RESEARCH REPORT 365 - Health and Safety Executive

1 HSE Health & Safety Executive Development and validation of the HMRI Safety culture inspection toolkit Prepared by Human Engineering for the Health and Safety Executive 2005 RESEARCH REPORT 365 HSE Health & Safety Executive Development and validation of the HMRI Safety culture inspection toolkit Human Engineering Shore House 68 Westbury Hill Westbury-On-Trym Bristol BS9 3AA Her Majesty s Railway Inspectorate (HMRI) currently has a programme in place to validate the implementation of recommendations that have arisen from public inquiries such as the Cullen Inquiry. A number of themes have been identified within the extensive set of recommendations, one of which relates specifically to Safety culture and requires all UK rail organisations to implement an effective Safety culture.

2 The aim of the current work is to develop a pragmatic approach and methodology for the inspection of Safety culture in UK rail companies, which focuses on a limited number of indicators that are known to influence Safety culture. These indicators are: Leadership Two-Way Communication Employee Involvement Learning Culture Attitude Towards Blame This REPORT and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy. HSE BOOKS Crown copyright 2005 First published 2005 ISBN 0 7176 6142 3 All rights reserved.

3 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to ii HEL/HSE/041053b/RT02 Issue: 0115 March 2005 ACRONYM LIST HMRI Her Majesty s Railway Inspectorate HSC Health and Safety Commission HSE Health and Safety Executive Page iii HEL/HSE/041053b/RT02 Issue.

4 01 15 March 2005 MANAGEMENT summary Background Her Majesty s Railway Inspectorate (HMRI) currently has a programme in place to validate the implementation of recommendations that have arisen from public inquiries such as the Cullen Inquiry (Reference 1). A number of themes have been identified within the extensive set of recommendations, one of which relates specifically to Safety culture and requires all UK rail organisations to implement an effective Safety culture. The aim of this work programme is to develop a pragmatic approach and methodology for the inspection of Safety culture in UK rail companies, which focuses on a limited number of indicators that are known to influence Safety culture.

5 These indicators are: Leadership Two-Way Communication Employee Involvement Learning Culture Attitude Towards Blame The Health and Safety Executive (HSE) commissioned Human Engineering Limited to develop a toolkit based upon the five indicators listed above, and to validate the effectiveness of the toolkit through a series of inspection visits at a range of UK rail companies. The intention was that the toolkit would be made available to Her Majesty s Railway Inspectors to assist in the validation of the recommendation arising from the Cullen Inquiry (Reference 1). In order to achieve this, Human Engineering undertook a work programme which incorporated the development of an inspection toolkit, the completion of a pilot inspection, and a series of inspections across rail organisations to validate the toolkit.

6 Defining the Requirements of the Toolkit A literature review was undertaken to identify the main features of the five Safety culture indicators and approaches to measure Safety culture. The RESEARCH undertaken in support of the literature review is reported in detail within Reference 2. Interviews were also conducted with a range of subject matter experts, such as rail industry stakeholders and HMRI inspectors, to gain an understanding of industry best practice with regard to Safety culture assessments and the usability requirements for the toolkit. Based upon the background RESEARCH and the outcomes of the consultations, it was decided that the components of the toolkit would consist of: A question set A pocket card An overview diagram A guide for HMRI Inspectors Development of the Toolkit The toolkit components were developed to reflect the findings of the background RESEARCH .

7 In order to develop an objective and consistent Safety culture toolkit a pilot visit and a series of further visits were undertaken to validate the toolkit. The main lessons learned during these visits were used to refine and develop the final version of all the components of the toolkit. The question set has been developed to be used during interviews and discussions with employees from all organisational levels regarding the five indicators of Safety culture. The interviews have been structured around six scenarios which anchor the questions to realistic events or systems. The Page iv HEL/HSE/041053b/RT02 Issue: 01 15 March 2005 responses from the interviews are to be used to compare actual performance against assessment criteria which are evaluated using evidence points that are indicative of either satisfactory or unsatisfactory practice.

8 During the pilot and validation visits a few issues were identified with regard to the technical content and A4 format of the question set. It was identified that the assessment criteria, evidence points, and questions needed expanding and refining, and the format of the tool needed to be more practical for the inspector to be able to use it effectively. Therefore, appropriate modifications were made. After a series of refinements and re-testing, the final question set consists of an A5 sized spiral bound booklet. This is much easier to use than the original A4 sized version and provides a simple and straightforward approach to interviewing.

9 A pocket card and overview diagram were also developed to support the question set. These provide the inspector with additional options he/she can use when conducting the inspection, according to their personal preference. As a result of the visits there were minimal changes made to the structure of the pocket card and the overview diagram. The inspectors guide is a handbook for HMRI inspectors and is intended to provide interpretative guidance on how to use the Safety culture inspection toolkit, considering all stages of the inspection process including planning, assessing and reporting. The final versions of the different components of the toolkit have been presented within the following annexes: Annex A- Question Set Annex B- Pocket Card Annex C- Overview Diagram Annex D- Inspectors Guide summary of Findings for the Validation Visits In order to validate the toolkit a pilot visit and six further visits at a range of railway organisations were undertaken.

10 The toolkit allowed for an analysis of the companies visited to be undertaken. The main strengths and key issues in relation to the 5 indicators have been outlined in this REPORT and are discussed in detail in Reference 5. The findings of the visits are confidential, therefore any identifying information ( company names) has not been revealed in this document. Conclusions and Recommendations The Safety culture inspection toolkit provides a flexible approach to measuring objectively the effectiveness of a rail organisation s management system in promoting a positive Safety culture. The different components of the toolkit provide the inspectors with a variety of options with which to conduct their inspections.