Ranking of Process Safety Cultures For Risk-Based Inspections Using Indicative Safety Culture Assessments

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.
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. 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 hmsolicensing@cabinet-office.x.gsi.gov.uk
ii
HEL/HSE/041053b/RT02 Issue: 01 15 March 2005
ACRONYM LIST
HMRI Her Majesty’s Railway Inspectorate

HSC Health and Safety Commission
HSE Health and Safety Executive
Page iii
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. 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.
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. 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
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.
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.
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. 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 (i.e. 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. The toolkit components also provide inspectors with the flexibility to use
whichever option suits their personal inspection styles.
The flexibility in the design of the toolkit allows the inspector to measure all five safety culture
indicators. However, the toolkit also provides the flexibility to concentrate on one particular indicator
of safety culture, if required. For example, if the inspector wanted to investigate specifically the extent
to which employees are involved in decision making, safety planning, and providing ideas for
improvement, then the toolkit allows for this. The presentation of the assessment criteria and
evidence points in the question set and pocket card provide insight into the type of evidence that
should be present within the organisation.
Recommendations
The inspectors’ guide provi des a comprehensive account of how to plan, assess and report the safety
culture inspection using the toolkit. It is recommended that the guide be used as a training manual to
accompany a formal training course. A training course will allow all HMRI inspectors to gain an in-
depth understanding of the background to the tool, how to use it and provide the opportunity for
instant clarification.
Page v
It is recommended that the effectiveness of the toolkit and its approach be evaluated once it has been
fully integrated by HMRI inspectors. This will allow any issues and concerns about its usability that
may be apparent at a latter stage, to be addressed and resolved.
It should be appreciated that the five indicators used to develop the toolkit are not conclusive, and
should be reviewed for incorporation within the toolkit in the future.
Page vi
CONTENTS
1. INTRODUCTION............................................................................................................1
1.1 BACKGROUND......................................................................................................... 1
1.2 REQUIREMENTS ...................................................................................................... 1
1.3 AIM AND OBJECTIVES ............................................................................................. 2
Aim........................................................................................................................... 2
Objectives ................................................................................................................. 2
1.4 STRUCTURE OF THE REPORT ................................................................................ 2
2. DEFINING THE REQUIREMENTS...............................................................................4
2.1 OVERVIEW............................................................................................................... 4
2.2 BACKGROUND RESEARCH ..................................................................................... 4
Literature Review....................................................................................................... 4
Consultation With Rail Stakeholders ........................................................................... 4
2.3 IDENTIFICATION OF THE TOOLKIT COMPONENTS ................................................. 5
3. DEVELOPMENT OF THE TOOLKIT ............................................................................6
3.1 REQUIREMENTS OF THE TOOLKIT ......................................................................... 6
Applicability to a Variety of Rail Organisations ............................................................. 6
Health and Safety Management Framework ................................................................ 6
Vertical Slice Approach .............................................................................................. 6
3.2 TOOLKIT FEATURES ................................................................................................ 7
Colour Coding to Represent the Five Indicators ........................................................... 7
Assessment Criteria ................................................................................................... 7
Scenario Based Approach.......................................................................................... 8
3.3 VALIDATION OF THE TO OLKIT ................................................................................ 8
4. THE QUESTION SET ....................................................................................................9
4.1 INITIAL DEVELOPMENT........................................................................................... 9
Assessment Criteria ................................................................................................... 9
Evidence Points....................................................................................................... 10
Scenario Based Approach........................................................................................ 11
Scenario Overview................................................................................................... 11
Required Documentation.......................................................................................... 11
Questions ................................................................................................................ 11
Format of the Question Set ....................................................................................... 12
4.2 EVOLUTION OF THE QUESTION SET .................................................................... 12
Edits Made to the Wording ....................................................................................... 12
Expansion of the Scenario Approach and Assessment Criteria ................................... 12
Expansion of the Evidence Points ............................................................................. 14
Questions as Memory Prompts................................................................................. 15
Amendments to the Format and Layout of the Question Set ....................................... 15
4.3 FINAL VERSION OF THE QUESTION SET .............................................................. 16
5. THE POCKET CARD...................................................................................................17
5.1 INITIAL DEVELOPMENT......................................................................................... 17
5.2 EVOLUTION TO THE FINAL VERSION OF THE POCKET CARD.............................. 17
6. THE OVERVIEW DIAGRAM .......................................................................................18
6.1 INITIAL DEVELOPMENT......................................................................................... 18
6.2 EVOLUTION TO THE FINAL VERSION OF THE OVERVIEW DIAGRAM ................... 18
7. THE INSPECTORS’ GUIDE........................................................................................19
8. SUMMARY OF THE DEVELOPMENT OF THE TOOLKIT........................................20
9. SUMMARY OF FINDINGS FOR THE VALIDATION VISITS.....................................21
Page vii
9.1 OVERVIEW.................................................................................................................... 21
9.2 COMPANY A.................................................................................................................. 21
Summary of the Main Strengths ..................................................................................... 21
Specific Issues ............................................................................................................... 21
9.3 COMPANY B.................................................................................................................. 22
Specific Issues ............................................................................................................... 22
9.4 COMPANY C ................................................................................................................. 23
Specific Issues ............................................................................................................... 23
9.5 COMPANY D ................................................................................................................. 24
Specific Issues ............................................................................................................... 24
9.6 COMPANY E.................................................................................................................. 25
Specific Issues ............................................................................................................... 26
9.7 COMPANY F.................................................................................................................. 26
Specific Issues ............................................................................................................... 27
9.8 COMPANY G ................................................................................................................. 27
Specific Issues ............................................................................................................... 28
10. CONCLUSIONS AND RECOMMENDATIONS......................................................... 29
10.1 CONCLUSIONS ............................................................................................................. 29
10.2 RECOMMENDATIONS .................................................................................................. 29
11. REFERENCES.......................................................................................................... 30
APPENDIX A: EXAMPLE OF THE INITIAL VERSION OF THE QUESTION SET . 31
APPENDIX B: INITIAL VERSION OF THE POCKET CARD .................................. 34
ANNEX A: HMRI SAFETY CULTURE INSPECTION QUESTION SET

ANNEX B: HMRI SAFETY CULTURE INSPECTION POCKET CARD
ANNEX C: HMRI SAFETY CULTURE INSPECTION OVERVIEW DIAGRAM
ANNEX D: HMRI SAFETY CULTURE INSPECTION INSPECTORS’ GUIDE
Page viii
1. INTRODUCTION
1.1 Background
1.1.1 Her Majesty’s Railway Inspectorate (HMRI) has an ongoing programme of work to validate
the implementation of recommendations arising from public inquiries concerning rail
incidents. One such recommendation, which originated from Lord Cullen’s inquiry into the
incident at Ladbroke Grove (Reference 1) concerned the development of an improved
safety culture within rail organisations. While other safety-critical industries have
developed safety culture tools and models, no suitable solution existed that the HMRI
could use to undertake validation inspections of safety culture within rail organisations.
1.1.2 The conclusions drawn from the Cullen Inquiry emphasised the significance of a number of
aspects of safety management and safety culture. Amongst those identified were safety
leadership, communications, continuous learning, “blame culture”, staff motivation, training
and competency, and interdependency. Existing research also highlighted a number of
key indicators of positive safety culture that matched well with the conclusions drawn by
Lord Cullen. The HMRI identified five indicators as the basis for validation inspections on
safety culture. These indicators included:
• Leadership.
• Two-Way Communication
• Employee Involvement
• Learning Culture
• Attitude Towards Blame
1.1.3 The Health and Safety Executive (HSE) commissioned Human Engineering Limited to
develop and validate a toolkit for use by Her Majesty’s Railway Inspectors, to assist in the
validation of the safety culture recommendations. The aim was for the development of a
pragmatic approach that focuses on the five indicators listed in paragraph 1.1.2, to capture
evidence of company safety culture practice.
1.2 Requirements
1.2.1 The work programme sought to satisfy a number of requirements. These included:
• Focus: whilst there are other facets of safety culture the approach should focus
on five key indicators; leadership, two-way communication, employee
involvement, learning culture and attitude towards blame.
• Clarity and Ease of Use: the approach should be easy to use and interpret, as
well as being free of technical jargon.
• Comprehensible: it should be understandable and interpretable by an individual
with experience of the rail industry, though with little direct experience of safety
culture.
• Application: the approach should be applicable to assess the safety culture in
all rail organisations that are involved in safety critical work.
• Reliable: different assessors, given the same information, should be expected to
make more or less the same assessment of an organisation.
• Evidence Based: criteria that are to be assessed should be traceable to credible
sources including empirical evidence, legislation, standards and other guidance.
• Good Practice: the approach should be based on what is considered to be good
practice, or what is reasonable and practicable for rail organisations to comply
Page 1
with. It is not reasonable for all organisations to aspire to best practice in all
disciplines.
1.3 Aim and Objectives
Aim
1.3.1 The principle aim of this work programme was to develop a safety culture inspection toolkit
that inspectors can use to undertake inspections of safety culture within UK rail
companies.
Objectives
1.3.2 The main objectives of this work programme were to ensure that the:
• Toolkit focuses on the objective and psychological aspects of safety culture and
incorporates a methodology that, as far as practicable, captures what happens in
the company, (a ‘reality check’) rather than focusing on the perceptions of staff.
• Toolkit measures what it is intended to.
• Inspection approach can be applied appropriately to all rail organisations.
• Questions in the toolkit can be applied successfully at all organisational levels.
• Format and layout of the toolkit are appropriate for use by mobile inspectors.
• Findings of a visit can be used to produce a comprehensive account of an
organisation in relation to the five indicators of safety culture.
1.3.3 In order to achieve the aim and objectives, the project incorporated:
• The development of an inspection toolkit.

• The completion of a pilot inspection.
• A series of inspections at a range of UK rail companies to validate the toolkit.
1.4 Structure of the Report
1.4.1 This report has been structured to highlight the key stages that took place during the
development and validation of the HMRI safety culture inspection toolkit. These stages
are reported below:
Section 2: Defining the Requirements

1.4.2 This reports on the key sources used to develop the initial version of the toolkit and
highlights the scope for the components of the toolkit.
Section 3: Development of the Toolkit

1.4.3 The section outlines the underlying features that are consistent throughout all the different
components of the toolkit.
Sections 4, 5, 6, and 7: The Components of the Toolkit

1.4.4 Each section summarises the stages that were undertaken to develop and validate each of
the toolkit components, namely the question set, the pocket card, the overview diagram,
and the inspectors’ guide. This details specifically how the initial version of each
component was developed, the key lessons learned during the pilot and validation visits
and the subsequent rationale behind the refinements made to the components.
Section 8: Summary of the Development of the Toolkit

1.4.5 This section provides a brief summary of how the toolkit components were developed, the
principal changes made during the testing phases and outlines the final version of the
toolkit.
Page 2
Section 9: Summary of the Findings for the Validation Visits
1.4.6 This section summaries the main strengths and issues in relation to the five indicators of
safety culture that were identified during the pilot inspection and six further validation visits.
Section 10: Conclusions and Recommendations

1.4.7 This documents the main outcomes of the stages to develop and validate the toolkit, and
also highlights any recommendations that should be considered.
Page 3
2. DEFINING THE REQUIREMENTS
2.1 Overview
2.1.1 This main aim of this section of the report is to outline:
• The background research undertaken to develop the toolkit.

• The main components of the toolkit.
2.2 Background Research
2.2.1 As part of the development of the HMRI safety culture inspection toolkit, a number of
sources were used to conduct the initial background research. These sources have been
summarised below.
Literature Review
2.2.2 A literature review was undertaken to identify the main features of safety culture within the
academic and applied literature, focusing on cross-industry research carried out from 1986
onwards. This included a review of:
• Theoretical definitions of safety culture.

• The characteristics or indicators of a positive and negative safety culture in
relation to the five safety culture indicators specified by the HSE, namely:
leadership; two-way communication; employee involvement; learning culture, and
the attitude towards blame.
• The safety culture/climate assessment tools that have been used in a variety of
other safety-critical industries.
2.2.3 This review has provided sound guidance for the development of the HMRI safety culture
inspection toolkit. The literature review is reported in detail in Reference 2. For each
indicator, guidance has been taken from the research and used to develop the toolkit so
that it can be used to identify the appropriate evidence that will indicate good or poor
safety culture practice.
Consultation With Rail Stakeholders

2.2.4 In order to develop an objective and tailored safety culture inspection toolkit, interviews
were conducted with a range of subject matter experts. These included meetings with rail
industry stakeholders and HMRI Inspectors.
2.2.5 The main aims of these meetings were to:
• Share experience of addressing safety culture and safety behaviour within the rail
industry.
• Identify industry best practice and challenges.
• Identify the strengths and limitations of existing tools and methodologies.
• Identify user requirements for those conducting the inspections and those
responding to the findings of inspections.
2.2.6 The output from these interviews were collated and have been integrated within the design
and structure of the HMRI safety culture inspection toolkit.
Page 4
2.3 Identification of The Toolkit Components
2.3.1 The scope of the work programme indicated that the toolkit components should, as a
minimum, include a question set and an inspectors’ guide.
2.3.2 Based on the background research, and specifically the feedback obtained from HMRI
Inspectors, it was decided that the toolkit should consist of:
• A question set.
• A pocket card.
• An overview diagram.
• A guide for HMRI Inspectors.
2.3.3 The overview diagram and pocket card would provide inspectors with alternative formats
to the question set. Although the question set, pocket card and overview diagram would
contain the same information; the different formats would allow the inspectors the freedom
to conduct their inspections using the options that suit their personal preferences.
2.3.4 The next section describes the key characteristics of the toolkit; sections 4, 5, 6 and 7
provide specific detail concerning the development of each component.
Page 5
3. DEVELOPMENT OF THE T OOLKIT
3.1 Requirements of the Toolkit
3.1.1 The HMRI required a tool that is suitable for use within the different functional components
of the UK rail industry.
Applicability to a Variety of Rail Organisations

3.1.2 The toolkit has therefore been designed to measure the effectiveness of safety culture
within a broad range of UK railway organisations including, Train Operating Companies,
Freight Operating Companies, Infrastructure Maintenance Companies, and Train
Maintenance Companies.
Health and Safety Management Framework

3.1.3 The HSE Model for Successful Health and Safety Management (Reference 3), also known
as POPMAR (which refers to the key stages of the system: Policy, Organisation, Planning,
Monitoring, Audit, and Review) and the Health and Safety at Work Regulations (Reference
4) are complementary. The POPMAR model provides best practice guidance on health
and safety management; where as the Health and Safety at Work Regulations refer to the
regulations that a company should adhere to in relation to health and safety management.
As mentioned above these two approaches are complimentary, and have thus been used
as the basis for a suitable health and safety management framework that adheres to best
practice guidance and regulations against which the toolkit could be developed.
3.1.4 The health and safety management framework outlines the steps that should be taken to
ensure that there are effective arrangements in place to manage health and safety. The
key stages of the framework and a brief definition of each of the stages are presented in
Figure 1.
Figure 1- Health and Safety Management Framework

3.1.5 The framework has been incorporated into the tool to ensure that best practice and
regulatory principles of effective safety management are being addressed in the
assessment approach. This is discussed in greater detail in sections 4, 5, 6 and 7 which
describe the development of the toolkit components.
Vertical Slice Approach

3.1.6 The toolkit has been designed to verify what management think is happening, is actually
happening at all organisational levels. The approach should be suitable for one-t o-one
interviews or adhoc discussions to take place with employees to collect data regarding
safety related behaviours, processes and attitudes. The assessment should include and
Page 6
compare the responses of employees through a ‘vertical slice’ of the organisation, i.e. from
a variety of organisational layers. The vertical slice should segment the organisation at all
levels from the top to the bottom.
3.2 Toolkit Features
3.2.1 The different components of the toolkit include a number of consistent features. These
features form the underlying characteristics of the toolkit and have been used to provide
an objective method to assess safety culture within a range of railway organisations.
3.2.2 The consistent features of the toolkit consist of:
• Colour coding to represent the five indicators.

• Assessment criteria.
• Scenarios.
3.2.3 These features have been discussed in detail below.
Colour Coding to Represent the Five Indicators

3.2.4 A colour scheme has been utilised to bring clarity to the toolkit. The five safety culture
indicators are colour coded. This theme runs throughout the question set, pocket card,
overview diagram, and the inspectors’ guide. Figure 2 illustrates the colours used
throughout the toolkit to depict the five indicators.
3.2.5 Icons have also been used to represent each indicator, should it not be possible to print
the toolkit in colour.
Leadership
Two-Way Communication
Employee Involvement
Learning Culture
Attitude Towards Blame
Figure 2- Five Safety Culture Indicators Colour Coding Scheme
Assessment Criteria
3.2.6 In order to measure the five safety culture indicators, the background research identified a
number of sub components of each safety culture indicator which can be used to assess
each indicator. The assessment criteria provide more information about how the five
safety culture indicators should be evaluated, and what aspects to focus on during
interviews.
3.2.7 Selection of the assessment criteria was based on factors such as whether they:
• Could be measured objectively in an inspection setting.

• Were applicable across the rail industry.
• Related to the Cullen (HSC, 2001) recommendations.
Page 7
• Had been validated by previous research.
Scenario Based Approach

3.2.8 The scenarios were selected through consultation with HMRI inspectors and from
evidence derived from the literature review. Factors that were used as the basis for
selection included:
• The applicability of the scenario to different types of rail organisations.

• The suitability of the scenario for discussion with personnel from different areas
within the organisation, and from all levels within a vertical slice of the
organisation.
• The opportunities within the scenarios to provide the means for eliciting sufficient
information concerning each of the assessment criterion.
• The appropriateness of the scenario to the interviewee.
3.3 Validation of the Toolkit
3.3.1 In order to validate the toolkit components, a pilot test and six validation visits were
conducted at a range of rail organisations including train operating companies, freight
operating companies, train maintenance companies, and a company responsible for
infrastructure management. During each visit, the usability of the toolkit was tested and an
assessment of the organisation’s safety culture was undertaken. After each visit, any
refinements required to the toolkit components were made and then the toolkit was re
tested during the next visit.
3.3.2 The findings from each inspection have been documented within a separate report
(Reference 5). The specific issues identified with the toolkit components are detailed in
the next section which has been organised according to the four different components of
the toolkit, namely, the question set, the pocket card, the overview diagram, and the
inspectors’ guide. The sections for the question set, pocket card and overview diagram
describe:
• How each component was developed initially.

