REPORTING AND INVESTIGATION SAF04 - VolkerRail

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REPORTING AND INVESTIGATION SAF04

Issue no: 4 Date: 05/02/2020 Parent document: SAF04

Approved for IMS: IMS Coordinator Document owner: HSQES Director Workspace file: N/A Page 1 of 25

1. PURPOSE

The purpose of this procedure is to specify the management process for the reporting and subsequent investigation of unplanned events. An unplanned event includes work-related injuries, occupational illnesses, damage to plant and equipment, damage / contamination of the infrastructure, nuisance complaints, road traffic collisions and any event that has the potential to cause any of the afore mentioned events, widely known as close calls and near misses. From this point forward ‘event’ means any of the above. The implementation of the process associated to this procedure will ensure that corrective actions can be taken to reduce the chance for reoccurrence. It will ensure VolkerRail’s legal and moral duties within various legislation are complied with and that the specific client requirements are addressed i.e. Railway Group and Network Rail Standards, Transport for London etc. This procedure includes references where applicable to both the ORR-Risk Management Maturity Model RM3 and BS ISO 45001:2018 to show correlation with the requirements of each.

2. SCOPE

The procedure is mandatory and applies to all VolkerRail (VR) staff, agency staff, contractors, their supply chain and visitors. It applies to all VR activities on all infrastructures, static or transient sites, within VR offices and depots. Joint Venture and Alliance procedures may supersede the requirements of this procedure. Where VR are the appointed Principal Contractor on an Alliance, this must first be agreed with the VR HSQES Director. Where VR are not the Principal Contractor on an Alliance and an accident or incident occurs involving VR staff or contractors, then arrangements shall be in place to ensure the VR HSQES Director is informed through the agreed alliance incident reporting procedures.

3. REFERENCES (INPUTS) / RELATED DOCUMENTS Client Standards

London Underground Cat 1 Standard 1-558 Formal Investigation of Incidents London Underground Cat 1 Standard S1556 Incident Reporting and investigation Network Rail NR/L2/INV/002 Accident and Incident Reporting and Investigation Network Rail NR/L3/OHS/0046 The Reporting, Investigation and Recording of Safety and Sustainable

Development Events and Close Calls within Infrastructure Projects Network Rail NR/L3/INV/3001 Reporting and Investigation Manual

Legislation

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Health and Safety at Work etc. Act The Railways (Accident Investigation and Reporting) Regulations The Railway and Transport Safety Act The Railways and Other Guided Transport. Systems (Safety) Regulations The Construction (Design and Management) Regulations

Railway Group / Industry Standards

Rail Industry Standard RIS-8047-TOM Reporting of Safety Related Information Rail Industry Standard RIS-3119-TOM – Accident and Incident Investigation Rail Industry Standard RIS-2273-RST Post Incident and Post Accident Testing of Rail Vehicles BS ISO 45001:2018 – Occupational Health and Safety Management ORR – RM3 Risk Management Maturity Model





VolkerRail Procedures

ENV08 – Management of Environmental Incidents ENV09 – Management of Protected Sites and Species PER03 – Disciplinary Procedure PER25 – Absence Management QUA10 – Document Retention Schedule SAF07 – Safety Critical Certification Suspension, Withdrawal or Reinstatement SAF16 – Drugs Alcohol and Medication SAF40 – Emergency Response and Management SAF93 – Management of On Call Arrangements CMS16 – Competence Development Plan

Systems

Airsweb AVA – Safety Software Accident Incident Reporting Software Web-based System ‘AVA’ platform. Allows the capture of Accident, Incident, Close Call and Audit information as well as dashboard and reporting tools.

SMIS - Safety Management Intelligence System, also known to many as 'SMIS', is the rail industry's on-line enterprise safety and business intelligence software, incorporating the national database for recording safety-related events that occur on the rail network in Britain.

4. DEFINITIONS Definition Meaning

Accident An unplanned, uncontrolled event giving rise to death, ill health, injury or loss

Airsweb VolkerRail’s approved accident and incident reporting and investigation event management system

Airsweb report A preliminary investigation to establish the facts and preliminary causes of the event and whether there is a need for further investigation

Area for Improvement A proposal made following an investigation to change an existing control measure or define a new control measure to eliminate or mitigate a potential risk. The finding did not contribute to the root cause but it is advisable to utilise all learning from the investigation to prevent future accident/incident/close calls/near misses

Assault Any event in which a person is physically assaulted, subjected to verbal abuse or has been threatened with violence, whether or not there is injury

Close Call An unsafe act or condition that could result in personal injury or damage

Corrective Actions Required to address failing/s that led to root cause(s). These are mandatory and must be completed

Designated Competent Person (DCP)

The person nominated to have overall responsibility for the management of investigations.

LIDCP – Local Investigation Designated Competent Person

FIDCP – Formal Investigation Designated Competent Person

The DCP shall meet the following requirements:

1. Must have successfully completed an investigation course in the last 3 years

2. Must hold IOSH Managing Safely or hold NEBOSH General Certificate (or equivalent)

3. Must be a member of a professional body in accordance with their specific discipline

4. Must maintain their CPD in accordance with their professional body (e.g. IOSH/ICE)





Definition Meaning

5. Specific to the Environment and Sustainability discipline, they must hold IEMA Practitioner Membership (or equivalent - minimum may be achieved through Certificate in Environmental Management)

6. Specific to the Quality discipline, they must hold a minimum of Practitioner level with the Chartered Quality Institute, working towards full Chartership and have at least 5 years’ experience in a senior quality role with a Lead Auditor qualification.

Employee Directly paid employees paid monthly, weekly or hourly. This does not include agency or any other labour supplied persons

Environmental Incident An unplanned or uncontrolled event that has negative environmental consequences and requires immediate response to minimise the impact

Fatality Any injury or condition that results in the death of a person. Death from natural causes is not reported unless it can be demonstrated there is reason to suspect the death arose in connection with work

Formal investigation A formally structured investigation of an event led by VolkerRail’s DCP or client, i.e. Network Rail, Transport for London etc.

High Potential The term ‘High Potential’ is used as a means to highlight events with actual or potentially serious consequences that arise because of a failure of VolkerRail controls. In identifying these, actual and potential consequences of each event are considered and assessed against the likelihood of the consequences based on frequency, using historical data

Immediate Cause As defined by the HSE within HSG245:

The most obvious reason why an adverse event happens e.g. the guard is missing, the employee slips; there may be several immediate causes identified in one adverse event i.e. the thing that had to be there at that moment in time for the accident to happen

Incident An unplanned or uncontrolled event, which has resulted in damage or loss to property, plant, materials or the environment or a loss of business opportunity. Incidents do not include those events that are categorised as Operational Close Calls.

IS0 45001 International Standard Organisation – Health and Safety Management System

Lead Investigator A competent person by virtue of their knowledge, expertise or experience appointed by the DCP to lead and manage the investigation. The Lead Investigator shall also meet the following requirements:

1. Must have successfully completed an investigation course in the last 3 years

2. Must have completed IOSH Managing Safety training or hold NEBOSH General Certificate (or equivalent)

3. Must hold IEMA Practitioner Membership (or equivalent - minimum may be achieved through Certificate in Environmental Management) specific to the Environment and Sustainability discipline

4. Must have completed airsweb training

Local investigation An investigation of an event for which a formal investigation remit is not required

Near Miss An unplanned and/or uncontrolled event involving a train or rail mounted plant, which has the potential to cause personal injury. A Near Miss is an outcome of an Operational Close Call

Non-workers Members of the public, visitors, passengers

Operational Close Call An unplanned or uncontrolled event which occurs on the operational railway and has the potential to cause injury or damage (known previously as Irregular Working)





Definition Meaning

OTM On Track Machine

Public Invited or uninvited (trespasser) members of the public

Quarantine The act of removing a piece of equipment from service and keeping it separated/isolated until an investigation is carried out.

Reportable Those events defined under RIDDOR, as having to be notified to the ORR, HSE or Local Authority

RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrence Regulations

RM3 Risk Management Maturity Model

Road Traffic Collision A road traffic collision is an incident involving a vehicle on a road or other public area which causes injury to any persons in the vehicle, 3rd party injuries, damage to an animal, damage to another vehicle or damage to property construction/fixed structure

Root Cause As defined by the HSE within HSG245:

An initiating event or failing from which all other causal or failings spring. Root causes are generally management, planning or organisational failing

SPAD Signal Passed at Danger, meaning any occasion when any part of a train progresses beyond its authorised movement to an unauthorised movement. See RIS-3119-TOM for further definition

SMART This mnemonic refers to SMART actions/recommendations that are Specific, Measureable, Achievable, Relevant and Time bound.

Underlying Cause As defined by the HSE within HSG245:

The less obvious 'system or organisational reason’ for an adverse event happening e.g. pre-start up machinery checks are not carried out by supervisors, the hazard has not been adequately considered with a suitable and sufficient risk assessment, production pressures are too great etc.

VRCC VolkerRail Control Centre which operates on a 24/7 basis

SMIS Rail Safety and Standards Board Safety Management Intelligence System

5. PROCESS

5.1 General Responsibilities

All employees have a legal duty within the Health and Safety at Work etc. Act to co-operate with their employer so far as is necessary to enable their employer to ensure that their legal duties can be complied with. This includes compliance with the requirements of this procedure in relation to reporting and co-operation with any investigations that arise. Investigators shall be selected by their Line Manager and approved by the Designated Competent Person (DCP). The Line Manager shall complete the Suitability Assessment for Investigators form (SAF04F12) and Role and Conduct of Employees and Investigation Team (SAF04G06) and forward to the Training and Competence Administrators who will arrange training following successful DCP approval, where applicable. The investigation team shall co-operate with the Lead Investigator to achieve the objectives of the remit and shall not disclose any information to any other parties whilst the investigation is underway without the authority of the Lead Investigator. For further guidance about role and conduct of employees and the investigation team, please refer to SAF04G06.





5.1.1 Employees/Contractors

Any VR employee or sub-contractor, who sustains an injury because of an accident at work or is involved in any of the events listed in SAF04G01, is responsible for reporting the event within two hours. For further details, refer to Section 5.2

5.1.2 Line Managers

Line Managers are responsible for ensuring all staff under their area of responsibility are briefed on the requirements of this procedure. This should form part of the Company Induction process. If there is a requirement to suspend any/all competence(s) then Line Managers should refer to SAF07 – Safety Critical Certification Suspension, Withdrawal or Reinstatement.

5.1.3 Site Managers / Supervisors (or equivalent)

The Site Managers / Supervisors (or equivalents) are responsible for ensuring the following actions are taken (as applicable) following an event and that the details are reported to VRCC within two hours:

a) Stop works (area or whole site)

b) Assess casualties, area, damage, potential hazards

c) Ensure emergency services are notified (police must be contacted for fatalities)

d) Arrange First Aid by a nominated First Aider(s)

e) Ensure the casualty is accompanied to the hospital that is detailed within the Task Brief (if nature of injury does not require ambulance)

f) Preserve scene and evidence

g) Isolate associated plant or equipment (All reasonable steps must be taken to secure/quarantine the scene of the accident/incident and any equipment/vehicles to preserve evidence. All items should be quarantined if possible)

h) Identify all witnesses

i) Initiate any further response required by SAF40

j) Ensure initial statements / evidence is gathered as listed in Section 5.3 to facilitate the completion of the Investigation Report SAF04F06

k) Assess the individual(s) i.e. those who witnessed or were involved in the event who may be affected and their health and wellbeing is potentially at risk. This review can be done by completing the Checklist for Post Incident Care & Support SAF04F13. This form must be completed within 24hrs following the event.

5.1.4 VolkerRail Control Centre

The VRCC Duty Controllers are responsible for the following:

a) Recording an accurate and concise account of the event within the airsweb system

b) Arranging assistance / support by initiating any specific emergency response procedures (i.e. Oil Spill response) as per SAF40 Appendix B

c) Maintaining contact with the Site Supervisor and H&S On-Call to ensure updates are received

d) Escalation of information in line with the emergency command structure, client control centres and enforcing authorities

e) Instigating actions as a result of the discovery of any protected sites and/or species during the work in line with VR Procedure ENV09

5.1.5 Health & Safety / Quality / Environmental Advisors and Managers

The Health & Safety / Quality / Environmental Advisors and Managers are responsible for the following:

a) Supporting the businesses with the investigation process





b) Maintaining the airsweb system to close events

c) Providing updates to the client within 24 hours in the format agreed with the client

d) Ensuring the notification of RIDDOR events to the enforcing authority within the timescales required

5.1.6 Designed Competence Person (DCP)

For Local Investigations the DCP (LIDCP) will be:

a) Senior H&S Manager Specialist Businesses

b) Senior H&S Manager Major Projects

c) Head of Quality Systems

d) Head of Environment & Sustainability

e) Discipline specific Professional Head

For Formal Investigations the DCP (FIDCP) will be: a) HSQES Director

b) Lead Investigator (Deputy for HSQES Director)

c) Engineering Director

d) Head of Track Engineering (Deputy for Engineering Director)

e) Professional Head of Train Operations

f) Driving Standards Manager (Deputy for Professional Head of Train Operations)

The FIDCPs are responsible for the following: a) Issuing a remit (the investigation matrix in SAF04G04 offers guidance on what unplanned events require

remits and formal investigation)

b) Managing and supporting the investigation process

c) Appointing competent investigators to lead investigations

d) Identifying the investigation team

e) Taking the decision, in conjunction with the Line Manager, to suspend any/all competence(s) in line with the requirements of SAF07.

5.1.7 Lead Investigator

The Lead Investigator is a competent person by virtue of their knowledge, expertise or experience appointed by the DCP to lead and manage the investigation. They are responsible for the following:

a) Nominating appropriate members to assist with the investigation process including collation of evidence

and any other supporting information required

b) Arranging meetings to review the draft investigation report with the panel members and any other interested persons and agreeing the final content of the report

c) Ensuring that the investigation achieves the requirements of the remit

d) Recommending and agreeing corrective actions, areas for improvement and other appropriate actions with the action owners

e) Maintaining the original documentation that supports the investigation and Airsweb system throughout the process and handover to the Rail Investigation Coordinator once the report is ready to be issued.





5.1.8 Rail Investigation Coordinator

The Rail Investigation Coordinator is responsible for the following:

a) Monitoring the status of investigations and identifying any overdue timescales to the DCP

b) Supporting the Lead Investigator with the administration of the investigation file

c) Distributing Formal and Local Investigations to individuals nominated by the Lead Investigator. For Formal Investigations, as a minimum, this includes the HSQES leadership group

d) Maintaining the master investigation files in conjunction with the airsweb log

5.1.9 Senior Data and Reporting Analyst

The Senior Data and Reporting Analyst is responsible for the following:

a) Managing the recording of events into SMIS in line with the Rail Industry Standard RIS-8047-TOM Reporting of Safety Related Information

b) Assisting the Health & Safety, Quality or Environmental Advisors and Managers with the report to the Enforcing Authorities

c) Preparation of investigation causal and action analysis from the Airsweb system for HSQES leadership group meetings, monthly performance report, business balanced scorecards and Learning from Investigation meetings.

