'The Toss of a Coin', Chapter 14 / 1

International railway safety consultant

The first time came as a surprise. It was the summer of 1989 and I’d just finished acting as the main liaison with BR’s legal team at the Clapham Junction Judicial Inquiry. I was approached by the BR international consultancy organisation, Transmark, to ask if I would be prepared to spend three weeks in Western Australia advising the Freight Manager of Westrail, Martin Baggott, based in Perth, on quality management. All my work on TQM in the UK had been applied to the passenger businesses, but I didn’t see why the same principles shouldn’t work for freight traffic also and the thought of a funded trip to Australia was a big temptation, so I accepted.

The main freight activities of Westrail were between Perth and Kalgoorlie where trains for the transcontinental route across the Nullarbor Plain were marshalled. I spent sometime with Martin gathering data about the causes of unpunctuality and complaints and then assessed and prioritised the investment necessary to make serious improvements – in many ways a similar exercise to the study I’d done for John Nelson and John Prideaux on the East Coast Main Line in the UK. It was spring in Australia and I shall never forget the profusion of wild flowers I saw on that trip, including some very exotic ones in and around Perth and Freemantle.

The Transmark consultant in Australia wanted me to return home via Sydney and meet some of the railway people there, but there was an internal air strike going on and that brought home to me just how remote Perth was from any other city. The only way I could reach Sydney was via a 17 hour flight to Singapore and back to New South Wales, so we agreed that visit would have to be postponed. I spent a couple of days on the return journey sightseeing in Singapore and then 48 hours in Bombay visiting the girl and her family, whose education my own family sponsored through ‘Save the Children’. This visit had enormous repercussions to be recounted later in chapter 15.

On my return I became Project Manager for the Du Pont Safety Management Review, Brian Burdsall succeeding me as BR’s Quality Manager. This led to an intensive three years’ work as Head of Safety Policy before another overseas opportunity arose. In March 1992 my presence was requested in South Africa. The nationalised transport industries of South Africa were being privatised starting with the national airline, and plans were being discussed for Spoornet, the state railway company. The South African Spoornet top managers were engaging with government on the legislation required for safety of the railways and seemed to think that something like the operating rulebook could be enshrined in law.

However, before signing off they arranged a conference and invited three safety specialists from different regulatory regimes – a senior manager from the Federal Railroad Authority (FRA) of the United States, an Italian from the European Union of Railways (UIC) and Alan Cooksey, Deputy Chief Inspector of the UK Railway Inspectorate. For some reason I cannot now remember, Alan was not available and I was asked to go in his place. Each of us described our systems to the Spoornet and South African Ministry of Transport officials. I remember the American advising the South Africans to avoid the FRA approach at all costs – it was far too prescriptive although probably essential for the USA which had over 600 independent railroads, many of them comparatively small. The Italian reeled off the lists of standards that were being laboriously developed by the UIC and my description of the UK Safety Case regime which had just been agreed as the means of validating the new privatised train operating companies aroused most interest.

The conference was taking place in a small game park about 40 miles from Johannesburg – it was novel to wake up and see the middle part of a giraffe’s neck passing the window – and about midway through the proceedings the result of the referendum about negotiations to end Apartheid was announced. The managers were relieved at the outcome – they feared revolution had the vote been for Apartheid’s retention – but now realised that probably within months they might have an ANC Minister of Transport who may well wish to see investment in the suburban railways into the townships. I was asked by the Chairman of Spoornet how I would apply a Safety Case to the Soweto suburban railway and I merely stated that he would need to identify the highest risks first from accident and incident data collected. I asked him what he thought his greatest risks were.

‘Oh, that’s easy,’ came the reply, ‘we have on average five murders a week on the suburban service.’

