Confidential Incident Reporting and Analysis System for the UK Rail Industry
CONFIDENTIAL INCIDENT REPORTING AND ANALYSIS SYSTEM
FOR THE U.K. RAIL INDUSTRY
CIRAS is the Confidential Incident Reporting and Analysis System for the Rail
Industry. It is only just over 3 years since the decision to develop a U.K. national
scheme was taken in November 1999. Since that time over 2,500 incident
reports have been received and currently 77,000 railway staff are enrolled and
have been briefed on the use of the scheme. Perhaps even more impressively,
there has not been a single instance of confidentiality being breached and the
information has been used in numerous ways to enable changes to be made to
enhance safety throughout the industry.
CIRAS will provide a confidential route for employees in the railway industry to
report safety related concerns to an independent body with the expectation that
they will receive a considered response. Analysis of all these reports will
contribute positively to a safer railway.
The development of CIRAS has been a challenge. Its successful introduction
owes a great deal to the many hours spent by representatives from areas of the
industry who have contributed to the work of the CIRAS Implementation Group,
Steering Committee and Charitable Trust.
The decision to develop a national scheme was taken in the wake of the
Ladbroke Grove accident, by a cross industry working group. The system was
based on the model which had been piloted in Scotland. The country was
divided into three regional centres and following a competitive tendering process,
Region 1 (Scotland and the North of England) was operated by Strathclyde
University, Region 2 (Middle England) by W S Atkins and Region 3 (South of
England) by QuinetiQ. It was agreed that this first phase should include all safety
critical and safety related staff1 employed by Railway Group Members. In each
region liaison groups (involving representatives from the companies involved and
the unions) were established, to enable safety issues which had been reported
into the system to be addressed by the companies concerned. Journals are
1 Safety critical staff are staff undertaking safety critical work, as defined in the 1994 Railways (Safety
Critical Working) Regulations. Safety related staff may be considered as staff involved in activities that
have an indirect impact on the safety of the operational railway.
published from each region which are mailed to all employees in the scheme
giving information on the reports which have been made and the actions which
have followed. The data collected from the three regions were then combined to
form a National CIRAS database (initially managed by Strathclyde University and
more recently by Atkins). A charitable
trust was established to act as the
independent custodian of the data and to ensure that the confidentiality of the
system was not compromised.
For any confidential reporting system to be successful from the outset, all of the
staff associated must not only be encouraged to use the system and be briefed
on how to use the system, they must also b e entirely confident that they can trust
the confidentiality of the system. The initial briefing given to staff on the use of
the scheme is therefore of primary importance. In fact within the first year over
68,000 safety critical staff had been briefed and were starting to use the scheme.
Having enrolled and briefed all of the drivers, signallers and safety critical and
safety staff of the main contractors, a further goal has been to make the system
available to all of the railway infrastructure contractors and subcontractors since
they are exposed to equal risk. As this group are highly mobile and one
company may have staff working in more than one of the existing regions, a
fourth centre which will be for infrastructure staff nationwide is currently being
established and should be operating having briefed all of the staff, later this year.
4. CIRAS Principles
- Any report will be accepted from any employee working in the rail industry.
- Any safety related subject will be accepted relating to employee health,
engineering and operations.
- CIRAS is additional to company reporting systems.
- Reporters must give their personal details, which will remain confidential.
- Personal responses will be available to employees of participating
- The system will not process real-time reports.
- All information systems and intellectual property is the property of the
CIRAS Charitable Trust.
- The method of operating CIRAS will be determined by the National
4.2 Obligations on participating companies
Participating companies agree to:
- Commit sufficient resources to prepare considered responses to reports.
- Nominate a company representative as a point of contact.
- Promote the use of CIRAS, through briefings and other means.
- Pay subscriptions in a timely manner
- Support the workings and activities of the National Steering Group.
4.3 Deliverables .
CIRAS will deliver to all industry stakeholders:
- Insights and practices which can be of assistance to managers in their
responsibility for the management of any area of safety involving
employee health, engineering, operations.
- An analysis of the reports received, which provides intelligence on the
effectiveness of the risk control framework.
- An outlet for responding to an individuals’ safety related issues.