5.2 Reporting Requirements

All accidents (including assaults), occupational ill health disorders/conditions, close calls, operational close calls, incidents and environmental incidents that occur on VR premises, managed depots or involve VR employees, their contractors and members of the public must be reported to VRCC within two hours by the person involved or the Site Manager / Site Supervisor. The following details must be provided as a minimum: a) Date and time of the event

b) VR business unit

c) Project or contract name and number

d) Location where the event has occurred

e) Brief description of what has happened

f) Any reported injuries or damage

g) Immediate actions taken

For full guidance on the reporting of these events, refer to SAF04G01. This document also provides clarity to the escalation requirements associated to where VR are or are not Principal Contractor for the works related to the event.

5.2.1 Timescales

Within two hours:

Initial report to VRCC Immediate response and preservation of evidence exercise instigated VRCC to escalate to all interested parties (on-call, Network Rail SCO247, ORR etc.) VRCC to have completed the ‘Initial Review’ stage of Airsweb AVA.

Within 24 hours:

The Site Manager / Site Supervisor on site will forward all statements and evidence collated to the Rail Investigation Coordinator within 24 hours.





For events that happen on a specific client infrastructure, refer to the relevant standards for reporting guidelines and requirements.

5.2.2 Occupational ill health

Where an instance of occupational ill health is confirmed as part of health surveillance and on receipt of a written statement from a registered medical practitioner stating that an employee has been diagnosed with an occupational disease such as Carpel Tunnel Syndrome or Hand Arm Vibration Syndrome, the Occupational Health Nurse will inform the Training & Competence team in writing of the diagnosis. The Training & Competence Manager is responsible for reporting the diagnosis, if required by the RIDDOR regulations, to the HSE or ORR. VolkerWessels Occupational Health team will ensure restrictions imposed following diagnosis are formally recorded on the individual’s occupational health record and the VolkerRail database and communicated. The individual’s Line Manager and H&S Advisor/Manager will arrange for a review of the management of the health risks in the workplace. For further guidance on the types of conditions that must be reported, refer to SAF04G01.

5.2.3 Road Traffic Collisions

Where the driver of a company provided car, hire car, company owned commercial vehicle, a hired, leased, contract commercial vehicle or employee driving their own vehicle on company business, is involved in an accident and/or road incident, they must report this within two hours to the company insurers Zurich.

Zurich will complete a report form over the telephone and then notify VRCC who will subsequently record the details in airsweb.

The VWUK Fleet Administrator will ensure the Zurich insurance form is uploaded to airsweb and all the necessary fields are completed. The Health & Safety Advisors / Managers will assist the Line Manager with an investigation where the VR driver has been injured using the SAF04F06 template or applicable client investigation form.

Any subcontractor involved in a collision whilst travelling in connection with their contracted works with VR must report the details to VRCC directly.

The subcontractor’s employer is responsible for investigating road traffic collisions involving their staff.

Any VR employee involved in a collision whilst travelling in connection with their works with VR must report the details to Zurich directly.

The VolkerWessels Driving for Work Policy and Handbook provides full details of the framework to maintain a management system for minimising road traffic incidents.

5.3 Preservation of Evidence

Items of plant/equipment should be placed in a specified quarantine area and marked up accordingly. The items should remain in quarantine until such time that the investigation is complete, and agreement has been reached with the Lead Investigator to remove from quarantine. Under no circumstances should items be removed/used etc during the investigation process and whilst in quarantine. Arrangement shall be made for the collection of evidence relating to an event. Priority should be given to perishable evidence, interviewing of personnel / obtaining statements using form SAF04F03, taking photographs and making sketches of the scene. Evidence will be categorised as follows: a) Physical/Perishable (equipment, environment, position of controls)

b) People (those involved directly and indirectly, site sketch showing position of people/equipment)





c) Data (voice recordings from VRCC, data loggers from MEWPS, tampers etc.)

d) Documents (training certificates, Work Package Plans/Safe Systems of Work/Task Briefing Sheet/prestart

checks, maintenance logs etc.)

5.4 Agreeing the Level of Investigation

The DCP will discuss the event with those detailed in paragraph 5.4.2 and agree the level of investigation, within 24 hours using the event severity matrix.

5.4.1 Event Severity Matrix

The purpose of the event severity matrix is to determine the level of investigation required.

Investigation Level Low Potential – airsweb report only Medium Potential – Local investigationHigh Potential – Formal investigation

The process requires an element of judgement used by the DCP with input from the Professional Head and other key members of the organisation as deemed appropriate.

SAF04G04 provides guidance on how to rank events using the potential severity matrix facility in airsweb to help determine the actual and potential severity, the potential of the event reoccurring and the action that should be taken following such an event. Using a combination of professional experience, historical knowledge of previous events and an understanding of forthcoming work activities of a similar nature, the potential severity of the event may be increased to high.

5.4.2 High Potential Event Conference Call

For any event identified as having an actual or potential severity rating of high, a conference call is required to take place with key members of the organisation, no later than 24 hours after the event where reasonably possible, considering that some reports will be received outside of normal office working hours. There is a dedicated conference call number to facilitate this requirement. Conference call details can be found on SAF04F11, which must be used to log all the information about the event and post event management. All calls must be recorded using the Intercall facility (see SAF04G08). The record of this call, along with SAF04F11 will form part of the evidence file. The purpose of the call is to complete an early review of the event to capture the circumstances while still recent, making sure that preservation of evidence on site and off site is being undertaken, the required immediate actions have been taken and agree next steps and resources required for the investigation. The following people will be required to support the conference call:

Lead Investigator HSQES Director (or a suitable deputy) Engineering Director (or a suitable deputy) Director Specialist Businesses / Major Projects (as applicable) Operations Director Regional Director H&S On-call Representative Senior H&S Manager Specialist Businesses / Major Projects (as applicable) Project Manager (or equivalent) Professional Head for the discipline of works VRCC Duty Manager Data & Reporting Strategy Manager (or suitable deputy)





The items that will be discussed are: 1. Initial Findings – identify what the initial findings are and what immediate corrective actions have been

taken.

2. Immediate risk to business – understanding the immediate risks to the business operations, employees or supply chain and agree what actions need to be taken to restore normal working.

3. Cooperation – Identify who VR will need to cooperate with to enable effective two-way communication and cooperation.

4. Communication needed:

a) Internal – Agree if a Shared Learning / HSQES / Engineering Alert needs to be issued (immediately) based on the initial known facts which may require the business to take immediate actions i.e. stop work/do something different.

b) Client – Agree how the client HSQES representative will be notified of the level of investigation, who is leading/should be the point of contact and potential interfaces required between VR and the client, in order that the investigation can be completed in line with the agreed remit

c) Industry / External / Enforcing Agency – Agree if there any legal reporting requirements and if an urgent safety related advice needs to be raised via the NIR3350 or NIR8250 system

5. Level of Investigation – Agree if the investigation will be local for medium potential events or formal for high potential events. Those on the call will identify the investigation lead and subject matter experts to support.

Following the initial call, the Lead Investigator and investigation team, with the support of the Senior Data and Reporting Analyst, will have a follow up conference call to discuss / agree the following, using the Intercall facility (see SAF04G08) and recording the details on the SAF04F11:

a) Evidence collection - Prioritising the quarantining / collection of perishable evidence, interviewing of people involved and witnesses, recording a list of physical evidence, taking photographs and making sketches of the site

b) Records of previous related events – review of any previous or similar events and their corrective actions / areas for improvement

5.4.3 Circumstances where a Formal Investigation may not be required

There may be circumstances whereby the HSQES Director, in consultation with the enforcing authorities or Infrastructure Manager, determines that a formal investigation is not required; providing that VR can demonstrate that:

a) An external organisation’s investigation will enable the Infrastructure Manager or VR to meet the objectives

and purpose of this procedure

b) A VR led investigation would duplicate effort, in terms of the investigation remit that has been set, the costs and impact on individuals, which would exceed the benefits of a VR investigation.

5.5 Undertaking the Investigation

5.5.1 Investigation Team

All investigation teams will consist of the following as a minimum:

A Lead A Health & Safety, Quality or Environmental/Sustainability Advisor / Manager. A Safety Representative A subject matter expert (SME)

The Lead Investigator may seek support from specialist / technical advisors when it is considered that such expertise will assist the investigation.





5.5.2 Objectives

The Lead Investigator will make clear the purpose and objectives of the investigation.

5.5.3 Analysis Tools (Ref : ISO 45001, A.10.2) (RM3 – MRA 3)

There are many tools and techniques for structuring the investigation, analysing adverse events and identifying root causes. The most common methods used in the railway industry are:

Five Whys; Barrier Analysis; STEP Analysis Causal Tree/ Cause and Effect Analysis; Swiss Cheese Model; Domino Analysis; Failure, Modes, Effects, Analysis (FMEA); Fault Tree Analysis (FTA).

There are advantages/disadvantages with all methods however, the ‘Swiss Cheese’ model is the preferred method to be used for internal investigations. Investigations completed with regard to the engineering department are advised that the FMEA/FTA models may be used, as these models are better suited to meet the needs of the engineering discipline. Where possible and following a suitable and sufficient risk assessment, the investigation team should undertake a re-enactment of the event, or take an opportunity to observe the same activity to better understand the environment, conditions, and work factors involved. Frodingham Depot and J3 OLE training span can be used to carry out the re-enactment in a safe and controlled environment.

5.5.4 Witness Statements

Interviews should be completed as soon as possible within the investigation process. The investigation team will interview the “eye-ear witnesses” (people who have seen and heard or heard the events) and others. Eyewitnesses may be your best or only source of information for determining the sequence of events. Information gathered should be used to produce a time-line and create a chronological order of events. The mental state of the witnesses concerning critical accident stress should be considered. They may be in shock or traumatised following the event. Interviews need to be conducted in a quiet, private, comfortable location that are free of disruption. The interview evidence should be used to inform the sequence of events. SAF04F03 should be used to capture the information given by the witnesses. Interview notes taken by the investigation team should be used to develop the analysis / sequence of events and kept for the evidence file. Wherever possible, all interviews should be recorded using an audio device such as a Dictaphone and transcribed and used as evidence for the investigation file. This will support the interview process and ensure a more relaxed and natural environment. All recorded interviews will be protected and not shared outside of the investigation team. Once the sequence of events has been established it may be necessary to contact witnesses to ask follow-up questions. See section 1.4 of SAF04G01 for information on home visits that may be required to gather information and or statements from witnesses.





5.5.5 Information Gathering and Investigation File

For all levels of investigation, the investigation team will commence the collection of information/evidence using the folder structure contained with SAF04G05 Investigation File Guidance. The folder has been structured so that the investigation team can ensure that all necessary evidence is collected and collated in an organised way and is structured as follows (additional folders can be added as necessary): 1. Statements and Interviews

2. Photographs and CCTV

3. VRCC voice tapes

4. Site Documentation

5. Events of a similar nature or involving same location, equipment or individuals

6. Training and Certification

7. Induction Records, TBTs and Briefings

8. Policies, Documents, Guidance or Procedures

9. Legislation

10. Client or Statutory Reporting Forms and Investigations

11. Communication

12. Actions – post incident

13. Miscellaneous

14. Plant, Equipment and Materials

15. Analysis

16. Report

All final records will be held on airsweb and the original investigation file must be passed to the Rail Investigation Coordinator when complete.

All records will be archived in line with the VR Document Retention Schedule QUA10.

5.6 Investigation Reports 5.6.1 Airsweb report

For events identified as an airsweb report only, the system must be completed in full and finalised with any necessary remedial corrective actions issued within 14 days. All information should be updated to the airsweb log with copies of any supporting documentation (photos, statements etc.).

5.6.2 Local Investigation report

a) Templates All Local Investigations must be completed using SAF04F06. Other Clients, Joint Venture or Alliance templates may be used providing that they offer VR the same level of information that is contained with the airsweb system and investigation reports.

b) Timescales A draft report must be completed within 14 days of the event. The Lead Investigator shall complete the Local Investigation Report within 28 days. The following table gives an outline for the investigation team to follow to ensure timely completion of the investigation. This timeline is intended as guidance only and there may be deviation depending on influencing factors that are specific to each investigation.





In exceptional circumstances, such as key witnesses not being available, then this timescale may be exceeded with agreement from the VR FIDCP and Lead Investigator.

Local Investigation Timeline – 4 weeks

Action Action Owner Target DateQuarantine plant / equipment Investigation lead Incident + 0 day Obtain VRCC voice tapes VRCC Duty Manager Incident + 1 day Visit accident / incident site (record / collect evidence if site visit not already completed)

Investigation team Incident + 2 days

Set dates for / conduct interviews Investigation team Incident + 3 days Gather evidence, review and analyse evidence: interviews, statements, site paperwork, competencies, photographs, laboratory test results, procedures, standards, D&A screening results etc.


Issue Initial HSQES/Engineering Alert – (What we know – What we don’t know) (where necessary)

Investigation lead Incident + 6 days

Review/transcribe interview voice recordings with evidence Investigation team /Rail Investigation Coordinator

Incident + 6 days

Draft STEP/Causal Analysis Investigation team Incident + 7 days Draft Barrier Analysis Investigation team Incident + 9 days Draft local investigation report Investigation lead Incident + 12 days Issue draft local investigation report, STEP, Causal and/or Barrier Analysis for review


Local Investigation Timeline – 4 weeks

Action Action Owner Target Date

Issue HSQES/Engineering Alert (where necessary) HSQES / Engineering Director

Incident + 18 days

Inform the client of any known delays that may impact on meeting the required timescales for submitting the final report

LIDCP Incident + 21 days

Finalise local investigation report and appendices and issue for signature

Investigation Lead / LIDCP

Incident + 24 days

Issue final local investigation report and analysis Rail Investigation Coordinator

Incident + 28 days

Issue Shared Learning (SAF04F10) Investigation team /Rail Investigation Coordinator

Incident + 28 days

If the investigation is found to be complex and there is a risk of the investigation taking longer, then the Lead Investigator should approach the Senior H&S Manager Specialist Business/Major Projects who will discuss and agree to an extension of time as appropriate, this should be communicated and agreed with the relevant client representative as appropriate. The Rail Investigation Coordinator will issue a weekly report to all the H&S Advisors and Managers identifying the events that have exceeded the 28-day investigation timescale.

c) Acceptance for Issue The Lead Investigator will sign the investigation form once they are satisfied that the investigation is complete and ready for issue. The LIDCP will ensure a meeting is conducted for the investigation panel/team to review and finalise the investigation report and agree SMART corrective actions with the action owners. This can be done face to face, through Microsoft Lync/Skype or conference call.





The content will be reviewed and accepted for issue by the LIDCP to determine if it has reached a satisfactory conclusion, root cause/s has been established, the fair culture model has been followed and SMART corrective actions agreed. Where the report is rejected, the LIDCP will explain / provide comments and further action needed. The Lead Investigator will resubmit to the LIDCP when the comments have been addressed. The acceptance of the investigation can be done through any of the following: a) Provide a ‘wet ink’ signature on the investigation report

b) Provide a scan of the ‘wet ink’ signature on the investigation report

c) Provide an email to the lead investigator that states they agree with the content

d) Issue of the Report

The Rail Investigation Coordinator is responsible for distribution of all Local Investigation Reports to the relevant persons within the business. As a minimum this will be:

General Manager Project Manager Safety Representative Corrective Action Owners Health & Safety, Quality and / or Environment Advisor/Manager for the relevant business area Client representative as advised by the LIDCP

A shared learning document will be produced for local and formal investigations – see Section 5.11.