• The refinements made following the pilot and during the series of validation visits.
• The final version of the toolkit component.
Page 8
4. THE QUESTION SET
4.1 Initial Development
4.1.1 The aim of the question set is to provide a structured set of questions that can be used as
the basis for interviews with staff at all levels within a rail organisation to elicit information
regarding the systems, procedures and attitudes their organisation has towards safety.
4.1.2 The findings derived from the background research and consultation with rail stakeholders
were used to develop the specific technical content of the question set, namely:
• Assessment Criteria.
• Evidence Points.
• Scenario Based Approach.
• Scenario Overview.
• Documentation Required.
• Questions.
• Format of the Question Set.
4.1.3 These features have also been used to develop the pocket card and the overview diagram
and are discussed below.
Assessment Criteria
4.1.4 The initial version of the question set incorporated 11 assessment criteria which are
presented within Figure 3.
Leadership
Performance vs. safety priority

Safety management leadership
Two -Way Communication
Promotion and awareness of safety culture

Safety concern reporting
Discussion and awareness of safety issues
Learning Culture
Safety concern investigation

Incident investigation
Employee involvement in safety decision making
Individual ownership of safety responsibilities
Attitude to Blame
Awareness and adherence to personal

accountabilities
Presence of a just culture
Figure 3- Safety Culture Indicators and Initial Assessment Criteria
Page 9
4.1.5 Each scenario can be assessed against two or three assessment criteria. The
assessment criteria are colour coded to show how they link to the five safety culture
indicators.
4.1.6 An example of what each assessment criteria aims to assess is provided below:
• Performance vs. safety priority - Safety should always be prioritised as more

important than operational performance.
• Safety management leadership - All management should be committed to
safety and should demonstrate this by conducting regular safety tours in all
operational areas. Safety tours should provide the opportunity for all staff to
discuss safety issues with management.
• Promotion and awareness of safety culture - All personnel should be aware of
and understand safety goals, targets and issues. There should also be visible
efforts by senior management to communicate that they are committed to
developing a positive safety culture.
• Safety concern reporting - There should be clear and easy to follow procedures
to report safety concerns. The reporting system or process should be accessible
to all.
• Discussion and awareness of safety issues - There should be multiple
channels for communication about safety.
• Safety concern investigation - The organisation should take specific steps to
monitor known problems, identify new ones, detect trends over time and develop
effective preventative measures.
• Incident investigation - Incident investigation procedures should include root
cause analysis, ensure that lessons are learnt and that improvement actions are
introduced throughout the organisation.
• Employee involvement in safety decision making - All personnel should be
involved in any changes, new initiatives etc. that may affect their job roles.
• Individual ownership of safety responsibilities – An Individual’s safety
responsibilities should be clearly defined within personal job descriptions.
• Awareness and adherence to personal accountabilities - Personnel should be
aware of, understand and adhere to personal accountabilities.
• Presence of a just culture - Retribution and blame should not be seen as the
purpose of investigations when things go wrong. Investigation procedures should
clearly distinguish between different degrees of culpability (e.g. blameless,
system-induced or negligence induced errors).
Evidence Points
4.1.7 Features that can be used to evaluate the performance of the company against each of
the assessment criterion were originally termed “performance indicators” but then re
named “evidence points” as it was thought this reflected their function better. Where
possible these are grounded in evidence from the literature, standards, guidelines or best
practice identified in the background research. Evidence points are categorised as being
indicative of either satisfactory or unsatisfactory performance and grouped accordingly.
The inspector should use these as a guide to assess whether the answer given is
representative of satisfactory or unsatisfactory practice.
4.1.8 Satisfactory evidence points outline what is considered to be good practice, or reasonably
practicable for compliance within the rail industry. The organisation should be able to fulfil
these criteria in terms of financial and personnel resources, legal requirements, and time
allocation.
Page 10
4.1.9 Unsatisfactory evidence points outline aspects of company practice that would suggest the
organisation is not complying with good practice, or what is reasonably practicable to
expect on each assessment criterion.
Scenario Based Approach

4.1.10 The toolkit was initially organised into six sections which corresponded to scenarios. They
were designed to provide a context for eliciting the required information regarding the
company’s safety culture.
4.1.11 The initial scenarios selected for inclusion in the question set are presented in Figure 4.
A: Normal Operations of the Day
B: Safety Issues
C: Degraded Operations: Time

vb Critical or Difficult Situation
D: Safety Consideration During

vb Change Management
E: Incident Operations: Incident

vb Management
F: Management of Safety
Figure 4- Initial Scenarios
Scenario Overview
4.1.12 Detail was provided within the question set about each scenario. A brief description of the
scenario and the information that the scenario should reveal from discussions with each of
the operational levels (e.g. senior and middle management and frontline safety critical
staff) was also outlined. In addition, examples of specific scenarios relating to the different
types of rail companies were provided to guide the inspector in tailoring the questions to
specific contexts with which the interviewee may be more familiar. See Appendix A for an
example of the scenario approach used in the initial version of the question set.
Required Documentation
4.1.13 For each scenario, it was identified that a selection of documents may be required to verify
that the reported evidence was a true reflection of actual practice. Alongside each
scenario overview, a list of documentation was provided for the inspector to use as a
reference source.
Questions
4.1.14 For each of the six scenarios a series of questions was developed to investigate the extent
to which the company operates within a satisfactory safety culture.
4.1.15 The questions were derived:
• To explore the safety issues associated with the scenario.

• To provide an opportunity to identify evidence in support of the assessment
criteria.
• To reflect the principles described within the Health and Safety Management
Framework (detailed within section 3.1.4).
Page 11
4.1.16 The questions included in the question set consisted of both open-ended and closed
question styles, for example:
• Open-ended question- “How does/did management try and make themselves

approachable?”
• Closed question- “Was the concern investigated thoroughly and remedial actions
developed and implemented if required?”
Format of the Question Set

4.1.17 The initial version of the question set was based on an A4 sized landscape view, and was
double sided, with a spiral binding at the bottom/top edge of the page. When turning the
pages two pages were always visible:
• Page 1: Scenario- This highlighted the aim of the scenario, the assessment
criteria being measured and the specific safety culture indicators being assessed.
In addition, specific scenarios relating to the different types of rail companies
were provided.
• Page 2: Questions- The question page was more detailed, as this provided
specific questions in a flow chart style that the inspector should use to identify
what happens in relation to the scenario highlighted on page 1. This page also
provided the inspector with evidence points in relation to the assessment criteria
being measured. These evidence points were to be used as a guide to assess
the company’s performance.
4.1.18 An example of the two-page format of this initial version of the question set has been
presented in Appendix A.
4.2 Evolution of the Question Set
Edits Made to the Wording

4.2.1 During the pilot and validation phases of the toolkit it was identified that some of the
questions, assessment criteria, and evidence points could be interpreted as being
ambiguous. As the inspector may conduct the inspection under limited time constraints,
the wording of these features needs to be self-explanatory. It was decided that each
question, assessment criterion, and evidence point should be simple to understand, and
therefore appropriate refinements were made to the wording.
Expansion of the Scenario Approach and Assessment Criteria

4.2.2 The pilot inspection highlighted that it would be beneficial to expand the original
assessment criteria. The scenarios made it possible for the measurement of further
assessment criteria. Additional assessment criteria were therefore developed. A list of the
final assessment criteria and the scenarios to which they are relevant are displayed in
Figure 5.
Page 12
Safety Management Scenario
Management Visibility
Employee Involvement in Safety Discussion
Safety Culture/Climate Monitoring

Safety Concern
Internal Safety Concern Reporting System
Approachable Management
Culture of Trust
Assessment
Safety Concern Investigation and Mitigation Procedure
criterion
Safety Concerns Log
Change Management
Employee Participation in Change Processes
Employee Training about the Change
Employee Motivation
Active Response to Feedback
Transfer of Information About Shift Duties

Safety Information Communication System
Comprehension of Safety Information

Employee Awareness of Accountabilities
Time-Critical or Degraded Situation
Safety Prioritised Behaviour

Performance vs. Safety Management Priority
Safety Accountability
Incident Management
Incident Investigation System K Leadership

E Two -Way Communication
Fault Allocation Process
Y Employee Involvement
Disciplinary Process
Learning Culture
Feedback Systems Attitude to Blame
Figure 5- Six Scenarios and their Associated Assessment Criteria
4.2.3 Figure 5 also demonstrates the relationship between the safety culture indicators and the
assessment criteria, using the colour-coding theme that has been adopted throughout the
toolkit.
4.2.4 A brief example of what each refined assessment criteria aims to assess is provided
below:
• Management Visibility - All management should be committed to safety and
should demonstrate this by conducting regular safety tours in all operational
areas. Safety tours should provide the opportunity for all staff to discuss safety
issues with management.
• Employee Involvement in Safety Discussions – Safety management methods
should serve to provide an opportunity to all staff for open discussion of safety, to
identify risks and mitigate against these risks.
• Safety Culture/Climate Monitoring- Management should monitor and review
employee thoughts, opinions and feelings concerning the effectiveness of safety
management, for example by conducting safety climate/culture surveys.
• Internal Safety Concern Reporting System- There should be clear and easy to
follow procedures to report safety concerns. The reporting system or process
should be accessible to all.
• Approachable Management- There should be opportunities for face-t o-face
discussion with management, and management should take responsibility for
dealing with safety concerns once they have been identified.
Page 13
• Culture of Trust - Operational staff regularly report concerns when it is
appropriate to do so, and reports should be made that concern a range of issues.
• Safety Concern Investigation and Mitigation Procedure - The organisation
should take specific steps to monitor known problems, identify new ones, detect
trends over time and develop effective preventative measures.
• Safety Concerns Log – All concerns reported should be logged for reference,
and efforts should be made by management to analyse repeat or similar
concerns.
• Employee Participation in the Change Process - All personnel should be
involved in any changes or new initiatives etc. that may affect their job roles.
• Employee Training about the Change – If required, the relevant individuals
should be trained to the required level of competence before the change takes
place.
• Employee Motivation – Employees should report that they feel involved and
included in the change process.
• Active Response to Feedback – There should be strategies in place to
communicate the outcomes of the consultation about the proposed change.
• Safety Information Communication System - Safety information (relating to
both personal safety and major accident avoidance) should be communicated at
the start of the shift or whenever there is a handover of duties.
• Comprehension of Safety Information – Staff should have all the information
necessary to conduct their shift safely.
• Employee Awareness of Accountabilities - Personnel should be aware of,
understand and adhere to personal accountabilities.
• Safety Prioritised Behaviour- There should be no pressure to maintain
performance standards, potentially at the cost of safety.
• Performance vs. Safety Management Priority – There should be evidence that
management stipulate clearly and repeatedly to operational staff that safety is the
first priority.
• Safety Accountability – Management should take responsibility for the
consequences when they prioritise performance over safety.
• Incident Investigation System - Incident investigation procedures should
include root cause analysis and, ensure that lessons are learnt. Improvement
actions should be introduced throughout the organisation.
• Fault Allocation Process – Care should be taken not to apportion blame before
the root cause analysis is complete. The purpose of the situation should be to
learn from the incident, rather than apportion blame.
• Disciplinary Process – Clear procedures for deciding upon the relevant
disciplinary actions should be in place.
• Feedback Systems – There should be strategies in place for communicating the
outcome of investigations, e.g. via briefings, newsletters etc.
Expansion of the Evidence Points

4.2.5 A requirement for additional evidence points was also identified. Further evidence points
were therefore identified from the background research and incorporated within the
question set.
4.2.6 An example of some of the expanded evidence points used for the Safety Concern
scenario are detailed in Figure 6.
Page 14
Figure 6- Example of Evidence Points
Questions as Memory Prompts

4.2.7 To improve the flexibility of the questions it was decided that it was more appropriate to
provide questions that are worded simply as memory prompts for inspectors. Inspectors
will be able to use the prompts to word questions appropriately according to the particular
person or role being interviewed.
Amendments to the Format and Layout of the Question Set

4.2.8 The most fundamental refinements were made to the format and layout of the question
set.
4.2.9 The A4 layout proved to be too cumbersome during the inspection visits. The size of the
toolkit needed to be smaller, especially when conducting interviews in operational settings
(i.e. in workshops). A smaller format would make it easier to hold when interviewing.
4.2.10 An inspector’s workload during an interview can be quite challenging. He/she will have
limited time to read the question; ask the question; listen to the response; write the
response down (if conducting the interview alone); interpret the response, and think about
what he/she needs to ask next. Due to such time constraints, it may be difficult for the
inspector to take full advantage of the information about scenarios and documentation that
may be required as evidence. It was therefore decided that it would be more useful to
include only the key information needed to conduct the visit, such as the questions and
evidence points. Whilst the other information is useful it would be more suitable to present
this information within the inspectors’ guide, for reference.
4.2.11 A brief one-page instructions page provided at the beginning of the question set was also
included to remind inspectors of how to use the question set.
4.2.12 A one-page summary of the five indicators was also added to provide a reference point to
which inspectors could refer to when explaining the purpose of the safety culture
assessment to interviewees.
4.2.13 A colour scheme runs throughout the toolkit which corresponds to the five safety culture
indicators. These colours have also been used to explain which safety culture indicator is
applicable to each assessment criteria. The inclusion of a small key to the five safety
Page 15
culture indicators alongside the assessment criteria assists the inspector in understanding
to which indicator each assessment criterion relates.
4.2.14 Presenting the questions in a flow diagram structure proved to be very limiting. It was not
easy to follow the flow chart during an interview. It was therefore decided that it would be
simpler to present the questions as bullet points so that the inspectors can ask the
question in any order.
4.2.15 It was identified that the categorisation of questions under the headings of the health and
safety management framework did not add any value during an interview. Understanding
that the questions have been structured according to the framework is useful, but this is an
underlying theme. Therefore, it was decided that the relationship of this framework to the
questions should be included in the inspectors’ guide for reference.
4.3 Final Version of The Question Set
4.3.1 Based upon the issues outlined above, the question set was edited to enhance its
usability. The modifications made were tested throughout the remaining validation visits
and no significant further modification requirements were identified.
4.3.2 The final version of the question set is presented in A5, portrait layout and printed double
sided with a spiral bound at the left hand spine. The question set is laminated to allow for
outdoor usage and to make it more durable. The final version of the question set is
presented in Annex A.
Page 16
5. THE POCKET CARD
5.1.1 The purpose of the pocket card is to provide inspectors with a memory prompt for the
features that can be used to measure safety culture. This card will allow inspectors to
glance quickly at the high level features of the scenarios, five indicators of safety culture,
health and safety management framework and assessment criteria included within the
question set. It is envisaged that this will be most useful in informal settings, for example
when talking to staff during walkabouts in operational / frontline areas.
5.1.2 The pocket card has been designed with the intention that it should be suitable to fit inside
a jacket pocket. The card is double sided, laminated and presented in colour to reflect the
colour theme that runs throughout the question set. The two sides of the initial version of
the card illustrated the following:
• Side A depicted the six scenarios and their associated assessment criteria.
• Side B depicted the five safety culture indicators and the health and safety
management framework.
5.1.3 The initial version of the pocket card is presented in Appendix B.
5.2 Evolution to the Final Version of the Pocket Card
5.2.1 During the pilot and validation visits it was identified that the design of the pocket card was
sufficient for the visits that were undertaken. However, the technical content has been
refined to reflect the revisions made to the content of the question set discussed in the
previous section, such as the expansion of the assessment criteria.
5.2.2 The indicators and health and safety management framework did not provide any obvious
assistance during the inspection process. Therefore, side B of the pocket card was refined
to display the assessment criteria according to each of the five indicators, i.e. all the
criteria that measure leadership have been listed together. It was perceived that the
refined version would provide inspectors with a reference source that would help collate
the findings from the interviews against the indicators being assessed. To see the final
versions of the pocket card, please refer to Annex B.
Page 17
6. THE OVERVIEW DIAGRAM
6.1.1 The overview diagram summarises the principles of best practice in relation to each of the
five indicators. This diagram provides more detailed information compared to the pocket
card, and provides the inspectors with an alternative option for use during inspections.
6.1.2 The diagram is presented on an A3 page and is colour coded to be consistent with the
other components of the toolkit. The diagram is structured as a matrix to demonstrate the
relationship between the following underlying features of the toolkit:
• The health and safety management framework.

• The six scenarios.
• The assessment criteria for each of the six scenarios.
• A brief description of the type of evidence that will be required to satisfy the
assessment criteria.
6.2 Evolution to the Final Version of the Overview Diagram
6.2.1 The design of the overview diagram was perceived to be sufficient for the visits that were
undertaken. Minor amendments have been made following the pilot and validation visits to
ensure that the technical content reflects that of the final question set. To see the final
version of the overview diagram, please refer to Annex C.
Page 18
7. THE INSPECTORS’ GUIDE
7.1.1 The inspectors’ guide is a handbook to guide HMRI inspectors on how to prepare for
safety culture inspections and how to use the toolkit. It is intended to provide guidance on
all stages of the inspection process including planning, assessing and reporting. It gives a
detailed account of the inspection methodology and techniques that should be used to
achieve a valid and reliable assessment.
7.1.2 The inspectors’ guide has been developed in parallel with the other toolkit components.
7.1.3 The guide is comprehensive and easy to use and includes the following features:
• The guide specifically outlines the main aims and objectives of the toolkit.
• The underlying features of the toolkit are also outlined within the guide, such as
the vertical slice approach that should be used when interviewing; the
applicability of the toolkit to a variety of rail organisations, and an explanation of
the underlying health and safety management framework that has been used to
structure the questions.
• Information about the specific content of the different components of the toolkit
has been provided. For example, detailed information in relation to the six
scenarios, to provide an understanding of how context can help to facilitate the
interview
• Evidence points have been included that correspond to the evidence points in the
question set, however expanded information has been provided to help the
inspector to determine whether the responses made during an interview are
consistent with a positive or negative safety culture.
• Instructions on when and how to use the different components are included. For
example, the applicability of the pocket card when conducting site visits.
• A pro forma recording sheet has also been provided. This should allow
inspectors to record during an interview the main strengths and weaknesses
related to each safety culture indicator.
• A pro forma letter and assessment plan that can be used by the inspector to
confirm arrangements for the inspection, and outline the details of the
assessment with the company being inspected.
• A template to formally report the findings of the inspection has also been
developed. This will allow inspectors to report the main findings of the
inspections in a structured and consistent format.
• A legislative framework has been outlined to provide a quick reference to the
health and safety regulations to which rail companies should adhere.
7.1.4 The final version of the guide is available as an A4 spiral bound booklet and is presented
in Annex D.
Page 19
8. SUMMARY OF THE DEVELOPMENT OF THE TOOLKIT
8.1.1 The toolkit provides inspectors with a range of options to use when conducting safety
culture inspections, namely: a question set, a pocket card, and an overview diagram
8.1.2 In summary, the features of the question set include:
• Six scenarios to provide a context against which interviews could be structured.

• A series of questions that can be used to identify the extent to which the
company is satisfying the evidence points associated with the specific
assessment criteria relevant to each of the five indicators of safety culture.
• Positive and negative evidence points that are to be used to evaluate the
company against each of the assessment criteria.
8.1.3 The pocket card outlines the five indicators, assessment criteria, and the scenarios.
These are presented on two sides of the card:
• Side A- Assessment criteria organised according to scenarios.

• Side B- Assessment criteria organised according to the five safety culture
indicators.
8.1.4 The overview diagram presents the following information in a matrix format:
• The five safety culture indicators.

• A brief description of the type of evidence that will be required to satisfy the
assessment criteria.
8.1.5 An inspectors’ guide has also been developed which describes the aims and objectives of
the toolkit and provides an outline of how to conduct the inspection in a consistent and
objective manner.
8.1.6 The toolkit was tested during a pilot visit and six further visits to a range of rail
organisations. A few issues related to the technical content and format of the question set
were identified. The refinements to the question set consisted of:
• Expanding the assessment criteria and evidence points.

• Refining the questions to ensure that they are not ambiguous in any way.
• Reducing the size of the question set format.
• Presenting the questions as bullet points.
8.1.7 Minimal changes were made to the structure of the pocket card and the overview diagram.
Those refinements that were made were undertaken to reflect the modifications made to
the specific technical content of the question set. 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
Page 20
9. SUMMARY OF FINDINGS FOR THE VALIDATION VISITS
9.1 Overview
9.1.1 In order to validate the toolkit a pilot inspection and six further inspection visits were
conducted at a range of railway organisations, including train operating companies, freight
operating companies, a maintenance company, and an organisation responsible for
infrastructure management. This section of the report outlines the strengths and
weaknesses in safety culture that were identified using the toolkit at the organisations
visited. The findings of the visits are confidential, and therefore the summaries are
anonymous.
9.2 Company A
Summary of the Main Strengths

9.2.1 The assessment identified a generally positive and encouraging culture of safety within
Company A. Management are clearly aware of the need for effective safety management
and have already implemented many successful initiatives which support and maintain the
existence of a positive safety culture, such as the introduction of safety days and an open-
door policy. There is also a strong and consistent emphasis on safety.
9.2.2 The series of steps taken to communicate effectively the safety message throughout the
organisation are aspects that can be particularly commended. Staff were generally
positive and confident about their safety roles, had a high level of awareness of safety, and
expressed good safety reporting behaviour.
Specific Issues
Safety Leadership
• Senior Executive Visibility in Operational Areas - Whilst the company have a
structured system of conducting management safety tours, concerns were raised
that senior executives do not take part in these tours at a sufficient frequency, and
are subsequently at risk of generating a communicative distance between
themselves and operational areas.
• Safety Climate Surveys – Minimal efforts were made to make operational staff fully
aware of the outcome and actions taken in response to the safety climate surveys
that had been undertaken.
Two -Way Communications

• Safety Concern Information Central Database – The company may need to
ensure that there is a central mechanism, to enable the collation and transfer of
safety concern information that is reported to management.
• Consultation with Employees at all Stages of the Change Programme - Whilst
affected parties were consulted regarding proposed changes, the company would
also benefit from the involvement of affected employees and subject matter
experts at every step of the change management programme, including design,
development, evaluation and trials.
• Safety Validation Process –Concerns were raised that the safety validation
process is not always complete prior to the change actually being implemented.
Evidence of a Learning Organisation

• Objective Selection of Issues for Investigation – It was identified that safety
issues are selected for analysis based on the investigators personal experience
of what is priority, rather then any other measure.
Page 21
• Consistent Information about Mitigation Measures - Safety information that is
disseminated to staff outlines the safety issues that have recently been identified,
however no efforts are made to explain how to reduce the risk of the issues
occurring again.

