1. Fair culture investigations

2. Fair culture principles
What’s changing/staying the same
The remit
TU participation
The investigation
10 Incident Factors
Fair culture flowchart
The report
Independent review panel
Refresher training
Advice and support

4. What’s changing
Fair culture flowchart to be used where an unsafe act is identified
All alleged breaches of lifesaving rules to be investigated
Revised trade union participation
Independent review panels
Revised templates

5. What’s staying the same?
Investigate what happened and identify immediate cause
Investigate why it happened and identify underlying causes
Use the 10 Incident Factors and Investigator Prompts

6. The remit Essentially the same
Simplified template for local investigations
New 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), and
relevant 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 team
Arrange participation through the central contact list on Connect
Invite the TU that is appropriate for the grades being interviewed/involved

9. TU participation
A 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 investigation
Investigations that previously would have subject to investigation
Follow your training/Investigators’ Handbook
Arrange TU participation through contact list on Connect
Use the 10 Incident Factors and Investigator Prompts
Use the fair culture flowchart to classify any unsafe acts
May need to be validated by the Independent Review Panel
Investigations where the incident is the breach of the lifesaving rule
As above
Remember we are investigating the safety incident not the individual
January SLCC

11. 10 Incident Factors
The 10 Incident Factors sit at the core of our investigation process
Part 4 of the Investigators’ Handbook
Investigator prompts
help investigators establish what Incident Factors might have been causal or contributory to an accident or incident
Part 2 of the Investigators’ Handbook
Latest version (2.1)

12. 10 Incident Factors Communications Knowledge, skills and experience
The Incident Factors support the investigation of any incident or accident
They provide investigators with prompts that can be used to generate potential areas of investigation and to check that all possibilities have been explored
Covers 10 key areas which have been identified as common underlying and contributory factors in incidents and accidents
Communications
Knowledge, skills and experience
Practices and processes
Supervision and management
Information
Work environment
Workload
Personal
Equipment
Teamwork

13. An example
During 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.

14. Fair culture flowchart

15. Fair culture flowchart

16. Report – revised section A
Event summary, conclusions, recommendations and local actions
Summary of the accident/incident
Immediate cause
Behavioural cause (using fair culture flowchart)
Underlying cause
Other safety related issues identified
Recommendations
Local 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 actions
The 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).

18. Does the ‘description’ fit?

19. Independent review panel
Who
RSIM, HRBP, Independent senior manager, TU H&S rep
Support from Ergonomics, Senior Investigator, Change Consultant as required
What
Check fair culture flowchart has been used correctly
That report supports the decision
All investigations where malicious intent/personal benefit identified, sample of others
When
Sent to Panel by DCP once they are satisfied
An interim report may be considered if more time is needed to develop underlying causes and recommendations
Where Panel disagrees with report discuss with DCP/Lead and require further investigation

20. Refresher training
Mandatory for those wishing to maintain their Lead Investigator competence
To be completed between July 2013 and June 2014
Human factors e-learning
One day workshop focusing on:
Using the 10 Incident Factors to prepare for interview
Effective interview technique
Applying the fair culture process

21. Advice and support Accident Investigation pages on Connect
Guide to the 10 Incident Factors
Guide to using the Fair Culture flowchart
Fair culture FAQ
Senior Investigators
Change Consultants
Accident Investigation Forum
Dial in surgeries
Fridays at 2pm (June 14, 21, 28)
Dial then passcode followed by #

22. A ‘series’ process Safety investigation
A remitted accident/incident investigation.
TU participation
10 Incident Factors
‘Behavioural cause’
Unsafe acts classified using the flowchart.
Underlying causes identified as usual
Review Panel
All cases of malicious or personal benefit to be verified by Panel.
May be returned for further investigation
Consequence
Coaching, etc tracked as local actions at RRP.
Any formal disciplinary to commence after Panel verification