5.6.3 Formal Investigation Report

a) Remit The FIDCP will agree the objectives and timescales of the formal investigation within 48 hours and document this using SAF04F04. On agreement of the remit, the Lead Investigator shall:

Inform the investigation panel members of the requirement to assist with the investigation process including the collation of evidence and any other supporting information required. The panel members must be competent in both conducting the investigation and what is being investigated.

Arrange a briefing of the investigation objectives to the investigation panel and actions needed

b) Appointing a Lead Investigator

The FIDCP will appoint a Lead Investigator who must be independent of the project involved in the circumstances being investigated and must not have any direct line management responsibility for the staff, contractors or equipment involved in the event to be investigated. The FIDCP must be satisfied that the person is considered competent to:

Conduct the investigation, or has access to competent technical advice on those aspects outside their own technical competence

Identify safety matters which justify urgent action before the investigation report is completed Identify the need for corrective actions / areas for improvement Are experienced and competent in accident/incident investigation

c) Templates

All Formal Investigations must be completed using SAF04F06. Other Clients, Joint Venture or Alliance templates may be used providing that they provide VR with the same level of information that is contained with the airsweb system and investigation reports.





d) Timescales A draft report must be completed within 21 days of the event. A final report must be completed within eight weeks of the event. The following table gives an outline for the investigation team to follow to ensure timely completion of the investigation. This timeline is intended as guidance only and may be subject to deviation depending on influencing factors that are specific to each investigation. In exceptional circumstances, such as key witnesses not being available, then this timescale may be exceeded with agreement from the VR FIDCP and where applicable, the client.

Formal Investigation Timeline – 8 weeks

Action Action Owner Target DateConduct DCP Conference Call DCP Incident + 0 day Quarantine plant / equipment Investigation lead Incident + 0 day Obtain VRCC voice tapes VRCC Duty Manager Incident + 1 day Visit accident / incident site (record / collect evidence if site visit not already completed)


Set dates for / conduct interviews Investigation team Incident + 5 days

Formal Investigation Timeline – 8 weeks

Action Action Owner Target DateGather evidence, review and analyse evidence: interviews, statements, site paperwork, competencies, photographs, laboratory test results, procedures, standards, D&A screening results etc.


Issue Initial HSQES/Engineering Alert – (What we know – What we don’t know) (where necessary)


Review/transcribe interview voice recordings with evidence Investigation team / Rail Investigation Coordinator

Incident + 9 days

Conduct a further review and analysis of evidence: interviews, statements, site paperwork, competencies, photographs, laboratory test results, procedures, standards, D&A screening results etc.


Draft STEP/Causal Analysis Investigation team Incident + 16 days Draft Barrier Analysis Investigation team Incident + 18 days Draft formal investigation report Investigation Lead Incident + 21 days

Issue HSQES/Engineering Alert (where necessary) HSQES / Engineering Director

Incident + 25 days

Issue draft formal investigation report, STEP, Causal and/or Barrier Analysis for review

Investigation Lead Incident + 28 days

Review period for draft formal investigation report comments/feedback

Investigation team, Directors and DCP

Incident + 42 days

Inform the client of any known delays that may impact on meeting the required timescales for submitting the final report

FIDCP Incident + 42 days

Finalise formal investigation report and appendices and issue for signature

Investigation Lead Incident +49 days

Issue final formal investigation report and analysis Rail Investigation Coordinator

Incident + 56 days

Issue Shared Learning (SAF04F10) Investigation team / Rail Investigation Coordinator

Incident + 56 days





If the investigation is found to be complex or key information is not available and there is a risk of the investigation taking longer, then the Lead Investigator should approach the FIDCP who will discuss and agree to an extension of time as appropriate. This shall be given in writing and forms part of the investigation file. This should be communicated and agreed with the relevant client representative as appropriate.

e) Acceptance for Issue Once the investigation panel has agreed that the objectives of the investigation remit have been met, a root cause identified, SMART corrective actions agreed with the action owner(s) and the investigation panel are in full agreement with the content, the report should be passed to the FIDCP for review. The FIDCP will either approve or reject the investigation following review. Where rejected the DCP will explain / provide comments and further action needed. The Lead Investigator will resubmit when the comments have been addressed. The acceptance of the investigation report can be provided by any of the following: a) Provide a ‘wet ink’ signature on the front page of the investigation report b) Provide a scan of the ‘wet ink’ signature on the front page of the investigation report c) Provide an email to the lead investigator that states they agree with the content

f) Issue of the Report

The Rail Investigation Coordinator is responsible for distribution of all Formal Investigation Reports to the persons identified within Appendix F of the report template. The report will only be issued once: a) The review of content and acceptance for issue process is complete

b) The investigation file has been loaded to airsweb

5.7 Legal Professional Privilege

Legal Professional Privilege ('LPP') is a right which protects communication between a party, their lawyers, and sometimes third parties from disclosure to other parties (such as prosecuting public bodies), as long as certain circumstances are met. There are two types of LPP: litigation privilege and legal advice privilege.

5.7.1 Litigation Privilege

Litigation privilege covers discussions carried out in contemplation of litigation, whether currently ongoing or anticipated and can cover communications between solicitor and client as well as communications with third parties. Litigation privilege does not apply to documents created in anticipation of an investigation. There needs to be reasonable contemplation of litigation, i.e. prosecution or the filing of a case at court, for litigation privilege to apply to communications between lawyers, clients and third parties.

5.7.2 Legal Advice Privilege

Legal advice privilege is confined specifically to communications between lawyer and client and those communications must be for the purposes of giving or receiving legal advice. Legal advice privilege does not apply to records of an internal investigation, as those records will not be for the purposes of giving or receiving legal advice. Copies of legally privileged documents should not be issued to any third party without authorisation from HSQES Director.

5.8 Root Cause (Ref : ISO 45001, A.10.2, A.10.3, A.9.3) ( RM3 – MRA3 , MRA 5)

All investigations shall identify the immediate, underlying and root cause(s) of the event. This will be included within the investigation reports.





5.9 Lifesaving Rules and Fair Culture

There is a clear system in place to recognise behaviour around the Lifesaving Rules, whether that is rewarding positive actions or responding to breaches fairly. For all investigations, VR will use the ‘Guide to Using the Fair Culture Model’ SAF04G07 to assess any breaches of the Lifesaving Rules, establish root cause for those breaches and respond fairly. The Fair Culture Model (FCM) shall be used for all individuals involved. Where more than one person is involved, it will be necessary to work through the FCM for each person. The consequence matrix within SAF04G07 will guide the investigation team on determining appropriate actions based upon the investigation findings. All outcomes will be seen as an opportunity for organisational learning and the promotion of a fair culture.

5.9.1 Consequences for error and violation

Where the FCM analysis has identified human error or violation, the investigation team will discuss the report findings to ensure suitable corrective actions are put forward in line with SAF04G07. The Lead Investigator is responsible for ensuring that HR are provided with all the evidence and information required to enable them to adequately discharge their duties, without the need for HR to undertake any further investigation(s). The information provided by the Lead Investigator will give HR adequate and unambiguous justification for the action that is required to be taken. Wording for the investigation reports corrective action will be as follows: “As a result of this investigation, and in line with the FCM analysis, this investigation recommends that the individual is subject to [the appropriate Company’s HR Procedure’s / a programme of re – training / re – assessment /etc.]”

5.9.2 Recognising positive behaviour around the Lifesaving Rules

Where the FCM analysis has identified an individual has carried out a positive intervention or they have behaved positively around the Lifesaving Rules with regards to safe working practices, which has reduced the risk of human error or adverse situations, then the investigation report will ensure recognition is given by the individual(s) Line Manager. Examples of positive recognition could be in the following ways: a) Nomination for Contribution to Safety Award

b) Formal praise given to the individual(s) which is briefed to the company as a positive intervention

c) Individual receives positive performance appraisal through their PDR

d) Individual is given the opportunity to coach others on safe behaviours

e) Recognise the supervisor/manager if it is deemed their positive behaviours have contributed to the

individual/team’s safe actions/interventions

5.10 Corrective Actions and Areas for Improvement (Ref: ISO 45001 – A.10.2, A.10.3) (RM3 – MRA 3, MRA 5)

Corrective actions are mandatory and directly relate to the event. They are required to address a failing that led to root cause(s) and will be detailed in the investigation report. Investigations can identify areas of concern, an event, or a condition, that increases the risk of an accident/incident in the future, or is something that highlights areas for improvement. These factors would not necessarily have contributed to the event being analysed. Addressing these through the investigation is still important to the business to ensure continual improvement and learning.





An area for improvement is a proposal made by the investigation team, to change an existing control measure or define a new control measure to eliminate or mitigate a potential risk. Areas for improvement should be recorded in SAF04F06 Appendix H Other Non-Contributory Issues Identified. This Appendix H is not required to be submitted externally with the investigation report, but will be used internally within the business to ensure all actions are tracked to closure. Corrective actions and areas for improvement will be categorised to enable further analysis at the Learning from Investigations quarterly review steering group meetings. When developing corrective actions and/or areas for improvement, the investigation team will manage the unintended consequences of these, ensuring a full analysis is undertaken of existing risk assessments, company and industry standards and processes. This will ensure the action is SMART and does not have a negative impact. The investigation team should use VolkerRail Procedure SAF09 – Validation of Change to Organisation or Integrated Management System. Following identification of the root causes and application of the ‘Fair Culture’ model, corrective actions and areas for improvement will be agreed and documented within the investigation report. Areas for improvement and corrective actions must be written clearly and be structured in such a way to include the following principles: a) Detail the issue/investigation finding that is being addressed (multiple investigation findings can be

incorporated in to one action where possible)

b) Be clear on the intent of the areas for improvement/corrective action

c) Be specific but not prescriptive in terms of the corrective action requirements, for the action owner to be able to effectively manage a positive outcome

Corrective actions must follow the SMART principle: 1. Specific targets a specific area for improvement 2. Measurable quantify or at least suggest an indicator of progress/success 3. Achievable has been agreed, is aligned with specific goals and specifies who will do it 4. Relevant is specific to the investigation findings that need to be addressed 5. Time-bound specify when the result(s) can be achieved The action and its timescale must be discussed and agreed with the person who it will be assigned to, prior to the report being signed off.

5.10.1 Recording of Corrective Actions (Ref : ISO 45001 - A.10.1)

The Rail Investigation Coordinator is responsible for ensuring all actions arising out of any level of investigation is added to the airsweb event via the ‘add action’ section and assigned to the action owner.

The Quality Coordinator will issue a fortnightly report to the General Managers or equivalent to confirm the status of investigation actions. The status and effectiveness of actions will be included in the Learning from Investigations quarterly review meetings.

5.11 Learning (Ref: ISO 45001 – A.10.2, A.10.3, A.9.3) ( RM3 – MRA 3, MRA 4, MRA 5)

A shared learning document SAF04F10 will be produced for all events ranked with a severity rating of medium or high. Once the investigation is finalised for medium and high severity events, the investigation team will undertake an event review. This review will include those involved in the event, safety representatives and General Managers as a minimum. The review will go through the investigation report, shared learning document and discuss any additional learning following the event that can be cascaded across the business.





To monitor the effectiveness of investigations and to ensure that there has not been a recurrence of a similar event, a Learning from Investigations quarterly review will be undertaken. This will include the General Managers of the business being reviewed and action owners where relevant. The outputs from this meeting will be fed back in to the HSQE leadership group meetings.

5.12 Records

5.12.1 Accident Book

Under the requirements of The Social Security (Claims and Payments) Regulations employers are required to keep an accident book, which must be kept readily available. There is no longer a specified ‘accident book’ (BI 510), however, any book or electronic method may be used, as long as all the relevant details are correctly entered and proper records are maintained. The information must be readily available in hard copy and the format approved by the relevant Secretary of State. Airsweb will be used for maintaining all records associated to accidents.

5.12.2 Investigation Forms, Evidence, Correspondence

The Lead Investigator is responsible for maintaining records associated to the investigation whilst it is in progress and passed to the Rail Investigation Coordinator at the earliest opportunity for saving to the shared folder before appending to the airsweb system record on completion of the investigation. To ensure all the necessary evidence is collected and collated in an organised way, the investigation team should use the investigation folder template SAF04G05. All final records will be held on airsweb. Hard copies must be passed to the Rail Investigation Coordinator once the report has been issued for retention in line with the VR Document Retention Schedule QUA10.

5.13 Reporting to Other Interested Parties and into Systems

5.13.1 Statutory Reporting and Enforcing Authorities

A matrix of events that require reporting to the Enforcing Authorities and their timescales is held by VRCC. Guidance on whether or not an accident or incident is reportable under the relevant regulations should be obtained from a Health & Safety or Environmental Advisor or Manager and/or the HSQES Director. It is the responsibility of the Health and Safety Advisor/Manager to provide written reports using the Enforcing Authorities approved forms within the timescales required. It is the responsibility of the Health & Safety Advisor/Manager or the Data and Reporting Strategy Manager to provide written reports using the Enforcing Authorities approved forms within the timescales required. The Training & Competence Manager will report any Occupational Health related reports, i.e. cases of disease, to the ORR or HSE. All copies of escalation records must be filed with the airsweb event log.

5.13.2 RSSB Safety Management Intelligence System

It is the responsibility of the Senior Data and Reporting Analyst to input events into the Safety Management Intelligence System (SMIS) as required by Railway Group Standards.

5.13.3 Network Rail Supply Chain Control

It is the responsibility of the VRCC Duty Controller to ensure that all accidents, incidents, road traffic collisions and operational close calls on Network Rail Infrastructure or Projects are reported to Network Rail SCO/247 within two hours and then subsequently entered in to i-tracker within 24 hours. The VRCC Duty Controller must obtain and record all Network Rail reference numbers within the airsweb log.





5.13.4 British Transport Police

The British Transport Police serve the railway environment and its community. This covers the tracks, stations, trains and all related rail infrastructure across England, Scotland and Wales. It also covers the London Underground system, Docklands Light Railway, the Midland Metro tram system, Croydon Tramlink, Sunderland Metro and the Glasgow Subway. The following circumstances must be reported to VRCC who will in turn notify the British Transport Police. The VRCC Duty Controller must obtain and record a reference number within the airsweb log. Littering

Menacing groups

Suspicious vehicles, packages or items

Threatening or abusive behaviour (this includes rowdy, noisy or drunken behaviour, offensive or threatening language)

Vandalism

The Environmental Advisor / Manager, in agreement with the Environment Agency or Natural England, will notify the police wildlife crime unit of any potential wildlife crime.

5.14 Inquests

Any requests for attendance as a witness at a coroner’s inquest should be forwarded to the HSQES Director.

5.15 Training and Assessment

IOSH accredited investigation training will be provided for all those individuals that are responsible for undertaking investigations, as determined by the business / project competence profile. The training will be held over five day’s duration and will require an end of course assessment and completion of an investigation report in order to gain the qualification, with a validity of three years. A one-day refresher for recertification will take place every three years. Training will include access to a training span to allow for interactive scenarios. For individuals that require an awareness of the investigation process, a one-day course that covers the key elements of this procedure and the legal requirements for ensuring that thorough investigations are undertaken will be provided.

