Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
762 items
1 source
35 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
70match
31 - Prevent in-service failure of train-borne safety equipment
Efforts should be concentrated on ensuring that AWS and other train-borne safety equipment does not fail in service through preventable causes. This should include regular replacements of equipment, maintenance of full service records and provision for full traceability of repairable parts and components (para 15.8).
Matched on
terms: safety
Inquiry recommendation
66match
14 - National procedures on failure of train-borne safety equipment
Clear procedures for steps to be taken on failure of any train-borne safety equipment should apply nationally, subject only to such company variation as is fully justified (para 15.11).
Matched on
terms: safety
Inquiry recommendation
62match
10 - National Tip Safety Committee
A National Tip Safety Committee should be appointed to advise the Minister and to co-ordinate research into the problem of tip safety and of bulk disposal of industrial waste products (Paragraph 289).
Matched on
terms: safety
Inquiry recommendation
62match
59 - Review of Safety Cases and franchising arrangements
The above recommendation to include review of Safety Cases and franchising arrangements and consideration of action by the Rail Regulator (para 16.22).
Matched on
terms: safety
Inquiry recommendation
62match
46 - A single body to set interior safety standards
A single body should be empowered to specify common standards for safety features in the interior of passenger vehicles and to identify and approve types of vehicles and/or operators to which particular standards are to apply (paras 11.6, 16.18).
Matched on
terms: safety
Inquiry recommendation
62match
44 - Review of internal safety features in passenger vehicles
A review should be carried out by ATOC, with input from all interested bodies, on the ways in which internal safety features may be modified and standardised to provide the best practicable means of emergency exit under accident conditions, including vehicles lying on their side, to include the provision of emergency lighting and standardised public announcements (paras 11.11,...
Matched on
terms: safety
Inquiry recommendation
62match
21 - Controllers' posts designated safety-critical
Controllers’ posts in Railtrack and TOCs should be designated as “safety-critical” as defined in the Railways (Safety Critical Works) Regulations 1994 (para 9.15).
Matched on
terms: safety
Inquiry recommendation
62match
12 - Designate train-borne safety equipment as vital or not
All train-borne safety equipment should be clearly designated as to whether or not it is vital to the continued running of the train (para 15.11).
Matched on
terms: safety
Inquiry recommendation
61match
COVID-M6.5 - Regulatory Inspection Protocols in an Emergency
The Care Quality Commission in England, Care Inspectorate Wales, the Care Inspectorate in Scotland and the Regulation and Quality Improvement Authority in Northern Ireland should each develop adaptable protocols for carrying out on-site, hybrid and remote inspections in a future public health emergency. These protocols should be guided by the core principle of continuing on-site inspections where possible....
Matched on
terms: quality
Inquiry recommendation
57match
8 - Monitor driver transfers and numbers trained
Railtrack and ATOC should monitor the transfer of drivers between operators and the numbers of drivers trained by each TOC and consider whether there are any safety implications involved (paras 5.5, 16.5).
Matched on
terms: safety
Inquiry recommendation
53match
23 - Planning authority control over new tips
Local Planning Authorities should be given powers of control over the starting of new tips and the extension of existing tips. The Minister should have power to exclude in a proper case, any claim for compensation if permission to tip or to continue tipping is withheld or refused on grounds of safety (Paragraph 295).
Matched on
terms: safety
Inquiry recommendation
53match
12 - Standard Code of Practice for tips
A standard Code of Practice should be prepared for consideration by the National Tip Safety Committee with a view to its being issued publicly and applied to all tips, whether in the ownership of the National Coal Board or otherwise (Paragraph 291).
Matched on
terms: safety
Inquiry recommendation
53match
38 - Review of Condition H11 of the Track Access Conditions
There should be a review of Condition H11 of the Track Access Conditions which should make clear that no regulating decision is to be made on the basis of protecting commercial interests. Safety and security must be paramount considerations (paras 4.13, 7.6, 16.16).
Matched on
terms: safety
Inquiry recommendation
53match
24 - GWT records of maintenance staff competencies
GWT should maintain full records of competencies for all maintenance staff as required by job descriptions and safety responsibility statements (paras 6.8, 15.6).
Matched on
terms: safety
Inquiry recommendation
49match
45 - Dates and means for improving existing stock
The review should consider dates and means for the introduction of identified improvements to existing stock (para 11.2, 15.16).