• Employee Wellbeing During Incident Investigation –It was identified that the
incident investigation procedure is putting the employee through psychological
distress and embarrassment as employees feel that they are perceived as “guilty
until proven innocent”.
9.3 Company B

9.3.1 Positive efforts are made by senior management to conduct safety tours at a range of
locations and functions. Feedback about the safety tours is forwarded to the locations
visited. It was confirmed by frontline, middle and senior management that safety is always
paramount and that staff adhere to rule books and working procedures.
9.3.2 Management have made visible attempts to develop an informative organisation, such as
introducing a safety newsletter, conducting safety briefings every 13 weeks, and displaying
safety information in notice cases and safety boards. Senior management also
demonstrated that they are committed to safety by conducting and attending safety
meetings, such joint safety committee and safety management group meetings.
9.3.3 There was evidence to suggest that safety representatives and union representatives are
involved in decision-making. Positive efforts were demonstrated for the involvement of
driver team managers in the design of the cab for new rolling stock, prior to its introduction.
9.3.4 It was reported that accident statistics, trends, and excessive hours are monitored. The
extent to which this takes place was not confirmed.
9.3.5 There are clear systems in place for investigating incidents. For example, a “SPAD form”
and “SPAD Investigation Checklist” are used to identify why a SPAD has occurred. An
“Incident and Welfare Post-Interview Questionnaire” and “Health and Welfare Post-
interview Questionnaire” are also used to identify any precursors to the incident.
Specific Issues
Safety Leadership
• Safety Vs. Performance Message - It was reported that maintenance staff often
jump down from platforms on to the track. This is not considered to be safe
practice.

• Clarification of Briefings - There was no evidence that the safety briefings provide
the opportunity for two-way communications to take place between operational
staff and management.
• Cascaded Information - Senior management confirmed that they do not believe
that all information is disseminated down appropriately to all operational levels.
• Verbal Safety Concern Communication System - It was confirmed that safety
concerns are usually reported verbally to direct line managers and are rarely
written down.
• Effective Feedback Mechanisms - Frontline staff and senior management
reported that feedback is not provided in a timely manner.
• Open Reporting - Management reported that there have been a few cases where
safety concerns have been reported directly to CIRAS, rather than directly with
Page 22
the company. This may be an indication that staff are reluctant to raise issues to
management.
• Operator Involvement - During a training programme, it was highlighted by
operational staff that there were functions in the cab that were not appropriate.
Involving the end user in the design and risk assessment of the cab on a
proactive basis would have been a better approach to identifying any problems
with the cab design.
Existence of a Learning Organisation

• Learning from Others - It was reported that there have been limited efforts made
to learn from other train operating companies. Management expressed that each
company has different risks, therefore there have been limited efforts to learn
from other companies.

• Usage of the Refusal to Work System - It was reported that a refusal to work
procedure exists although this has only been used once in the last five years.
The company has not investigated the reason why this system may not be used.
• Three Strikes Out - It was identified that there is strong perception that if a driver
has three SPADs then they will lose their job. Although this is not a policy, it was
confirmed by middle management that this is often normal practice within the
organisation.
• Guilty Until Proven Innocent - It was reported that drivers are considered to be
blameworthy if they have been involved in misconduct. If the incident was
caused by human error then the driver is considered not to be blameworthy.
9.4 Company C

9.4.1 There are a number of best practice initiatives in place to promote two-way
communications, for example frontline staff have a positive attitude towards
communicating safety concerns to management, and a number of mediums are used to
communicate safety information, such as briefings, notices, videos etc. A confidential
reporting system also exists.
9.4.2 The interviews revealed a positive learning culture. For example, efforts are made to learn
from other companies, incidents are logged in a database, and a tracking system exists to
monitor recommendations from incidents.
9.4.3 There was also positive evidence of a “just” culture rather than a blame culture. It was
identified that a good chain of care process is in operation, the incident investigation
procedures consider a number of influencing factors, and staff reported that the
disciplinary system is fair.
Specific Issues
Safety Leadership
• Management’s Perception of Staffing Requirements- Concern was raised with
regard to the shortage of drivers. Whilst it is recognised that senior management
have made concerted efforts to recruit trainee drivers, it was indicated by staff that
there is an immediate requirement for qualified drivers to meet current workload
demands.
• Rolling Issues- It was verified from documented evidence and verbal reports that
there are numerous rolling issues that are recorded repeatedly.
Page 23
9.4.4 No issues related to two-way communications were identified at this company.
• Involvement of Health and Safety Representatives- There was some
inconsistency highlighted about the lack of representation of health and safety
representatives during safety meetings, joint safety committees, incident
investigations.
• Safety Validation Process- Concerns are raised that the safety validation process
is not always complete prior to the change actually being implemented.

• Appropriate and Timely Feedback about Incidents- It was reported that feedback
about reported incidents is usually communicated through the grapevine, on a
need to know basis, or is sometimes communicated via briefings. Timely
feedback is also not always provided.

9.4.5 No issues related to attitude towards blame were identified at this company.
9.5 Company D

9.5.1 Company D has demonstrated positive efforts towards conducting regular safety audits (in
which operational staff are actively involved), safety walkabouts, and prioritising safety
over performance. Local committee meetings are also held to discuss safety matters.
9.5.2 Safety information is disseminated via an array of sources, such as notice boards, posters,
weekly safety briefings, safety refreshers (to communicate any new learning points),
special instructions, traction bulletins, and training programmes.
9.5.3 There is evidence to suggest that information is communicated clearly between shift teams
using a handover sheet, and with the provision of an overlap in shift times for the handover
to take place.
9.5.4 Senior management involve operational staff when conducting safety tours. Here safety
issues are discussed and the actions to be undertaken are decided.
9.5.5 Clear efforts have been made to encourage a culture of learning, for example actions
stated in National Incident Reports have been used, and statistics have been analysed
from internal incidents and accidents for discussion at safety meetings.
9.5.6 Company D have tried to undertake many positive steps to establish a fair culture that is
supportive and understanding to staff. It was reported that there are positive efforts to
investigate the underlying cause(s) of incidents, rather than merely apportioning blame to
the frontline operator.
Specific Issues
Safety Leadership
• Consistent Approaches to Health and Safety Management - It has been
highlighted by senior management that health and safety practices differ across
the various depots in the company.

• Safety Tours- Safety tours are used as an opportunity to observe working
practices, instead of using this opportunity to discuss safety issues with
operational staff.
Page 24
• Verbal Communication Systems - It was reported that safety concerns are
communicated verbally to safety representatives, and supervisors. A verbal
communication process for communicating concerns is weak.
• Reliable Communication System - It was noted that numerous issues have been
reported about the unreliability of the radios that safety critical staff must use to
communicate critical information to each other. It was reported that this issue has
been raised to management on a number of occasions by a range of staff,
however no action has been taken.
• Clear Roles, Responsibilities and Lines of Communication- There is evidence to
suggest that the introduction of a new staff grade has caused resistance and
dissatisfaction amongst frontline staff and has left staff confused as to what they
should do if they have a concern, and to whom they should report the concern.

• Feedback about Safety Concerns/Incidents- Staff indicated that they do not
receive feedback about safety concerns that have been reported. It was reported
that feedback about incident investigations is only provided to those concerned in
the incident, although on most occasions this only happens if the member of staff
asks to receive it.

• Assigning Blame- It was reported by frontline staff that the perception exists that if
they report a concern, then they will be blamed for its occurrence. It was also
reported that some middle management think that there is a perception from
frontline staff that reporting may involve undergoing intense interviews with
management.
9.6 Company E

9.6.1 Senior and middle management are required to conduct safety tours as part of their
performance objectives.
9.6.2 A cascade based briefing system is used throughout the organisation to communicate
safety information from senior management, such as incident investigation outputs, safety
meeting outputs, safety responsibilities, changes etc. It was also reported that
management often send newsletters to employees’ home addresses. Late notice cases
are also used to communicate any safety critical information that may be required
regarding working practices.
9.6.3 Safety critical staff are provided with mobile phones to allow them to communicate with
each other when out on site visits.
9.6.4 There is active involvement of health and safety representatives as well as union
representatives when decisions are made that will affect operational staff. Operational
staff reported that they are often invited to attend safety tours, and are invited to contribute
to discussions regarding changes.
9.6.5 Personnel highlighted that a variety of methods are used to learn lessons from others, or
from experiences internal to Company E, such as National Incidents Reports,
managements attendance at a variety of committees / meetings with other parties, and
daily conference calls are held between depot managers to discuss any maintenance
issues, safety issues etc.
9.6.6 A near-miss reporting system exists. Senior management stated that all accidents are
reported formally and investigated by conducting a mock up.
Page 25
Specific Issues
Safety Leadership
• Safety Priority in Relation to Shift Times- Drivers reported that they are often
asked by management to work over the recommended 12 hour shift duration.

• Reluctance to Report Safety Concerns- There is the perception by some staff that
if they report a concern it will not be dealt with. No feedback is provided to staff
regarding any action that is taken; therefore, there is reluctance to report
concerns.
• Change Verification Process- It was reported by senior management that this
process is not always completed prior to the change actually being implemented.
• The Role of Health and Safety Representatives- Health and safety
representatives highlighted that their job role takes priority over their health and
safety responsibilities, and they often find it difficult to get release from their work
activities to assist in the investigation of incidents, or risk assessments.

9.6.7 No issues related to evidence of a learning organisation were identified at this company.

• Blame Culture- Concern was raised regarding the tendency towards blaming the
driver for an incident. The extent to which root cause analysis is undertaken could
not be concluded.
• Fear of Reporting Safety Concerns - It was reported by all occupational levels that
if they report a safety concern it is likely that disciplinary action will be taken.
9.7 Company F

9.7.1 One of the most impressive and consistent indicators of a positive safety culture is the
strong emphasis from management upon the importance of safety.
9.7.2 Communication is generally good, with health and safety representatives used as the key
mediators between frontline staff and management at all levels. Effective channels are in
place that allow safety information to be disseminated to staff at all levels within the
organisation. Safety related information is communicated to staff at all levels using a
variety of sources, such as during the induction training, briefings, posters, and via a LED
screen.
9.7.3 It was evident from discussions with employees that there is a positive relationship
between frontline staff and union representatives. Monthly representative meetings are
held, to which frontline employees are invited to provide an input. Opportunities also exist
for frontline staff to voice their opinions concerning any decisions that are likely to affect
them.
9.7.4 Management revealed that they try to encourage staff to fill in accident report forms,
communicate safety concerns, report near misses, and the accident investigation system
described to Human Engineering at the time of the visit appeared to be thorough. The use
of disciplinary action against employees was perceived as being fair by most of those
interviewed, and was reported by those interviewed to be applied generally within a “just”
manner.
Page 26
Specific Issues
Safety Leadership
• Senior Management Participation in Safety Tours - There was no evidence of any
structured and scheduled visits conducted by senior management.
• Reactive Approach to Risk Management –Whilst risk assessments have been
carried out for all new equipment, in some areas of the company risk
assessments are carried out on a reactive rather than a proactive basis. There
was no evidence of the implementation of an objective system that is used to
decide whether a risk assessment is required.
• Formal Safety Management System - There is no formal health and safety
management system within the company.

• Frequent Communication to Senior Management -There seems to be no other
formal method for informing senior management on a more regular basis about
safety concerns apart from during quarterly committee meetings.
• Real-Time Communication System for Drivers - There are limited methods that
drivers can use to communicate to the depot if they have any safety concerns
whilst driving their route. The existing communication systems are limited
because they do not allow drivers to report their concerns immediately. It was
reported that company mobile phones are available but these are reserved for the
drivers of the last shift at night.
• Verbal Communication Systems - The assessment identified that there is a strong
culture to report safety concerns, or communicate safety issues verbally.
• Safety Boards - It was reported by frontline staff that they often suffer from “notice
fatigue” which arises because there are too many posters to read.
• Employee Participation in the Change Process - It was reported that staff are not
consulted about any major changes that are implemented to operational
procedures. It was apparent that staff are only informed about these changes
once they have been implemented.

• Comprehension of Posters/Notices – It was reported that there is frequently no
justification provided about why changes to existing instructions, or new
instructions, are implemented (e.g. changes to speed restrictions).

• Health and Safety Responsibilities - Health and safety responsibilities are not
defined specifically within staff job descriptions.
9.8 Company G

9.8.1 The general impression gained about Company G is that a positive and effective safety
culture exists. In particular, commendable efforts were demonstrated in relation to two-
way communication; for example, monthly briefings are conducted that provide the option
for operational staff to feed information back to management. The organisation also
appears to be keen to learn from incidents and defects reported both externally through
the National Incident Reporting system, and internally through the defect databases.
Evidence was acquired to highlight the involvement of employees in decisions that are
likely to affect them. There was also no evidence to suggest that an unjust blame culture
exists at the depot that was visited.
Page 27
Specific Issues
Safety Leadership
• Rolling Issues- Although it was evident that safety management meetings take
place, it was reported that a number of rolling issues are raised on repeated
occasions.
• Safe Access and Egress to Vehicles- It was reported by middle management that
safe provision for the access and egress to vehicles by cleaners is not provided.
• Health and Safety Representatives for Cleaners- Currently there are no health and
safety representatives acting on behalf of the cleaning staff.

• Verbal Reporting of Safety Concerns- It was reported that cleaning staff usually
report their concerns verbally to management.
9.8.2 No issues related to the involvement of employees were identified at this company.

9.8.3 No issues related to the existence of a learning organisation were identified at this
company.

9.8.4 No issues related to the organisation’s efforts to display a blame culture were identified at
this company.
Page 28
10. CONCLUSIONS AND RECOMMENDATIONS
10.1 Conclusions
10.1.1 This work programme has provided the opportunity to develop a validated, objective and
consistent toolkit that is suitable to assess the effectiveness of a rail organisation’s safety
culture. The toolkit has been developed to ensure that:
• It is focused on the five indicators of safety culture specified in the scope of the
work provided by the HSE.
• Clarity and ease of use have been considered.
• The toolkit is comprehensible.
• It is applicable to a range of rail organisations and organisational levels.
• It is reliable and evidence based, and is based on good practice guidance.
10.1.2 The HMRI Safety Culture Inspection Toolkit provides a flexible approach to conducting
inspections. The different components of the toolkit provide the inspector with a variety of
options that can be used during inspections to suit their personal inspection styles.
10.1.3 The flexibility in the design of the toolkit allows the inspector to measure all five safety
culture indicators. However, the toolkit also provides the flexibility to concentrate on any
one particular indicator of safety culture, if required. For example, if the inspector wanted
to investigate specifically the extent to which employees are involved in decision making,
safety planning, and providing ideas for improvement then the toolkit allows for this. The
presentation of the assessment criteria and evidence points in the question set provides
insight into the type of evidence that should be present within the organisations.
10.1.4 Based on the pilot and validation visits, it was possible to verify that the toolkit can be used
within a range of rail organisations to identify the strengths and weaknesses of the
companies visited to be identified in relation to the five indicators of safety culture. It is
also possible to conclude that the toolkit can be used to interview staff at all organisational
levels. A separate confidential report summarises the findings of the visits (Reference 5).
10.2 Recommendations
10.2.1 One of the components of the toolkit is the Inspectors’ Guide. This provides a
comprehensive account of how to plan, assess and report the safety culture inspection
using the toolkit. The guide has been developed to be self-explanatory. However to
increase understanding of the whole approach it is recommended that the guide be used
as a training manual to accompany a formal training course. A training course will allow all
HMRI inspectors to gain an in-depth understanding of the background to the tool and how
to use the toolkit. This will also allow inspectors to resolve any concerns that they may
have with the toolkit.
10.2.2 The toolkit was used to conduct a number of visits to assess the state of an organisation’s
safety culture, and also to test the toolkit’s usability. Human Factors consultants from
Human Engineering Limited undertook these visits. It is recommended that the
effectiveness of the toolkit and its approach be evaluated once it has been fully integrated
within the HMRI, and after a reasonable period of time. This will allow any issues or
concerns regarding its usability to be addressed and resolved.
10.2.3 The scope of this work programme was to develop a pragmatic approach and
methodology for the inspection of safety culture which focuses on five indicators of safety
culture. It should be appreciated that these five indicators are not conclusive and that
there are other features of safety culture, which the toolkit may not be measuring but which
should be reviewed for incorporation within the toolkit in the future.
Page 29
11. REFERENCES
1. Health and Safety Commission (HSC). 2001. The Ladbroke Grove Rail Inquiry. Part 2
Report. The Rt Hon Lord Cullen PC. HSE Books.
2. Human Engineering Limited. 2005. A Review of Safety Culture and Safety Climate Literature
in Support of The Development of the Safety Culture Inspection Toolkit. Technical report
HEL/HSE/041053b/RT01.
3. Health and Safety Executive. (HSE) 1997. Successful Health and Safety Management.
HSG 65. HSE Books. ISBN 0 7176 1276 7.
4. Health and Safety Commission. (HSC) 1992. Management of Health and Safety at Work
Regulations 1992 Approved Code of Practice.
5. Human Engineering Limited. 2005. Findings of the Safety Culture Assessment Toolkit
Inspections. Technical report HEL/HSE/041053b/RT03.
Page 30
APPENDIX A:
EXAMPLE OF THE INITIAL VERSION OF THE QUESTION SET
APPENDIX A:
EXAMPLEOF THE INITIAL VERSION OF THE QUESTION SET
Page 31
APPENDIX A:
Page 32
APPENDIX A:
Page 33
APPENDIX B:
INITIAL VERSION OF THE POCKET CARD
APPENDIX B:
Page 34
Side A:
Scenarios and their Associated Assessment Criteria
D: Safety Consideration During Change

A: Normal Operations of the Day
Management
Promotion and awareness of safety culture
Employee involvement in safety decision making
Awareness and adherence to personal accountabilities Individual ownership of safety responsibilities
B: Safety Issues
E: Incident Operations: Incident Management
Safety concern reporting Incident investigation
Safety concern investigation
Presence of a just culture
C: Degraded Operations: Time Critical or F: Management of Safety
Difficult Situation
Safety management leadership
Performance vs. safety priority
Discussion and awareness of safety issues
Key to Indicators: Leadership Two-Way Communication Learning Culture Employee Involvement Attitude to Blame
Side B:
5 Safety Culture Indicators Management of Safety Framework
Leadership
Control:
Who is responsible?
Planning and Effectiveness:
Employee Involvement Organisation: What How is it done in
systems are in place? practice?
Learning Culture
Monitoring and Reviewing: Information Flow:
Are outcomes measured What happens to the
Attitude to Blame and actions taken? information gained?
APPENDIX B:
Page 35
ANNEX A:
HMRI SAFETY CULTURE INSPECTION QUESTION SET
Her Majesty's Railway

Inspectorate Safety
Culture Inspection
Question Set
ISSUE 01: 11 March 2005
Aims of the 5 Safety Culture Indicators
Leadership
There are explicit and continuous steps taken by management to ensure
that goals, targets and issues are made clear, and are known to all
personnel. An indicator of good safety leadership is that safety is always
prioritised over performance.
There are multiple channels for the discussion of safety matters, concerns
and goals between and within all levels of the organisation. The flow of
information should be in an upwards as well as a downwards direction.
Personnel from all levels within the organisation are involved in decision-
making, safety planning, and providing ideas for improvement. Employee
participation and feedback is actively sought.
Learning Culture
Steps are taken to monitor known problems, identify new ones, detect
trends over time and develop effective preventative measures. Efforts are
made to ensure that lessons are learnt from incidents, including the wider
application to other situations. Intervention measures are introduced for all
situations.