6. ASSOCIATED GUIDANCE & INFORMATION

SAF04G01 – Reporting Guidance SAF04G02 – Reporting and Investigation Flowchart SAF04G03 – Close Call Reporting Guidance SAF04G04 – Use of the Event Severity Matrix to Determine Level of Investigation SAF04G05 – Investigation File Guidance SAF04G06 – Role and Conduct of Employees and Investigation Team SAF04G07 – Network Rail – A Guide to Using the Fair Culture Model SAF04G08 – Use of Conferencing Facility SAF04G09 – Terms of Reference - Learning from Investigations - Quarterly Review

7. DOCUMENTATION (OUTPUTS)

SAF04F02 – OTM Incident Interim Report Form SAF04F03 – Witness and Injured Person Statement SAF04F04 – Formal Investigation Remit SAF04F06 – Investigation Report SAF04F10 – Investigation Summary/Shared Learning SAF04F11 – High Potential Event – Record of DCP Conference Call SAF04F12 – Suitability Assessment for Investigators SAF04F13 – Checklist for Post Incident Care and Support





HSE-54-VR Close Call Report card

Appendices to SAF04F06 – Investigation Report

Appendix A – Sequence of Events Appendix B – List of Individuals Involved Appendix C – Supplementary Detailed Information Appendix D – Evidence List Appendix E – Causal Analysis Diagram Appendix F – Distribution Appendix G – Fair Culture Analysis Model Flowchart Appendix H – Other Non-Contributory Issues Identified Appendix I – Barrier Analysis

8. ISSUE RECORD

Issue Date Comments

1 09/11/2012

The procedure has undergone a major review and has been completely re-written. A summary of the key changes are below:

Replaces SQE/04, SQE/04a, SQE/05

Level 1, 2 and 3 investigation structures removed.

Section 6.7 - Introduces an interim report form to effectively document the review and further actions of the event without having to undertake an investigation

Introduction of new forms for consistency - service damage information gathering, investigation information gathering, investigation template, OTM Incident Form recognised in procedure and assigned form number

Section 6.11.8 - Introduction of ‘Just Culture’ approach

2 23/01/2014

The procedure has undergone an annual review to ensure it remains effective. Various paragraphs have been amended:

Section 6.1 Responsibilities, Section 6.2 Reporting General Requirements, Section 6.6 Statutory Reporting, Section 6.7 Industry Reporting / Other Interfaces, Section 6.8 Local Investigation, Section 6.9 Fleet and Road Safety Investigation, Section 6.10 Formal Investigation, Section 6.11 Undertaking the Formal Investigation,

The following forms have been amended/added:

Form SAF04F01 – renamed Local Investigation Form

Form SAF04F03 - service damage information form details removed and will be captured in Airsweb. Content replaced by ‘Witness Report Form’

Form SAF04F04 – renamed Formal Investigation Remit

Form SAF04F06 – renamed Formal Investigation Template

Form SAF04F07 – new form - Fleet and Road Safety Investigation Form

3 26/03/2019 Complete re-write of the whole procedure.

4 05/02/2020

Update to various sections of the procedure (5.1.2, 5.1.3, 5.1.6, 5.1.7, 5.1.9, 5.2.1,5.2.3, 5.3, 5.4.1, 5.4.2, 5.10, 5.10.1)

Update to guidance (SAF04G01, SAF04G03, SAF04G04, SAF04G09)

Amendment to various sections throughout SAF04F06 and SAF06F11

Withdrawal of SAF04F07





9. WHAT HAS CHANGED IN THIS LATEST ISSUE AND WHY? Main Procedure References Systems - references made to Airsweb AVA and SMIS Section 5.1.2 Additional text as requested by Karen Watson Section 5.1.3 Included in point g) All reasonable steps must be taken to secure/quarantine the scene of the accident/incident and any equipment/vehicles etc to preserve evidence. All items should be quarantined if possible. Section 5.1.6 Additional text to FIDCPs as requested by Karen Watson as bullet e) Section 5.1.7 Reference to Airsweb system added into bullet e) Section 5.1.9 Added bullet c) responsibility for Senior Data & Reporting Analyst to be responsible for preparation of causal and action analysis for HSQES LG, Performance Reports and Quarterly Reviews. Section 5.2.1 Include requirement for VRCC to have completed the Airsweb AVA initial review stage which is a result of AVA implementation. Section 5.2.3 Updated to reflect withdrawal of SAF04F07. Section 5.3 Updated to include quarantine requirements. Section 5.4.1 Severity matrix table image removed as included in SAF04G04 Section 5.4.2 Added Data & Reporting Strategy Manager into initial call to support legal, client and industry reporting. Section 5.10 Revised reference to use the RSSB Taking Safe Decisions to SAF09 - Validation of Change. Section 5.10.1 Rail Investigation Coordinator no longer issues a weekly report to the GM's confirming the status of investigations. This is done fortnightly by the Quality Team as part of the Corrective Action report. Responsibility changed to Quality Coordinator. Guidance SAF04G01 Reporting Guidance Updated to reflect changes to Close Call card reference number SAF04G03 Close Call Reporting Guidance Updated to reflect new VRCC telephone number and remove card template and old card reference number SAF04G04 Guidance on the use of the severity matrix Recreate severity matrix table SAF04G09 Quarterly Review – Terms of Reference Updated to reflect the split of workshop/review group and strategic elements





Forms SAF04F07 – Road Safety Investigation Form (RTC) - Withdrawn SAF04F06 - Investigation Template

Section 10.2 Conclusions and Causes New section added to conclusions and causes 10.2.1 and 10.3.1 to incorporate Airsweb immediate and underlying causal analysis. This is required so that the Rail Investigation Coordinator has the information required to update and close the Airsweb event.

Section 10.5 Severity New section added to validate what the potential and actual severity of the event was. This should be done in reference to the Airsweb severity matrix and SAF04G04 'Guidance on the use of the severity matrix. This is required so that the Rail Investigation Coordinator has the information required to update and close the Airsweb event.

Section 12 Corrective Actions New section added to corrective action table to record 'potential severity if left unresolved'. Requirement of AVA to weight the actions by severity and assist with target setting.

SAF04F06 Appendix H - Other Non-Contributory Issues Identified New section added to each area for improvement to record 'potential severity if left unresolved'. Requirement of AVA to weight the actions by severity and assist with target setting. Rail Investigation Coordinator needs this data to raise the actions from the report. SAF04F11 Record of DCP Conference Call Include Data & Reporting Strategy Manager and Senior Data & Reporting Analyst on initial call Removed need for Data & Reporting Strategy Manager to be present on follow up call

10. BRIEFING REQUIREMENTS

All new employees will receive an introduction to the Integrated Management System (IMS) at induction, according to the nature of the role. All employees with an email address receive the ‘Record of Revisions’ each month, which details changes to the IMS. All Line Managers retain the responsibility to ensure their staff are briefed on changes as appropriate. The following table defines how revised issues of this document are briefed to existing employees according to related specific responsibilities. This is determined using the ‘RACI’ principle. Those roles identified as ‘Responsible’ and ‘Accountable’ should receive a formal awareness briefing facilitated by the Document Owner.

Discipline Role RACI Type of briefing

All All Roles Informed Awareness

HR HR Manager Informed Awareness

Senior Management HR Director Informed Awareness

Delivery Driving Standards Manager Responsible Detailed

Engineering Professional Head of Civil Engineering & Multi-Disciplinary Design

Responsible Detailed

Engineering Professional Head of Track Engineering and Welding


Engineering Engineering Manager – Plant (Prof Head of Rolling Stock & Plant)


Engineering Head of Signalling Engineering Responsible Detailed

Engineering Professional Head of Train Operations Responsible Detailed





Discipline Role RACI Type of briefing

HSQES VRCC Duty Manager / Controller Responsible Detailed

HSQES Environment & Sustainability Manager Responsible Detailed

HSQES Senior H&S Manager Responsible Detailed

HSQES Trainee / H&S Manager / Advisor Responsible Detailed

HSQES Head of Quality Systems Responsible Detailed

HSQES Data and Reporting Strategy Manager Responsible Detailed

HSQES Senior Data & Reporting Analyst Responsible Detailed

HSQES Rail Investigation Coordinator Responsible Detailed

HSQES Training & Competence Manager Responsible Detailed

HSQES Training & Competence Advisor Responsible Detailed

Project Management Project Manager- Civils (Senior / Assistant) Responsible Detailed

Project Management Project Manager- Power (Senior / Assistant) Responsible Detailed

Project Management Project Manager- Signalling (Senior / Assistant) Responsible Detailed

Project Management Project Manager- Track (Senior / Assistant) Responsible Detailed

Project Management Operations Manager Accountable Detailed

Project Management Operations Manager - North Accountable Detailed

Project Management Operations Manager - South Accountable Detailed

Project Management Operations Manager (OTM) Accountable Detailed

Project Management Operations Manager (POM) Accountable Detailed

Project Management Operations Manager- OLE Accountable Detailed

Project Management Operations Manager- Signalling Accountable Detailed

Senior Management Engineering Director Accountable Detailed

Senior Management HSQES Director Responsible Detailed

Senior Management Business Manager - E&P Accountable Detailed

Senior Management Business Manager - OLE Accountable Detailed

Senior Management Business Manager - OTM Accountable Detailed

Senior Management Business Manager - POM Accountable Detailed

Senior Management Business Manager - SP&W Accountable Detailed

Senior Management Construction Manager- E&P Responsible Detailed

Senior Management Construction Manager- OLE Responsible Detailed

Senior Management Construction Manager- Signalling Responsible Detailed

Senior Management Construction Manager- Track Responsible Detailed

Senior Management Director of Major Projects Accountable Detailed

Senior Management Director of Specialist Businesses Accountable Detailed

Senior Management General Manager Accountable Detailed

Senior Management Managing Director Accountable Detailed

Senior Management Operations Director Accountable Detailed

Senior Management Plant Director Accountable Detailed

Senior Management Programme Director Accountable Detailed

Senior Management Regional Director LNE Accountable Detailed

Senior Management Regional Director LNW Accountable Detailed

Senior Management Technical Director Accountable Detailed





Competence RACI Type of briefing

DCP (Designated Competent Person) Responsible Detailed

Rail Lead Investigator Responsible Detailed

Safety Representatives Responsible Detailed

On-call staff Informed Awareness

First Aiders Informed Awareness

11. IMS AUTHORISATION Document owner approval: Stuart Webster-Spriggs, HSQES Director, 05/02/2020

Approval for IMS: Paula Roberts, IMS Coordinator, 05/02/2020


REPORTING GUIDANCE SAF04G01



Contents

1. ACCIDENTS (INCLUDING ASSAULTS) 2

1.1 ACCIDENTS ON DUTY 2 1.2 PRE-EXISTING CONDITIONS / INJURIES 2 1.3 HOSPITAL TREATMENT 3 1.4 ABSENCE FROM WORK AND RETURNING TO WORK 3 1.5 PERSONAL ACCIDENTS TO MEMBERS OF THE PUBLIC 4 1.6 ASSAULTS 4

2. ILLNESS / ILL HEALTH 4

3. CLOSE CALLS 5

4. OPERATIONAL CLOSE CALLS 5

5. INCIDENT 6

5.1 ENVIRONMENTAL 7 5.1.1 IMPACT CATEGORIES AND EXAMPLE EVENT TYPES 7 5.1.2 ENVIRONMENTAL EVENT IMPACT CATEGORISATION 8 5.2 ROAD TRAFFIC COLLISION 10

6. SECURITY 10

7. PROCESS FOR REPORTING AND RECORDING (PC AND NON PC WORKS) 11





1. Accidents (including Assaults)

1.1 Accidents on duty

Personal accidents occurring to employees travelling to or from their normal place of work will not be treated as accidents on duty unless:

a) It occurs just prior to booking on or just after booking off duty at the employee’s normal place of work

b) It occurs whilst in road vehicles owned, hired or leased by VolkerRail, and being driven by employees or conveying employees to work.

c) The employee is travelling from home direct to a location other than their office or depot (e.g. to attend

a training course or meeting, or to undertake special duties). 1.2 Pre-existing conditions / injuries

Where a person’s absence from work is reported or believed to be due to a ‘pre-existing condition’ (e.g., long-standing back or knee conditions), it is necessary to establish whether any further injury or recurrence of such ‘pre-existing condition’ was the result of ‘an accident arising out of, or in connection with work’. The Local Investigation Report SAF04F06 will be used to establish this. The term ‘arising out of or in connection with work’ is further explained in the HSE guidance booklet on RIDDOR, which sets out three key factors which are covered by the phrase and must be considered when deciding if an accident arose ‘out of or in connection with work’. To ensure alignment to the specific definitions of work-related accidents, it is necessary to define if the accident was arising out of or in connection with work. The following statements should be checked; note that more than one statement can apply:

a) The manner of conducting an undertaking

This refers to the way in which any work activity is being carried out for the purposes of an undertaking (task), including how it is organised, supervised or performed by an employer or any of their employees, or by a self-employed person. For example, boxes spread across a walkway cause someone trying to get around them, to be injured.

b) The plant or substances used for the purposes of the undertaking

This includes any machinery, equipment, appliance, or substances used in connection with the place of work or with processes carried out there.

c) The condition of the place of work being used

This includes the state of the structure or outside area forming part of the place of work and the state and design of floors, paving, stairs, lighting etc. For example, a temporary wall collapses, injuring a passer-by. If in doubt, please seek further guidance from your H&S Advisor/Manager. The following table provides examples of whether a further injury or recurrence would be reported as an accident at work. In this example, the person suffers from a pre-existing back problem.

Person experiences back problem at work, but not as a result of an accident associated with a work activity (e.g. whilst standing up or sitting down)

Not to be treated as an accident at work as it did not arise out of or in connection with work.





Person experiences back problem as a result of an accident associated with a work activity (e.g. whilst engaged in a lifting activity)

To be treated as an accident at work as it did arise out of or in connection with work.

1.3 Hospital Treatment

The Supervisor must establish who is to accompany the injured person to the hospital and ensure that safe systems of work and levels of supervision are not compromised. Those responsible for safe systems of work or site supervision must not leave site unless relieved by a suitably competent and authorised individual. If a situation arises where these arrangements cannot be complied with, the issue must then be escalated to H&S On-call. Personnel must not deviate from the arrangement unless authority is given and this must be recorded in the Airsweb log by VRCC.