Matched on
classifier match
Inquiry recommendation
49match
33 - Monitor supply of new AWS parts
ATOC and Railtrack should monitor the supply of new AWS parts and components to ensure continued availability on an indefinite basis, including the introduction of improved components (para 15.7).
Matched on
classifier match
Inquiry recommendation
45match
68 - Running with AWS isolated where ATP is fitted
GWT, Railtrack and HMRI should consider whether trains with AWS isolated can run normal services where ATP is fitted and operational (para 15.10).
Matched on
classifier match
Inquiry recommendation
45match
41 - Review operation of ARS
Railtrack should review the operation of ARS to consider whether more green signals should be booked ahead of higher speed trains, and generally whether the speed and length of trains is adequately taken into account (para 16.16).
Matched on
classifier match
Inquiry recommendation
45match
30 - Improved AWS test box at all depots
An improved AWS test box, capable of detecting faults not revealed by the magnet test, should be provided as standard issue at all maintenance depots (paras 6.11, 9.22, 15.6).
Matched on
classifier match
Inquiry recommendation
45match
25 - GWT to monitor maintenance staff workload
GWT should regularly monitor the workload of all maintenance staff (para 15.6).
Matched on
classifier match
Inquiry recommendation
45match
18 - Failure to provide fault reporting means a disciplinary offence
Failure to provide forms, defect repair books or other means of reporting faults should be regarded as a disciplinary offence (para 16.11).
Matched on
classifier match
Inquiry recommendation
41match
21 - Inspectorate inspection of tips; reports to local authorities
Tips (active or disused) should be regularly inspected by Her Majesty's Inspectorate of Mines and Quarries. Their reports should be available to local authorities (Paragraph 295).
Matched on
classifier match
Inquiry recommendation
41match
20 - Regular inspection of all tips
Provision should be made for regular inspection of all tips by qualified persons (Paragraph 295).
Matched on
classifier match
Inquiry recommendation
41match
19 - Report tip slides and fires
The Mines (Notification of Dangerous Occurrences) Order, 1959, should be amended so as to include tip slides and fires among the matters required to be reported forthwith to Her Majesty's Inspectorate of Mines and Quarries (Paragraph 295).
Matched on
classifier match
Inquiry recommendation
41match
14 - Local authority access to tipping plans and appeal
A local authority should have access to plans for tipping and reports on existing tips and, if not satisfied with them, should have a right of appeal to the Minister, who might appoint an independent expert to conduct an examination and make recommendations (Paragraph 295).
Matched on
classifier match
Inquiry recommendation
41match
13 - Strengthened Inspectorate responsible for tip control
Her Majesty's Inspectorate, strengthened by the addition of qualified civil engineers and armed with additional statutory powers, should be made responsible for ensuring the discharge by National Coal Board officials of their duties in relation to tip stability and control (Paragraph 291).
Matched on
classifier match
Inquiry recommendation
41match
11 - NCB keeps prime responsibility for its tips
The National Coal Board should continue to have prime responsibility in respect of all tips in its ownership (Paragraph 290).
Matched on
classifier match
Inquiry recommendation
41match
70 - Back paper audits with unplanned inspections
Paper-based audits should be backed up by unplanned inspections and other direct observation of the work under review (para 16.26).
Matched on
classifier match
Inquiry recommendation
41match
69 - Paper procedures must not become divorced from reality
All parties in the industry must ensure that paper-based procedures do not become divorced from reality. This should include senior managers maintaining a direct knowledge of the situation in railway workplaces (para 16.25).
Matched on
classifier match
Inquiry recommendation
41match
66 - Keep ATP fully operational on Great Western lines
ATP should be maintained in a fully operational state on Great Western lines currently fitted, until replaced by an equally effective train protection system (para 15.14).
Matched on
classifier match
Inquiry recommendation
41match
61 - Review of acceptance and approval of new equipment or stock
S&SD together with HMRI and other bodies having responsibility for accepting or approving new equipment or stock should review their procedures with a view to reducing delay and introducing fast-track procedures where possible (para 15.7).
Matched on
classifier match
Inquiry recommendation
41match
60 - Enlarge or re-organise inter-company bodies
Consideration should also be given, for the purpose of the above recommendations, to enlarging or re-organising existing inter-company groups, including considering whether the Railway Group should include ROSCOs and component suppliers (para 16.20).
