French, pictured above, joined British Rail on a management training course after university (LSE). “I wanted to get into heavy industry, and rail had a good training scheme,” he recalls. Having done so, he turned his focus to new-build projects: initially at the Channel Tunnel, and then spent six years on the Channel Tunnel Rail Link as head of operations and safety. Feeling a desire to return to day-to-day operations – or as he puts it, “to get my boots into some ballast” he joined RAIB as a principal inspector in 2004. In 2009 he was named deputy chief inspector, and became chief inspector in 2015.
Operations Engineer: I was interested to read your analysis of and conclusions about the Welsh rail disaster (profiled in March 2022: see www.is.gd/opizig).
Simon French (SF): The Welsh accident was a very detailed investigation indeed. It was difficult scene to work in; there was a massive spillage of fuel and a fire. It took us 48 hours to even get to the train. What was curious about that one is that we were pretty sure of the cause of the derailment before we got there, because we had had access to CCTV images from a level crossing that showed sparks and smoke coming from a wheelset. So we had a good idea before we got to the train, although piecing together why took a lot of work.
OE: Please would you outline the investigative process, in general?
SF: At the simplest level, our process starts with a notification. There are all sorts of incidents and minor accidents; we have strict criteria of which we deploy to. Then, the first priority is to gather evidence, and we start with vulnerable evidence, which will change state. We also collect witness evidence and photographs, surveying, whatever might be required. That first stage is critical because so much evidence can’t be retrieved once the site is cleared, so we have to work carefully. Then we bring that to base.
We have to have a systematic understanding of the evidence that we have got, and so we catalogue it, examine it, test it, and then carry out a causal analysis. That procedural analysis is fundamental. Beyond that or in parallel with that, we have a process of continuous review and challenge. People that are new to the organisation might be shocked that they are constantly asked to justify their conclusions. We are an evidence-based organisation, so it’s normal to us, part of our culture, that if we don’t see enough evidence, we will call it out, and go round the houses, or state a degree of uncertainty.
We aim to have a chain that you can follow backwards from recommendations to conclusions to analysis to evidence to the activity itself.
We don’t work in a bubble. We are talking to industry and various parties, and at the end of the process, we formally consult, and everyone gets the opportunity to throw rocks at us if we’re wrong, or correct us if we’ve misunderstood something, or provide new evidence. That is important, because sometimes people involved won’t understand until we get through the entire process the significance of the evidence that they have.
OE: How much uncertainty is involved in root cause analysis of incidents?
SF: One thing we’re not is Hercule Poirot. I watch Poirot on the TV and enjoy it, and at the end he takes the flimsiest of evidence to assemble a flaky case, gathers everyone in the drawing room, and helpfully the villain always admits the crime. The flakiness of the evidence is never tested. But we live in a world full of uncertainty. That’s an important part of our job, and nothing to be frightened of; that’s the nature of the world. We can’t always know with absolute certainty. Our approach to deal with this is openness. If we are uncertain, it’s important for us to qualify the degree of uncertainty.
We think it is so important to present uncertainty, because very often behind that is a safety lesson. We can’t suppress an important piece of safety learning because we can’t be 100% sure that it was a factor.
OE: How does your role compare to the rail regulator?
SF: Our regulations are clear about our role to improve railway safety. There is no blame, and no apportioning of liability. We are not here to say that such and such was partly responsible for lives lost or damage caused. And we don’t prosecute. We are separate from ORR (Office of Road and Rail), which has a key function to investigate breaches of health and safety. The police have a role to investigate accidents to see if a crime has been committed.
OE: Are your reports not legally actionable? For example, in the Welsh case, you were very clear to blame the accident on poor brake maintenance?
SF: Our evidence has never been used to support a prosecution. If others, such as ORR or the Police, wish to bring a prosecution, they will have conducted their own investigation. There is evidence that we will share – technical evidence, broken widgets. And to correct your point, we did not blame the accident on maintenance. We presented the facts. These are public documents; others will draw their own conclusions.