Developing a just culture is the acceptance that the ultimate responsibility
for incidents lies with the organisation, and investigations take full account
of multi-causality. The purpose of investigations is not to assign retribution
or blame, but to learn from incidents.
How to use this Question Set
This booklet has been divided into six sections that
correspond to six scenarios.
Page 1 of each scenario section provides:
● The scenario topic. This should be used to provide context for

the interview questions.
● Information about who should be interviewed and what

information the scenario could reveal about these people.
● A description of the scenario to help set the scene before

starting the interview.
● Question prompts that may be used to direct the interview.
Pages 2 and 3 of each scenario section provides:
● The scenario topic.
● Examples of evidence points that are indicative of satisfactory

and unsatisfactory behaviour or practice for each of the
assessment criteria. These can be used to help assess whether
the organisation has implemented and is maintaining a positive
safety culture.
● The key to the 5 safety culture indicators.
N.B. Both positive and negative points should be

identified and reported in relation to each
scenario!
Questions
This page is intentionally blank
Safety Management
This scenario should reveal important information about:
- Senior and middle management's commitment to safety in the company.
- Operational staff awareness of safety and how safety is managed.
Setting the Scene:

Think about how senior and middle management manage
safety.
The following questions may be useful:
● What formal systems are in place for managing safety in the workplace, i.e.
safety tours, safety management systems, policies, safety briefings etc?
● Are safety responsibilities defined?

- Are all personnel, including contractors, aware of their responsibilities for
their own safety, and the safety of others?
● Do management spend time in operational areas?

- How often, and what is the impact?
● How effective are management when they conduct safety tours?

- Are management aware of the risks in the operational areas?
- How are the risks identified and the priorities associated with each risk
assessed?
● How is the effectiveness of safety management systems/procedures and

policies monitored?
- Does this include any formal trend analysis?
- How are changes in legal requirements/industry practices tracked,
and how is the safety management system updated to reflect these
changes?
● Do management involve staff at all levels in safety related decision making?

- Are there opportunities for operational staff and management to
communicate with each other?
● Do management monitor and review employee thoughts, opinions, and

feelings concerning the effectiveness of safety management within the
organisation?
- How is this done (i.e. safety climate / culture surveys)?
- Who takes part in this?
- Are the results fed back to all staff?
Safety Management
Satisfactory:
9There are systems in place to manage safety.
9Regular safety tours of operational areas are conducted (best practice: one hour
per week for senior executives, one hour per day for middle managers).
9Safety management systems such as safety tours are used to identify risks and
mitigate them.
9Management give high visibility to improvement programmes.
9There is clear evidence that action lists are developed, signed and tracked.
Unsatisfactory:
8The safety management process is not formalised and entered into managers'
schedules.
8Safety management systems serve as a monitoring, auditing and checking
function only.
8Safety issues are not actively sought out by management.
8Safety issues identified by management are not dealt with, but are just "filed".
Satisfactory:
9There are opportunities for operational staff and management to communicate with
each other.
9Recipients of the safety culture/climate survey have explained to them, why the
survey is being done and how the results will be used.
9The survey results are produced in an action plan to address the most serious
weaknesses.
9Actions are implemented as soon as possible after completion of the survey,
and are fed back to the surveyed group as rapidly as possible.
9Issues or areas of weakness are discussed with the respondents to clarify
details.
9There is a dwell time between surveys of 18 months to 2 years.
9The survey is completed by a representative proportion of the company.
Unsatisfactory:
8Results are not fed back to the surveyed group in an appropriate manner.
8No, or limited effort, is made to assess safety perceptions of employees within the
company.
8Management's vision of safety is not shared by all staff, and vice versa.
8No actions or priorities result from the survey.
Safety Management
Employee Involvement in Safety Discussions
Satisfactory:
9Employees are invited to comment on decisions about their job roles that may
affect their safety or the safety of others.
9Safety management methods serve to provide an opportunity to all staff for open
discussion of safety, to identify risks and mitigate against these risks.
Unsatisfactory:
8Employees are not invited to comment on safety.
8Management use safety tours as an opportunity to talk at operational staff, instead
of using this as an opportunity to identify employees' opinions and safety concerns.
Key to indicators: Leadership Two-way communication
Attitude Towards Blame Employee Involvement Learning Culture

Safety Concern
- What senior and middle management do when a safety concern is
reported to them.
- What operational staff do when they have a safety concern.
Setting the Scene:

Think about what happens when someone has a
safety concern.

● What systems are there in place for staff to report safety concerns
e.g.confidential systems, approachable management etc?
- Do staff know who to report safety concerns to?
- Who do staff actually report safety concerns to?
- Do staff find it easy to approach management about safety concerns?
● How effective are management in dealing with safety concerns?

- Do management recognise the report as an issue that needs addressing
promptly?
- Do they deal effectively with organisational, as well as personal safety
concerns?
● Do management accept that it is their responsibility to deal with the safety

concern, once it has been reported?
● What do management do with the information obtained from the safety

concern reports?
- How often do the issues get resolved, always? occasionally? never?
- Do staff feel action is appropriate and timely?
● How competent/effective are management in dealing with the safety concerns

raised?
● Are staff provided with feedback about the outcome or progress of the reported
concern?
● Is the effectiveness of the reporting system ever reviewed?
● Are the issues tracked from the time that they are raised through to closure?
- How is this done?
- Is there a budget allocated for the management of safety concerns?
Safety Concern
Satisfactory:
9There are systems/procedures in place to report safety concerns.
9Clear and easy to follow procedures are in place for safety reporting.
9The system is accessible to all operational staff.
9The reporting system is structured.
Unsatisfactory:
8There is no system in place for reporting safety concerns.
8The system is time consuming, or there is inadequate time for reporting.
8Operational staff are not aware of, or encouraged to use the system.
Satisfactory:
9There are opportunities for face-to-face discussion with management.
9Managers frequently ask if operational staff have any safety concerns.
9Operational staff report (when asked) that managers are approachable.
9Management take responsibility for dealing with safety concerns once they have
been identified.
Unsatisfactory:
8Management fail to make decisions.
8The same issues are raised at each meeting, but are not resolved.
8Management have to be sought out, or are rarely available.
8Management take an 'its not my problem' or 'just live with it' attitude.
8Management resist taking responsibility for safety concerns when they are
faced with them.

8Management are seen to be concerned about safety issues, however actions are
just "shelved".
Culture of Trust
Satisfactory:
9Operational staff regularly report concerns when it is appropriate to do so.
9In general, reports are made concerning a range of issues.
9The refusal to work system is used and is respected by management.
9Management take active responsibility for dealing with safety concerns once they
have been highlighted.
Unsatisfactory:
8Operational staff concerns are not reported to management for reasons such as:
● Staff are concerned that the report would get someone else in trouble.
● Staff perceive that nothing would get done.
● Employees feel that they may be deemed responsible for causing the issue.
Safety Concern
Satisfactory:
9A prompt and thorough assessment of the risk and its consequences is
conducted.
9A corrective action plan is developed to mitigate the concern.
9Operational staff receive feedback about the outcome and the progress of the
report.
Unsatisfactory:
8The concern is not fully investigated, corrected or prevented.
8Progress is not monitored or tracked.
8Timely and effective mitigation measures are not applied to resolve the concern.
Safety Concerns Log
Satisfactory:
9All concerns are logged for reference by all staff.
9Repeat or similar concerns are gauged and analysed.
9The information is accessible to all.
Unsatisfactory:
8There is no log for reported concerns.
8The log is not monitored or updated on a regular basis.

Change Management
- How changes are controlled.
- How senior and middle management involve operational staff in the change
process.
- The extent to which operational staff are consulted and involved in safety related
decisions.
Setting the Scene:

Consider a time when the company underwent a
significant change.

● Are proposed changes planned using a structured method?
● Under the change process is a log maintained of the key risks and recorded
action plans for the management of these risks?
● Are changes implemented in a controlled manner?

- How is this done?
● Who is responsible for identifying and involving the appropriate staff in this
process?
● Are there systems/procedures in place to assess the potential impact of the

impending change?
- Is a training needs analysis conducted?
- How are changes to procedures, roles and responsibilities managed?
● How are staff at all levels involved in the change management process?
- Are staff given the opportunity/encouraged to comment on proposed
changes before they are implemented?
- Do management involve staff in an effective and timely manner?
- Do management recognise the limitations of not involving staff in the
change process?
● How are staff informed of the change if they are not adequately involved in the
change management process?
- When is this done?
Change Management
Employee Participation in the Change Processes
Satisfactory:
9Key personnel in the change management team ensure that the end user is
consulted.
9Discussion groups and briefings etc. are used to inform affected individuals.
9End-users are consulted and have the opportunity to contribute to decisions
through activities such as workshops and user trials.
9Employees are actively encouraged to participate in all stages of the change
process.
9There is a structured and planned process to manage change.
9The procedures to manage change are usable, and are easily applied.
Unsatisfactory:
8Affected parties are not kept sufficiently informed.
8End-users contribute only at the end of the design process.
8There is a lack of evidence that the information gained from workshops,
discussion forums etc. is used.
8Affected parties are not informed about the change until it has been implemented.
8Management fail to recognise the limitations of not involving affected staff in the
change process in an effective and timely manner.
Satisfactory:
9A training needs analysis is conducted to assess the levels of training required to
prepare for the change.
9If required, the relevant individuals are trained to the required level of
competencies before the change takes effect.
9Employees are given the opportunity to comment on, or contribute to the training
process.
9Employees understand the training.
9Competency is ensured and maintained.
Unsatisfactory:
8Employees do not receive sufficient training to maintain operational safety during
post-change operations.
8No training is provided to employees regarding the change.
8Training is not put into place in a timely manner, i.e. training is provided several
days/weeks/months after the change has been implemented.
8There are no records of who has / has not been trained, or when training has taken
place.
Change Management
Employee Motivation
Satisfactory:
9Employees report that they feel involved and included in the change process.
9Employees hold positive attitudes towards the planned changes.
9Employees have trust in management to implement an efficient and
successful change.
9Employees have the opportunity to report their thoughts on the change
programme.
Unsatisfactory:
8Employees are mistrustful of management's ability to implement the change
safely.
8Employees hold negative attitudes towards the change process.
8Employees do not have the opportunity to raise their concerns about the change
programme.
8Changes in roles and responsibilities are not understood.
Satisfactory:
9There are strategies in place for communicating the outcomes of the consultation
process.
9It is ensured that employees receive rapid feedback in response to comments and
suggestions made.
9Every attempt is made to incorporate employees' suggestions and comments into
the design process.
Unsatisfactory:
8Employees report not receiving adequate feedback following consultation.
8No feedback is provided to operational staff about the suggestions that they have
made.


- How senior and middle management communicate safety critical information
(including personal safety responsibilities) to operational staff.
- The extent to which operational staff receive and understand safety critical
information that is communicated to them.
Setting the Scene:

Think about the chain of events at the start of a new shift or
when there is a handover of duties.
● How is safety related information communicated to staff at the start of a new

shift, shift handover, or where a handover of duties is required?
● Who, or what, is responsible for communicating this information to staff?

- Is this communication effective?
● How is it determined what information must be communicated?
● What type of information is communicated?

- Are all risks and mitigation measures communicated?
● What are the consequences of not communicating the information?
● What is done to ensure that the information communicated has been

understood accurately?
- Do staff have the necessary information to operate their shifts adequately?
- Are all the risks and mitigation measures understood?
● Is the communication system reviewed and monitored for its success?

Satisfactory:
9Safety related information is communicated at the start of the shift or whenever
there is a handover of duties.
9A range of safety related issues are covered, including both personal safety and
major accident avoidance, and how to mitigate against these.
9Managers are on hand to deal with safety related concerns or issues.
9The communication system is reviewed and monitored for its success.
9Safety information is communicated face-to-face by management to all levels
and/or via notices, log books etc.
Unsatisfactory:
8Not all safety issues are covered (e.g. information is limited only to one or two 'hot
topics', neglecting other areas).
8Management have to be actively sought out, and/or staff are reluctant to approach
them.
8The communication system fails to prepare the individual to operate their shift
adequately and safely.
8Risks are stated, however there is a failure to communicate how to mitigate
against these.
8The adequacy of the communication system is reviewed infrequently.

Satisfactory:
9All staff are aware of their safety responsibilities.
9Regular checks are carried out to ensure that all staff are aware of their
responsibilities (for instance using spot checks or briefing attendance signature
records).
Unsatisfactory:
8Safety responsibilities are unclear and changeable.
8Temporary changes are not always considered.
8Management and operational staff generally fail to take responsibility for
communicating the safety information.
Satisfactory:
9Staff are proactive in their approach to safety information.
9Staff have all the information necessary to conduct their shift safely.
Unsatisfactory:
8Staff are unable to give an overview of the safety information that applies to them.
8Approaches used to disseminate information are limited.
8The information communicated is ambiguous, or difficult to comprehend.

Time-Critical and Degraded Situation
- The emphasis senior and middle management place on safety compared to
performance, and how this is communicated to operational staff.
- Whether commitment to safety is reflected in operational staff behaviour during

time-critical or degraded situations.
Setting the Scene:

Think about when there was a time critical and
difficult / degraded situation.

● How is safety managed during a time critical and difficult / degraded situation?
● Do staff report feeling adequately prepared to deal with this type of

situation?
● How is the message communicated to staff that safety is the highest priority?
● Do staff understand their roles and responsibilities in this situation?
● Are there any circumstances during which a member of staff is placed under
pressure to meet performance objectives?
- Where does this pressure come from?
- Are management aware of where pressure is being applied and by whom?
- Do management understand the risks posed when performance is
prioritised?
- Are management willing to take responsibility for any issues that emerge
as a result of prioritising performance over safety?
● Do management check that safety is being prioritised by operational staff?

- How is this done?
● Who is responsible for communicating the safety priority message to

operational staff?
- How do management remain confident that staff understand the balance
between safety and operational performance?
● Are reviews conducted to ensure that management prioritise safety

procedures?

Satisfactory:
9Employees have the knowledge, skills and resources available to deal with the
situation, without compromising safety.
9Safety is put first throughout.
9Employees report that there is no pressure from management or peers to maintain
performance standards at the cost of safety.
Unsatisfactory:
8Employees report a pressure to maintain performance standards, potentially at
the cost of safety.
8Safety has been compromised at the expense of performance.

Satisfactory:
9Management stipulate clearly and repeatedly to operational staff that safety is the
first priority, using methods such as:
- Verbal communication (safety tours, briefings, safety days).
- Written communication (notices, within job profiles, safety publications and
newsletters).
9Management demonstrate/promote the commitment to safety to customers and
clients.
9There is a sufficient health and safety budget.
9Management monitor the emphasis placed upon safety by staff e.g. via spot
checks.
Unsatisfactory:
8Evidence that safety could be swamped by the noise around performance e.g.
hard hitting performance campaign.
8Commitment to achieving performance targets that is greater than demonstrated
for safety.
8The emphasis placed upon performance at the expense of safety is not mentioned,
and there is no "buy in" to this message.
Satisfactory:
9Management take responsibility for the consequences when they prioritise
performance over safety.
9Everyone is clearly informed and are aware of their roles and responsibilities in a
time-critical and degraded situation.
Unsatisfactory:
8Management do not take responsibility for consequences when they prioritise
8Clear roles and responsibilities are not communicated adequately or understood
by all staff in a time- critical and degraded situation.

Incident Management
- The actions taken by senior or middle management to investigate the underlying
causes of an incident, and then implement mitigating measures.
- The involvement of operational staff in the investigation and disciplinary process.
Setting the Scene:

Think about the chain of events following an incident.

● What proportion of incidents are investigated?
● Upon what criteria is an incident selected for investigation?
● How was/is the specific incident investigated?
● Who is responsible for investigating an incident, and why?
● What factors did/do the incident investigation procedure specifically

investigate?
- Is this sufficient to identify what really happened?
● How is/was the individual involved in the incident treated?

- Was this appropriate?
● How is/was the cause of the incident determined?
● Are/were any actions taken to prevent the incident from occurring again?
- Are/were immediate as well as long-term avoidance actions considered/
implemented?
- How is/was the risk of this type of incident re-occurring identified, and
mitigated?
- How quickly were/are actions implemented and understood by relevant
parties?
● What disciplinary procedures were/are applied here, and how was/is this
done?
- Was/is this effective?
● Were/are the recommendations from the investigation communicated

throughout the company?
- Who was/is this communicated to?
- What and how was/is this disseminated throughout the company, i.e.
information pertaining to what actually happened, recommendations
based on the incident, or just the outcome of the incident?
- How was/is it confirmed that the information disseminated is understood
by everyone?
Incident Management
Incident Investigation System
Satisfactory:
9A thorough root cause analysis investigates all possible underlying causes and
events leading to the incident.
9A preventative and corrective action plan is developed to prevent re-occurrence.
9A key individual (or individuals) is/are designated to manage and supervise
this process.
9The investigation process is completed within a sensible (usually prompt) time.
Unsatisfactory:
8The investigation does not commence immediately, or is drawn out over an
inappropriate length of time (e.g. over several months).
8The investigation focuses on local or obvious faults, or individual failures and
neglects other 'hidden' factors e.g. industry or company wide processes.
8No efforts are made to ensure that the incident does not occur again.
8The immediacy of responding is inadequate.
Satisfactory:
9Care is taken not to apportion blame before the root cause analysis is complete.
9The purpose of the situation is to learn from the incident, rather than to apportion
blame.
Unsatisfactory:
8Blame is apportioned or insinuated prior to any investigation commencing.
8Blame is apportioned until the individuals involved are proven 'not guilty'.
Incident Management
Satisfactory:
9The procedures distinguish clearly between different degrees of culpability (e.g.
blameless, system- induced or reckless errors).
Unsatisfactory:
8There are no clear procedures for deciding upon the relevant disciplinary actions.
8Disciplinary procedures are limited in distinguishing between different degrees of
blameworthiness.
Feedback Systems
Satisfactory:
9There are strategies in place for communicating the outcomes of the investigation
e.g. briefings, newsletter, articles in corporate magazines and notices.
9Preventative campaigns are installed throughout the organisation to raise
awareness of the factors contributing to the incident.
9Hard (equipment) as well as soft (training and procedures) actions are
highlighted.
Unsatisfactory:
8Communication does not target all safety-critical employees and is limited to
certain areas.
8The information communicated is difficult to comprehend, and fails to serve its
purpose.
8There is no personal feedback to those involved in the incident.