Matched on
classifier match
Inquiry recommendation
41match
43 - Long-term review of speed and casualty numbers
HMRI should keep under long-term review the effect of speed on numbers of casualties in rail accidents (para 11.7).
Matched on
classifier match
Inquiry recommendation
41match
42 - Take Dr Murphy's risk analysis into account in any LRM review
Any further review of LRM should take into account Dr Murphy’s risk analysis (para 16.16).
Matched on
classifier match
Inquiry recommendation
41match
40 - More Level 2 and 3 Policy Statements
More Level 2 and 3 Policy Statements should be introduced having due regard to any relevant risk analysis (para 6.16).
Matched on
classifier match
Inquiry recommendation
41match
39 - Review Level 1 Policy Statement
Railtrack should review their Level 1 Policy Statement in the light of any amendment to Condition H11 (para 6.16).
Matched on
classifier match
Inquiry recommendation
41match
36 - Review maintenance contracts for what checks are covered
Railtrack should review all maintenance contracts to ensure that all parties are aware of what checks are included and which excluded (paras 3.16, 16.14).
Matched on
classifier match
Inquiry recommendation
41match
35 - Regular checks on signal alignment and sighting
Railtrack should ensure that checks on alignment and sighting of signals are made at least annually, and at a greater frequency to be determined on the basis of errors found (paras 3.16, 16.14).
Matched on
classifier match
Inquiry recommendation
41match
34 - Check signal alignment and sighting at commissioning
Railtrack should ensure that the alignment and sighting of signals is confirmed at the time of commissioning, both from the signal and from the track, and appropriate records made, including photographs (paras 3.16, 16.14).
Matched on
classifier match
Inquiry recommendation
41match
32 - Ownership and rights in AWS equipment
Contractual ownership and other rights in AWS equipment must be clarified and defined (paras 15.7, 16.21).
Matched on
classifier match
Inquiry recommendation
41match
29 - Maintenance to check history of reported defects
Maintenance procedures should require checking of the history of reported defects, including repeat faults, and the taking of appropriate action (paras 6.14, 15.6).
Matched on
classifier match
Inquiry recommendation
41match
28 - Flow-chart of the sources of repair work
Maintenance staff should be provided with a flow-chart to show the derivation of all sources of repair work, to include RAVERS (with check on repeat items) and appropriate structure for Request, Repair Book and Maintenance Control items (para 15.16).
Matched on
classifier match
Inquiry recommendation
41match
27 - A-Exam documentation to require ATP reset and self-test
Documentation for the A-Exam should require ATP reset and self-test (para 6.8).
Matched on
classifier match
Inquiry recommendation
41match
26 - Detailed examination checklists for maintenance staff
A current and detailed list of items required to be inspected for each examination should be prepared for and used by maintenance teams (paras 6.8, 15.6).
Matched on
classifier match
Inquiry recommendation
41match
17 - Simpler fault reporting procedures
Fault reporting procedures should be reviewed and made as simple and convenient to use as practically possible. They should include provision for an acknowledgement and an explanation if relevant (para 16.11).
Matched on
classifier match
Inquiry recommendation
41match
13 - AWS is vital to the continued running of the train
AWS is to be regarded as vital to the continued running of the train (para 15.11).
Matched on
classifier match
Inquiry recommendation
41match
11 - Avoid using several documents for one operational issue
The use of more than one document (whether Rules, Group Standards or otherwise) to cover a single operational issue should be avoided, save where proper reasons exist for use of multiple sources (para 15.9).
Matched on
classifier match
Inquiry recommendation
41match
10 - Rules and Group Standards clear and unambiguous
Railtrack must ensure that Rules and Group Standards applicable to operators, including drivers, are clear and unambiguous. In particular, Railtrack should urgently complete the review of operating Rules to ensure they are workable in the privatised, fragmented industry (para 16.6).
Matched on
classifier match
Inquiry recommendation
41match
9 - Review of drivers' working hours
Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).
Matched on
classifier match
Inquiry recommendation
41match
7 - National qualification and accreditation system for drivers
Railtrack together with ATOC should establish a national qualification and accreditation system for drivers including centrally held records to be available to the current employer (paras 5.5, 16.5).
Matched on
classifier match