1.4 Absence from work and returning to work

Instances of absence from work due to injury as a result from an accident at work must be reported in line with VolkerRail’s Standard PER25. This also requires the employee’s Line Manager to conduct a return to work interview and establish whether the injury sustained prevents them from carrying out the full range of their normal duties. The HR Manager will escalate any issues or concerns noted relating to an employee’s medical fitness to the business Health and Safety Advisor/Manager. The day on which the accident occurred will not be included in the calculation of the number of days that an employee is absent from work due to an accident. The number of days absent will include any days that would not normally have been working days. Where the injured person(s) is required to give a statement and/or be interviewed to determine the facts of the event, a home visit may be required. Home visits can only be undertaken with consent from the injured person(s). This will be agreed between the injured person and the business Health and Safety Advisor/Manager. If consent for a home visit is not given then a suitable location other than the home address will need to be agreed. This may be the injured persons normal place of work if they are fit enough to travel to that location. The person undertaking the visit at the injured person’s home or agreed alternative location must ensure they are accompanied (no more than two people are required to undertake this visit). Depending on the severity of the circumstances and whether a home visit is appropriate for the injured person(s), an assessment must be made on each individual case, which will be discussed between HR and the Health & Safety Advisor/Manager for the business. Where the injured person does not agree to a home visit or to meet at an alternative location, the information required must be taken over the phone and recorded on the SAF04F03 – Witness/Injured Person Statement. The following requirements must be met when taking statements/information over the phone:

a) The injured person must understand that it will be a telephone interview b) Where possible the interview may be recorded (note the injured person must be made aware that

the conversation is being recorded) c) The injured person must receive an email of the telephone interview for their signature to confirm

it is a true record of the discussion (or the transcript if recorded) Should the injured person choose to email their statement, then this must be from their company email address. This email statement is still required to be printed and signed by the injured person. (Note: in all cases, where statements are being taken it must be made known to those providing the statements that it may be disclosed and used as evidence if required).





1.5 Personal Accidents to Members of the Public

Injuries to members of the public, including visitors, should be reported irrespective of whether the person was taken to hospital as a result of the injuries. This includes: a) A person who is not an employee or contractor but who is on or in a VolkerRail managed site or premise

e.g. visiting offices or sites.

b) A person who has no business with the railway, but becomes affected by VolkerRail works, notably users of level crossings, bridges or designated walkways / segregation where VolkerRail works are being undertaken.

A member of the public may report an accident, either in person at the time of the accident or several hours/days later, by telephone or in writing. In all cases, the individual should be directed to the local manager or senior person on site who will then in turn register the details with VRCC.

1.6 Assaults

Any event, in which a person is abused, threatened or assaulted in circumstances relating to their work, must be reported as soon as possible to VRCC.

2. Illness / Ill Health

Cases where natural causes (for example, heart attack, epileptic fits) lead to the injury, or death of a person and these are not attributable in any way to the operation of VolkerRail, need not be reported. However, where there is doubt as to the circumstances of the death or injury, the details must be passed to VRCC. H&S On-call must revise these details when more information becomes available. The following provides a summary of the types of disorders/conditions that if are confirmed as part of health surveillance, and on receipt of a written statement from a registered medical practitioner stating that an employee has been diagnosed with an occupational disease, the Occupational Health Nurse will inform the Training & Competence team in writing of the diagnosis.

Occupational Illness Further details / comments

Musculoskeletal disorders Includes:

Carpal tunnel syndrome; Cramp of hand/forearm, or traumatic inflammation of the tendons,

due to repetitive movements; Subcutaneous cellulitis of the hand, knee or elbow (known as

‘beat' conditions) arising from physically demanding work causing severe or prolonged friction or pressure

Hand-arm vibration syndrome All confirmed cases of HAVS, i.e., Stockholm staging ‘stage 1’ and above, to be reported and all will be statutory reportable under RIDDOR.

Noise induced hearing loss

Infections due to biological agents

Includes:

Leptospirosis; Hepatitis; Tetanus; Lyme disease; Legionellosis.





Occupational Illness Further details / comments

Lung diseases Includes:

Mesothelioma; Asbestosis; Pneumoconiosis (including that resulting from dust exposure

during sandblasting by compressed air); Occupational asthma arising from exposure to sensitizing agents

(including isocyanates).

Skin diseases Includes:

Skin cancer; Occupational dermatitis arising from exposure to skin sensitisers

(including, for example, cement, plaster or concrete; organic solvents; biocides, preservatives and disinfectants).

Lead exposure

Work-related stress

Decompression sickness

Cataract due to electromagnetic radiation

The Training & Competence Manager is responsible for reporting the diagnosis, if required by the RIDDOR regulations, to the HSE or ORR.

3. Close Calls

A close call is an unsafe act or condition that could result in personal injury or damage to property or the environment. Close calls can be made by either the Airsweb QR code reporting tool, telephone to VRCC, close call card (HSE-54-VR) or email to [email protected] . If a situation is recognised as unsafe and requiring immediate action or near the line, i.e. where there is imminent danger on / to the live operational railway, the relevant Signaller and VRCC must be immediately informed to facilitate swift action. For full guidance, refer to SAF04G03.

4. Operational Close Calls

An Operational Close Call is an unplanned or uncontrolled event, which occurs on the operational railway and has the potential to cause injury or damage (known previously as Irregular Working). If left unresolved these may directly affect the safe operation of the railway and lead to a safety incident and therefore require immediate action. Operational Close Calls are categorised in one of four ways. Examples are given in the table below:





OCC Category Definition

Protection An OCC involving the work group (e.g. Controller of Site Safety (COSS) or a lookout) which results in incorrect or inadequate implementation of a line blockage, working outside of the protection limits or removal of protection. This includes near misses with staff whilst red zone working (areas where trains are still running), staff being slow to clear the line, or a failure to have a safe system of work in place.

Possession An OCC involving implementation of a possession (i.e. Person In Charge of a Possession (PICOP), Engineering Supervisor, Nominated Person) which results in the incorrect placement of protection, inadequate or incorrect protection arranged, or irregularity in the removal of protection. Isolation placed incorrectly (i.e. outside of possession limits or prior to the possession being taken, trolleys placed outside of possession limits).

Operating Any OCC as a result of an operator (e.g. a signaller or controller) giving permission for protection to be laid with a train not yet having passed the site of work; signalling a train into a possession / line blockage, vehicles or pedestrians trapped between gates at a level crossing or given permission to cross when the line is not clear; failure to caution trains; miscommunication when the signaller is in the lead; two trains in section; train routed into an isolated section, switching incident.

On Track Machine or Plant / Engineering Train / Equipment

Any OCC involving on track plant or engineering trains or involving incorrect use or placement of equipment or materials, for example unauthorised movements within possessions, machines or plant overturning, unsafe operation of machines or plant, equipment or materials fouling the running line, irregularities involving scaffolding on

5. Incident

An incident is an unplanned or uncontrolled event, which has resulted in damage or loss to property, plant, materials or the environment or a loss of business opportunity. Incidents do not include those events that are categorised as Operational Close Calls as detailed in Section 4. This includes, but is not limited to: An unplanned or uncontrolled event that resulted in harm to the environment or breach of legislation e.g.

section 61 consent or working without having obtained a consent Any event that is defined as a Dangerous Occurrence within RIDDOR Service Strikes Road Traffic Collisions OTM incidents, such as cable strike, bridge strike, oil spill/leak, dangerous occurrence, possession

irregularity etc. Any instance of route crime, trespassing and / or theft on Company or the Client’s property Any situation which is prejudicial to health or a nuisance to lineside neighbors or the wider community For an OTM incident SAF04F02 should be completed and submitted by the end of the shift in which the incident occurred.





If there is no impact or effect on the environment, people and/or property then this should be reported as a Close Call. Note that an environmental event may have multiple impacts. Where this is the case, the impact category corresponding to the highest criteria selected should be assigned.

5.1 Environmental

5.1.1 Impact categories and example event types

For the purposes of reporting, environmental events have been classified according to the following impacts:

Sub Environmental Incident Category Examples

Impacts to land and/or water

This includes environmental events that result in, or have the potential to result in, pollution to land and/or water, such as leaks, spills, unauthorised discharges and fly tipping.

a) Hydrocarbon spillages to land / water (including petrol, hydraulic oils and cutting oils);

b) Spillages of hazardous materials to land / water;

c) Spillages of low-hazard products with polluting potential to land / water (detergents, disinfectants, foodstuffs, fertilisers, paints and dyes, other organic liquids);

d) Loss of cable or transformer oil to land / water; e) Waste disposed of at an unlicensed site or fly

tipping.

Impacts to air

This includes environmental events that have an impact or potential impact on air.

a) Activities creating dust with little or no suppression contributing to poor air quality;

b) Visible emissions from combustion units on plant or equipment;

c) Other airborne particulates.

Impacts to nature conservation sites and species

This includes environmental events that have an impact or potential impact on protected sites and species.

a) Causing harm or disturbance to European, National or Biodiversity Action Plan (BAP) protected species;

b) Damage or disturbance to both statutory or non-statutory protected sites;

c) Confirmed spread of an invasive species; d) Damage to a tree protected under a Tree

Preservation Order

Impacts to lineside neighbours and the wider community

This includes environmental events that are injurious, or likely to cause injury, to the health of or nuisance to residents, occupiers of premises or members of the public.

a) Noise at levels such as to affect sleep; b) Vibration leading to property damage; c) Dust in eye or triggers an existing health

condition; d) Odour, smoke or fumes emitted from the work

site; e) Artificial lighting shining directly into resident’s

property; f) Accumulation of rotting waste that could attract

rats and has the potential to spread disease.





5.1.2 Environmental event impact categorisation

Each environmental event is classified dependent upon the severity of the event.

Category Definition

Category 1

Catastrophic and irreversible environmental damage

Irreparable damage to protected sites and / or unlicensed killing of a local / regionally significant protected species population

Category 2

Major, serious, persistent and/or extensive impact or effect on the environment, people and/or property.

Long term remediation (more than 6 months) or destruction of property required

Pollution that causes a persistent (7+ days) and / or extensive (>2km) impact

Pollution involving toxic, hazardous or infectious materials / wastes

Water pollution causing death of 100 or more fish

Unable to continue normal use of a nationally significant area of land and / or water by the public

Closure of licensed potable water abstraction point

Air pollution / land contamination resulting in fatality, serious injury (such as loss of limb or organ) or acute effect on human health

More than 50 complaints in 24 hours

Involvement of the national press

Causing actual or damage to statutory protected site or a nationally protected species or its habitat

Disruption to commercial interested leading to an interruption in production





Category Definition

Category 3

Significant impact or effect on the environment, people and/or property.

Pollution / contamination of land / water / air that requires short-term remediation (between 2 weeks and 6 months) or causes minor (repairable) property damage.

Pollution that has an impact over an area or at least 200m

Water pollution causing death of 10 or more fish

Unable to continue normal use of a locally significant area of land and / or water by the public

Closure of a minor unlicensed potable water abstraction (e.g. serving 1-2 households)

Air pollution / land contamination resulting in injury involving the need to attend hospital or effect on human health

More than 10 complaints in one week

Noise complaints that also involved a breach of consent

Involvement of the local press or contact from the local MP

Disturbance to statutorily protected site of Nationally protected specifies or habitat.

Causing actual hard or damage to non-statutorily protected site or a Biodiversity Action Plan species or its habitat.

Damage to tree protected under a Tree Preservation Order (TPO)

Confirmed spread on an invasive species

Disruption to commercial interests having limited impact on production

Category 4

Minor or minimal impact or effect on the environment, people and/or property.

Pollution / contamination of land / water / air that has no effect on its quality / use

Pollution that has an impact over an area of less than 200m

No effect on the normal use of land and / or water by the public, only individuals or a select group affected

Release(s) to the atmosphere likely to cause only aesthetic impacts e.g. dust

Less than 10 complaints in one week

No press involvement

Disturbance to non-statutorily protected site or a Biodiversity Action Plan species or its habitat

Category 5

Negligible impact or effect on the environment, people and/or property.

Spill of less than 20 litres

Fly tipping





5.2 Road Traffic Collision

A road traffic collision is an incident involving a vehicle on a road or other public area, which causes injury to any persons in the vehicle, 3rd party injuries, injury to an animal, and damage to another vehicle or damage to property construction /fixed structure. If you are involved in a collision, which causes damage or injury to you / any other person, vehicle, animal, or property, you must report the details to the company insurer Zurich. Zurich will then notify VolkerRail Control Centre to raise an Airsweb report and the investigation process will commence. Any subcontractor involved in a collision whilst travelling in connection with their contracted works with VolkerRail must report the details to VolkerRail Control Centre directly. The subcontractor’s employer is responsible for the investigation of road traffic collisions involving their staff. Any VolkerRail employee involved in a collision whilst travelling in connection with their works with VolkerRail must report the details to Zurich directly. The requirement to include injuries as a result of a Road Traffic Collisions in VolkerRail’s performance data occurs when the employee or contractor was travelling whilst on duty in connection with VolkerRail works. VolkerRail employees should refer to VolkerWessels UK Driving for Work Policy and Handbook for further details.

6. Security

The following types of Crime / Security events should be reported to VRCC if directly involved or witness of: Alarm Event Building Infrastructure & Utility Issue Crime Law Enforcement Contact Peace Disturbance Property Damage – Incidental Suspicious Activity Theft of any VolkerRail asset Trespassing





7. Process for reporting and recording (Principal Contractor and Non-Principal Contractor)

Event

VolkerRail Principal Contractor

managed property or site

airsweb

Accident, Incident, Operational Close Call, Security, RTC

Network Rail SCO/247 and/or

Route

i‐tracker

Close Call System (bulk upload)

Network Rail managed

infrastructure or property

Other Principal Contractor’s

managed property or site

Network Rail SCO/247 and/or use

Close Call Form

Network Rail Route Control

Other Principal Contractor’s system

Close out by Network Rail and/or

VolkerRail

Close out by Network Rail

Close Call

Network Rail HSEA or Close Call System

Other Principal Contractor’s system

Close out by other Principal Contractor

Yes No

Fault?

airsweb

Action by VolkerRail

Action by Network Rail

airsweb


REPORTING AND INVESTIGATION FLOWCHART SAF04G02


Approved for IMS: IMS Coordinator Document owner: Rail Investigation Lead Workspace file: N/A Page 1 of 2

NEXT PAGE FOR INVESTIGATION


REPORTING AND INVESTIGATION FLOWCHART SAF04G02



Assign identified actions and

timescales for completion

Agree Actual /Potential Severity of Event

Undertake Local investigation and record findings

Local Investigation Report

Records to be uploaded to airsweb

Undertake Formal Investigation and record findings

Formal Investigation Report

Publish report and findings , track completion of actions /

investigation status(Findings Actions )

Close Event in airsweb system

HighMediumLow

LSR applicable

Complete airsweb investigation and record findingsairsweb Report

Breach or Compliance

Work through Fair Culture Flowchart /Guidance

Decide Positive Consequence

Record Outcome and Decide Rule

Breaking Consequence

No

Yes

Breach Compliance


CLOSE CALL REPORTING GUIDANCE SAF04G03



Contents

1. OBJECTIVE 2

2. INTRODUCTION 2

3. WHAT IS A CLOSE CALL? 2

4. THE PROCESS 4

4.1 QR CODE REPORTING 4 4.2 VOLKERRAIL CONTROL CENTRE 4 4.3 EMAIL / TEXT 4 4.4 CARD 4

5. PROCESSING CLOSE CALLS 5

6. CLOSE CALLS REQUIRING FURTHER INVESTIGATION 5

6.1 LOW POTENTIAL CLOSE CALLS 5 6.2 MEDIUM POTENTIAL CLOSE CALLS 5 6.3 HIGH POTENTIAL CLOSE CALLS 5

7. MONITORING CLOSE CALL DATA 5

8. FEEDBACK 6

9. THE REWARD PROCESS 6





1. OBJECTIVE

The objectives of our Close Call initiative are:

To encourage the identification and reporting of Close Calls so that they can be removed before they result in injury or damage

To increase the awareness of risk and improve the culture of personal responsibility To learn from Close Calls reported, through root-cause analysis that will prevent any future recurrence

This best practice guidance document has been prepared to assist us in understanding what a close call is, what action to take and how we can learn to stop reoccurrence and reduce the risk of something more serious happening.