Developed under the HMRI Rail Delivery Programme by
Human Engineering Limited.
ANNEX B:
HMRI SAFETY CULTURE INSPECTION POCKET CARD
Side A: Assessment Criteria organised according

to Indicators
Leadership
Feedback Systems
Employee Motivation
Learning Culture
Safety Concerns Log

Culture of Trust
Side B: Assessment Criteria organised according
to Scenarios
Safety Management

Safety Concern
Culture of Trust
Safety Concerns Log
Change Management

Employee Motivation

Time-Critical or Degraded Situation

Incident Management
Incident Investigation System K Leadership

E Two-Way Communication
Learning Culture
Feedback Systems Attitude to Blame
ANNEX C:
HMRI SAFETY CULTURE INSPECTION OVERVIEW DIAGRAM
HMRI SAFETY CULTURE TOOLKIT OVERVIEW DIAGRAM
SCENARIOS ASSESSMENT Health and Safety Management Framework

Planning and Monitoring and
CRITERIA CRITERIA Control Effectiveness Information Flow Reviewing
Organisation
(Who is responsible?) (How is it done in (What happens to the (Are outcomes measured
(What systems are in information gained?)
practice?) and actions taken?)
place?)
Management Visibility There is evidence that All safety related systems /

procedures, policies and There is evidence that there There is evidence that Management make concerted procedures are monitored
A: Safety Management Safety Culture/Climate are defined management management display their efforts to provide opportunities and reviewed regularly.
schedules have been
Monitoring developed to deal with roles with clear commitment to safety to for frontline staff to comment on
responsibilities for safety. employees in a visible and or discuss safety matters. Safety climate surveys are
Employee Involvement in the management of completed by staff and the
safety. consistent manner.
Safety Discussions results are disseminated
throughout the company.
Internal Safety Concern

Reporting System There is evidence that the safety
Clear and accessible There are designated Staff receive feedback from There is a system in place to
people responsible for concern reporting system is
Approachable Management systems are in place to management about the monitor and review the success
effective.
B: Safety Concern enable staff to report safety dealing with safety issues. progress made on actions of the safety concern reporting
Culture of Trust concerns. All employees are aware of Safety issues are investigated, resulting from a concern system.
who these people are. and actions are taken by being reported.
Safety Concern Investigation management to mitigate any
and Mitigation Procedure risks.
Safety Concerns Log
Employee Participation in There is a structured and Key personnel within the There is evidence that Personnel are prepared / Management recognise the
Change Process planned process to manage change management team employees are informed and trained to deal with limitations of not involving
change. are responsible for ensuring consulted about the change in a operational changes staff in proposed changes.
Employee Training about the
C: Change Management that the end user is timely and comprehensive effectively. The change process is
Change consulted before changes manner. monitored and reviewed to
Employee Motivation are implemented. ensure that it remains
appropriate.
Active Response to
Feedback
There is evidence that systems There is evidence that there A range of safety issues are All employees are aware of Procedures are in place to
Safety Information or procedures exist for the are clear roles and communicated, including safety issues associated with monitor the success of the
Communication System communication of daily safety responsibilities and systems personal safety and major their current roles/tasks and are communication measures.
D: Transfer of Information Employee Awareness of information. in place to communicate accident avoidance, and how to aware of how important it is to
about Shift Duties Accountabilities safety information mitigate for these. communicate safety related
information.
Comprehension of Safety
Information
Safety is always prioritised Management are responsible Employees have the There is evidence that
Safety Prioritised Behaviour Management stipulate
above performance. for ensuring that the safety knowledge, skills and efforts are made by
clearly and repeatedly that
Performance vs. Safety priority is always adhered to. resources available to deal management to review and
E: Time-Critical and safety is the first priority
with the situation without monitor the emphasis
Degraded Situation Management Priority Staff at all levels understand using verbal and written
compromising safety. placed on safety.
their responsibilities for safety. communication methods.
Incident Investigation There is evidence of a Key management roles have All contributing factors are Frontline staff are provided with There is evidence that the
System thorough incident responsibility for investigating investigated with equal clear feedback from effectiveness of the
investigation process which the incidents promptly. consideration. management about the investigation process is
F: Incident Management Fault Allocation Process aims to reveal the root investigation and monitored and reviewed
The purpose of the investigation
Disciplinary Process cause of the incident. recommendations/actions regularly.
is to learn from the incident,
rather than apportion blame. arising as a result of the
Feedback Systems investigation.
Key to 5 Safety Culture Indicators: Leadership Two-Way Communication Employee Involvement Learning Culture Blame Culture
ANNEX D:
HMRI SAFETY CULTURE INSPECTION INSPECTORS' GUIDE
Her Majesty’s Railway Inspectorate (HMRI)

Safety Culture Inspection Toolkit
Railway Inspectors’
Guide
1
Contents
Section 1:
Introduction to the Inspectors’ Guide 1
Section 2:
Background 3
Section 3:
Planning 7
Section 4:
The Assessment 14
Section 5:
Reporting 34
Section 6:
Reviewing and Monitoring 44
Section 7:
Conclusion 46
Appendix A:
Detailed Evidence Points 47
11 March 2005 i
Acronym List
ACSNI Advisory Committee on the Safety of Nuclear Installations
ACOP Approved Code of Practice
COMAH Control of Major Accident Hazards
FOC Freight Operating Company
HMRI Her Majesty’s Railway Inspectorate
HSC Health and Safety Commission
HSCER Health and Safety (Consultation with Employees) Regulations
HSE Health and Safety Executive
IAEA International Atomic Agency Authority
INSAG International Nuclear Safety Advisory Group
MHSW Management of Health and Safety at Work Regulations
TOC Train Operating Company
SMS Safety Management System
11 March 2005 ii
Introduction to the
1 Inspectors’ Guide
Key Questions:
¾ What is this document?
¾ Who is it produced for?
¾ What is the aim?
11 March 2005 Safety Culture Inspection Guide 1

1.1 Introduction
Her Majesty’s Railway Inspectorate (HMRI) Safety Culture Inspection Inspectors’ Guide is a handbook
for HMRI inspectors to use in conjunction with the HMRI Safety Culture Inspection Toolkit. It 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. It gives a detailed
account of the recommended inspection methodology and techniques that should be used to achieve a
valid, reliable assessment.
The production of this guide has been based upon:
• Consultation with current HMRI Inspectors,
• The findings of a series of inspections carried out at a range of UK
rail organisations, which were used to validate the toolkit. (see
Human Engineering Limited, 2005, ‘Development and Validation of
the Inspection toolkit’).
1.2 Aims
The overriding objective of the Inspectors’ Guide is to provide a detailed

overview of how the Safety Culture Inspection Toolkit should be used to conduct
a valid and reliable safety culture inspection.
To achieve this objective, the Inspectors’ Guide provides a step-by-step account

of the activities and procedures that it is recommended are followed during the
inspection process.
The guide is laid out in six sections which are described briefly in Figure 1.
Figure 1: An overview of the six sections of the Inspectors’ Guide
Key Question Coverage
Section 1 Introduction This section provides a broad introduction to the

guidance and describes how the document should
be used.
Section 2 Background This section provides the background and rationale
to the inspection process.
Section 3 Planning This section provides guidance on how to plan and

prepare for the inspection.
Section 4 The Assessment This section discusses in detail the stages involved
in a safety culture inspection using the toolkit.
Section 5 Reporting This section contains guidance on how to record

and report the findings of the inspection.
Section 6 Reviewing and Monitoring This section gives an account of follow on activities.

2 Background
Key Questions:
¾ Why inspect for safety culture?
¾ What is the legislative framework?
¾ What are the objectives of the safety culture
inspection?
¾ What makes up the Safety Culture Inspection
Toolkit?

2.1 Why Safety Culture?
The importance of safety culture has been highlighted following recent inquiries into two major rail
incidents. The Southall crash on 19 September 1997 resulted in 7 people losing their lives with 139
others being injured. The Ladbroke Grove rail crash on 5 October 1999 resulted in 31 deaths with over
400 other people injured. Public inquiries were chaired by Professor Uff1 and Lord Cullen2, who took a
fundamental look at the rail industry and examined the generic safety issues facing it. The
Government agreed that the 295 recommendations from the Public Inquiry reports set a convincing,
necessary and challenging agenda for change. 25 of these recommendations related to the underlying
conditions of culture and management practice.
In the Ladbroke Grove Report (Chapter 5), Lord Cullen suggested that safety culture in the UK rail
industry could be improved by increased safety leadership, employee involvement, communication,
fault reporting and trust.
He felt that the improvement in safety culture was key to

reducing the management deficiencies that lead to unsafe acts
by employees. In the submission of the HSE “…the need for a
positive safety culture is the most fundamental bought before the
Inquiry”.
As the appointed enforcing authority for health and safety in the
rail industry, HMRI has a fundamental role to play in the
framework for the continued improvement of safety. Specifically,
the review and inspection of safety culture is a crucial aspect of
HMRI’s responsibilities. HMRI has launched an ongoing
programme of work in relation to safety culture, including the
The aftermath of the Ladbroke Grove
development of clear programmes of work for inspectors to
rail disaster, 5 October 1999
undertake.
A Safety Culture inspection methodology has been developed for use by HMRI inspectors. The
toolkit outlines a consistent and effective method by which the characteristics of a positive safety
culture can be measured. It provides a pragmatic approach and methodology for the inspection of
safety culture in UK rail companies.
2.2 The Scope

A fair judgement of an organisation’s safety culture should be based
upon the behaviour and attitudes of employees (organisational
culture), as well as general knowledge and observation of the
systems and procedures in place (corporate culture). A detailed
picture of what is shaping the culture of the organisation should be
built up over a period of time, considering a range of departments,
services lines and employees.
This tool can be used as a basis for inspecting a variety of railway
organisations (including Train and Freight Operating Companies,
Infrastructure Management Companies and Train Maintenance
Companies).
41
HSC (Health and Safety Commission). 2000. The Southall Rail Accident Report. Professor J. Uff. HSE Books
2 HSC (Health and Safety Commission). 2001. The Ladbroke Grove Rail Inquiry, The Rt Hon Lord Cullen. HSE Books.
2.3 Basis of Regulation
The safety culture assessment focuses on 5 key indicators of a positive safety culture that are implicit
within the safety management system:
•Leadership
•Two-way communication
•Learning organisation
•Staff involvement
•Attitude to blame
Whilst no legal requirements make reference to safety culture in an explicit way, there are provisions
identified relating to staff involvement and communications. Consultation and communication
practices are particularly important to securing the benefits of a positive culture. Central are the
requirements in the Management of Health and Safety at Work Regulations (MHSW), 1999 and
ACOP1. Regulation 10 – Information for employees and Regulation 11 – Co-operation and co-
ordination are highlighted. Of wider relevance are: MHSW Regulation 5 – Implement health and
safety arrangements; Regulation 14 – Employees duties. Inspectors may also need to look for
compliance with the requirements of the Safety Representative & Safety Committees Regulations,
1977; Health and Safety (Consultation with Employees) Regulations, 1996; and Health and Safety
Information for Employees Regulations, 1989.
The current Railways (Safety Case) Regulations, 20002 (amended) provide for a development plan
that should call for continuous improvement in safety management systems (SMS). This disappears
in the proposed new regulations but the SMS does have to be approved in the Part A certificate [Part
A & B certificate replaces the safety case]. The SMS must be capable of controlling risks arising from
normal operating conditions and foreseeable degraded, abnormal or emergency conditions. Many
companies quite appropriately recognise that safety culture is one, key element of this. Deficiencies
identified in the current safety culture assessment need to be related to the SMS and any
enforcement action considered using (until revoked) Regulation 10 ‘Duty to comply with the safety
case’. Regulation 11 ‘Co-operation’ may also be relevant.
The current approach to inspection requires assessment of both corporate and organisational
behaviour. The general legal requirements for corporate issues, it is anticipated, would be covered
by the Health and Safety at Work etc Act, 1974 Sections 2, 3, 4; whereas the personal behaviour
would be taken under Sections 7, 8 and 37.
51
1refer to L21 guidance publication
2refer to L52 guidance publication Safety Culture Inspection Guide
2.4 Safety Culture Inspection Objectives
Objective 1:
A consistent, structured approach
The Safety Culture Inspection Toolkit aims to provide a standardised framework for inspecting safety
culture in the UK rail industry. The tool provides guidance to help HMRI inspectors judge the safety
culture, based upon general knowledge of the systems in place (corporate culture), as well as the
behaviour and attitudes of employees (organisational culture). The judgement should be based on a
picture that is built up over a period of time, concerning a wide range of employees, departments and
locations (e.g. depots, stations).
Objective 2: Figure 2: Five Safety Culture

Focused on five main elements of safety culture Indicators
Whilst there are many components of safety culture, the
toolkit is focused on five key indicators (see Figure 2), which
are specified in Lord Cullen’s Inquiry into Ladbroke Grove1.

Leadership
Section 4.3 provides more detailed information of these
indicators.
Objective 3:
Focus on organisational and corporate culture
The toolkit is specifically interested in the safety-related
behaviour of employees, i.e. “how things are done around
here” (organisational culture), as well as the systems and
procedures in place (corporate culture). Judgements should

Learning Culture
be based upon walkthroughs and talkthroughs with
employees, direct observations of documentation and
procedures, and the inspector’s general knowledge of the

organisation which has been established over time.
Objective 4:
Applicability to a variety of rail organisations
The toolkit is designed so that it can be used to assess safety culture within a broad range of UK
railway organisations including Train Operating Companies, Freight Operating Companies,
Infrastructure Maintenance Companies and Train Maintenance Companies. The toolkit offers a
methodology for structuring the inspection process, however the inspector should be guided by what is
appropriate and realistic within the inspection setting.
Objective 5:
Vertical Slice Approach
Judgements formed by the inspector should, in part, be based upon walkthroughs and
talkthroughs with employees of the company. The inspection should include and compare the
responses of employees through a ‘vertical slice’ of the organisation, i.e. from a variety of
organisational layers. These layers include senior management, middle management and
operational workforce (see Table 1 in Section 3.1 for more information).
Objective 6:
Flexibility
As familiarity with the toolkit method increases, the order
and manner by which the questions are asked can be
adapted depending on the context (e.g. the rail company,
department, or the employee being spoken to).
1 HSC (Health and Safety Commission). 2000. The Southall Rail Accident Report.
Professor J. Uff. HSE Books 6
3 Planning
Key Questions:
¾ What needs to be prepared?
¾ What documents should be requested?
¾ How should the company be approached?
¾ How should the inspection be structured?
Safety Culture Inspection Guide 7

3.1 Assessment Planning
The inspector should decide:

• Who should be involved in the inspection,
• The areas that the inspection should target,
• The inspection timescale.
Assessment Methods
Walkthroughs and talkthroughs with employees should be used as the principal method for collecting
data (in conjunction with direct observations of systems, procedures and written records). A sample of
employees should be selected from different organisational layers of the organisation (in order that their
responses can be recorded and compared). Organisational roles can be categorised into three broad
areas which are:
• Frontline staff
• Middle management
• Senior management
Table 1 gives an overview of each of these organisational categories, and provides details of example
job roles or titles belonging to each category with whom it would be appropriate to request an interview.
It may prove useful to dedicate a period of time (e.g. a morning) to each organisational category.
Table 1: Description of organisational roles that should be included in the inspection
Organisational Description / Definition Example of job titles

Category
Front line staff Personnel who perform principally an operational TOC/FOC:
role. In some organisations these may also be • Train driver,
referred to as production staff. Some of these • Station staff.
people may have responsibility for the supervision
of small teams within their own work area. Infrastructure management:
• Signaller,
Of particular interest are those whose work is safety • P-way gang members
critical. Train Maintenance:
• Electrical or Mechanical fitters
• Fleet engineer
Middle management Personnel who are responsible for a department or TOC/FOC:
operation within the company. Of particular interest • Driver Standards Manager
are: • Station Supervisor
• Operational Managers: responsible for a group of Infrastructure management:
frontline staff. • Engineering Supervisors
• Safety managers: responsible for a particular area Train Maintenance:
of safety. • Workshop Supervisor
Senior management Personnel who are responsible for a large area of All company types:
the company and who make strategically critical • Head of Safety
decisions. They may be executive directors, or • Head of Operations
head of an area of the business. Of particular
interest are members of senior management who • Operations Executive
take responsibility for safety, or operational areas. • Safety Managers

How many people should be interviewed?
The objective of the inspection is to include as many individuals as possible from each of the
organisational role categories depicted in Table 1. This will help to establish an informed judgement
based on a range of individuals from different organisational levels, departments and experience.
How long should it last?

The inspector should plan for the safety culture inspection to be conducted over the course of several
days. However, this time is likely to vary depending upon the size and geographical location of various
departments of the company.
Where should the inspection take place?

The areas you visit will depend on:
• Which personnel you need to speak to;
• The nature and industry sector of the company.
The inspector should visit as many sites as possible (including head office, workshops, stations or
depots), to build up a detailed picture of the general culture, rather than specific sub-cultures.
Frontline areas
When visiting frontline areas, it is recommended that talkthroughs take place in a quiet room or within the
operational area, if suitable. The inspector may also ask to ‘walkthrough’ processes with employees
within the operational area. Care should be taken not to compromise safety by removing a member of
staff from the operational area. If required, the company being assessed needs to provide cover for any
staff involved in the safety culture inspection.
Middle and senior management

Middle and senior managers will often have office facilities or meeting rooms available which could be
used for interviews. It is recommended that the company is notified of the requirement to use such
facilities prior to the inspection taking place.

3.2 Notifying the company and requesting documentation
How should I notify the company?

Figure 3 provides a summary of the activities that should be completed when preparing for the
inspection. The preparation includes time for discussion with the company, which should serve to
introduce the aims of the inspection and clarify logistical arrangements.
Figure 3: Preparation Checklist
The inspector should discuss with the company:
The aims and justification for the inspection
Likely areas to be visited
Target personnel to be interviewed
Proposed dates for the inspection
The inspector should request:
Availability of meeting rooms or quiet areas for interviews
The following documentation:
(1) Paperwork from 3 incident investigations
(2) Change management documents relating to a major change

project
(3) Internal safety promotional material e.g. newsletters
(4) The safety case
The inspector should send:
A pro forma introductory letter
A pro forma assessment plan
The inspector should contact the company as early as possible to discuss (a) the objectives and agenda
for the inspection, and (b) appropriate timescales. A pro forma letter (see Figure 4) and an Assessment
Plan (see Figures 5 and 6) should be sent to confirm the arrangements and outline clearly the details of
the inspection.

Figure 4: Pro forma Introductory Letter: Example
Safety Planning Manager

Company
Address
Dear (name)
Further to our recent telephone conversation, please find below further information regarding the
proposed Safety Culture Inspection by Her Majesty’s Railway Inspectorate (HMRI).
There is ongoing work within HMRI on validating the implementation of recommendations from public
inquiries. A number of themes have been identified within the extensive set of recommendations and
one of these relates to ‘safety culture’. The progress report for 2003 on this theme noted that ‘the
development of an improved culture is still patchy, with some companies pressing ahead more
effectively than others’. On safety leadership and communication it was noted that ‘the effect of
measures to secure cultural change has not yet penetrated down through all levels of all parts of the
industry’. In light of these comments it was recommended that ‘the validation of these
recommendations will benefit from clear programmes of work for inspectors to undertake’.
Safety Culture is an area for inspection within the implementation plan for the forthcoming year. As
discussed, I would like to visit <company name> on <agreed date>, to conduct a safety culture
inspection using the HMRI safety culture inspection tool. During the course of my visit it would be
appreciated if you could act as a facilitator and guide to the necessary personnel, and provide access
to relevant documentation. Where feasible I would wish to interview personnel at front line locations or
in small groups. It is anticipated that I will be on site for no more than two days and shall endeavour to
minimise any disruption to your operations.
The interviews will be structured around five indicators of safety culture:

Leadership,
Two-way communication,
Learning culture,
Employee Involvement, and
Attitude towards blame.
I may also ask to see and take photocopies of relevant documentation, for instance job profiles or
meeting minutes. In order for the visit preparation to be completed, would you please send copies of
documentation relating to three incident investigations. I shall choose one of the three to discuss
during the visit. Relevant personnel will be asked to talk through the incident. I have attached a visit
plan that contains further information regarding the inspection and a proposed outline for the visit.
Should you have any questions concerning the inspection, please do not hesitate to contact me.
Many thanks for agreeing to our visit.
Yours sincerely,
Name

Figure 5: Pro forma Assessment Plan: Template
Safety Culture Inspection

Visit Plan
Company Name:
Inspector
Required Personnel
Facility
Requirements
Day One
Agenda
Day Two

Figure 6: Pro forma Assessment Plan: Example
Safety Culture Inspection

Visit Plan
Company Name: Welsh Country Trains
Inspector Irene Seymour
Individuals from a range of organisational levels will be required for walkthroughs/

Required Personnel talkthroughs, including the following roles:
• Senior Executive Manager
• Senior Managers of Operations and Safety
• Middle Management of Operations
• Frontline Staff (those with a safety-critical role)
• Safety Representatives
• Union Representatives
In order to minimise disruption and maintain safety, we would be grateful if personnel cover
could be organise to deputise for staff whilst they are being interviewed.
Facility Meeting rooms will be required in which talkthroughs and focus groups with managers and
Requirements frontline staff will be conducted.
A meeting room will also be required to conduct a management wash-up session at the end
of the inspection.
Day One
Agenda
9:00 – 10:00 Introduction to key contact personnel
10:00 – 12:00 Introductions and interviews with safety management and other key
managers
13:00 – 16:00 Interviews with a minimum of two safety representatives or operational
managers (various locations)
Day Two
9:00 – 10:30 Walk through frontline locations (accompanied by safety representative)
10:30 – 14:00 Interviews with staff members drawn from some of the following roles:
• Train drivers
• Engineering / train maintenance
• Train preparer
• Drivers Standards Managers
• Catering staff/management
14:30 – 16:00 HMRI private wash-up session
16:00 – 16:30 Wash-up session with management

4 The Assessment
Key Topics:
¾ Overview of the methodology
¾ Toolkit Components
¾ Five safety culture indicators
¾ Health and Safety Management Framework
¾ Scenario Approach and Assessment Criteria
¾ Six scenarios
¾ The Question Set
¾ The Pocket Card
¾ The Overview Diagram

4.1 Overview
The Safety Culture Inspection Toolkit has been developed to provide guidance and supporting materials
for conducting a safety culture inspection. It comprises four components, details of which are provided in
Section 4.2. The toolkit provides:
• A question structure for use during interviews and discussions,
• Details of documentation that should be reviewed,
• Information regarding assessment criteria, and evidence upon which a judgement can be
based.
The toolkit outlines a methodology for discussions with employees at the organisation, which should be
used to elicit information regarding the safety culture of the company. Discussions should be structured
around six scenarios, which anchor the interview to realistic events or systems. A colour scheme has
been utilised to bring clarity to the toolkit. The five safety culture indicators are colour coded. Figure 8
illustrates the colours used throughout the toolkit to depict the five indicators. Icons have also been used
to represent each indicator, should it not be possible to print the toolkit in colour.
The content of the interview should be compared against performance on certain assessment criteria,
which evaluate performance against evidence points that are indicative of satisfactory and unsatisfactory
practice. The discussions should follow the health and safety management framework stages, described
in Section 4.4.
4.2 Safety Culture Inspection Toolkit Components
The Safety Culture Inspection Toolkit provides materials, questions and a methodology for completing a
successful safety culture inspection. As shown in Figure 7, the toolkit consists of a Question Set, a
Pocket Card, an Overview Diagram and an Inspectors’ Guide (this document).
Figure 7: Summary of the materials used for Safety Culture Inspection
Safety Culture Toolkit Components
1 Question Set
Provides scenario based
content against which to 2 Pocket Card
conduct the interviews or A pocket sized overview
discussions. of the interview 3 Overview Diagram
(See Annex A). methodology that can be
used as a memory An A3 diagram providing Inspectors’
prompt. summarised details of best 4 Guide
practice performance in
(See Annex B). relation to the five indicators This document.
and the health and safety Provides an overview of
management framework. how the toolkit should
be used to conduct an
(See Annex C). inspection
15
4.3 Five Safety Culture Indicators
This section describes
• What is meant by Safety Culture Indicators and Assessment Criteria
• How they are used within the Safety Culture Inspection Toolkit
What are Safety Culture Indicators?

