Rail Industry Fragmentation
59 items
2 sources
Fragmentation within the rail industry leading to siloed decision-making and misaligned incentives, hindering integrated investment.
Cross-Source Insight
Rail Industry Fragmentation has been flagged across 2 independent accountability sources:
55 inquiry recs
4 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (55)
FENN-150 — Consider establishing a single passenger safety inspectorate for all transport
Recommendation: Consideration should be given to the establishment of a single passenger safety inspectorate charged with monitoring and supervising standards in all passenger transport.
Unknown
LADB-11 — Implement joint training for signallers and drivers to improve understanding
Recommendation: Signallers and drivers should jointly attend away days and other training processes to develop their mutual understanding (para 9.28).
Unknown
LADB-15 — Expeditiously progress ATOC study on central licensing of drivers
Recommendation: The ATOC study on the central licensing of drivers should be progressed expeditiously (para 9.50).
Unknown
LADB-16 — Consider applying NVQs to the driver licensing scheme by ATOC
Recommendation: ATOC should consider the application of NVQs to the driver licensing scheme presently under their consideration (para 9.52).
Unknown
LADB-30 — Commend the W S Atkins report on signal sighting practice
Recommendation: The report by W S Atkins “Initial Study of Signal Sighting Practice on Railtrack Infrastructure”, Issue 1, 6 March 2000, is commended (para 11.19).
Unknown
LADB-34 — Reconsider the use of "disregard" in the SPAD Group Standard
Recommendation: The use of the word “disregard” in the Group Standard on SPADs and its associated documentation should be reconsidered (para 11.29).
Unknown
LADB-47 — Implement unique, persistent alarm for all SPAD occurrences
Recommendation: There should be a unique alarm for SPADs, which should sound until it is turned off (para 12.21).
Unknown
LADB-48 — Enhance signaller speed for emergency point movement actions
Recommendation: The speed with which signallers can take action to move points in an emergency should be improved (para 12.22).
Unknown
LADB-49 — Investigate automatic signal replacement to Danger after SPADs to prevent collisions
Recommendation: There should be a study of the possibility of the automatic replacement of a signal to Danger where a SPAD has occurred and the layout is such that there is a significant danger of collision (para 12.27).
Unknown
LADB-5 — Require holistic safety and risk assessment for all track or signalling changes
Recommendation: Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should …
Unknown
LADB-50 — Introduce automatic audible cab warning for CSR trains passing danger signals
Recommendation: Subject to satisfactory risk assessment, an arrangement should be made whereby, when a train which is fitted with the CSR passes a signal at Danger, an audible warning automatically sounds in the cab (para 12.28).
Unknown
LADB-51 — Establish national direct radio communication system between trains and signallers
Recommendation: There should be a national system of direct radio communication between trains and signallers (para 12.29).
Unknown
LADB-52 — Instruct IECC staff to preserve CSR data disks following SPAD incidents
Recommendation: Signallers, managers and maintenance staff working at IECCs should be instructed as to the need to preserve CSR data disks in the event of a SPAD taking place (para 12.30).
Unknown
LADB-53 — Consider HST cab and bogie enhancements for improved driver protection and safety
Recommendation: The enhancement of the cabs on HSTs to improve driver protection along with energy absorption and compatibility with other vehicles, and the enhancement of measures for the retention of bogies on the coaches of HSTs, should be considered, subject to …
Unknown
LADB-54 — Review crashworthiness standard for new vehicles after Ladbroke Grove crash
Recommendation: The current standard for crashworthiness in respect of new vehicles should be reviewed in the light of the crash at Ladbroke Grove with respect to the objectives referred to in Recommendation 53 (para 13.4).
Unknown
LADB-55 — Consider retrofitting Turbos with enhanced welds, couplers, and anti-overriding devices
Recommendation: In the case of Turbos, the enhancement of end pillar weld connections, the possible enhancement of crashworthiness by weakening the ends and strengthening the saloon of the cars, and the fitting of shear-out couplers and anti-overriding devices should be considered, …
Unknown
LADB-56 — Review crashworthiness standard to safeguard survival space after Ladbroke Grove crash
Recommendation: The current standard for crashworthiness should be reviewed, in the light of the crash at Ladbroke Grove, in order to ensure that there are adequate measures for safeguarding survival space (para 13.5).
Unknown
LADB-57 — Consider improved welding and aluminium grades for new aluminium vehicles
Recommendation: In the case of new vehicles constructed of aluminium, consideration should be given to: (i) the use of alternatives to fusion welding; (ii) the use of improved grades of aluminium which are less susceptible to fusion weld weakening; and (iii) …
Unknown
LADB-58 — Revise crashworthiness Group Standard for realistic scenarios and high-speed testing
Recommendation: The revision of the Group Standard for crashworthiness should be pursued with particular reference to: (i) the design requirements for more realistic scenarios; (ii) high speed accidents; and (iii) dynamic verification testing (para 13.17).