2. INTRODUCTION

Close Calls are accidents and incidents waiting to happen, and could occur to anyone at any time. Every time a Close Call is reported and fixed a potential accident and incident is prevented. If Close Calls are not reported, they are allowed to remain in the workplace and potentially more serious Close Calls will occur repeatedly, leading to serious injury, time away from work and can have life changing consequences for the individuals involved. Studies have shown that a significant number of close calls occur before this takes place, many without management ever knowing about them. Reporting close calls helps us learn, which will help improve the way that we carry out health, safety and environmental management and reduce the risk and occurrence of serious accidents or incidents which could impact on our people, project programmes, reputation and the environment we work in. To support this we need all employees and contractors of VolkerRail to following our Attitude, Influence and Management (AIM) campaign:

Attitude

A good attitude towards safety and the environment will result in effective close call reporting indicating that you are committed to improving the work environment for you and others.

Influence Influence a safe working environment by reporting and encouraging colleagues to do the same

Management Management are committed to continual improvement and will positively act on all close calls raised.

3. WHAT IS A CLOSE CALL?

Close Call – An unsafe act or condition that could result in personal injury or damage.

Examples of these are: An oil drum fell over and oil nearly ran into a drain Badly insulated power tools Cords trailing across walking route Excavations not protected or signposted properly Hazardous materials incorrectly stored Insufficient task lighting loose carpet tiles on a staircase Lorry reversing without a banksman Operating equipment without utilizing the required guards or personal protective equipment Overgrown access routes Overloaded skip





Padlock on access gate broken Poor drain protection Poorly maintained newt fencing Trip hazards lying around a site Water on the floor posing a slipping risk Wood with nails sticking out.

Operational Close Call - an unplanned or uncontrolled event which occurs on the operational railway and has the potential to cause injury or damage (known previously as Irregular Working). See NR/L3/OHS/0046 Appendix B for a more detailed list of example operational close call events.

Category Definition

Protection An OCC involving the work group (e.g. Controller of Site Safety (COSS) or a lookout) which results in incorrect or inadequate implementation of a line blockage, working outside of the protection limits or removal of protection. This includes near misses with staff whilst red zone working (areas where trains are still running), staff being slow to clear the line, or a failure to have a safe system of work in place.

Possession An OCC involving implementation of a possession (i.e. Person In Charge of a Possession (PICOP), Engineering Supervisor, Nominated Person) which results in the incorrect placement of protection, inadequate or incorrect protection arranged, or irregularity in the removal of protection. Isolation placed incorrectly (i.e. outside of possession limits or prior to the possession being taken, trolleys placed outside of possession limits).

Operating Any OCC as a result of an operator (e.g. a signaller or controller) giving permission for protection to be laid with a train not yet having passed the site of work; signalling a train into a possession / line blockage; vehicles or pedestrians trapped between gates at a level crossing or given permission to cross when the line is not clear; failure to caution trains; miscommunication when the signaller is in the lead; two trains in section; train routed into an isolated section; switching incident.

On Track Machine or Plant / Engineering Train / Equipment

Any OCC involving on track plant or engineering trains or involving incorrect use or placement of equipment or materials, for example unauthorised movements within possessions, machines or plant overturning, unsafe operation of machines or plant, equipment or materials fouling the running line, irregularities involving scaffolding on operational infrastructure.

Design close call A design close call is a significant design feature or omission with the potential to cause harm or injury to people or the environment, which should have been picked up earlier in the design review / verification process. Some examples are:

Something which has been signed off and subsequently found to have the potential to cause harm or injury to people or the environment;

A design which harbours a latent hazard, which has the potential to cause harm or injury to people or the environment. This may be the result of design assumptions or option decision which have not been adequately tested; or

A set of parameters which places members of the project team under sufficient stress to endanger or damage their wellbeing or compromise their ability to fulfil their role effectively this is likely but not necessarily the result of pressure to deliver on time or something similar. However there are other potential causes of stress which could be design or individual specific e.g. having to design to a bare minimum clearance





4. THE PROCESS

4.1 QR Code Reporting

Close Calls can be directly reported into the airsweb system by scanning a QR code. Each project has a dedicated QR code that, when scanned, takes the user to a close call reporting page optimised for mobile usage. This allows for faster reporting by cutting down the administration time associated with reporting close calls. Once logged, close calls will be investigated and closed by a nominated member from the project, or the client, and where requested, an automated email will be triggered providing feedback to the original reporter. Minimal data usage is required; however uploading evidence/photos will increase the data usage.

4.2 VolkerRail Control Centre

You can contact the VolkerRail Close Call Administrator 01302 791187. The following details must be provided to enable us to respond in an effective manner: Date and Time Project Details / No. Name Employer Role Contact Details Location What have you seen? What could have happened? What action was taken Suggested actions to be taken Any additional information such as pictures, structure / signal numbers and mileposts that can be given is also beneficial to ensuring the close call is dealt with as quickly as possible.

4.3 Email / Text

If you prefer, you can email a scanned copy of the card or the details of the close call to [email protected] or text to 07507 308425. The following details must be provided to enable us to respond in an effective manner: Date and Time Project Details / No. Name Employer Role Contact Details Location What have you seen? What could have happened? What action was taken Suggested actions to be taken Any additional information such as structure / signal numbers, mileposts and photographic evidence that can be emailed will be regarded as useful information.

4.4 Card

Close Call boxes will be provided at all offices, depots and sites, however, to ensure a prompt response we encourage that completed cards (HSE-54-VR) are handed to your site supervisor, site access controller or line manager as soon as possible. All completed cards will be reviewed and entered to airsweb.





Remember: if a situation is recognised as potentially significant or severe and requires immediate action on or near the line, the relevant Signaller and VRCC must be immediately informed to facilitate swift action. These situations are deemed as Operational Close Calls.

5. PROCESSING CLOSE CALLS

All close calls submitted directly via QR code, email, text and VRCC will be assigned to the appropriate project and tracked to a satisfactory close through the airsweb system. Where required this information will be escalated to the client for rectification and tracked by the Close Call Administrator through airsweb. All close call cards submitted will be collected by the nominated person and distributed to the relevant supervisor / manager. On receipt of the relevant Close Call cards, the supervisor / manager will immediately review (including site inspection where necessary), take any immediate corrective actions and complete the management section of the card. The cards will then be forwarded to the Close Call Administrator [email protected]. The Close Call Administrator will ensure that all Network Rail Close Calls are inputted to the RSSB Close Call System using the bulk upload facility in time for the Periodic submission.

6. CLOSE CALLS REQUIRING FURTHER INVESTIGATION

All close calls will be closed out within the timescales as determined by level of priority: Priority 1 (high): 24 hours Priority 2 (medium): 7 days Priority 3 (low): 30 days If on review, using the airsweb severity matrix, the situation has potential serious consequences a Local or Formal Investigation maybe instigated. This will then follow the process detailed in Section 5.4 of the SAF04 procedure. The Close Call Supervisor will actively engage with projects through attendance at Business HSQES leadership group meetings.

6.1 Low potential Close Calls

The project teams will nominate one representative to receive the weekly report of all open close calls for the business. The nominated person will be responsible to provide close out actions and assist with closure of low potential close calls. Where applicable, the Safety Representatives may be utilised to upload supporting evidence to airsweb to identify that the reported close call has been mitigated or removed.

6.2 Medium Potential Close Calls

All medium close calls will be reviewed by the project H&S Advisor/Manager to determine if a local investigation is required. Airsweb should be updated by the H&S Advisor/Manager to provide supporting information for closure of the close call.

6.3 High Potential Close Calls

High potential close calls will be managed through the SAF04F11 process to determine the level of investigation. Airsweb should be updated by the H&S Advisor/Manager to provide supporting information for closure of the close call, where applicable.

7. MONITORING CLOSE CALL DATA

Close Calls will be reviewed at the monthly Group and Business HSQES leadership group meetings to identify emerging trends and recommend actions to reverse the trend. This may take the form of topical toolbox talks, engagement briefings, or a review of working arrangements.





8. FEEDBACK

Feedback can be given directly to the reporter if requested. Alternatively, the Close Call report board shown below will be maintained at sites / offices with actions taken and lessons learnt.

9. THE REWARD PROCESS

VolkerWessels UK and VolkerRail are committed to supporting our charitable partners by each report raised leading to a donation to the nominated charities. Furthermore, VolkerRail have committed to a further donation to their local charity for each report closed. The AIM Awards process is designed to encourage all members of staff to contribute to our performance in all aspects of HSQES by recognising and rewarding the individual or team that has made the most significant contribution on a monthly basis. The awards are a development of the current Contribution to Safety - Rewards and Recognition Scheme which has now been extended to encompass recognition of individuals or teams who have made a significant contribution to our strategic goals. The AIM awards will focus on the specific goal areas underpinned by our AIM principles (Attitude, Influence, Management) and are aimed to encourage staff to contribute to our safety performance. Staff can nominate any employee, agency staff or subcontractor, by completing the nomination form and send it to [email protected]. All nominations are reviewed by the HSQES Director and winners announced at the HSQES leadership group and via InSite articles.. Multiple nominations are encouraged however; the nomination cannot be a duplication of another. Any duplicate nominations will be void For further details email [email protected].


GUIDANCE ON THE USE OF THE SEVERITY MATRIX SAF04G04

Issue no: 2 Date: DRAFT Parent document: SAF04


1. Using the process

The process requires an element of judgement using a combination of professional experience, historical knowledge of previous events and an understanding of forthcoming work activities of a similar nature. All investigation leads with input from the HSQES team as well as their senior team as deemed appropriate, shall use the process. The matrix in Section 2 will help determine the actual and potential severity and the opportunity of the event recurring.

1.1 Guidance for ranking ‘Severity’

This provides level of significance for:

a) Injury to people b) Business impact (continuation of operations / reputation / financial) c) Impact on the environment

1.2 Guidance for ranking Likelihood of Re-occurrence

Likelihood of Re-occurrence

Detail

Rare Only under freak conditions could this re-occur Unlikely If other factors were present, then it may re-occur but probably would notLikely May re-occur if additional actions or events trigger it Very likely Will re-occur if additional factors are presentProbable Will re-occur given current working practices / workplace conditions

Consider how often this type of task is undertaken Consider how often a Close Call or accident occurs from this chain of events Consider how near the event was to being more serious Consider if the working environment was a factor

GUIDANCE ON THE USE OF THE SEVERITY MATRIX SAF04G04



2. Severity Matrix

Investigation LevelLow Potential – airsweb report only Medium Potential - Local High Potential - Formal


INVESTIGATION FILE GUIDANCE SAF04G05

Issue no: 1 Date: 26/03/2019 Parent document: IMS Section Number


1. Purpose

This document provides specific guidance in how the investigation team can ensure that all evidence is collected and collated in a structured way. The SAF04 Appendix D – Evidence List should be used to record the evidence that has been collected that supports the investigation and root cause analysis. This list is not exhaustive and should be added to where necessary. 2. Scope

The file structure for all formal investigations is detailed in this guidance document. This structure should also be applied to local investigations where the investigator considers it is necessary to ensure a thorough investigation is carried out. 3. Uploading Evidence Files

On the completion of a formal investigation, the Rail Investigation Coordinator is responsible for ensuring that all evidence files are uploaded on to the airsweb system as a zip file. The file copies on the server will be deleted and paper copies stored in a fire proof cabinet. For local investigations, the lead investigator is responsible for ensuring that the evidence files are uploaded to airsweb in the same way. 4. File Structure

The following investigation file structure should be followed for all investigations to ensure that a thorough investigation is undertaken, giving consideration to all aspects of events, documentation, leading up to the accident/incident/close call.

4.1 Statements and Interviews

Recorded interviews Transcribed interviews Written statements

This section should include any documented statements from personnel involved and records of any interviews undertaken as part of the investigation. All statements should be a written account, which is signed and dated on each page, as a true account. Any recorded interviews should be transcribed and included with the file. Look for inconsistencies in statements and try to understand where the anomalies lie. This may be due to memory recall and require a different type of interview technique to be applied by the investigator, e.g. cognitive or visualisation interview techniques.

Relevant personnel include:

• Injured Parties • The responsible Line Manager • Witnesses (eye and ear) • Key personnel to the work activities involved • Any person(s) involved prior to and / or leading to the incident e.g. Planners, Resource Managers etc. • Maintenance staff

Witness statements should outline the following:

• The witness’ role / involvement in the incident • Their knowledge of the sequence of events leading up to the incident • Information on the systems / methods used





4.2 Photographs and CCTV

CCTV Equipment photographs Material photographs Plant photographs Post event site visit photographs

These may include:

• Photos of the site set-up • The area of the incident • Photos of any equipment involved • Damage to plant or equipment • Extent of contamination or spillages • CCTV viewed and saved

4.3 VRCC Voice tapes

Where the event has been reported to VRCC, all voice tapes should be requested. VRCC will provide a timestamp on each recording submitted.

4.4 Site Documentation

Risk Assessments Site Diagrams - Schematics Site Documentation Work Information

This section should include relevant site documentation. This should include:

• Site Supervisors Instructions • Copies of relevant Environmental Permits / Consents

This section should include information relating to the works being carried out. This should include:

• Client works order / instruction • Construction drawings • Relevant site plans / layout drawings • Any related work programmes • Copy of site traffic and pedestrian plan • Work Package Plans / Method Statements / Task Briefs • Risk Assessments • Safe System of Work Packs / Permits • PPE documentation

4.5 Events of a similar nature or involving same location, equipment or individuals

This information can be obtained from the Senior Data and Reporting Analyst and the details should be specific to the investigation being undertaken.

4.6 Training and Certification

Insert copies of qualifications, certificates or any other proof of attendance to courses that may be relevant to the incident. These may include courses such as:

• Plant operator courses (CPCS) • NRSWA courses • CSCS cards / equivalent





• Manual handling training • Inductions • Relevant Environmental training • Other relevant Health and Safety training • Internal awareness (HSEQS) training

4.7 Induction Records, TBTs and Briefings

Insert copies of induction records, toolbox talks (TBT) and attendance sheets for the relevant TBT’s undertaken.

4.8 Policies, Documents, Guidance or Standards

Insert any relevant group policies, documents, guidance or standards. These may include:

• Group procedures / guidance • Environmental • Group documents • Legal compliance documents • Standard templates etc.

4.9 Legislation

Insert whole or relevant sections of related legislation, or Approved Codes of Practice, if required as a direct reference to the investigation.

4.10 Client or Statutory Reporting Forms and Investigations

Insert copies of any statutory reports or investigations. These may include:

• ORR F2508 Form • HSE F2508 Form • RAIB Notification Form • RT3118 Signal Passed at Danger Investigation Form • Network Rail Prelim Investigation Form

4.11 Communication

Conference calls Emails

This section should include any key communication relating to the incident. For example:

• DCP Conference Call recordings • Internal correspondence • Evidence of communication cascade • Relevant decision and action logs • Correspondence with the client • Correspondence with enforcing authorities • Correspondence with the injured party • Advice from specialists or external bodies • Correspondence from members of the public • Correspondence from solicitors

4.12 Actions – post incident

Insert any evidence of immediate action taken to prevent a reoccurrence.