He went on to tell me that they locked a driver in at either end of the EMUs as it was too dangerous to walk up the platform at the Soweto terminus. He also told me that the average life expectancy of a travelling ticket collector on that service was six weeks – although I found that difficult to comprehend. I’m not sure if he meant literally ‘life expectancy’ or whether no-one was prepared to do the job for more than six weeks. On any criteria no other railway management I knew would contemplate running a service at such a high risk.

When the conference was over, celebrated by a traditional Zulu dinner and dancers from a local native village, I suddenly found that the last planned days of my visit were to be spent with my American and Italian colleagues as guests of Spoornet on the Blue Train all the way to Cape Town with 36 hours sightseeing there on the Table Mountain and at the Cape of Good Hope before returning home.

A couple of months later in May 1992 I was asked by an Australian consultant, David Hyland, to undertake some work to underpin investment priorities for Sydney’s City Rail network. In previous years I had engaged David to help me develop prioritisation of investment cases for the infrastructure departments of BR as part of my reliability remit. He now wanted something similar for City Rail – the management were looking to see if modernisation of the system or its replacement by road was the best option. I spent a couple of weeks undertaking this work with David – including a Sunday sailing in David’s yacht under the Harbour Bridge and in front of the Sydney Opera House – and when it had been successfully concluded I was invited to visit Bill Casley, whom I’d met previously on one of the annual railway safety conferences when he was the Executive Director of the New South Wales Transport Safety Bureau, and was now heading the Australian national rail regulatory authority in Canberra.

I went by train from Sydney to Canberra, not a particularly fast or popular journey, and when I’d finished there I found myself invited to fly to Melbourne to spend just an evening meeting the Victoria State railway team led by Ian Dobbs who had been a very young Area Manager I’d appointed – with some reluctance from my Operating colleagues – to the post of Area Manager Watford. They were all very keen to hear of the changes BR had made in safety management since Clapham and, in particular, about risk management and the prioritisation of investment by the use of cost-benefit analysis.

In 1994 I was asked by David Churchill, formerly a BR Manager, now Head of the transport safety regulatory body of Canada in Ottawa, to spend time with him and his department applying some of the methodology of safety management that I’d helped to implement on BR. I was asked to go to Montreal to meet both managers and trade union officials of VIA Rail and was invited to travel there in the cab of a massive diesel electric locomotive on a ‘huge’ load of four ‘tilt’ coaches with a few desultory passengers. The trip was mainly memorable for the number of open crossings over which we screamed with horn blaring, and the number of times the driver and inspector pointed out otter dams being built in streams and wetlands beside the track which – unless dismantled - would flood and damage the permanent way.

Earlier, in 1992 David Rayner and I had visited Wellington in New Zealand as part of the annual safety seminars we’d set up after the Tokyo safety conference in 1989 and we’d developed a high regard for the privatised Tranzrail’s safety management system which their Safety Director, Ray Ryan, had devised with help from an academic, Professor David Elms from Christchurch University.

It was with some concern, therefore, that we learned that Tranzrail (TZ) was being prosecuted in the Crown Court over the severe injury to a six year old boy who’d fallen several years before from the coach end veranda of the Coastal Express running between Picton and Christchurch in the South Island. Apparently the transport regulatory authority had failed to make any case against Tranzrail within the allowed timescale, and such was the public and media concern that the Crown Prosecutor had charged Tranzrail with ‘unlawful killing’, a very serious charge, even though the accident had occurred before privatisation.

Tranzrail asked BR to send someone to review their safety systems and give evidence in court for the defence as an expert witness and David asked me to go. I spent the month of December 1995 in Wellington being briefed by Tranzrail’s QC and Ray Ryan, with John Mitchell, a senior BR mechanical engineer who’d been asked to examine Tranzrail’s engineering standards and practices as the accident had occurred through the failure of a metal handrail which had come adrift as the boy passed through the veranda and fallen from the train as it lurched.

