to prepare for interviewEffective interview techniqueApplying the fair culture process
21 Advice and support Accident Investigation pages on Connect Guide to the 10 Incident FactorsGuide to using the Fair Culture flowchartFair culture FAQSenior InvestigatorsChange ConsultantsAccident Investigation ForumDial in surgeriesFridays at 2pm (June 14, 21, 28)Dial then passcode followed by #
22 A ‘series’ process Safety investigation A remitted accident/incident investigation.TU participation10 Incident Factors‘Behavioural cause’Unsafe acts classified using the flowchart.Underlying causes identified as usualReview PanelAll cases of malicious or personal benefit to be verified by Panel.May be returned for further investigationConsequenceCoaching, etc tracked as local actions at RRP.Any formal disciplinary to commence after Panel verification