Unknown
LADB-59 — Consider retrofitting enhanced security for seating in Turbos and tables in HSTs
Recommendation: The enhancement of the security of seating in Turbos and of tables in HSTs should be considered, subject to an assessment of feasibility, costs and benefits, with a view to possible retro-fitting (para 13.19).
Unknown
LADB-6 — Improve Railtrack procedures for implementing and monitoring accepted recommendations with clear accountability
Recommendation: Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation …
Unknown
LADB-60 — Conduct market research on safety measures to include informed passenger views
Recommendation: Comprehensive market research in regard to safety related measures should be carried out in order to take account of the views of informed passengers (para 13.20).
Unknown
LADB-61 — Enhance fire protection by reviewing fuel tank standards and repositioning vulnerable tanks
Recommendation: The following measures should be considered with a view to enhancing protection against fire: (i) a review of Group Standards in respect of improved crash resistance of fuel tanks; (ii) consideration of the feasibility of reducing fuel inventories and of …
Unknown
LADB-62 — Extend Railway Safety Case Regulations to include emergency escape arrangements explicitly
Recommendation: The scope of Schedule 1 to the Railway (Safety Case) Regulations 2000 should be extended so as to include explicitly the arrangements which the duty holder has established in regard to facilities, instructions and signs for the escape of persons …
Unknown
LADB-63 — Ensure HSE provides adequate guidance for evacuation and escape provisions
Recommendation: The provisions in the schedule as to evacuation and escape should be supported by adequate guidance from the HSE (para 14.3).
Unknown
LADB-64 — Keep public information code of practice on train safety and emergencies updated
Recommendation: The code of practice on public information on train safety and emergencies should be kept up to date (para 14.6).
Unknown
LADB-65 — Standardise passenger safety information and train evacuation and escape procedures
Recommendation: So far as is feasible, the safety information issued to passengers and the means by which they can be evacuated or escape from a train should be standardised (para 14.8).
Unknown
LADB-66 — Establish system to collect human factors data on passenger safety after rail accidents
Recommendation: A system should be established for the collection of human factors information pertinent to issues of passenger safety following rail accidents (para 14.8).
Unknown
LADB-67 — Provide general safety advice to passengers before and after boarding trains
Recommendation: Passengers should be given general safety advice both before and after they have boarded their train (para 14.14).
Unknown
LADB-68 — Obtain expert advice on passenger actions during known serious onboard dangers
Recommendation: Expert assistance should be obtained on the advice which should be given to passengers as to what to do in the event of there being a known threat of serious danger to them in remaining on board (para 14.14).
Unknown
LADB-69 — Endorse providing onboard explanatory information about individual train emergency facilities
Recommendation: The provision on board of explanatory information about the emergency facilities of individual trains is endorsed (para 14.14).
Unknown
LADB-7 — Extend recommendation implementation monitoring to include Train Operating Companies
Recommendation: Consideration should be given to extending sub-para (ix) of Recommendation 6 to recommendations which are directed to one or more of the TOCs and others (para 7.106).
Unknown
LADB-70 — Endorse using onboard announcements to highlight passenger safety information
Recommendation: The use of on-board announcements to draw attention to safety information is endorsed (para 14.16).
Unknown
LADB-71 — Make luminous emergency sign requirement retrospective for all trains
Recommendation: The requirement for emergency signs to be luminous should be made retrospective (para 14.18).
Unknown
LADB-72 — Develop universally understandable emergency signs for all trains, without text.
Recommendation: So far as is feasible, emergency signs on all trains should be capable of being understood by passengers without the necessity to read text (para 14.19).
Unknown
LADB-73 — Research and implement a common emergency signage system across all Great British trains.
Recommendation: There should be research with the aim of arriving at a system of signage which is common to all trains in Great Britain (para 14.20).
Unknown
LADB-74 — Research methods to safeguard emergency lighting systems from sudden deceleration forces.
Recommendation: Research should be carried out into the means of safeguarding emergency lighting systems from disablement by the forces involved in sudden deceleration (para 14.21).
Unknown
LADB-75 — Consider providing "snap wands" as supplementary emergency lighting on trains.
Recommendation: The provision of “snap wands” should be considered as a supplementary means of providing lighting in an emergency (para 14.22).
Unknown
LADB-76 — Modify internal coach doors to facilitate emergency egress by December 2003.
