Paul Coleman has written a good summary of what happened at Elsenham and since. He has given permission for me to add the link here.
In May 2013 I was invited to speak at a UN conference in Geneva along with Network Rail and the Rail Safety Standards Board from the UK about the work being done in the UK to reduce the risk at level crossings. Compared to other countries, we have one of the lowest number of accidents and fatalities when considering the size of our rail network. It was very interesting to hear what other countries are doing to reduce risk but also to get a flavour of the cultures and attitudes to lives lost.
One significant difference across Europe is that often the highway authorities are also responsible – not just the railway which appears to be the case in the UK. A shift in emphasis to working in partnership with local authorities about level crossings might make closure and upgrades more efficient.
The UN ECE commissioned a short film and asked me to be involved – this is aimed at all stakeholders and will be launched at the International Level Crossing Awareness Day on 3 June. You can watch the video here.
In April I was very honoured to be named as the Management Consultants Association’s (MCA) Change Management Consultant of the Year at their prestigious awards ceremony. Of course I knew I had been short listed which is quite something in itself – the MCA awards are the “Oscars” of the management consultancy industry.
Atkins had been short listed in the Change Project in the Public Sector category too for the project team that went in to help Network Rail set up the level crossing programme. Atkins took a number of clients, including some of the national level crossing team from Network Rail, to the awards dinner and ceremony and of course it turned into quite a celebration when we were named winners in both of the categories we entered!
The entry for me was based on the work I have been doing with Network Rail since Sir David Higgins, the Chief Executive of Network Rail asked me to become their Level Crossing User Champion in July 2011. At the time the company was under investigation from the Office of Rail Regulation following discovery of previously undisclosed risk assessments.
The MCA Award submission can be read here.
The Times sponsors the awards and published a supplement about the winners on 22 May 2014 which can be read here.
The article about me is entitled “the mother who took on Network Rail” which is a little more ‘tabloid’ than I expected but I guess it’s true.
The Sunday Times took a slightly different angle for an article they published on 18 May 2014 which you can read here. The photo was taken soon after the successful prosecution of Network Rail over their failings at Elsenham and an old friend commented “Nice photo – who is the old bird in the background?” So no chance of my success going to my head!
I’ve been on a roller coaster of emotions over the last few days following the publication of the Transport Select Committee report into safety at level crossings. The report can be seen in full here.
Friday, 7 March 2014 started when I set my alarm to hear Mark Carne, the new CEO at Network Rail, and Reg Thompson, Charlie’s dad, on the BBC Radio 4 Today programme. I was concerned that Reg seemed to have forgotten that NR had already apologised for the failings in 2012 following the prosecution for Elsenham and how badly treated we had been following Liv and Charlie’s deaths. I was annoyed with John Humphries who suggested that Mark was the new CEO because his predecessor had been fired over NRs failings. Had I been on the programme I would have challenged this more stridently than Mark did. David Higgins, who has moved on to take over at HS2, was actually the one who initiated the changes at Network Rail and facilitated the £130m funding that enabled the national level crossing programme to get underway.
What I have realised over this weekend is the depth of feeling that still exists over the way Network Rail has behaved in the past, and apparently still does to some families who have been so badly traumatised by the death of their loved ones in such circumstances. As I have been working with Network Rail for the past two and a half years to help them focus on the changes that need to be made, I have been in a privileged position and can see how things are changing – but their reputation has a very long way to go before it can catch up with what is really happening. I feel rather like I have betrayed other families by trying to focus on the positive things that are happening – especially when others are clearly feeling very aggrieved about the callous way they are being treated still.
On reflection I would rather be in this position, no matter how uncomfortable it has made me feel personally, than still feeling that I was up against a huge monolithic company like Network Rail as I did for so many years. We had to fight to get Network Rail to stop saying that Elsenham was a safe crossing – even after accident reports pointed out that the crossing was one of the most dangerous on the network. It was not until documents, that Network Rail had previously withheld, proved that they knew how dangerous Elsenham actually was, that David Higgins (CEO from Feb 2011 til Feb 2014) forced the company to acknowledge it’s failings and invited me to speak to their people about the impact those failings had on us. It is the honest and heartbreaking story of Liv and Charlie’s unnecessary deaths and the appalling aftermath that makes people stop and reconsider the way that they think and behave. That culture of blaming users for their own demise and the inability to acknowledge systemic failings will take a long time to change. Despite what many think, Network Rail is changing and that must continue.
Having met the new chief executive, Mark Carne, I have great confidence that he will drive the change through. He comes from the oil and gas industry where horrific incidents, such as Piper Alpha in 1988, have forced that sector into safer working practices over several decades.
In making the public apology required by the Transport Select Committee, Mark Carne said that the only safe level crossings are closed ones and otherwise they are all dangerous. It’s an obvious statement but one I have not heard from a senior manager in public previously. Robin Gisby, the managing director did say it at the Transport Select Committee hearing back in November 2013, I had presented only that morning to Network Rail’s executive board and button-holed him just before he gave his evidence reminding him that he really must stop saying “that level crossings are perfectly safe, if they are used correctly”. He was surprised that he did so but I had seen him on a news programme the week before saying just that!