The Safety Culture Inspection Toolkit was developed on the basis of 5 key indicators (outlined by Lord
Cullen within the Ladbroke Grove Inquiry). These indicators should be addressed to achieve a
successful safety culture. The five safety culture indicators, and a brief description of a good practice
approach, are described in Figure 8.
Figure 8: The five safety culture indicators and a description of good practice
Indicator Title Good Practice
There are explicit and continuous steps taken by

Leadership management to ensure that safety goals, targets and issues
are made clear to all personnel. The prioritisation given to
safety is balanced with, or is greater than the prioritisation
given to performance.
There are multiple channels for the discussion of safety

Two-Way Communication matters, concerns and goals between and within levels of
the organisation. The flow of information should be in an
upwards, downwards and horizontal direction.
Personnel from all levels of the organisation are involved in

Employee Involvement decision making, safety planning and providing ideas for
improvement. Employee participation and feedback is
actively sought.
Steps are taken to monitor known problems, identify new

Learning Culture ones, detect trends over time and develop effective
preventative measures. Efforts are made to ensure that
lessons are learnt from incidents, including the wider
application to other situations. Intervention measures are
introduced for all situations.
The company accepts that the ultimate responsibility for

Attitude Towards Blame incidents lies with the organisation, and investigations take
full account for multi-causality. The purpose of
investigations is not to assign retribution or blame, but to
learn from incidents.

4.4 Health and Safety Management Framework
The Health and Safety Management Framework shown in Figure 9 incorporates Regulation 5 of the
HSC’s Management of Health and Safety at Work1, and the POPMAR model outlined in HS(G)65:
Successful Health and Safety Management2. The POPMAR model provides best practice guidance
on health and safety management; where as the Health and Safety at Work Regulations refer to the
regulations that a company should adhere to in relation to health and safety management. These
two approaches are complementary , and have thus been used as the basis for a suitable health
and safety management framework that adheres to best practice guidance and regulations against
which the toolkit was developed.
Table 2 illustrates how the framework has been used to ensure that the questions contained in the
toolkit seek evidence concerning the fundamental principles of effective health and safety
management.
Figure 9: The Health and Safety Management Framework stages

Control
Who iis responsible?
s responsible?
Planning and Organisation Effectiveness

What systems are in How is it done in
place? practice?
Monitoring and Reviewing Information Flow

Are outcomes measured What happens to the
and actions
actions taken? information gained?
Table 2: A description of the Health and Safety Management Framework stages

Stage Description Example of related question
Planning and These questions aim to ascertain what E.g. Is there an effective reporting
Organisation organisational provisions are available e.g. system that can be used by
What systems are in place? procedures, equipment, IT systems, employees to highlight safety
documentation. concerns?
Control These questions aim to establish if E.g. Is there a designated person

Who is responsible? responsibilities have been defined and (or group of people) in place to
allocated to appropriate personnel. monitor the reporting system and
respond?
Effectiveness These questions aim to ascertain the E.g. How many reports were made
How is it done in practice? success of the organisational procedures and to management? What did they
systems in place, and the employee concern?
behaviour associated with them.
Information Flow These questions aim to investigate if there E.g. How is information regarding
What happens to the are appropriate channels of communication the safety concern communicated
information gained? in upwards, downwards and horizontal back to the respondent?
directions.
Monitoring and Reviewing These questions aim to establish if the E.g. How is the success of the
Are outcomes measured provisions in place are monitored and reporting system monitored and
and actions taken? reviewed for effectiveness. reviewed?
1 HSC. 1992. Management of Health and Safety at Work Regulations. Approved Code of Practice
2 HSE. 1997. Successful Health and Safety Management. HS(G)65. HSE Books. 17
4.5 The Scenario Approach and Assessment Criteria
What are scenarios?

A scenario is an example of an event or process with which staff are likely to be familiar during company
operations. The Question Set is structured into six scenario categories, which are listed in Figure 10.
Each scenario is designed to provide a realistic Figure 10: The six scenarios
context for eliciting the required information regarding
the company’s safety culture. The aim is for the Safety Management
scenario to act as a basis from which the interview
can develop, in order to assess what actually Safety Concern
happens, or how things are really done, within the
company.
Change Management
Section 4.6 provides further details about the context Transfer of Information about Shift Duties
of each scenario, and gives examples of appropriate
events that could be discussed during the interview. Time-Critical and Degraded Situation
Incident Management
How are the scenarios incorporated into the Question Qet?

The Question Set booklet is structured around the six scenarios specified in Figure 10, with several
pages dedicated to each scenario.
What are assessment criteria?

Safety culture should be measured against assessment criteria, which are key behaviours or company
practices that are relevant to each of the five indicators. The assessment criteria provide information
about how the five safety culture indicators should be evaluated, and what should be the focus of the
interviews. For instance, the indicator ‘Attitude to Blame’ (see Figure 11) can be assessed in terms of
five assessment criteria: Culture of Trust, Employee Awareness of Accountabilities, Fault Allocation
Process, Disciplinary Process and Safety Accountabilities.
Each scenario tackles at least three or four assessment criteria. An overview of how the scenarios and
assessment criteria relate to each other is provided in Figure 12. The assessment criteria are colour
coded to show how they link to the five Safety Culture Indicators.

A brief example of what each assessment criteria aims to assess is provided below:
• Management Visibility - All management should be committed to safety and should demonstrate this by
conducting regular safety tours in all operational areas. Safety tours should provide the opportunity for all staff
to discuss safety issues with management.
• Employee Involvement in Safety Discussions – Safety management methods should serve to provide an
opportunity for all staff for open discussion of safety, to identify risks and mitigate against these risks.
• Safety Culture/Climate Monitoring- Management should monitor and review employee thoughts, opinions
and feelings concerning the effectiveness of safety management, for example by conducting safety
climate/culture surveys.
• Internal Safety Concern Reporting System- There should be clear and easy to follow procedures to report
safety concerns. The reporting system or process should be accessible to all.
• Approachable Management- There should be opportunities for face-to-face discussion with management,
and management should take responsibility for dealing with safety concerns once they have been identified.
• Culture of Trust - Operational staff regularly report concerns when it is appropriate to do so, and reports
should be made that concern a range of issues.
• Safety Concern Investigation and Mitigation Procedure - The organisation should take specific steps to
monitor known problems, identify new ones, detect trends over time and develop effective preventative
measures.
• Safety Concerns Log – All concerns reported should be logged for reference, and efforts should be made by
management to analyse repeated or similar concerns.
• Employee Participation in the Change Process - All personnel should be involved in any changes or new
initiatives etc. that may affect their job roles.
• Employee Training about the Change – If required, the relevant individuals should be trained to the required
level of competence before the change takes place.
• Employee Motivation – Employees should report that they feel involved and included in the change process.
• Active Response to Feedback – There should be strategies in place to communicate the outcomes of the
consultation about the proposed change.
• Safety Information Communication System - Safety information (relating to both personal safety and major
accident avoidance) should be communicated at the start of the shift or whenever there is a handover of duties.
• Comprehension of Safety Information – Staff should have all the information necessary to conduct their shift
safely.
• Employee Awareness of Accountabilities - Personnel should be aware of, understand and adhere to
personal accountabilities.
• Safety Prioritised Behaviour- There should be no pressure to maintain performance standards, potentially at
the cost of safety.
• Performance vs. Safety Management Priority – There should be evidence that management stipulate clearly
and repeatedly to operational staff that safety is the first priority.
• Safety Accountability – Management should take responsibility for the consequences when they prioritise
• Incident Investigation System - Incident investigation procedures should include root cause analysis and
ensure that lessons are learnt. Improvement actions should be introduced throughout the organisation.
• Fault Allocation Process – Care should be taken not to apportion blame before the root cause analysis is
complete. The purpose of the process should be to learn from the incident, rather than apportion blame.
• Disciplinary Process – Clear procedures for deciding upon the relevant disciplinary actions should be in
place.
• Feedback Systems – There should be strategies in place for communicating the outcome of investigations,
e.g. via briefings, newsletters etc.
19
Figure 11: Safety Culture Indicators and Assessment Criteria
Leadership
There are explicit and continuous steps taken by Assessment Criteria
management to ensure that safety goals, targets and Management Visibility
issues are made clear to all personnel. The
prioritisation given to safety is balanced with, or is Performance vs. Safety Management Priority
greater than the prioritisation given to performance.
There are multiple channels for the discussion of Assessment Criteria
safety matters, concerns and goals between and
within levels of the organisation. The flow of Internal Safety Concern Reporting System
information should be in an upwards direction. Approachable Management
Feedback Systems
Personnel from all levels of the organisation are Assessment Criteria
involved in decision making, safety planning and
providing ideas for improvement. Employee
participation and feedback are actively sought. Employee Motivation
Employee Participation in the Change Processes
Learning Culture
Steps are taken to monitor known problems, identify Assessment Criteria
new ones, detect trends over time and develop
effective preventative measures. Efforts are made to Safety Culture/Climate Monitoring
ensure that lessons are learnt from incidents, including Safety Concern Investigation and Mitigation Procedure
the wider application to other situations. Intervention
measures are introduced for all situations. Safety Concerns Log

The organisation accepts that the ultimate Assessment Criteria
responsibility for incidents lies with the organisation,
and investigations take full account of multi-causality. Culture of Trust
The purpose of investigations is not to assign Employee Awareness of Accountabilities
retribution or blame, but to learn from incidents.

Figure 12: Relationship between Scenarios, Assessment Criteria and Indicators
Scenarios Assessment Criteria

A: Safety Management Management Visibility
B: Safety Concern Internal Safety Concern Reporting System

Culture of Trust
Safety Concern Investigation and Mitigation
Safety Concerns Log
C: Employee Involvement in Changes Employee Participation in Change Processes

Employee Training
Employee Motivation
D: Transfer of Information About Shift Duties Safety Information Communication System

E: Time-Critical or Degraded Situation Performance vs. Safety Management Priority

F: Incident Management Incident Investigation System

Feedback Systems
Safety Culture Leadership Learning Culture Attitude to

Indicators Two-Way Communication Employee Involvement Blame

4.6 Scenarios
During this section, each of the six scenarios will be discussed in more detail, and recommendations
given regarding appropriate events that can discussed during the interview.
The interviewee will be questioned and asked to think about events that they are familiar with when they
answer the questions. The discussion will then be based around the systems or processes that are in
place.
The scenario examples should:

• Provide the means for eliciting the required information regarding the assessment
criteria;
• Be a relatively significant event or occurrence,
• Be realistic and directly familiar to the interviewee.
Safety Management
Details
The Safety Management scenario considers the procedures and system in place for managing safety.
Specifically it explores senior and middle management’s commitment to safety, and the operational
employees’ understanding of safety and how it is managed.
This scenario assesses the following

Assessment Criteria:
Safety Culture/ Climate Monitoring
22
Safety Concern
Details
This scenario assesses the following assessment
The Safety Concern scenario considers what criteria:
happens when an employee has a concern about
safety. The aim is to reveal information about the Internal Safety Concern Reporting System
internal safety concern reporting methods, how they
are used, and what happens when a concern is
reported.
Culture of Trust
What are appropriate examples?
The interview should be based around an actual
safety concern that has been reported, or a
concern that the interviewee has had. Senior
Safety Concerns Log
management may feel more comfortable with
talking about the safety concern reporting system
in general, rather than a specific example.
Safety concern examples that could be used during the interviews fall into four categories. These are
listed in Table 3.
Table 3: Suitable Safety Issue concern examples that could be used during the interviews
Type of Concern Examples

A technical or maintenance issue • A relatively serious track or train defect
• Signal sighting issues
• Maintenance shortcomings
An issue with procedures, policies or rules • Rostering issues e.g. staff shortages
• Inadequate training
• Lack of availability of procedures or rule books
A concern which may implicate another • A colleague breaks a rule e.g. intoxication, not
member of staff i.e. ‘get someone into following procedures.
trouble’. • Concerns regarding a colleague’s ability to speak
or understand English.
A concern which is related to the behaviour • Trespass or vandalism
of members of the public • Physical or verbal assault, or threat of assault

Change Management This scenario assesses the following assessment
criteria:
Details
Employee Participation in the Change Process
The Change Management scenario considers how
changes are controlled and managed. The aim of
Employee Training About the Change
this set of questions is to reveal information about
how operational staff are consulted and involved in
the change process. It is also to ensure that a Employee Motivation
structured and planned process to manage change
exists. Active Response to Feedback

The interview should be based around an actual major change project.
Table 4: Suitable change project examples that can be used during the interviews
Type of Change Examples

Changes to new or used equipment • The introduction of new classes of traction, rolling stock
or vehicles, which introduce a new type of risk
• The introduction of a new radio system which results in
a change to working practices
Introduction of new operations • The introduction of passenger services by a duty holder
who previously only operated freight services, or vice
versa.
• The introduction of dangerous goods or container train
operations where they have previously not been
operated.
Organisational change. • Significant changes in resource levels of staff/
contractors carrying out safety critical work.
Introduction of new risks • Changing the scope of operations, which introduces a

type of risk which the duty holder does not currently
manage. For example running trains on overhead lines
or conductor rail where previously this was not the case.
The inspector should view relevant change management documentation before, or during the inspection.
Documents could include change reports, risk assessments, change management procedures, and any
documents which outline how employees were consulted and involved during the change process (e.g.
focus group agenda, briefing documents, human factors integration plan).

Details This scenario assesses the following

The Transfer of Information about Shift Duties assessment criteria:
scenario considers the procedures available for
communicating safety critical information to and Safety Information Communication System
between operational staff. The aim is to examine
the safety information communication system, and Employee Awareness of Accountabilities
to investigate the extent to which employees are
aware of relevant safety information and Comprehension of Safety Information
accountabilities.

The interview should be based around a process whereby information must be transferred between
employees of the same, or different levels of the organisation. The transfer of information should be
critical for successful operations. This could include:
• The start of a new shift;
• During a shift handover;
• At the beginning of a process (e.g. maintenance of a new stretch of track).
If, during the interview, the interviewee is not aware of an appropriate case study that can be used,
an hypothetical example can be used instead.

Details
The Time-Critical and Degraded Situation scenario This scenario assesses the following
considers how safety is managed during a difficult, or assessment criteria:
degraded situation. The aim of this scenario is to
reveal important information about the emphasis

senior and middle management place on safety
compared to performance, and whether this

commitment to safety is reflected in operational staff
behaviour during time-critical or degraded situations.

The interview should be based around a time-critical
or degraded event that the interviewee has
experienced. Figure three outlines examples of
events that can be used during interviews.
Figure 13: Suitable degraded situation examples that could be used during the interviews
Organisation Type
A Train or Freight An infrastructure A train maintenance

Operating Company maintenance company company
Suitable situations: Suitable situations: Suitable situations:

• Maintenance work is not
• Driver of train is late • Fault detected on a single
completed in the allocated
booking on shift unit of rolling stock. Is the
possession time.
• The service is running whole stock re-checked /
• The service is running removed from operation?
severely behind schedule
severely behind schedule
and a trespasser, or
and a trespasser, or debris,
debris, is found near the
is found near the track
track

Incident Management
Details
The Incident Management scenario considers the
chain of events following a major incident. The aim This scenario assesses the following
is to reveal information about how the company assessment criteria:
investigates the incident (in particular, how or if
blame is allocated), and what the company does to Incident Investigation System
ensure that lessons are learnt from the incident and
appropriate mitigation measures introduced. Feedback Systems
What are appropriate examples? Disciplinary Process

If possible the interview should be based around an
actual incident that has taken place. Suitable Fault Allocation Process
incidents that could be used during the interviews
are considered in Figure 14. These incidents types
are intended to be used only as a guide. During the
course of the inspection the inspector may come to
learn of a more appropriate incident.
Figure 14: Suitable incident case studies that can be used during the interviews
Organisation Type
A Train or Freight An infrastructure A train maintenance

Operating Company maintenance company company
Suitable Incidents: Suitable Incidents: Suitable Incidents:
• A SPAD • A SPAD • A SPAD

• A derailment • A derailment • Train split
• Buffer stop collision • Traction current failure
The inspector should also read relevant investigation documentation. This would include documents
such as the investigation report, details of the preventative measures taken, and updates to disciplinary
procedures. Some of these documents can be collected during the inspection itself. However it would
be advantageous to obtain some of the documents prior to the inspection to enable sufficient preparation
to be undertaken.

4.7 The Question Set
The Question Set is structured into six scenarios. Each scenario section begins by providing information
relating to the scenario, and how to introduce this to the interviewee. It also contains questions that
could be used as a guide for the general structure of the interview. This will help to ensure that the
relevant assessment criteria are being considered fully and effectively. A sample scenario section taken
from the Question Set is provided in Figures 15 and 16.
Figure 15: Sample scenario taken from the Inspection toolkit Question Set
This is the scenario title

Safety Concern
- What senior and middle management do when a safety concern is This section outlines the
reported to them. aim of the scenario
- What operational staff do when they have a safety concern.
Setting the Scene:

Think about what happens when someone has a Setting the scene: this
safety concern. suggests how the
inspector could introduce
the scenario to the
● What systems are there in place for staff to report safety concerns
interviewee
e.g.confidential systems, approachable management etc?
- Do staff know who to report safety concerns to?
- Who do staff actually report safety concerns to?
- Do staff find it easy to approach management about safety concerns?
These are examples of
● How effective are management in dealing with safety concerns? prompt questions that the
- Do management recognise the report as an issue that needs addressing inspector may use to
promptly? focus the interview.
- Do they deal effectively with organisational, as well as personal safety
concerns?
● Do management accept that it is their responsibility to deal with the safety

concern, once it has been reported?
● What do management do with the information obtained from the safety

concern reports?
- How often do the issues get resolved, always? occasionally? never?
- Do staff feel action is appropriate and timely?
● How competent/effective are management in dealing with the safety concerns

raised?
● Are staff provided with feedback about the outcome or progress of the reported
concern?
● Is the effectiveness of the reporting system ever reviewed?
● Are the issues tracked from the time that they are raised through to closure?
- How is this done?
- Is there a budget allocated for the management of safety concerns?

Assessment Criteria
The Question Set describes the assessment criteria which are applicable to the scenario.
These assessment criteria are related directly to the five safety culture indicators, which are
colour coded for easy reference. Evidence points that are indicative of unsatisfactory and
satisfactory practice are listed below each assessment criteria heading. A sample of the
assessment criteria taken from the Question Set is provided in Figure 16.
Figure 16: Sample Scenario taken from the Inspection toolkit Question Set (continues
from Figure 15).
Safety Concern This is the scenario title

Satisfactory:
9There are systems/procedures in place to report safety concerns.
9Clear and easy to follow procedures are in place for safety reporting.
9The system is accessible to all operational staff. The assessment criteria
9The reporting system is structured.
Unsatisfactory:
8There is no system in place for reporting safety concerns.
8The system is time consuming, or there is inadequate time for reporting.
8Operational staff are not aware of, or encouraged to use the system.
Satisfactory:
9There are opportunities for face-to-face discussion with management.
9Managers frequently ask if operational staff have any safety concerns.
9Operational staff report (when asked) that managers are approachable.
9Management take responsibility for dealing with safety concerns once they have
been identified.
Unsatisfactory: The satisfactory and

8Management fail to make decisions. unsatisfactory performance
8The same issues are raised at each meeting, but are not resolved. indicators
8Management have to be sought out, or are rarely available.
8Management take an 'its not my problem' or 'just live with it' attitude.
8Management resist taking responsibility for safety concerns when they are
faced with them.
8Management are seen to be concerned about safety issues, however actions are
just "shelved".
Culture of Trust
Satisfactory:
9Operational staff regularly report concerns when it is appropriate to do so.
9In general, reports are made concerning a range of issues.
9The refusal to work system is used and is respected by management.
9Management take active responsibility for dealing with safety concerns once they
have been highlighted.
Unsatisfactory:
8Operational staff concerns are not reported to management for reasons such as:
● Staff are concerned that the report would get someone else in trouble.
● Staff perceive that nothing would get done.
● Employees feel that they may be deemed responsible for causing the issue.