4.13 Miscellaneous

D&A Results Design Records





Fatigue Risk Index calculations Formal Investigation Remit Maintenance Records Mobile Phone Records/Logs Product Acceptance Records Resource Allocation Weather Reports

This section should contain any other information or evidence not covered by previous sections. This may also include (additional folders can be added as necessary):

• Health and safety inspections carried out on site • Housekeeping checks or schedules • Findings from other related investigations • Details of any tests or surveys carried out

4.14 Plant, Equipment and Materials

COSHH assessments Data Logger downloads Maintenance records Operator’s manuals Plant specifications Thorough examination records

This section allows for the inclusion of details relating to any plant, equipment or materials involved. This can include:

• Weight information • Manufacturer’s instructions • Condition reports • Material safety data sheets • Alternative materials available • Application of equipment • Service and maintenance schedules and records • Post incident inspections / condition reports • Plant assessments • Product assessment records

4.15 Analysis

Appendix A – Sequence of Events Appendix E – Causal Analysis Diagram Appendix G – Fair Culture Analysis Appendix I – Barrier Analysis STEP Analysis

This section should include any analysis that has been undertaken to determine the root cause. There are many analysis methods available and additional folders can be added as necessary, detailing the specific analysis model/method used.

The fair culture analysis undertaken for the individual(s) involved, should detail the reasoning around the decisions made, using the SAF04G07 A Guide to Using the Fair Culture Model. This should be recorded on SAF04F06 Appendix G.

4.16 Report

Appendix B – List of Individuals Involved Appendix C – Supplementary Detailed Information





Appendix D – Evidence List Appendix F – Distribution Appendix H – Other Non-Contributory Issues Identified Draft Report Final Report

This section should contain all versions of the draft report showing all revisions and iterations made, in particular information detailing where review comments have been discounted and why.


ROLE & CONDUCT OF EMPLOYEES AND INVESTIGATION TEAM SAF04G06



1. Introduction

This document must be read in conjunction with the Suitability Assessment for Investigators SAF04F12. By assigning a VolkerRail employee to be an investigator, the business and the investigator accepts the requirements noted in this guidance document for that investigator to fulfil their role. VolkerRail are committed to providing a safe, responsible, efficient and healthy work environment to the benefit of all employees, sub-contractors and our stakeholders. To support this, we need all our investigators to follow our Attitude, Influence and Management (AIM) campaign: VolkerRail’s 'AIM' is there to ensure consistency and understanding in promoting an open culture which will ensure the effectiveness and success of our investigations and reducing repeat events. Our AIM encompasses the following key messages:

Attitude: actively encourage positive behaviour and actions to ensure a safe, responsible, efficient and healthy working environment for all our employees, sub-contractors and stakeholders. Influence: leading by example and ensuring all employees have the opportunity to influence their own working environment, and that of others through effective two-way communication. Management: fair and consistent treatment of all employees, sub-contractors and stakeholders through listening, involvement and recognition.

2. Investigation Team

The investigation team shall co-operate with the Rail Investigation Lead to achieve the objectives of the investigation remit. Investigation team members shall not assume the role of advocate, spokesperson or advisor of witnesses, or inhibit in any way the establishment of facts of the giving of evidence, when evidence is being collated. Observers may however at the discretion of the Rail Investigation Lead be permitted to express a view, put questions to witnesses and participate in discussions prior to the drawing up of conclusions and recommendations.

3. Duty of All Staff and Contractors to Co-operate

All staff and contractors are legally obliged under the Health and Safety at Work Act 1974 to cooperate with any investigations that are undertaken following any accident or incident. A refusal by any party to co-operate is to be treated in a serious manner. A member of staff must be advised that as well as having legal obligations under the Health and Safety at Work Act to cooperate in the investigation, they are contractually obliged to do so by virtue of their Contract of Employment. A consistent refusal may result in the person concerned being suspended from duty and disciplinary action being instituted. A refusal by a Contractor’s employee (this includes self-employed persons working for the Contractor) must be referred to the appropriate level of management within the Contractor’s organisation. This will be carried out by the HSQES Director. All cases where there has been a refusal by an employee or member of Contractor’s staff to cooperate in an investigation must be reported to the HSQES Director.





4. Staff Working Hours/Rest Periods

The working hours of staff may be extended and/or rest periods reduced, as required in order to facilitate investigations. Should extensions/reductions be required they should be managed in accordance with VolkerRail Standard SAF06 Management of Fatigue (Control of Working Hours). If considered appropriate, staff should be relieved from duty for initial interview and released from duty on their next turn of duty to enable statements that are more detailed to be obtained. In all cases, it must be clearly agreed with each individual when their report will be provided.

5. Confidentiality Statement

When VolkerRail undertake an investigation, it will be necessary to obtain evidence, including obtaining witness statements. This could be a witness statement as a direct witness to an incident, an employee or as a victim. Investigators may also receive personal data from third parties if it is relevant to an investigation. Investigators may also collect personal data if someone is suspected of committing a criminal offence. When investigating, the investigator may collect personal data, which may consist of the following:

• name;

• email address/correspondence address;

• date of birth;

• details of employment and job role;

• details of individuals involvement in an incident;

• depending on the nature of the complaint/request this may consist of sensitive categories of personal

data such as data concerning an individual’s health such as an injury or disability.

This Confidentiality Statement is intended to apply to all employees that are responsible for undertaking or supporting investigations on behalf of VolkerRail Limited. During an investigation, everyone has a right to have his/her personal data handled, stored and processed securely and in accordance with the General Data Protection Regulations and Data Protection Act 2018. Such data will only be processed for the purpose of a specific investigation. The types of information that we may be required to handle, include details of witness statements, evidence collected, photographs, including information pertaining to our clients, our stakeholders and our supply chain. The information required for an investigation, which may be held on paper or on a computer or other media, is subject to certain legal safeguards specified in the Data Protection Act 2018 (the Act) and General Data Protection Regulations. The Act and Regulations impose restrictions on how we may use and store that information. This Confidentiality Statement does not supersede other documentation where this subject is mentioned and should be read in conjunction with the ICT Policy, Employee Handbook and Statement of Main Terms and Conditions. Any breach of this statement will be taken seriously and may result in disciplinary action. In applicable circumstances, it may also be considered to amount to gross misconduct. In such instances, the Compliance Officer must be informed at the earliest opportunity. Protecting the business Data is information, which is stored electronically, on a computer, or in certain paper-based filing systems.





Personal data means data relating to an individual who can be identified from that data (or from that data and other information in our possession). Personal data can be factual (such as name, bank account details, address or date of birth) or it can be an opinion, for example on an individual’s performance or behaviour.

Sensitive personal data includes information about a person's racial or ethnic origin, political opinions, religious or similar beliefs, medical data including physical or mental health condition or sexual life.

Processing is any activity that involves use of the data. It includes obtaining, recording or holding the data, or carrying out any operation or set of operations on the data including organising, amending, retrieving, using, disclosing, erasing or destroying it. Processing also includes transferring personal data to third parties.

All personal and sensitive personal data must be kept strictly confidential and not be directly or indirectly revealed, reported, copied, published, communicated, disclosed or made available to any third party.

Permission must not be given to others to use confidential information, other than for legitimate business purposes and with appropriate authorisation.

Data security We must ensure that appropriate security measures are taken against unlawful or unauthorised processing of personal data and against the accidental loss of, or damage to, personal data.

The return of confidential information shall not release individuals from their obligations under this Confidentiality Statement.

6. Confidentiality Charter:

The Investigator/subject matter expert/employee will:

Ensure that confidential information provided will be used solely for the purpose of investigation

Investigate all accidents and incidents in accordance with “fair culture” (where applicable)

Always act with integrity and respect of others

Remain unbiased and non-judgmental

Collect and record information only if it necessary for an effective, thorough investigation, in

accordance with GDPR

Ensure that information is kept securely to ensure that only those authorised to do so can gain access

Ensure that information and evidence is not shared with anyone other than those who are members of

the relevant investigation panel

I confirm that I will not divulge any information relating to the undertakings either during the investigation or after

its conclusion.

I have read and understood the role and conduct of employees and investigation team and agree to abide by

the terms and conditions.

Signed: ___________________________________________________________________

Print name: ___________________________________________________________________

Date: ___________________________ Please forward a signed copy to the Rail Investigation Coordinator for their records

A Guide to using the Fair Culture Flowchart Page 1 of 19 Version 1.1 July 2013

A Guide to using the Fair Culture Flowchart

Author Lee Parlett, Corporate Investigation Manager Function S&SD Date July 2013 Version 1.1


Purpose of this Guide This guide is intended to provide an explanation of the Fair Culture Flowchart, how it should be used and how this fits in with the accident investigation process. Who the Fair Culture Flowchart can be used for The Fair Culture Flowchart can be used for any employee involved in a safety incident. The Fair Culture Flowchart is specifically for use following a safety accident or incident. The flowchart should be applied to the immediate cause identified by the investigation where it is an unsafe act and any other unsafe acts identified by the investigation. Although it promotes good management practice, it is not designed for use in other situations, such as poor general performance or absenteeism. If more than one employee is involved, it is essential to work through the Fair Culture Flowchart separately for each person. Who the Fair Culture Flowchart can be used by

Investigation team DCP Independent review panel Line managers

When to use the Fair Culture Flowchart It is important to see the use of the flowchart as part of the investigation and not the investigation. The normal investigation process should be followed, including using the Investigator Prompts for the 10 Incident Factors to plan for the interview(s), with the flowchart being used once the evidence has been reviewed. If new information comes to light, it can be worked through afresh and may or may not indicate a different conclusion. The 10 Incident Factors and associated Investigator Prompts are available in the Investigators’ Handbook. These have been updated (to version 2.1) and are available in a separate Guide to the 10 Incident Factors. How the Fair Culture Flowchart works The Fair Culture Flowchart guides you through a series of structured questions about the individual’s actions, motives and behaviour at the time of the incident. These questions move through four sequential ‘tests’ (the four columns of the flowchart):

The Deliberate Harm Test The Foresight Test The Substitution Test The Personal History Test

Working through each test in turn, possible reasons for the individual’s actions are reviewed and the most likely explanation identified. Your responses lead to a behaviour type which aligns with a list of recommended actions in the ‘consequences matrix’ for both the individual and their manager.


The Deliberate Harm Test In the overwhelming majority of safety accidents and incidents the individual did not intend the bad outcome. However in rare cases the intent was to cause harm or for personal gain where no concern was given to the consequences for safety. The Deliberate Harm Test asks questions to help identify or eliminate this possibility at the earliest possible stage. The Foresight Test If malicious intent or recklessness has been discounted, the Foresight Test examines whether procedures and safe working practices were adhered to and whether it was practicable to do so. The Substitution Test If procedures were not in place or proved ineffective, the Substitution Test helps to assess how a peer would have been likely to deal with the situation. The Personal History Test Finally, if peers were determined to have been likely to have acted differently then the Personal History Test seeks to determine whether this was a situation the individual often found themselves in. Consulting the individual With some of the questions in the fair Culture Flowchart, the only person who can answer the question accurately is the individual. It is therefore important to try and discuss the matter with them. However, there may be circumstances where:

this is not possible (for example, the individual has been arrested); or you simply do not believe their answer.

In these cases, you will have to form a view based on the balance of probability using the information before you. If new facts come to light you can work through the Fair Culture Flowchart afresh. Individual denies involvement If the individual says they were not involved in the incident the questions can be difficult to answer. It is possible that the individual:

really was not involved; is traumatised and confused about what happened; or is lying to cover up malicious intent.

Bear in mind that in a ‘blame culture’ individuals sometimes feel pushed into denying mistakes through fear of punishment. What to do if you‘re unable to answer a question If you cannot answer a question it is important to pause and try to establish the facts. Do not make assumptions. The Fair Culture Flowchart can be worked through stage by stage. The questions do not have to be answered in one go. Gather as much evidence as you can, but recognise that there could be situations where information proves patchy or inadequate. In these circumstances you may have to answer the question based on your best judgement.


The Deliberate Harm Test Guidance In the overwhelming majority of safety incidents the individual has decided to behave in a particular way but without the intent of causing harm or any other bad outcome. Sometimes people knowingly take risks, not necessarily with the intent of causing harm, but because they think they can do it better, or simply because it is more convenient for them or they get a thrill from deliberately not following the rules. However in rare cases the intent was to cause harm or for personal gain where no concern was given to the consequences for safety. The Deliberate Harm Test asks questions to help identify or eliminate these possibilities at the earliest possible stage. Was the action deliberate?

This question asks whether the actions were as intended, not whether the outcome was as intended. This is an important distinction. 10 Incident Factors If individuals are unaware of the correct course of action then investigation using the questions in the Knowledge, Skills and Experience Incident Factor will help with understanding why. When people forget steps in a process it is useful to consider what might had led them to forget and the extent to which they might have been distracted or overloaded. Personal and Workload Incident Factors will help identify these issues. Deliberate acts Consider whether the individual:

decided to take the action decided not to take the action refused to carry out an instruction

Non-deliberate acts Consider whether the individual:

forgot to take the action was prevented from taking the action

Was the action

deliberate?

No

Yes

Go to the Foresight Test

Go to next question


didn’t know they had to take that particular course of action Was the action well intentioned?

This question tries to identify the individual’s motives for taking the action they did and will help identify those who deliberately tried to cause harm or sought personal gain where no concern was given to the consequences for safety. Well intended actions In most cases where the actions were as intended the individual’s actions were well intentioned and they did not mean the harm that resulted. There are other reasons why the correct course of action was not followed. For example, the individual may not have been aware of the correct course of action, got confused, didn’t know how to apply the correct course of action or thought they were doing the right thing but just hadn’t appreciated the risks of their course of action. Malicious or reckless acts Deliberate acts of sabotage such as placing scrap rail across a running line or setting fire to lineside equipment where the intention was to cause disruption and in doing so put life at risk would require a ‘No’ answer. Also, in a very small number of cases individuals deliberately ignore safety procedures without thinking or caring about the consequences. These are reckless acts. There are individuals who knowingly break rules for their own personal benefit. Examples include cutting corners to leave work early or to get longer breaks, or because they get a thrill from deliberately not following the rules. It is likely that in cases of conscious, deliberate harm there will be a criminal investigation.

Was the

action well intentioned?

No

Yes

Go to the Foresight Test

Go to next step


Finally, using the criteria above decide whether the behaviour was:

Sabotage or malicious intention; or Reckless contravention for personal benefit.

Sabotage, malicious intention

or Reckless contravention for personal benefit


The Foresight Test Was the individual informed about the procedures?