- Intelligence to inform managers and thereby influence the priorities for
action agreed in safety plans, which contribute to the Railway Group
5. The Use of CIRAS Information
Every six months a report including an update on the information in the CIRAS
database, together with information on any new safety concerns which have
been raised in one area but will be of potential relevance to staff in other areas,
are sent to the management of all of the associated companies and to the
Railway Safety uses the information from the CIRAS database as an important
source of information for identifying underlying deficiencies and trends at an
industry level and as an input into their strategic safety planning process.
The Trades Unions are strong supporters of CIRAS since they believe that the
system assists communication because unlike the other safety reporting systems
which may be used by an employee, if a concern is raised through CIRAS a
response is required from the employer. Whilst it is accepted that there can be
variability in the quality of some of the responses, the need for appropriate action
is gaining recognition.
For the Train Operating Companies, signallers and contractors, specific safety
concerns have been addressed following the submission of CIRAS reports. For
example, a series of reports to CIRAS from train drivers across the country
suggested that the improved headlights on some of the newly introduced trains
were causing dazzle to drivers of oncoming trains. The action taken involved
renewed attention to the checking of headlight alignment and Railway Safety
prepared a revised Railway Group Standard. Other examples are available from
each of the three regions including cases involving: the provision of OFF
indicators where signals are not visible; the recruitment of additional staff to
address areas of high workload, the implementation of programmes for
ballast/foliage clearance; and the revision of local procedures to reduce reported
risks. Although CIRAS cannot always claim responsibility for such successes, it
can be a catalyst for companies taking action. In addition, the use of liaison
groups has enabled cross-company issues to be tackled effectively; a good
example of this involved Railtrack, London Underground and Chiltern Railways
who were able to address an issue requiring input from each company. There
are also examples of companies sharing information and best practice in
addressing concerns that are reported to CIRAS (e.g. one company was able to
provide a ‘near-miss’ form for use by another company within the liaison group).
Railway Safety recently commissioned a UK Market Research Company to
conduct an independent review into the effectiveness of CIRAS. The findings
from over 70 interviews of staff from the 3 regions at all levels were extremely
encouraging in that there was a high level of awareness of CIRAS and its broad
purpose. Overall, it was seen as independent from the rail companies and the
confidentiality of the CIRAS organisation was never doubted. It was generally
seen as effective for raising awareness of the safety issues, as being a safety
valve for staff and useful for shaming some companies into action. However, it
was not seen as always effective for getting an acceptable response from
companies or for resolving issues which resulted in tangible improvements.
There was strong support for the regional journals.
To have established a confidential reporting scheme which all of the thousands
of staff involved have learnt to use and trust, is a huge achievement. We are
now seeing the results of these efforts in the many instances of local and
regional changes which have been made as a result of individual reports. In
addition, to companies within the industry, organisations with an associated
responsibility for safety e.g. Railway Safety and HSE, benefit from the
information in the CIRAS reports. We have been encouraged by a change of
heart among some of the early protagonists, when they attended liaison group
meetings and were able to witness the quality of the dialogue on safety related
issues and the changes which were agreed as a consequence of CIRAS reports.
The next challenge is to review the process and consider future developments.
As the rail industry is continuously developing and changing it is important that
CIRAS adapts and moves forward in unison. Changes in the contracts for TOCs
for example, have implications for the structure of the three regions. A review is
currently being undertaken of the CIRAS journals and consideration is being
given to changes which can be made to the scheme which whilst assuring that
the quality will be maintained, may lead to a significant reduction in costs. We
are also exploring ways in which more individual and organisations can benefit
from the information obtained by CIRAS, whilst at all times ensuring that at no
stage will there be any instances of confidentiality being breached. At this stage
it is clear that we still have much to do.
It will never be possible to prove that CIRAS has prevented an accident but
there is no doubt that the existence of a confidential reporting system provides an
opportunity to learn about issues which might not have been discovered through
the other systems. In addition, the existence and support for a confidential
reporting system enables the railway industry to provide a clear demonstration of
their commitment to safety to both their staff and to the travelling public.
CIRAS Steering Committee
28 March 2003