I hear the inner dialogue of those reading this, and many others who challenge me about Network Rail not being to blame for Olivia and Charlie’s deaths. I’ve had quoted the Darwin theory about stupid people and the less offensive, but equally difficult to handle on a personal level, arguments about people having to take responsibility for their safety at level crossings. I agree, we do need to take responsibility for our own safety, and I have thought very long and hard over hundreds of sleepless nights about whether I had taught Liv how to use a level crossing properly in the same way we all do to cross the road when our children are little, or by example, obeying traffic lights when we drive them around.
However, Network Rail has a statutory duty to provide a level of protection to reduce risk at level crossings so that people can cross safely and they failed to do that at Elsenham. As a result two beautiful girls lost their lives in a split second error of judgement. But this was a fatal error of judgement that they should not have been able to make. Another train coming alarm, recommended following a death in almost identical circumstances in 1989, had not been actioned; there was no ticket machine on the north bound platform so the girls had to cross the track twice before they could even catch their train; many near miss incidents had occurred there which showed a complacency by local users that was replicated by children and adults as ‘normal’ behaviour to cross immediately behind trains. All of these things and many other factors could have been recognised at Elsenham and the pedestrian gates should have been locked to prevent the girls from stepping out the very second that the signals would have stopped – had there not been another train coming. As we later found out Network Rail had known about the dangers at Elsenham for several years before 2005. And the company withheld that evidence from the accident investigators, the rail regulator and even the Coroner so that the changes now being undertaken now did not start until 2011. Six years of denial – how many deaths on level crossings since 2005 might have been avoided in that time?
I can understand why the families feel so aggrieved, believe me, I have those intense periods of anger and hopelessness when I am faced with the reality of my loss not only of my beautiful daughter but also the loss of all that potential – her future, her successes and failures and my grandchildren that will never be. The loss of a child is beyond anything that can be appeased by a public apology.
As a project manager with a good understanding of risk management I, probably more than others, felt extremely frustrated that the legal arguments made by Network Rail before the Inquest thwarted all efforts to have Network Rail’s appalling risk management practices aired at that time. The opportunity to admit failings and make changes seven years ago was missed.
I can understand Olivia’s dad’s need to get to the bottom of who knew what and when and Reg not wanting to acknowledge that we had a full and unreserved apology from Network Rail two years ago . I can understand how other families feel when asked to remove posters and signs at a memorial to their loved one. I can understand the need to blame Network Rail for the death of the death of a loved one. My loved one was my precious child. Of course, I understand. But I also know that pointing the finger at individuals, in an operating environment which was systemically failing as Justice Taylor said of Network Rail over Elsenham, is not going to make any difference and could even generate defensive resistance to change. The company must acknowledge the past failings and those individuals must embrace the change and become advocates for a new way of working. If they don’t then I hope that their new chief executive will flush them out.
I leave flowers each year near the station at Elsenham to remind others of the lives lost there but I do not think that Network Rail should allow anything to be attached to the fences or railings near level crossings that can distract from the important safety instructions to users. I find it hard to understand how people who have lost a loved one would want to do something that might endanger others. I have also seen evidence from the Samaritans that although comforting to the families, these shrines are a reminder to those who see those sights that a railway line is an option when life gets too tough to carry on. (I have been there, too).
Since the evidence was found and I knew that the regulator would follow through to make change happen and the the chief executive would make the company face up to its failings, my focus has been to work with Network Rail to help make change happen; to make level crossings as safe as they can be and that can only happen by understanding the risks, prioritising the limited budget to target those crossings that pose the highest risk by closing them or upgrading them to the appropriate level of protection level.
That also means working with users to recognise the risks that level crossings pose by educating them to pay attention to the warnings, not to weave around barriers to catch a train or run across when the barriers are coming down, not to use phones or headphones when crossing, not to make crossings more dangerous by distracting users; we all need to set a good example in our use of crossings and encourage everyone to take extra care when using them.
The impact of Liv’s death has been truly awful for me and our family but it is also a traumatic experience for everyone who was involved in her death – the driver, Network Rail staff, emergency services and even the funeral director who looked after Olivia, when I couldn’t even hold her hand to say goodbye. We need to work together to reduce the risks on level crossings and prevent others from making the same fatal error of judgement that Olivia and Charlie did.
I spent time yesterday with some of the Network Rail National Level Crossing Team as they hosted an ‘away day’ with their newly appointed Route Level Crossing Managers (RLCMs). There were 8 of the 10 routes represented there.
All of these are experienced Network Rail operational people, in fact Darren Furness from the National Team said that there was 91 years of level crossing experience in the room!