Recommendation: In the case of every coach (on any train) which has internal doors which slide in the same direction one of the following should be carried out by 31 December 2003: (i) the coach should be fitted instead with opposite- …
Unknown
LADB-77 — Install override devices on staff-only doors for passenger emergency use.
Recommendation: The staff-only doors on all trains should have an override device to enable them to be used by passengers in an emergency (para 14.29).
Unknown
LADB-78 — Develop illuminated pictogram signage for emergency door mechanisms, conforming to standards.
Recommendation: Signage primarily in the form of pictograms similar to those used on aircraft, and depicting the correct operation of emergency door mechanisms, should be developed. The signage should conform to current human factors standards on signage and be displayed prominently …
Unknown
LADB-79 — Ensure emergency ladders are readily usable and quickly releasable on trains.
Recommendation: The daily routine check of every train should include confirming that all ladders can readily be used. A mechanism to enable ladders to be released quickly should be devised and fitted (para 14.35).
Unknown
LADB-8 — Railtrack to complete signal risk assessments for the Paddington area promptly.
Recommendation: Railtrack should ensure that the risk assessments and any consequent actions required under Group Standard GK/RT 0078 in respect of the signals in the Paddington area are carried out as soon as possible (para 7.125).
Unknown
LADB-80 — Review emergency hammer adequacy, signage, and illuminated location with backup power.
Recommendation: There should be a thorough review of the adequacy of the number of, and signage relating to, emergency hammers. This should include the provision of means of illuminating the location of hammers in an emergency, with a back-up power supply …
Unknown
LADB-81 — Research removable windows and window adequacy for emergency egress and spacing.
Recommendation: There should be research into the feasibility of, and risks associated with, removable windows, the adequacy of windows as a means of emergency egress, the number of dedicated windows which are necessary and the provision as to the maximum distance …
Unknown
LADB-82 — Test integrating emergency hammers into passenger alarm system for controlled release.
Recommendation: Tests should be carried out into the practicability of building emergency hammers into the passenger alarm system so that they could be released only after an alarm has been activated (para 14.50).
Unknown
LADB-83 — Assess feasibility and risk of incorporating escape hatches in all train carriages.
Recommendation: The incorporation of escape hatches in existing carriages should be the subject of feasibility and risk assessment and the provision of escape hatches in new carriages should likewise be considered (para 14.54).
Unknown
LADB-84 — Train all on-board train staff in evacuation and protection procedures.
Recommendation: All members of the on-board train staff (including persons working under contract) should be persons who have been trained in train evacuation and protection (para 14.62).
Unknown
LADB-85 — Study passenger-to-signaller communication systems for driver-only trains in emergencies.
Recommendation: The possibility of installing on driver-only trains a telephone by which passengers can communicate with the signaller in the event of the driver being killed or incapacitated should be studied (para 14.65).
Unknown
LADB-86 — Examine feasibility of a "roaming" communication system for train staff.
Recommendation: The feasibility of a “roaming” communication system for train staff should be examined (para 14.68).
Unknown
LADB-87 — Investigate implementing remote broadcasting from outside the train where unavailable.
Recommendation: The possibility of remote broadcasting from outside the train, where it is not already available, should be investigated (para 14.68).
Unknown
LADB-88 — Ensure unrestricted availability of all standard emergency equipment on passenger trains.
Recommendation: The availability on trains carrying passengers of the items of emergency equipment mentioned in the standard on emergency and safety equipment should be unrestricted (para 14.74).
Unknown
LADB-9 — Railtrack to conduct safety examination of Paddington station layout and operations.
Recommendation: Railtrack should conduct a safety examination of the layout over 0-2 miles from Paddington Station so as to satisfy the HMRI, if necessary by a risk assessment and additional measures, that it is safe for operation at current speeds and …
Unknown
9 — Improve joint working between hospital sites
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
RHI-37 — Reduce Organisational Silos
Recommendation: In keeping with the spirit of the Ministerial Pledge of Office, the Northern Ireland political parties, supported by the Northern Ireland Civil Service, should together agree a set of actions to reduce organisational silos arising between the government Departments and …
Gov response: [Note: The NI Executive responded to recommendations 5-7, 25, 37, 39-43 together as a group under the 'Ministers and Special Advisers' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full, with …
Accepted
No update 2+ yrs
PFD Reports (4)
Christopher McGuffie
Concerns: Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Responded
Robert Mullis
Concerns: A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Overdue
Lauris Kodors
Concerns: The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is in danger from an approaching train.
Overdue
Croydon Tram Incident
Concerns: The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public safety.
Pending