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Greg Morse LHSBR Editor and Operational Feedback Lead - Health and Safety Management A Better, Safer Railway
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Greg Morse LHSBR Editor and Operational Feedback Lead ...

Mar 22, 2022

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Page 1: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Greg MorseLHSBR Editor and Operational Feedback Lead -

Health and Safety Management

A Better, SaferRailway

Page 2: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 3: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Travelling by rail hasn’t been easy recently – for any of us.

But now all Britain’s rail companies are pulling together –

doing whatever it takes to return you to a national rail network you

can depend on.

Page 4: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Wednesday 17th October 2001

Page 5: Greg Morse LHSBR Editor and Operational Feedback Lead ...

20

4060

80

100

1200

Mile/h

20

40 60

80

1000

Brake pipe

Page 6: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Four fatalities

70 injured

Four seriously injured, including two members of staff

Page 7: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 8: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 9: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 10: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 11: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 12: Greg Morse LHSBR Editor and Operational Feedback Lead ...

20mph

20mph

20mph

20mph

20mph

Page 13: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Alastair Morton

Chairman of the Strategic Rail Authority

Page 14: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 15: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 16: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Gauge corner

Page 17: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 18: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 19: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 20: Greg Morse LHSBR Editor and Operational Feedback Lead ...

An incomplete appreciation of the risks presented by gauge

corner cracking, and

A consequent failure to develop and disseminate comprehensive

instructions on its identification and the control measures

required’.

Page 21: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Contact point

Page 22: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 23: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 24: Greg Morse LHSBR Editor and Operational Feedback Lead ...

U3ProbeU14

Probe

Sep 2000Mar 1995

Page 25: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Sep 2000

Page 26: Greg Morse LHSBR Editor and Operational Feedback Lead ...

U3Probe

untestableTotal loss of

rail bottom

Page 27: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Jan 2001

Jul2000Jun

2000May 2000Apr

2000Mar 2000Nov 1999

Page 28: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Oct 92000

Page 29: Greg Morse LHSBR Editor and Operational Feedback Lead ...

100mph

Page 30: Greg Morse LHSBR Editor and Operational Feedback Lead ...

100mph

Page 31: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 32: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 33: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 34: Greg Morse LHSBR Editor and Operational Feedback Lead ...

I have never been trained to recognise Gauge Corner

Cracking or understand what risks it brought with it.

Page 35: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Target 6 per year

1997 1998 1999 2000

Trac

k w

alks

Target 6 per year

1997/88 1998/99 1999/00

Cab

rid

es

Page 36: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 37: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 38: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Railtrack LNE Compliance and Engineering Manager –Was unable to follow a discussion of track work at Hitchin because

he didn’t understand its technical nature.

The Zone Quality Standards Manager -Had neither ‘knowledge of railway engineering nor railway safety’

Page 39: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Piper Alpha 6-7th July 1988167 fatalities

Page 40: Greg Morse LHSBR Editor and Operational Feedback Lead ...

David Ventry, Professional Head of Track at Railtrack HQ.

‘a key driver in the rise in the number of broken rails is the current poor maintenance or, more precisely, the lack of adequate and

appropriate maintenance’.

Nov 1999May 1999

Page 41: Greg Morse LHSBR Editor and Operational Feedback Lead ...

David Ventry, Professional Head of Track at Railtrack HQ.

the current state of the track on parts of our network [was] heading towards the boundary of acceptability’,

there was ‘widespread noncompliance’ with track maintenance standards and good practice.

the ‘balance between commercial drivers and safety’ was ‘overwhelmingly towards the commercial’

Nov 1999May 1999

Page 42: Greg Morse LHSBR Editor and Operational Feedback Lead ...

1997/88 1998/99

Bro

ken

Rai

ls

21%

755

937

Page 43: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Tom Windsor Rail Regulator

More clarity on what Railtrack deemed acceptable?

Nov 1999Aug 1999

Page 44: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Nov 1999Aug 1999

Project Destinystrategy

Replacing assets only when necessary and

not at fixed time

Need excellent knowledge of one’s

asset condition

Page 45: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Nov 1999Aug 1999

Project Destinystrategy

Replacing assets only when necessary and

not at fixed time

Asset?

Condition?

Expiry?Asset

Database

Page 46: Greg Morse LHSBR Editor and Operational Feedback Lead ...

‘that he alerted senior colleagues to the non-compliant state of rail maintenance, however, Railtrack as an organisation, failed to implement

and monitor his advice to ensure rails were properly maintained’

David Ventry, Professional Head of Track at Railtrack HQ.

Page 47: Greg Morse LHSBR Editor and Operational Feedback Lead ...

May 2000Jan

1999Early 1998

Poor Maintenance

Non-compliance with standards

Zone DirectorNick Pollard

Please investigate

it [was] very clear from recent events that [it was] not providing resources adequate to tasks and scope of the

maintenance contract’

Page 48: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Nov 2000May 2000Tom Windsor

Rail Regulator

Transport Technology

Centre

Metallurgy

Ultrasonic railflaw detection

Wheel-rail interaction

Brake design Suspension design

Page 49: Greg Morse LHSBR Editor and Operational Feedback Lead ...

20022001

2001 2002

Pro

fits

£733m Hatfield compensation

and costs

£200m

£-200m

£199m

£534m

Nov 2000

Page 50: Greg Morse LHSBR Editor and Operational Feedback Lead ...

The Health and Safety at Work etc Act 1974

£10,000,000+

£300,000

Sept 20052002

£3,500,000+

£300,000

Page 51: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Sept 2005

Page 52: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Sept 2005

Page 53: Greg Morse LHSBR Editor and Operational Feedback Lead ...

2000Sept 2005

Safety Case containing a Safety Management

System

Page 54: Greg Morse LHSBR Editor and Operational Feedback Lead ...

April20062000

Safety Certificate or Safety Authorisation

Page 55: Greg Morse LHSBR Editor and Operational Feedback Lead ...

April2006

Ladbroke Grove Accident 1999

Lord Cullen Inquiry

Railway Safety

Page 56: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Railway Safety

RiskAnalysis

Standards ReportingResearch and Development

System Interface Committees

Vehicle/Track systems interface

Vehicle/Structures

systems interface

Vehicle/Train Energy systems

interface

Whole system interface

Data & Information

systems interface

Vehicle/Train control &

communications

Vehicle/Vehicle system interface

Page 57: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Vehicle/Track systems interface

Vehicle/Structures

systems interface

Vehicle/Train Energy systems

interface

Whole system interface

Data & Information

systems interface

Vehicle/Train control &

communications

Vehicle/Vehicle system interface

Page 58: Greg Morse LHSBR Editor and Operational Feedback Lead ...
Page 59: Greg Morse LHSBR Editor and Operational Feedback Lead ...

1970-2010 2010 - 2020

Bro

ken

Rai

lsA

vera

ge p

er

year

400

200

750 per year

150 per year

600

800

Page 60: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Corporate Memory ?

Page 61: Greg Morse LHSBR Editor and Operational Feedback Lead ...

Greg MorseLHSBR Editor and Operational Feedback Lead

Health and Safety Management

A Better, SaferRailway