2 The Pocket Card
The Pocket Card (see Figure 17) provides an overview of the structure of the Safety Culture
Inspection methodology in a pocket sized format. It is designed to be used by Inspectors as a
memory prompt when the inspector chooses not to use the questions set.
The card is double sided. Side one of the card depicts the 22 assessment criteria organised
according to the five safety culture indicators.
Side two depicts the same assessment criteria organised according to the six scenarios.
Figure 17: The Pocket Card
Side One Side Two
Side A: Assessment Criteria organised according Side B: Assessment Criteria organised according
to Indicators to Scenarios
Leadership
Safety Management
Management Vi
Visibility Management Visibility
Performance vs. Safety Management Priority Employee Involvement in Safety Discussion
Safety Priori
Prioritised Behavi
Behaviour Safety Culture/Climate Monitoring
Two-Way Communication Safety Concern

Internal
Approachablle Management
Approachab
Culture of Trust
Acti
Active Response to Feedback Safety Concern Investigation and Mitigation Procedure
Safety Information Communication System Safety Concerns Log
Comprehensiion of Safety Informati

Comprehens Information Change Management
Feedback Systems Employee Participation in Change Processes
Employee Involvement Employee Training about the Change
Employee Motivation
Employee Training about the Change Transfer of Information About Shift Duties
Employee Motivation
Learning Culture Comprehension of Safety Information
Safety Culture/Climate Monitori

Monitoring Employee Awareness of Accountabilities
Safety Concern Investigation and Mitigation Procedure Time-Critical or Degraded Situation
Safety Concerns Log Safety Prioritised Behaviour

Culture of Trust Incident Management
Emp
Emplloyee Awareness of Accountabi
Accountabilities Incident Investigation System K Leadership
Fau
Faullt Allocation Process E Two-Way Communication
Disciplinary Process Disciplinary Process
Learning Culture
Safety Accountability Feedback Systems Attitude to Blame

3 The Overview Diagram
The overview diagram (see Figure 18) summarises the principles of best practice in relation to
each of the five indicators. This diagram provides more detailed information compared to the
pocket card, and provides the inspectors with an alternative option for use during inspections.
The diagram is presented on an A3 page and is colour coded to be consistent with the other
components of the toolkit. The diagram is structured as a matrix to demonstrate the relationship
between the following underlying features of the toolkit:
• The assessment criteria for each of the six scenarios.
• A brief description of the type of evidence that will be required to satisfy the assessment
criteria.

Figure 18: The Overview Diagram HMRI SAFETY CULTURE TOOLKIT OVERVIEW DIAGRAM
SCENARIOS ASSESSMENT Health and Safety Management Framework
Planning and Monitoring and
CRITERIA CRITERIA Control Effectiveness Information Flow Reviewing
Organisation
(Who is responsible?) (How is it done in (What happens to the (Are outcomes measured
(What systems are in information gained?)
practice?) and actions taken?)
place?)
Management Visibility There is evidence that All safety related systems /

procedures, policies and There is evidence that there There is evidence that Management make concerted procedures are monitored
A: Safety Management Safety Culture/Climate are defined management management display their efforts to provide opportunities and reviewed regularly.
schedules have been
Monitoring developed to deal with roles with clear commitment to safety to for frontline staff to comment on
responsibilities for safety. employees in a visible and or discuss safety matters. Safety climate surveys are
Employee Involvement in the management of completed by staff and the
safety. consistent manner.
Safety Discussions results are disseminated
throughout the company.
Internal Safety Concern

Reporting System There is evidence that the safety
Clear and accessible There are designated Staff receive feedback from There is a system in place to
people responsible for concern reporting system is
Approachable Management systems are in place to management about the monitor and review the success
effective.
B: Safety Concern enable staff to report safety dealing with safety issues. progress made on actions of the safety concern reporting
Culture of Trust concerns. All employees are aware of Safety issues are investigated, resulting from a concern system.
who these people are. and actions are taken by being reported.
Safety Concern Investigation management to mitigate any
and Mitigation Procedure risks.
Safety Concerns Log
Employee Participation in There is a structured and Key personnel within the There is evidence that Personnel are prepared / Management recognise the
Change Process planned process to manage change management team employees are informed and trained to deal with limitations of not involving
change. are responsible for ensuring consulted about the change in a operational changes staff in proposed changes.
Employee Training about the
C: Change Management that the end user is timely and comprehensive effectively. The change process is
Change consulted before changes manner. monitored and reviewed to
Employee Motivation are implemented. ensure that it remains
appropriate.
Active Response to
Feedback
There is evidence that systems There is evidence that there A range of safety issues are All employees are aware of Procedures are in place to
Safety Information or procedures exist for the are clear roles and communicated, including safety issues associated with monitor the success of the
Communication System communication of daily safety responsibilities and systems personal safety and major their current roles/tasks and are communication measures.
D: Transfer of Information Employee Awareness of information. in place to communicate accident avoidance, and how to aware of how important it is to
about Shift Duties Accountabilities safety information mitigate for these. communicate safety related
information.
Comprehension of Safety
Information
Safety is always prioritised Management are responsible Employees have the There is evidence that
Safety Prioritised Behaviour Management stipulate
above performance. for ensuring that the safety knowledge, skills and efforts are made by
clearly and repeatedly that
Performance vs. Safety priority is always adhered to. resources available to deal management to review and
E: Time-Critical and safety is the first priority
with the situation without monitor the emphasis
Degraded Situation Management Priority Staff at all levels understand using verbal and written
compromising safety. placed on safety.
their responsibilities for safety. communication methods.
Incident Investigation There is evidence of a Key management roles have All contributing factors are Frontline staff are provided with There is evidence that the
System thorough incident responsibility for investigating investigated with equal clear feedback from effectiveness of the
investigation process which the incidents promptly. consideration. management about the investigation process is
F: Incident Management Fault Allocation Process aims to reveal the root investigation and monitored and reviewed
The purpose of the investigation
Disciplinary Process cause of the incident. recommendations/actions regularly.
is to learn from the incident,
arising as a result of the
rather than apportion blame.
Feedback Systems investigation.
Key to 5 Safety Culture Indicators: Leadership Two-Way Communication Employee Involvement Learning Culture Blame Culture
Two-Way Communication 32
4.8 Interview Principles
Principle 1:
Focus on five main elements of safety culture
The scope of the Safety Culture inspection was to concentrate on the five safety culture indicators,
(see Figure 8) which are specified in Lord Cullen’s inquiry. A recording sheet is provided to note or
organise key issues against each of the indicators (see Figure 19).
Principle 2:
Challenge Responses
Challenge all responses. The underlying reason for a particular response should be identified. A key
question should be to ask why an individual responds in a certain way. The wide-ranging picture of
the organisation as a whole should be built up, and the evaluation based on a wide sample of
responses from many departments, individuals and locations. The inspector should identify and
recognise the occurrence of sub-cultures, which can be formed as a result of a local factor (e.g. the
personality of an individual manager), rather than larger scale organisational factors.
Principle 3:
Standardisation of the Toolkit
The question set offers a structured methodology that can be used during walkthroughs and
talkthroughs. It is based around six scenarios and 22 assessment criteria. This helps to ensure
that the assessment is standardised (a) between respondents, (b) between companies, and (c)
between inspectors.

Figure 19 Recording Sheet Date: Location:
Leadership
Feedback Systems
Employee Participation in the Change Process
Employee Motivation
Learning Culture
Safety culture/climate monitoring

Safety Concerns Log
Culture of Trust

34
32
5 Reporting
Key Topics:
¾ Critical evaluation
¾ Inspection reports

5.1 Evaluation
The toolkit is specifically interested in the safety-related behaviour of employees, i.e. how things are
done around here, as well as the quality of systems and procedures in place. The performance of the
organisation should be appraised critically against the satisfactory and unsatisfactory evidence points
associated with each assessment criteria (see Appendix A for a detail overview). Consideration should
be given to:
• The standard of other industry organisations,
• The associated risk consequence,
• The associated lost opportunities.
The inspector should reach a professional judgement about whether he or she is satisfied that the
organisation fulfils each assessment criteria within the safety culture inspection.
An inspector’s recording sheet is provided in Figure 19. This recording sheet can be used by the
inspector as a facility for taking notes during the discussions, or as a basis for organising assessment
information post-inspection.
The Inspector’s professional judgement should be based on information gathered during the inspection,
and previous visits to the organisation. Sources include:
• Employee responses from walkthroughs and talkthroughs,
• Analysis of documentation (e.g. procedures and job profiles),
• The inspector’s general knowledge of the organisation as it has developed over time.
5.2 Inspection Report
An inspection report should be produced that details the principal findings of the inspection in relation to
each of the five indicators. The report should highlight both the positive and negative evidence
identified during the inspection, and provide criteria for improvement.
A template structure for the report is provided in Figure 20, and an example answer provided in Figure
21.

Figure 20: Template Safety Culture Inspection Report
SAFETY CULTURE INSPECTION REPORT
Company:
Address:
Date of Visit(s):
Site Inspector:
Purpose of Visit
Background
Company Personnel Seen

Method
Findings of the Inspection
Safety Leadership
Conclusions
Summary of Recommendations
Figure 21: Example Safety Culture Inspection Report
SAFETY CULTURE INSPECTION REPORT
Company: Welsh County Trains
Address: 1 Station Road, Thomaston, Wales
Date of Visit(s): 21st and 22nd February 2005
Site Inspector: Irene Seymour
Purpose of Visit
The purpose of the inspection was to assess the safety culture of Welsh County Trains using the HMRI Safety Culture
Inspection Toolkit. Stemming from the Ladbroke Grove Inquiry Report Part 2 (2001), five indicators of safety culture
were focused on:
• Safety Leadership;
• Two-Way Communication;
• Employee Involvement;
• Existence of a Learning Culture;
• Attitude towards Blame.
Background
Welsh County Trains provides a freight rail service, and is based in North Wales. Every week, 1,000 rail freight
services are operated by Welsh County Trains across many parts of Wales and Western England, powered by nearly
80 locomotives.
Welsh County Trains have agreed to the inspection taking place, following conversations between Irene Seymour,
HMRI inspector, and Jason Steam, Head of Safety, Quality and the Environment at Welsh County Trains. This report
summarises the findings from the inspection.
Company Personnel Seen

Welsh County Trains Headquarters: Station Road
• Head of Safety, Quality and the Environment
• Incident Investigation Manager
• Safety and Risk Manager
Morgan Depot
• 3x electrical fitter
• 5x drivers
• Depot manager
Dinwiddy Street Depot

• 3x health and safety representative
• 4x team leader
• Depot manager
• 5x fleet engineer
Method
The visit was conducted over a two-day period at three different locations. During this time, interviews were
conducted with a sample of twenty-five employees drawn from senior and middle management, and frontline staff.
This number represents a relatively small sample of the total number of employees at Welsh County Trains.
Each participating member of Welsh County Trains staff was interviewed on an individual basis and each discussion
began by the interviewee being asked about his/her job role. Efforts were also made to verify verbal information by
requesting documentation, such as the safety case, incidents reports, change management documentation etc.
The question set comprised six sections, each containing a different scenario upon which the questions were based:
• Safety Management
• Safety Concern
• Change Management
• Transfer of Information about Shift Duties
• Time-Critical and Degraded Situation
• Incident Management
Each member of Welsh County Trains staff was asked questions from sections relevant to his/her role and the
responses were recorded. Evidence of documentation referred to during the discussions was requested, and provided.
Findings of the Inspection
Safety Leadership
The management of Welsh County Trains can be commended for their dedication to safety, and have already
implemented many successful initiatives to demonstrate this commitment:
• There is positive commitment from all management levels to conduct safety tours within Welsh County Trains.
All senior and middle management are required to conduct safety tours as part of their performance objectives,
which are stated in their roles and responsibilities statements. For example, the Chief Executive Officer of Welsh
County Trains is required to conduct 12 annual safety tours across the company. Management record any
observations and discussions in their personal “Safety Tour Log”.
• Welsh County Trains can be commended on the efforts taken to establish and broadcast with conviction the
message that the preservation of safety standards is always the priority over performance targets. Articles in the
weekly Safety Briefing Newsletter, the regular occurrence of safety days, and direct management presence in
frontline areas are strategies which contribute to the effective expression of this message.
• Frontline staff reported feeling prepared and confident about handling difficult, time pressured situations, and do
not report feeling pressured to ever compromise safety.
• There are many positive indicators for effective middle management leadership. Welsh County Trains managers
appear to have successfully instilled the message throughout the organisation that there is an open door policy
on safety. Frontline staff report that they would feel confident about approaching managers to discuss safety
issues and concerns.
Issue One:
Safety Priority in Relation to Shift Times- Drivers reported that they are often asked by management to work
over the recommended 12 hour shift duration. Although drivers have the right to refuse overtime, it is perceived
that management would not take too kindly to this. It could be suggested that indirect pressure is being placed
upon drivers to practice unsafe working. In addition, it was also reported that this pressure is usually exerted
from middle management rather than senior management. Management need to ensure that recommendations
with regards to working hours are being adhered to, and consequently safety is always being prioritised.
The steps taken by Welsh County Trains to promote two-way communication are discussed below:
• Frontline staff indicated that they have a positive attitude towards approaching some management. Middle
management such as Depot Managers are usually in frontline areas, and are often approached by staff. This
provides useful evidence of the management’s open-door policy, and a positive step towards two-way
communication.
• There is extensive awareness within the company that the safety magazine includes a suggestion box page
allowing staff to communicate safety related issues back to management.
• During a shift handover, it was reported by drivers that vital information is communicated verbally, whereas
depot staff communicate shift information using a logbook. It was observed at the depot that team leaders
record shift details on an electronic system, and an overlap in shift duties provides additional time for shift
information to be relayed verbally.
Issue Two:
Reluctance to Report Safety Concerns- It was reported that there is the perception by some staff that if they
report a concern it will not be dealt with. No feedback is provided to staff regarding any action that is taken;
therefore, there is reluctance to report concerns. It was also openly reported by some middle management
that they do not encourage staff to report minor incidents due to the amount of paper work that would need to
be conducted as a consequence. It is recommended that management should recognise the limitations of this
negative perception, and that they should provide widespread acknowledgement of the importance of reporting
safety concerns. They should also respond to action concerns in a timely manner.
Employee involvement in safety is a necessary part of ensuring that management receive all relevant safety
performance information and that user needs are taken into account during the development of new technology and
new systems. The Health and Safety Executive document HSG48 maintains that staff at different levels of the
organisation should be involved in identifying hazards, suggesting control measures and providing feedback. This
would lead to a perception of greater “ownership” and involvement.
• Generally, Welsh County Trains staff appear to be fully aware of their safety responsibilities and feel
empowered and positive towards their personal safety role. There is involvement of staff from all levels
of the organisation in safety briefings and safety days.
• There is active involvement of health and safety representatives as well as union representatives when
decisions are made that will affect operational staff. This is also verified in the safety case section
relating to change management.
• The inspection looked specifically at employee involvement in the implementation of change projects,
for instance the development of new technology or systems of working. During the change
management programme sampled, affected parties were notified of the changes and invited to
comment. Welsh County Trains uses a variety of channels to communicate this information, including
weekly notices, briefings and email.
Issue Five: Consultation with Employees at all Stages of the Change Programme - Whilst affected
parties were consulted regarding the proposed change, Welsh County Trains would also benefit from
the involvement of affected employees and subject matter experts at every step of the change
management programme, including design, development, evaluation and trials.
Issue Six: Safety Validation Process – Welsh County Trains should consider reassessing the process
of approving and validating alterations. Concerns are raised that the safety validation process is not
always complete prior to the change actually being implemented. It is recommended that Welsh
County Trains should ensure that the certificate of safety validation is complete prior to any change
taking place.
Welsh County Trains personnel highlighted that a variety of methods are used to learn lessons from others, or from
experiences internal to the organisation.
National Incident Reports are used to monitor incidents that may have implications for Welsh County Trains.
For example, if there is an incident / safety issue raised by another freight operator, then the organisation can
learn from this and respond promptly to investigate the issue internally.
Daily conference calls are held between depot managers to discuss any maintenance issues, safety issues etc.
This provides a useful mechanism to learn.
It was highlighted by management that feedback is provided to relevant personnel about the outcomes, and
recommendations of incident investigations. The extent to which this actually occurs at an operational level
could not be confirmed
An Aptitude Leadership System has recently been implemented to assist in the monitoring and scheduling of
competency assessments, for all grades and skill groups. This system is available company wide and can be
used to identify specific training requirements for all employees and to produce training reports.
Issue Six: Safety Culture/Climate Surveys- It was reported that safety culture/climate surveys have not been
conducted. It is obvious that there are a number of organisational changes that are taking place within the
different depots. It is recommended that management should look at the advantages of conducting regular
organisation-wide safety climate/culture surveys in order to gain a more comprehensive understanding of the
culture/climate at Welsh County Trains.
Issue Seven: Feedback about Safety Concerns/Incidents- Staff indicated that they do not receive feedback
about safety concerns that have been reported. It was reported that feedback about incident investigations is
only provided to those concerned in the incident, although on most occasions this only happens if the member of
staff asks to receive it. It was however reported by one individual that following more serious incidents
management have been known to take positive and timely action.
An observation highlighted by the Ladbroke Grove Inquiry is the prevalence of a blame culture in some areas of the rail
industry. A blame culture inhibits reporting, has a negative effect on staff motivation, prevents the thorough
examination of incidents and is thus detrimental to learning.
Welsh County Trains have taken many positive steps towards establishing a fair culture that is supportive and
understanding to staff. There are policies and procedures in place to ensure that during an investigation
process, the wellbeing of involved individuals is considered.
Frontline staff generally tended to report that the system of assigning blame was fair, suggesting that the belief
that justice will usually be dispensed is shared within the organisation.
Senior management stated that all accidents are reported formally. Forms are available on the company
intranet and are recorded in a company log. The line manager of the individual concerned is responsible for
investigating the cause of the accident.
Disciplinary procedures are clearly stated in the employee handbook.
Issue Nine: Employee Wellbeing During Incident Investigation – Whilst Welsh County Trains do generally
demonstrate considerable care and concern towards its employees, the organisation should however consider
reassessing the investigation process as this may make employees feel that they are perceived as guilty until
proven innocent. There is the possibility that this process will put the employee through psychological distress
and embarrassment, despite the fact that the cause of the incident could be a variety of factors.
Conclusions
Welsh County Trains can be commended for implementing several effective safety initiatives, which has resulted in
significant progress in the development of a positive safety culture.
There are several issues that remain a concern within Welsh Country Trains, which are summarised in the next section.
Summary of Recommendations
Based upon the outcome of the inspection, consideration should be given to continuing improvement of the following:
Issue One Safety Priority in Relation to Shift Times

Management should adhere to recommendations with regards to the drivers’ working hours, in order
that safety is prioritised.
Issue Two Reluctance to Report Safety Concerns

All management should support and disseminate widespread acknowledgement of the importance of
reporting safety concerns. They should also respond to action concerns in a timely manner.
Issue Three Consultation with Employees at all Stages of the Change Programme
Clear safety benefits will arise from including employees and subject matter experts in all stages of the
change management process.
Issue Four Safety Validation Process Completion

The organisation should ensure that the safety validation process is completed prior to the change
being implemented.
Issue Five Safety Culture/Climate Surveys

Regular organisation-wide safety climate/culture surveys will provide opportunities to gain a more
comprehensive understanding of the culture/climate.
Issue Six Feedback about Safety Concerns/Incidents

Good practice guidance highlights that strategies should be in place for communicating the outcomes
of a safety concern/incident. This will allow for greater learning to occur within the organisation.
Issue Seven Employee Wellbeing during Incident Investigation

The incident investigation process should be assessed to ensure that it is impartial and without
prejudices.
6 Monitoring and
Reviewing
Key Topics:
¾ Safety culture development plan,
¾ Human factors expertise team.

