CONFIDENTIAL INCIDENT REPORTING AND ANALYSIS SYSTEM

FOR THE U.K. RAIL INDUSTRY

(CIRAS)

1. Introduction

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.

2. Mission

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.

3. Development

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

4.1 General

• 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

companies.

• 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

Steering Group.

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

Safety Plan.

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

unions.

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).

6. Feedback

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.

7. Achievements

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.

8. Conclusion

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