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United States Department of Transportation United States Department of Transportation

Confidential Reporting: the UK Rail Experience

Document Series
Aidan Nelson
Subject Risk Reduction Program
Workshop: Improving Railroad Safety through Understanding Close Calls
Aidan Nelson Presentation:
Confidential reporting: the UK rail experience


Slide 1
Rail Safety & Standards Board


Slide 2
Confidential reporting:
the UK rail experience

Aiden Nelson
Director Policy amd Stadards
23 April 2003


Slide 3
History or reality today? [illustration of dual railroad tracks]


Slide 4
Has anything changed?

&##39;&##39;Engine drivers constantly complain .... of
the way in which signalls are placed; but it
is only in rare cases or after an accident
has actually occurred .... that
improvements are introduced&##39;&##39;

&##39;&##39;On several occasions the author has
examined signals where drivers have
made mistakes, and in every case has
found the true cause was the
defective state or position of the signal&##39;&##39;


Slide 5
Company or the individual?

&##39;&##39;Accidents constantly occur through the
defective system of working adopted by
the companies, but .... whatever the
system, when the accident causes the
death of a person, the railway servants are
liable to a charge of manslaughter&##39;&##39;


Slide 6
Blame them not us?

&##39;&##39;It has always been the custom, whenever
an accident happens, for the companies to
.... try to place all the blame on some
servant, in order that he may be punished,
and the responsible officers who are
really to blame for neglecting to provide
proper appliances may escape scot free&##39;&##39;


Slide 7

Safe Railway Working by Clement Stretton

Published: 1893


Slide 8
Experiment to national system
[illustration of video consoles in a rail control facility]


Slide 9
Rapid change in level of commitment

* Summer 1999

    A growing level of volunteer company interest

    Industry conference - support in principal but
    funding generally not in business plan

* Autumn 1999

    Cataastrophic rail accident

    Parliamentary interest

    All Railway Group now committed


Slide 10
Developing the national system

Broadly based industry steering group led
and facilitated by RSSB predecessors
managed the process

Concerns as to cost led to engagement of
&##39;&##39;newcomers&##39; being conditional on there
being a competitive procurement strategy

Core service provider contracted
nationally, regional centres funded by a
levy on number of staff enrolled


Slide 11
Some problems on the way

The transition from academically provided
to commercially provided service was not
without pain

IPR issues led us to a new taxonomy and
reverse fitting historic data to it

Issues of trust and confidentiality led to the
creation of a trust to own the taxonomy,
the data itself and to license use of system

Creative counting of staff to be enrolled


Slide 12
Commitment has to be underpinned

Railway Group Safety Plan

Railway Group Standard directly mandates enrolment of safety critical staff employed by Network Rail and train operators (The Railway Group)

Supply chain to Railway Group members has to be handled within contractual framework


Slide 13
But we have an open safety culture

Some organisations still feel they don’t need CIRAS

However the nature of the reports into the system illustrates that there is still a widely held concern that &##39;&##39;blame&##39;&##39; is alive and well in management thinking

Watch for local managers keeping the supply of CIRAS forms under surveillance


Slide 14
Why report to CIRAS?

Quite a few early reports are to test the system, in particular that it really is confidential

Because when I reported an issue openly nothing was done and we know that the CIRAS system guarantees a response

CIRAS operates across organisational boundaries


Slide 15
Quality of response

Too often the managerial response to a CIRAS report is defensive

This often reflects that the responding manager feels that self justification is necessary within the organisation

Independent peer review of responses raises quality considerably


Slide 16
Our role in CIRAS [illustration of bus, passenger car, and pedestrians at rail grade crossing with train approaching]


Slide 17

We facilitate, fund and act as managing agent for the CIRAS Trust

Our nominated trustee chairs the Trust

We facilitate the independently chaired industry steering group on which we have membership

We fund the independent chair of the industry steering group


Slide 18

We fund the core CIRAS facility and recover the costs from the general funding of RSSB

We provide procurement services

We undertake the annual census of enrolled staff

We undertake research to review the effectiveness of the system ?e.g. CIRAS journals


Slide 19
We too are members of CIRAS

All our staff are within the scope of the system

We also provide the lead managerial response on issues related to ambiguity in and /or the interpretation of the Rule Book and other Railway Group Standards


Slide 20
RSSB CIRAS Committee (1)

Newly formed, operates in the context of our safety leadership role within the rail industry

Works principally from CIRAS national report cross referenced with wider industry safety performance data and intelligence

Will request additional analysis from the CIRAS core facility as requires


Slide 21
RSSB CIRAS Committee (2)

Determines necessary RSSB action:

    Identify issues for further research

    Key issues monitored within quarterly
    and annual safety performance reports
    or generates a requirement for special
    topic reporting

    Influence Railway Group Safety Plan,
    national initiatives and standards

    Identify sources of risk for
    discussion at the RSSB risk review

    Initiate topic based workshops

Monitors progress / close out of actions


Slide 22
In conclusion: [illustration of rail worker on railroad tracks]


Slide 23
In short

Don’t underestimate the management challenges in creating a high integrity confidential reporting system

Don’t see it as a &##39;&##39;bolt on&##39;&##39;, rather See it as an integral component of your wider human error management programme

Champion and lead development from within the industry to create ownership and minimise scepticism


Slide 24
Rail Safety & Standards Board

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Last updated: Wednesday, April 23, 2003