I went painstakingly through all the safety documentation in the legal office with Ray and began to write my evidence of what I found. I paid particular attention to TZ’s accident information system for the company admitted that an unauthorised local depot modification to the handrails in 1981 had led to the failure – apparently the coaches were so old (1936 vintage) that standard replacements were unavailable and the depot people in Christchurch had improvised without Headquarter’s authority. If previous similar accidents or failures had been reported and nothing done, either the communication and information system had a weakness or management at the time had been negligent.

I found that Ray Ryan and his colleagues had introduced a very robust safety information system in the late 1980s and had painstakingly briefed it in throughout the system. In fact we discovered that there had been one or two incidents without causing any injury and local people had grumbled – but as so often is the case – no-one had reported it to their management.

The other major area I took an interest in was the vigour of their safety audit system, the extent to which management checked that the systems they had introduced were being implemented in practice. Again I found a robust system, well documented in both its processes and visits and findings carefully logged. At the end of the month I completed some forty pages of evidence that I was prepared to give indicating not only the strengths of these particular procedures but also that in my opinion TZ’s safety management systems were well ahead of the majority of national rail organisations at that time. I then relaxed by enjoying an evening of carol singing on the beach in the warm evening sunshine and went home for Christmas.

The case was to be heard in Wellington’s Crown Court in February 1996 and I duly went out and listened for the first fortnight to the prosecution case. The police had searched the TZ offices for relevant evidence and had taken copies of everything they thought useful in the case and the prosecution had hired an expert witness also, another safety consultant from the UK of whom I’d heard, but had had no dealings. My role during this time was to advise the defence QC on points made by the prosecution relevant to my area of knowledge and I was astonished to hear the expert they’d hired claim that TZ had no safety information or audit systems. During cross-examination, our QC handed the witness a copy of TZ’s safety audit system and asked him what he thought it was.

The man was most embarrassed and had been let down badly by the police who’d failed – in their ignorance – to find and select the relevant paperwork for the case. A series of witnesses claimed that they knew about the handrail design defect but had to admit under cross-examination that they were unaware that management had been advised. When the prosecution case had been completed and John Mitchell went into the witness box, he’d only begun to read his evidence when, at the end of the day the judge called the lawyers to his chambers and asked if the defence wanted to submit that – after hearing the prosecution case rebutted so strongly – there was no case to answer. We had a long debate that evening trying to tease out any potential drawbacks from taking up the judge’s suggestion and concluded we were being given a very strong hint by the judge that he felt the prosecution had failed to make their case. We therefore made our submission in the morning and after an hour’s deliberation, the court resumed to hear the judge dismiss the case through lack of evidence.

There is no doubt that the New Zealand regulatory authority could have made a successful prosecution using health & safety legislation even though the accident happened under a previous management and the defect causing the accident had occurred some 15 years previously. However, there was no way that the serious accusation of ‘unlawful killing’ could have been upheld. Even so, it had been a great strain for Ray Ryan and others most closely involved.

I was now faced with complex return flight arrangements and important assignments planned in India en route meeting people about the start up of some of the recently founded Railway Children charity projects in India. I therefore decided to let the arrangements stand and hired a car and spent nearly two weeks exploring the South Island ‘on holiday’ – my wife and son had joined me in 1992 at the safety conference and we’d had a ‘taster’ then of the beauties of the South Island as well as special train trips to the North Island volcanoes and Rotorua.

Fourteen years later I encountered an extraordinary coincidence. I was standing on the platform at Crewe waiting for a London train and there had been a major disruption. I saw an elderly couple on the platform looking bemused and offered to help. They turned out to be tourists from New Zealand and we got chatting – my 1995/6 visit came up in conversation – and then, extraordinarily, the man turned out to have been the schoolmaster of the young boy who’d fallen from the Coastal Express! What’s more, they’d kept in touch with him and were able to tell me that despite his severe injuries, including blindness, the boy was now a university student doing well and nearing graduation. I was able to feed this back to Ray Ryan and John Mitchell to round off the experience.