I had been asked to speak and, of course, tailored my talk to the audience, focussing this time on the real risk at level crossings and giving more emphasis than usual to the memo that been sent by the equivalent of a Level Crossing Manager of the day to the Route Production Manager. That memo, written a couple of years before, was not acted upon at the time but if it had, and the risk at Elsenham realised, then Olivia and Charlie would not be dead. Just installing a ticket machine on the other platform, a practical risk reduction solution which the writer suggested, would have avoided them having to cross the tracks in the first place. I asked these new Route Level Crossing Managers not to ignore the feedback they get from their teams and to help them to understand that risk management is not just about the dry quantitative stuff that comes out of their risk modelling software, but about real people – some of who will be disabled, deaf, old and slow, children – or worse – groups of children, people distracted by their phone or music player, or just plain tired.
Unless all level crossings are closed, which is not going to happen, there will always be accidents because people do and always will make mistakes. But what I want for these route-based level crossing management teams when they hear of an accident on their route, is to know with confidence that the risks had been properly assessed they that they had organised the correct level of protection there. I want there to be transparency – I don’t want to hear of them defending their lack of action on a risk score equating to 1 fatality in 44,000 years! I want them to really appreciate the responsibility that their roles carry and to go home at night knowing that they are doing the best possible job. A job that can really make a difference to the safety of the public.
The judge’s comments at the end of the Elsenham court case summed up Network Rail’s failures as systemic, rather than operational. I want to feel confident that the changes that National Level Crossing Team are driving through, with the Chief Executive’s support, are being acted upon at route level, and that behaviours will really begin to change.
One of the people introduced himself as a colleague of the assessor who completed the inaccurate (very low scored) risk assessment at Elsenham. I am told she was badly affected by the deaths of Olivia and Charlie and as a mother herself am sure she understands the devastating impact that the loss of our daughters has had on me and Charlie’s mother, in particular. This lady no longer works in risk management but she understands the huge responsibility that the role holds. I don’t blame her or hold her responsible for what happened. She was new to the job and probably hadn’t been trained properly, a result of the systemic failings. Her manager signed off her work, but it was clearly more of a tick box exercise to say that the assessments had been done than a real review of the risks, or a check of the work undertaken by a new assessor. That was over seven years ago.
What concerns me more is the RAIB report into the accident at Kings Mill just last May. This indicates that the lessons from Elsenham are still not being learned and shoddy attitudes to risk still exist on the ground. That has got to change.
The writer of the Elsenham memo, which described in such chillingly accurate detail the accident that would occur, has since retired. But the person who received the memo is now a Route Managing Director! I can only hope that their conscience was pricked sufficiently when the ORR investigators turned up to ask why it had not been acted upon, and that has brought about a change in behaviour that will now be driven down through the route organisations as these teams are finally put in place.
The RAIB (Rail Accident Investigation Branch – part of the DfT) published their report into the incident at Kings Mill crossing on 2 May 2012 last week. The incident resulted in the death of Philip Dawn who was cycling across the tracks when he was struck and fatally injured by a train. You can see the report here.
I hope the report made difficult reading for Network Rail’s route management team. The crossing was inadequately protected by the train drivers blowing the horn to warn crossing users. The line speed was increased and Network Rail approved the change in speed even though the time required to traverse the crossing was greater than the time allowed following the horn sounding.
The crossing had been promoted as part of a Heritage Trail and there is an increased risk with disabled users on mobility scooters using the crossing.
I spoke with Philip Dawn’s sister yesterday. The family are extremely disappointed that the report appears place the responsibility for Phil’s death on his shoulders. She had seen the train’s forward facing camera footage and accepts that her brother must have been wearing headphones as he did not react at all to the train horn sounded as the train approach the crossing and Phil was in it’s path.
Their concern is that two pedestrians helped him by holding the gate open so that he could ride across, and wonders if they had not heard the warning from the train – they were not wearing headphones. What if a deaf person wants to use the crossing? There is insufficient sighting to cross safely.
The crossing has now been amended – straightening what was a skewed crossing at about 40° so Phil was facing away from the train as it approached. As I was grateful for Liv and Charlie facing away from the train and quite literally did not know anything about it ;Phil’s sister takes comfort from the knowledge that he seemed completely unaware of the approaching train.
Network Rail are trialling a prototype warning at Kings Mill which provides a warning sound emitted at the crossing triggered by the train approaching and picked up through the vibration in the rails, but extra warnings appear to be emitted once the train has gone through and if this happens frequently enough the users will begin to lose trust in the warnings. They have at least straightened the crossing thereby shortening the crossing time.
The Inquest into Philip Dawn’s death is yet to be scheduled.
A sad start to 2013 with the news of a death on the level crossing at Yarnton in Oxfordshire. No details yet of what happened, but the initial unconfirmed report I heard suggested a mechanical failure of the car. It is another automatic half barrier crossing – the same type of barrier where a grandmother drove her car onto a crossing and it was hit by a train in Yorkshire less than a month ago. That day a little girl was killed. Today someone else lost their life.
Automatic half barriers are little more than car park barriers – affording little protection and providing no warning to the train via the signals if a car or other obstacle is on the track at the crossing.
Network Rail needs to invest in research into alternative more appropriate protection and to phase out these dangerous crossings.