OE: I understand that the content of interviews conducted by RAIB are confidential. How important is this aspect in the overall investigative process?
SF: We interview to gather information, and we present information in reports. We don’t share our records of interviews – witness statements – with any other party. To provide some context here, witnesses are required to tell us what they know and answer our questions, and it is an offence to mislead us. We require them to be completely open. If we are to require them to answer our questions, we also need to protect them from self-incrimination.
OE: Looking back over your tenure, what sort of conclusions have you drawn about the relationship between operations and safety? Does the term ‘safety culture’ have a resonance with you? What more can operators, whether they be in rail or other industrial sectors, do to prevent incidents and accidents?
SF: My background is in railway operations. As an operator, I understood no distinction between safety and operations; they were the same thing. Operations is about safety, and good operations is good safety. I try not to make a distinction that I don’t think is there. When I was a junior operator, I was out there inspecting signal boxes and freight yards, and the safety of operations was everything. It was indistinguishable in the job, all part of a continuum.
There are different ways of defining it [safety]. Operations is about the human in the system. Machinery has been designed by engineers to do tasks. Somewhere, to some degree, there are human beings interfacing with machinery, and they become part of the system of delivering a safe railway. For me, understanding how humans interact with the system is fundamental. Call it human factors, if you like.
The relationship between operations and safety is people. It’s how we train people; how we issue procedures and processes; and it’s part of the culture- the attitudes that people have. It’s about the human in the system.
The interaction between the human and the system is changing all the time. We have already seen that some areas have a high degree of automation. If we see more, it will introduce more challenges. How do people interact with a system that is largely automatic? Are we creating a role for railway people to essentially monitor an automatic system? Is that the right way to use people?
OE: What memories particularly stick in your mind from your tenure?
SF: My strongest memories come from meeting and talking to those most affected by accidents. They can be the most challenging and the most rewarding, sometimes. They might be bereaved families or colleagues of those that had lost their lives, or those that were injured, or those directly involved in the accident in some way. One thing I take away is a universal reaction. We see anger, hurt; all of the emotions that you would expect. We also see a huge understanding about why it is important for lessons to be learned. And that is universal. Sometimes people look for blame; that is understandable. But they also do understand why we do what we do, and how important it is to learn. I have been impressed by their dignity and the breadth of their understanding of our work.
OE: As a government department, Is RAIB cost-effective?
SF: We’re a department because we have extensive legal powers. We are a state organisation, and our powers have been provided by Parliament. That is why we are a government body. Of course we’re cost-effective. We have a constant flow of work from many less-serious accidents, but we are already set up and ready to deal with the very worst that the rail industry can throw at us.
And we have an enormous value to industry and society. The value delivered is through safety learning. Accidents are horribly expensive. What we deliver in independent, expert investigation really makes a difference in avoiding accidents in future. Of course you are never sure which accidents have been avoided, but you don’t need to deliver much safety improvement to cover our costs.
OE: What is your budget?
SF: £5m, and we have 43 people. The costs come down to salaries and the cost of investigative work, and bringing in expertise where we need it; sometimes that comes at a price.
OE: There has been talk of establishing a road accident investigation board. What is your view about such a move?
SF: I think it would bring enormous benefits. The AIB model ensures independent expertise and a sole focus on safety, and that’s got to be the right thing for the roads sector. While fatalities have dropped in the last two years as a consequence of COVID, in the period before, there was a long period where fatalities were not significantly dropping. Pre-COVID, the numbers were 1,800 fatalities every year, and in the region of 150,000 injuries. There is a vast cost to society in monetary terms and in the harm caused, and the suffering. So the business case for an AIB is overwhelming in that there is a huge problem to be solved.
My personal view is that the place to start is probably with commercial vehicles: HGVs and PSVs, in that very quickly when you look at those you get into consideration of organisational factors; systemic issues such as management, training, competence, maintenance of vehicles, so there is a huge potential for safety improvements.