Guidance If intent to harm has been discounted, apply the Foresight Test to determine whether procedures and safe working practices were properly adhered to. The Foresight Test does not try to remove an individual’s personal responsibility for their actions, but sets it in the context of potential problems with procedures. First clarify whether the action was governed by an agreed procedure or procedure. Do not simply assume this to be the case – check the documentation yourself. It is impossible to proceduralise every eventuality. Likewise, it is dangerous to apply procedures slavishly, without using judgement or taking into account particular circumstances. Failure to react to unusual circumstances can be as dangerous as routine contravention of procedures. The Substitution Test (described later in this document) acts as a safety-net when assessing situations where procedures were inadequate or not in place. 10 Incident Factors Questions in the Practices and Processes and Knowledge, Skills and Experience Incident Factors will help answer these questions. What would make this ‘Yes’ When considering this question you need to look at whether procedures or a safe way of working existed in the first instance. If the answer to this question is yes then you need to consider whether the individual knew about the procedures. This goes beyond looking at whether they have a certificate of competence and looking at the quality of the training and whether it covered this situation and the appropriate actions. If the procedure has recently been changed or introduced, check whether the individual had been briefed and what the quality of the briefing was.

Informed

about procedures?

No

Yes

Go to Substitution Test

Go to next question


Are the procedures clear and workable?

Guidance Do not automatically assume that procedures were workable and in routine use. Remember to establish the situation at the time of the incident; working practices may have been revised subsequently. Was the procedure clear? A procedure was only ‘clear’ if the individual had ready access to it. For example, if a procedure could only be accessed via the intranet but there was no computer in the work vicinity, the procedure could not be considered ‘clear’. Was the procedure workable? What at first sight appears to be a workable procedure may be problematic in practice:

Did the individual misinterpret an ambiguous or badly-written procedure? Was the individual unwittingly applying an outdated procedure? Were conflicting procedures in circulation? Was the procedure technically accurate but too laborious to apply routinely?

(If the procedure was technically accurate, but too time-consuming or complex to apply the individual may have had to disregard it in order to get the job done)

Did the procedure promote correct and sensible action? If the procedure was badly written or unworkable the individual may have made a professional judgement to disregard it. A procedure that is workable in routine situations might have failed in unusual circumstances, such as when there is degraded working or equipment failure. Was the procedure in routine use? It is unrealistic to assume that because a procedure existed staff were using it routinely. There are a variety of reasons why it might not be, some of which you may already have uncovered:

People weren’t aware they had to use it; The activity/context the procedure applies to just doesn’t happen that often ; Local custom and practice means there are alternative ways of working.

Procedures clear and workable?

No Yes

Go to Outcome 1

Go to Outcome 2


It is important to examine what the custom and practice is and why this might be different to the documented procedure. Did the individual decide not to apply the procedure? If the individual was aware of the procedure but decided not to apply it you need to establish their reason for doing this. For example, on establishing the underlying reason you may find that the individual was faced with an emergency situation and contravened a rule in order to avert immediate danger. If their action stemmed from difficulties applying the procedure, you would normally answer ‘no’ to the question, consider the consequences for ‘mistake caused by system’ and go on to apply the Substitution Test. If there was another reason, you would normally answer ‘yes’ to the question and move down the flowchart to the next box in the Foresight Test to consider whether the action was a contravention or a slip/lapse. Did the individual cut corners because they knew the procedure so well? Sometimes the individual was so familiar with the procedure they felt over-confident about cutting corners. Corner-cutting usually causes problems where the case concerned turns out to be atypical. The individual may be alone in cutting corners, or may work in an environment where this is routine. Sometimes the individual was so used to applying a familiar procedure that they acted instinctively and forgot there had been a change in practice. This may happen when:

an old procedure is replaced; an individual changes departments or locations; or an individual changes organisations.

In this instance, as long as the new procedure was clear and workable, then this is a case of an attentional slip. The consequence for slip/lapse should therefore be applied. Outcome 1

If you have arrived here from a situation where the action was deliberate and well intentioned then the behaviour is a contravention and the consequences for this should be applied. If you have arrived here from a situation where the action was not deliberate then the behaviour is a slip/lapse and the consequences for this should be applied.

Contravention

or Slip/lapse


Outcome 2

Having arrived here you should consider the consequences for ‘mistake caused by system’ and then go on to apply the Substitution Test.

Mistake

caused by system

Yes

Go to Substitution Test


The Substitution Test Would others have done the same thing?

Guidance If procedures were not in place or proved ineffective, apply the Substitution Test to assess how a peer would have been likely to deal with the situation. This test also highlights any deficiencies in the following that may have been involved in the safety incident:

training experience supervision

10 Incident Factors Questions in the Knowledge, Skills and Experience, Supervision and Management and Personal Incident Factors will help answer these questions. Questions to consider: Consider what a ‘reasonable’ peer acting sensibly would have done. Consider whether breaking the rule or not following the procedure has become the normal way of working. This way of working often remains invisible until there is an accident (or sometimes as the result of an audit). Routine rule violations are promoted by a relatively indifferent environment, i.e. one that rarely addresses rule breaking or rewards compliance: "we do it like this all the time and nobody even notices." When considering what the norm is and how others would have behaved it is important not to deduce the norm from blanket judgements and prejudices. For example:

Contractor COSS’s never have good local knowledge; Signallers never want to help maintenance; Possession support staff tend to be easily confused.

Would others

have done the same?

No

Yes Go to Personal History Test

Go to next question


The chances that other people would have done the same thing are increased if there is little checking that procedures are being adhered to and if managers turn a blind eye to those not following the rules. Selection, training and experience

Guidance Consider whether the individual was properly equipped to deal with the situation. If not, a system failure is indicated. Do not make automatic assumptions about the standards of training or supervision received. Sometimes a lack of training or supervision can affect an individual’s ability to apply common sense and ‘think on their feet’. If this is the case, additional coaching or support may be necessary. 10 Incident Factors Questions in the Knowledge, Skills and Experience, Supervision and Management and Personal Incident Factors will help answer these questions. When answering this question: Carefully check the following possibilities:

Gaps or deficiencies in the individual’s training; Being ‘thrown in at the deep end’, with insufficient experience to handle the

situation; Inadequate competence assessment and supervision.

Selection Look into how the individual has progressed into the role which led them to be undertaking the activity where the error was made: Has the progression provided sufficient and relevant experience? How was a decision made to appoint this individual to this role? What evidence is there to suggest that the individual has the appropriate non-

technical skills for this role?

Adequate

selection, training and experience?

No Yes

Go to Outcome 1

Go to Outcome 2


Training Look into any training the individual had received and make sure it was:

comprehensive; well-designed; and effectively delivered.

Supervision Check that supervision was both active and supportive. Outcome 1

Having arrived here you should consider the consequences for ‘poor judgment’. Outcome 2

Having arrived here you should consider the consequences for ‘mistake caused by system’.

Mistake

caused by system

Poor

judgement


The Personal History Test

Guidance This question is concerned with finding out whether the individual had a history of contravening procedures or whether there was a history of contravening this procedure at this location or within the team. The latter contraventions are sometimes referred to as routine violations where the contravention has become the norm. In order to help you establish whether this is the case consider:

Whether the contravention has been condoned by managers (i.e. have managers been turning a blind eye)?;

How long this way of working has been in existence and whether it’s so established that it’s only the incident that has brought it to light;

Management priorities and how they are communicated to staff – quite often routine rule violations are promoted by a relatively indifferent environment, i.e. one that rarely addresses rule breaking or rewards compliance: "we do it like this all the time and nobody even notices."

Where the history of contraventions is associated with the individual this is an indication that they present an additional risk. Consideration needs to be given as to whether this is an issue of training and competence or capability. 10 Incident Factors The questions in the Supervision and Management, Knowledge, Skills and Experience and Personal Incident Factors with help answer this question.

History of

contravening procedures?

No Yes

Go to Outcome 1

Go to Outcome 2


Outcome 1

Having arrived here you should consider the consequences for ‘routine error –personal history’. Outcome 2

Having arrived here you should consider the consequences for ‘routine error –different people’.

Routine error

different people

Routine error

- personal history


Recording the outcome It is the role of the investigation team to:

identify the behavioural cause of all unsafe acts identified during the investigation;

record local actions for the fair consequences to be applied by the individual’s line manager and their line manager (two separate actions).

Unsafe acts form the majority of the immediate causes identified during our investigations, but you may identify others too. It is important that the actions are phrased in an impartial way that directs the line managers to consult the consequences matrix and apply this appropriately; it is not the role of the investigation team to interpret the matrix. Here is an example of the wording that could be used: 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).





GUIDANCE ON THE USE OF DCP CONFERENCING FACILITY SAF04G08



1. Conferencing facility

West's Unified Communications Service provides this conference facility for VolkerRail. For training and more information, visit the following website: https://www.westuc.com/en-gb You can schedule and manage your conference call meetings, update contact settings, view reports and more with InterCall Online. https://www-emea.intercallonline.com/redirectAddUser.action

1.1 Dial in numbers

UK LocalCall Dial-In Number: 0844 493 4865 Toll-Free Dial-In Number: 0800 694 8053 Std Dial-in number: 0207 897 0111 Conference code: 2416403490 Leader PIN: 6990

2. Setting up the conference call

2.1 Getting started

The DCP is responsible for setting up the conference call by providing participants with the date and time of the call, your dial-in number and your conference code. At the specified time, dial your Reservationless-Plus dial-in number then enter your conference code, followed by #. When prompted, press *, then enter your leader PIN, followed by #. Your participants join the conference by dialing your number and entering the conference code.

3. Recording the conference call

To start recording the conference, the DCP should dial *2 at the beginning of the call. Participants will hear a prompt that the conference is being recorded once the recorder has joined. The recording will last the duration of the conference call and will be available for playback up to 30 days from the date the call was completed.

3.1 Accessing your recording online

Follow the steps below to access your recording:

1. Login to www.intercallonline.com with your username and password. 2. Select the Meetings tab and click on the third tab labeled Recordings Meetings.





You can access your archive by selecting the down arrow to the left of the Playback ID, then use one of the following options:

1. Select listen to start the streaming playback of the conference. 2. Select the download option to save your recording in .mp3 format to your computer

Save to the investigation folder AIID…. \\VR-DONC-FILE1\Safety\Formal Investigations\ Within the communications sub-folder





4. Helpful keypad commands:

Key Command Who *0 Operator assistance Conference 00 Operator assistance Individual *1 Dial-out to a participant Leader only *2 Begin/end conference record Leader only *3 Change entry/exit method (recorded names, tones, silence) Leader only *4 Private roll call *5/#5 Mute/unmute all participant lines Leader only *6/#6 Mute/unmute your own line Individual *7/#7 Lock/unlock conference (including operator) Leader only *8 Allow/disallow conference continuation Leader only *9 Start/join sub-conferencing 11 Third-party conference start - bypass hold music to start call as leader *51/#51 Lecture mode on/off Leader only #99 Disconnect all lines except leader’s Leader only *# Participant count ** List available keypad commands

5. Connect on the go with InterCall® MobileMeet®

Download the FREE MobileMeet app and have the ability to schedule, access and control your conference calls from your iPhone, iPad, Android or tablet.

6. Customer Service Information

6.1 General information

Owner name: Michelle Malone Company name: VolkerRail Owner number: 8267794 Web PIN: 9742 Customer service: +44 (0) 330 606 8606


TERMS OF REFERENCE - LEARNING FROM INVESTIGATIONS QUARTERLY REVIEW SAF04G09



1. Introduction

The ‘learning from investigations’ objective provides a focus for the business to embed an effective investigation process that produces SMART actions and prevents reoccurrence of events. The objective set out to: • Help the business understand why we do investigations

• Learn from events to prevent repeat occurrences

• Embed the application of Fair Culture in to the business, particularly around positive interventions

• Ensure shared learning across the business and wider industry

• Focus on human factors through investigation and feedback these findings into the material for the behavioural based safety sessions

A quarterly review meeting will take place to ensure the effectiveness of the objective. The intent of these quarterly reviews will be to demonstrate process improvements with the focus being on a consistent approach to investigations, which are to a standard that ensures a high-quality investigation is undertaken, that gets to root cause. The intent is that operational staff and senior management take accountability for leading and supporting investigations, making suitable and sufficient recommendations and ensuring effectiveness of lessons learnt.

2. Review Group

The VolkerRail HSQES Director will lead a working group session where the trained Lead Investigators present their reports and supporting information with the group in a supportive and learning environment. This methodology applied to the review will instil consistency and ownership under a peer review environment. The HSQES Director will be supported by the Rail Investigations Trainer, Training & Competence Manager and Behavioural Safety Lead to ensure constructive feedback with improvement opportunities highlighted for all delegates to learn from. Each investigation report will be self / group critiqued using the following areas / questions: • Has the investigation covered the remit (from the DCP conference call)?

• Timely submission of report?

• Have recommendations been closed within given timescales?

• Have post incident reviews taken place, captured in the report and deemed effective?

• Is the fair culture outcome correct and consistent (has it been applied to design, planning, management)?

• Have human factors been correctly identified and fed back (for the behavioural based safety sessions)?

• Have the correct Lifesaving Rule breaches been identified (if applicable) and fed back into the tracker?

• Has the VRCC / On-call response been effective?

• Are the actions SMART?

• Has the root cause been effectively determined?

• Has appendix H picked up all non-contributory but pertinent safety issues and actioned?

• Is sufficient evidence provided and properly referenced?

• Is the closure of actions deemed effective in preventing a recurrence?

• Has there been effective shared learning across the business and wider industry (where applicable)?

3. Strategic elements

The HSQES Director will maintain an action log from the Review Group outputs which, along with the current data on completion timescales and action close out timescales will form part of the quarterly review strategic update delivered to the HSQES Leadership Group meeting as established.


TERMS OF REFERENCE - LEARNING FROM INVESTIGATIONS QUARTERLY REVIEW SAF04G09



4. Meeting frequency and agenda

Meetings will be held quarterly (both the review group and subsequent strategic elements in the HSQES Leadership Group). The HSQES Director will arrange for all the relevant analysis/data and reports/appendices from the previous 3 months to be produced and distributed approximately 1 week in advance of the meeting. The agenda will be based on the above with the objective of achieving the following learning: Learning • Reduction in repeat events, demonstrated through the application of improved SMART actions from

investigations

• Analysis of similar industry incidents to further determine the effectiveness of investigation actions and learning

• Reduction in injury claims against the company and reduced costs

• Reduction of occupational health risks

• Undertake an analysis of the unintended consequences of actions

• Undertake a review to ensure continued learning from ‘safety issues’ raised through investigation but not contributory to the outcome

Process • Improvements on the timely completion of investigations demonstrated through a reduction in overdue

reports

• Those responsible for investigations taking ownership and driving completion within given timescales

• Management support for completion of investigations

• Lifesaving Rule breach tracker developed and is effective

• Review of VRCC coordinated incident response and effectiveness

• Review effectiveness of post incident event reviews

Training & Competence • Review application of learning from investigators

• Review / maintain investigators competence (utilise reconstructions, video and emergency response training)

• Analysis of issues/successes around those responsible having the skills and time to undertake investigations

• Critique submitted reports

Culture • Evidence that key stakeholders take responsibility/accountability for safety and investigations on their

projects

• HSQES team provide a supporting role for investigations including review of reports

• Improved application of fair culture analysis – both positive and negative

• Analysis of organisational safety culture through the RM3 process, notably criterion OC6 – Safety Culture

5. Membership and attendance

The HSQES Director will lead the review group. Membership is required as follows: • Senior Health & Safety Manager (as applicable)

• External safety consultant

• Training & Competence Manager

• Engineering Director (as applicable)

• Relevant Lead Investigators