6.1 Overview
Following the production of the inspection report, the rail company, assisted by the inspector, should create
a safety culture development plan outlining a strategy for the improvement of safety culture. The legal
requirements for these companies in relation to health and safety should also be cross-referenced to
produce this plan, these can be found in section 2.3.
The development plan should provide a clear direction forward, as agreed by both the inspector and the
organisation. The safety culture development plan should include:
• Clear, measurable proposals for achieving safety culture objectives,
• Details of timescales, resources and allocation or responsibility for when improvements
can be achieved;
• Details of how the plan will be implemented.
The production of the safety culture development plan, and the subsequent progress against the objectives
in the plan, should be monitored by the inspector during liaison meetings.
If the inspector is content with the response then the need for monitoring and reviewing is reduced.
However if there are serious shortcomings the inspector should consider appropriate actions, as guided by
the Enforcement Management Model. The inspector should also contact the Human Factors National
Expertise Team to discuss the appropriate actions.

7 Conclusion
This document is intended to be used by HMRI inspectors for the

undertaking of safety culture inspections in UK Rail Industry organisations.
It outlines the procedure and methodology for conducting a successful
and objective assessment, covering planning, assessing, reporting and
monitoring stages.
The Inspectors’ Guide should be used in conjunction with the following

documents:
• Safety Culture Inspection Question Set,
• Safety Culture Inspection pocket card,
• Safety Culture Inspection overview diagram.

Appendix A
Detailed Evidence Points
Appendix A provides detailed information concerning the positive and negative

evidence points, based upon those provided in the toolkit.
This information should be used by the inspector to make a professional judgement

about the performance of the organisation.

Safety Management Appendix A: Detailed Evidence Points
Key Issue “The more management focus on the delivery of safety as an integral part of the business, the more likely
they are to succeed…Culture is a reflection of the overall attitude of every component of management
within a company.” The Ladbroke Rail Inquiry, Part 2 Report, pp.60-61.
Evidence Points 9 = Satisfactory 8 = Unsatisfactory Main Reference Source: Details
(1) Management Visibility
HSC. 2001. The Ladbroke Grove Rail There should be systems in place for managers to demonstrate their commitment to safety, and for employee
9 There are systems in place to manage safety.
responses and behaviour to be monitored and reviewed. “Companies in the rail industry should be expected to
Inquiry. Part 2 Report. The Rt Hon
9 Regular safety tours of operational areas are conducted. Lord Cullen PC. HSE Books. demonstrate that they have, and implement, a system to ensure that senior management spend an adequate
time devoted to safety issues with front line workers” (Ladbroke Grove Rail Inquiry Part 2, pp. 64).
8 The safety management process is not formalised and entered into the Safety tours are a powerful means for management to ‘walk the talk’. The approach should be informal where
managers’ schedules. employees feel free to contribute, rather than being a ‘state visit’. At least one hour per week should be formally
scheduled into the diaries of senior executives for this walkabout, whilst middle ranking managers should
schedule one hour per day, and first line managers, 30% of their time.
9 Safety management systems such as safety tours are used to identify Good practice guidance from a range of There should be evidence that observations are systematically recorded and stored.
risks and mitigate them. literature.
Outputs should be systematically communicated to relevant parties.
9 There is clear evidence that action lists are developed, signed and tracked. Arthur D Little, Managing Safety
Through Culture, Learning Package. Clear efforts should be made to action any issues identified, and keep clear records of the status of the
8 Safety issues are not sought out actively by management. progress. The team should have clear timescales for delivery.
8 Safety issues identified by management are not dealt with, but are just Railway Safety (2001) Safety Tours, A Responsibilities for executing actions should be allocated and communicated to particular personnel.
"filed“. Good Practice Guide.
9 Management give high visibility to improvement programmes. HSC. 2001. The Ladbroke Grove Rail Safety commitment needs to come from the top, needs to be continually refreshed from the top, and needs to be
Inquiry. Part 2 Report. The Rt Hon highly visible. Regular walkabout visits of operational areas are a powerful tool for publicising new safety
Lord Cullen PC. HSE Books. initiatives, and for demonstrating that managers and directors take improvement actions seriously.
8 Safety management systems serve as a monitoring, auditing and Railway Safety (2001) Safety Tours, A Whilst safety management systems have an important role in monitoring safety standards, they also provide an
checking function only. Good Practice Guide. opportunity for the two-way discussion of safety with staff members.
(2) Safety Culture / Climate Monitoring

8
9 There are opportunities for operational staff and management to Railtrack. 2000/01. Railway Group
The organisation should demonstrate that there is a system in place for systematically measuring employee
communicate with each other. attitudes and behaviours surrounding safety. Specifically, management should consider the advantages
Safety Plan. Objective 5d
associated with conducting an organisation-wide safety climate survey at periodic intervals (every 18 months – 2
9 The survey is completed by a representative proportion of the company. years) in order to gain a more comprehensive understanding of the culture/climate.
HSE, Railway Safety Case Assessment “During 2000/01, Railway Group members will undertake company-wide safety culture surveys followed by the
9 There is a dwell time between surveys of 18 months to 2 years.
introduction of appropriate improvement initiatives” (Objective 5d, Railway Group Safety Plan, 2000/01).
Criteria (Section 5).
8 No, or limited effort, is made to assess safety perceptions of employees
The HSE Safety Case Assessment Criteria promotes the use of behavioural and staff attitude surveys as part of
within the company.
the systematic examination of safety culture.
9 Recipients of the safety culture/climate survey know why the survey is Good practice guidance from a range of Communicating the purpose of the safety culture/climate survey facilitates communication between different
being done and how the results will be used literature. organisational levels, and helps staff to understand why the survey is being conducted. This will also increase
the profile of safety and its importance.
Actions are implemented as soon as possible after completion of the Good practice guidance from a range of
9 survey, and are fed back to the surveyed group as rapidly as possible. literature. Providing feedback about activities that staff are involved in is a good precursor to a positive culture. This
Issues or areas of weakness are discussed with the respondents to feedback should be timely and comprehensive in order to achieve a positive culture. This aids learning and
9 encourages staff to take responsibility for ensuring that any risks are reduced.
clarify details. HSE, Railway Safety Case Assessment
8 Results are not fed back to the surveyed group in an appropriate manner. Criteria (Section 5). Feedback can be verbal or written, and include briefing meetings, written summaries, or newsletters.
8 Management’s vision of safety is not shared by all staff, and vice versa
9 The survey results are produced in an action plan to address the most Good practice guidance from a range of This action plans needs to be taken seriously and adhered to.
serious weaknesses literature.
Monitoring is only effective if the results are used to initiate remedial action, including where appropriate
8 No actions or priorities result from the survey organisational or policy changes. Arrangements should be in place covering how and where records are
kept, how data will be analysed, how data is referred to relevant managers, and how recommendations
and actions are tracked (HSE Safety Case Assessment Criteria, Section 5). 49
Appendix A: Detailed Evidence Points

Safety Management
(Continued…)
Evidence Points 9 = Satisfactory 8 = Unsatisfactory Main Reference Source: Details
(3) Employee Involvement in Safety Discussions
Employees should be involved in the discussion of health and safety. This will allow employers to take account
HSE, (1999). The Human Factors
9 Employees are invited to comment on decisions about their job roles
Guidance Note for COMAH Safety
of employee opinions before making any decisions. There should be evidence that responses are used to
that may affect their safety or the safety of others. identify and measure safety risks, and to plan health and safety training.
Report Assessors.
9 Safety management methods serve to provide an opportunity to all The organisation should demonstrate that safety discussions between management and employees occur in a
HSCER (1996) A guide to the Health and systematic manner, either through safety representatives, or with employees directly.
staff for open discussion of safety, to identify risks and mitigate
Safety (Consultation with Employees)
against these risks. The organisation should ensure that the content of the consultation is not to be used in disciplinary processes.
Regulations.
8 Employees are not invited to comment on safety. Elected representatives responsible for safety discussions should receive adequate training, time and facilities
to carry out these roles.
8 Management use safety tours as an opportunity to talk at operational Good practice guidance from a number
Whilst safety management systems have an important role in monitoring safety standards, they also provide an
staff, instead of using this as an opportunity to identify employees’ of rail organisations’ safety cases.
opportunity for the two-way discussion of safety with staff members. The manager should ask a lot of questions,
opinions and safety concerns. Arthur D Little, Managing Safety and the staff should be encouraged to comment on safety concerns.
Through Culture, Learning Package.
The approach should be informal, rather than being a ‘state visit’.
Railway Safety (2001) Safety Tours, a Observed persons should not see the manager taking notes
good practice guide.
50
Safety Concern Appendix A: Detailed Evidence Points

Key Issue “….the key characteristics of a healthy culture is a reporting culture”
Ladbroke Grove Inquiry Part 2 page 71
Evidence Points 9 = Satisfactory 8 = Unsatisfactory Main Reference Source Details
(1) Internal Safety Concern Reporting System
9 There are systems/procedures in place to report safety concerns. Reason, (1997) . Managing the Risks of “A confidential reporting system such as CIRAS could be used to tap into the informal structure of the
Organisational Accidents. Ashgate. organisation, and could thus be used to gauge what is actually happening and why” There is also the option for
9 The reporting system is structured.
reports to be treated confidentiality internally. However one viewpoint is that:“…if there was an appropriate and
HSC. 2001. The Ladbroke Grove Rail
8 There is no system in place for reporting safety concerns. Inquiry. Part 2 Report. The Rt Hon Lord just culture within an organisation rather than one of blame, then there would be no need for a confidential
Cullen PC. HSE Books. reporting system”. Ladbroke Grove Inquiry, pp. 68.
9 Clear and easy to follow procedures are in place for safety reporting. Clarke, S. 1998. Safety Culture on the UK
The system is time consuming, or there is inadequate time for Onerous and time-consuming reporting procedures have been found to affect the level of incident reporting.
8 Railway Network. Work and Stress 12 (3) p 7.
Employees should be encouraged to use the reporting system to ‘challenge’ safety.
reporting.
9 The system is accessible to all operational staff. Clarke, S. 1998. Safety Culture on the UK
Railway Network. Work and Stress 12 (3) p 7.
8 Operational staff are not aware of, or encouraged to use the
system. Provision is made for all staff to make reports with ease, for instance those without computer access should still
be able to make a report. Staff are aware of and understand the reporting procedures, which are jargon free.
(2) Approachable Management

9 There are opportunities for face-to-face discussion with HSE (1999). Reducing Error and Influencing The organisation should have an informal ‘open door policy’, whereby frequent opportunities are provided for
management. Behaviour, HS(G)48. employees to speak to management about safety concerns (e.g. morning briefings, management safety tours
8 Management have to be sought out or are rarely available and walkabouts). There must be some cue to the behaviour of reporting. Managers should frequently invite
9 Operational staff report (when asked) that management are employees to give comments or report concerns. The employees should be aware of where they can find a
approachable. more senior member of staff.
9 Managers frequently ask if operational staff have any safety
concerns.
The organisation should ensure that there is a positive reaction to safety concern reports. Employees making
9 Management take responsibility for dealing with safety concerns reports should be thanked, and recognition given.
The Newsletters of Event Investigation
once they have been identified.
Organizational Learning Developments, The manager to whom the concern was reported should take responsibility for investigating the safety concern,
8 Management take an ‘its not my problem’ or ‘live with it’ attitude Volume 3, Number 8, September 2000. The or, if this is not possible, pass this responsibility to a more appropriate member of staff.
8 Management are resistant to taking responsibility for safety Firebird Forum.
The employee who made the report should be kept informed of any efforts made to investigate and mitigate the
concerns that they are faced with. concern.
8 Management are seen to be concerned about safety issues,
The employee should be informed of the outcome of the report. If the concern is not considered appropriate to
however actions are just “shelved”.
investigate further, this should be explained to the employee.
8 Management fail to make decisions
(3) Culture of Trust
9 Operational staff regularly report concerns, when it is appropriate Good practice guidance from a range of
to do so. literature
Management should communicate clearly that there are no adverse effects to reporting a concern or incident.
9 In general, reports are made concerning a range of issues.
Management communicate clearly to all staff that it is fundamentally important to report concerns.
8 Operational staff concerns are not reported to management for
reasons such as: The organization should monitor safety reporting figures to measure the extent of the ‘reporting’ culture.
• Staff are concerned that the report would get someone else into
trouble. Issues are dealt with promptly so that staff can see the improvements that have resulted from their commitment.
• Staff perceive that nothing would get done. A range of issues (including incidents, near misses and safety risks) should be reported and not just ‘hot topics’.
• Employees feel that they may be deemed responsible for
causing the issue.
9 Management take active responsibility to deal with safety HSC. 2001. The Ladbroke Grove Rail Good practice guidance recommends that management have a strategic objective to ensure that they take
concerns once they have been highlighted Inquiry. Part 2 Report. The Rt Hon active responsibility for actioning safety concerns that have been reported. There should be evidence for a
Lord Cullen PC. HSE Books. ‘just’ reporting culture that is understood by the workforce.
The refusal to work system is used and respected by management
9 RSSB Guidance The organisation should demonstrate that all safety-critical staff have the right to refuse to work if they
think the work conditions are not safe; doing this will not affect their career progression. 51
Safety Concern Appendix A: Detailed Evidence Points
(Continued…)
(4) Safety Concern Investigation and Mitigation Procedure

9 A prompt and thorough assessment of the risk and its HSC: Safety Case Assessment Criteria (Section 4) The organisation should provide evidence that appropriate risk assessments are conducted following the
consequences is conducted. reporting of a safety concern. Concerns should be prioritised and a proactive and systematic approach taken
Good practice guidance from a range of literature for their investigation.
8 The concern is not fully investigated, corrected or
prevented. The organisation should follow the approach to risk assessment as documented in the Railways (Safety Case)
Regulations 2000, including 2003 amendments.
9 A corrective action plan is developed to mitigate the HSC: Safety Case Assessment Criteria (Section 4) There is clear evidence that action plans are developed or that visible action is being undertaken to resolve
concern. the concern in both a timely and effective manner. The course of action should be communicated back to
Good practice guidance from a range of literature the person who reported the concern.
8 Timely and effective mitigation measures are not applied
to resolve the concern. The organisation should follow the approach to risk assessment as documented in the Railways (Safety
Case) Regulations 2000, including 2003 amendments.
9 Operational staff receive feedback about the outcome and International Nuclear Safety Advisory Group
progress of the report. (INSAG). 2002, Key Practical Issues in There is positive evidence to suggest that feedback is given both to those who report the issue and to others
Strengthening Safety Culture. INSAG-15, Vienna. who may benefit from the learning opportunity.
8 Progress is not monitored or tracked. Good practice guidance from a range of literature The organisation should be able to demonstrate that they have a system or procedure for monitoring the
progress made to resolve the safety concern. A tracking system should ensure that all progress is
traceable.
(5) Safety Concerns Log
9 All concerns are logged for reference by all staff. Good practice guidance from a range of literature
All concerns should be logged, and clear efforts made to analyse any trends and mitigate any issues.
8 The is no log for reported concerns.
The organisation should provide evidence that the re-occurrence of similar issues can be detected and
analysed.
9 Repeat or similar concerns are gauged and analysed.
Employees within the company should be aware of the system and be able to access it if required. If this is not
9 The information is available to all. appropriate, employees should receive regular updates (e.g. CIRAS reports). Making this information available
company-wide enhances employee understanding of where risks lie and how to prevent the concerns from
8 The log is not monitored or updated on a regular basis.
occurring again. It also heightens the profile of the system.
52
Change Management Appendix A: Detailed Evidence Points

Key Issue “There can be no doubt that, if the rail industry is to reach the level of performance
required, highly motivated staff at all levels will be required…Good communications….are
not about telling people what they should do; rather, they are concerned with involvement
and participation.” Ladbroke Grove Inquiry Part 2, pp. 66 and 69

(1) Employee Participation in Change Processes
9 Key personnel within the change management team ensure that the end HSE, 2000. Improving Maintenance: a There should be evidence that a ‘user acceptance manager’, or a similar role, is appointed.
user is consulted. guide to reducing error. HFGR.
The effects of the proposed changes on the stress levels and morale of staff should be considered. Positive
8 Management fail to recognise the limitations of not involving affected indicators include the provision of clear, up-to-date information about the change, minimising the period of
staff in the change process in an effective and timely manner. uncertainty, involving individuals in key decisions, providing information about the change.
HSCER (1996) A guide to the Health Good practice suggests that opportunities should be provided to allow consultation with the employees who will
9 Employees are actively encouraged to participate in all stages of the be affected by the changes, prior to implementation.
change process. and Safety (Consultation with
Employees) Regulations. Management should ensure that the safety validation process is complete prior to any change being
8 End-users contribute only at the end of the design process
implemented.
9 Discussion groups and briefings etc. are used to inform affected HSC (2002) Consulting Employees on Consultation should cover: any change which may substantially affect health and safety at work; the health and
individuals Health and Safety: A guide to the law. safety consequences of introducing new technology; the safety implications of new procedures, equipment or
ways of working.
8 Affected parties are not kept sufficiently informed.
8 Affected parties are not informed about the change until it has been The organisation should be able to demonstrate how changes are communicated to employees. Examples
implemented. include team briefings, safety circles, liaison committees, and written publicity (e.g. newsletters).
9 End-users are consulted and have the opportunity to contribute to Good practice guidance from a range of The organisation should demonstrate that employees are actively involved in decisions, not just passive
decisions through activities such as workshops and user trials. literature. consultation.
Methods could include workshops, focus groups, the allocation of positions of responsibility for the change,
8 There is a lack of evidence that the information gained from workshops,
suggestion boxes, or use of human factors initiatives (e.g. human-centred change).
discussion forums etc. is used
9 There is a structured and planned process to manage change. HSC: Safety Case Assessment Criteria. There should be an effective and reliable system for managing change, and for reducing health and safety
risks to as low as reasonable practical. The organisation should be able to demonstrate how health and safety
9 The procedures to manage change are usable, and are easily applied. measures are identified, and how changes are validated, both before and after the change process.
(2) Employee Training about the Change

9 A training needs analysis is conducted to access the levels of training Good practice guidance from a range of
The organisation should demonstrate how they assess the skills and abilities of the current workforce against
required to prepare for the change. post-change skill requirements. Evidence of a documented and structured training planning process should be
literature.
provided.
8 Employees do not receive sufficient training to maintain operational
safety during post-change operations A key member(s) of the human resources or change management teams should be responsible for the training
needs analysis and training planning.
8 No training is provided to employees regarding the change.
Arthur D Little, Managing Safety
9 If required, the relevant individuals are trained to the required level of Through Culture, Learning Package.
Best practice is for the safety message to be integrated into all aspects of the training rather than keeping
competencies before the change takes effect. safety as an entirely separate subject. Good training increases employees’ attitudes to ‘new initiatives’.
8 Training is not put into place in a timely manner, e.g. training is provided Training should be tailored to the needs of the audience (e.g. matching language style to the preferences of the
several days/weeks/months after the change has been implemented. trainees).
9 Employees understand the training. Good practice guidance from a range of Training should be tailored to the needs of the audience to ensure maximum understanding and uptake (e.g.
literature. matching language style to the preferences of the trainees).
9 Competency is ensured and maintained.

9 Employees are given the opportunity to comment on, or contribute to HSC (2002) Consulting Employees on “Consultation with employees must be carried out on matters to do with their health and safety at work,
the training process. Health and Safety: A guide to the law. including the planning of health and safety training” (HSC 2000). Good consultation methods could be the
provision of feedback forms and the open invitation to comment.
8 There are no records of who has/has not been trained, or when training Good practice guidance from a range of The organisation should demonstrate that written records of training history are kept in an appropriate manner
has taken place. literature. and location. Good practice would be to allow the employee access to these records to increase individual
involvement and responsibility for their own skill development.
53
Change Management Appendix A: Detailed Evidence Points
(Continued…)
Details
Evidence Points 9 = Satisfactory 8 = Unsatisfactory Main Reference Source
(3) Employee Motivation
9 Employees report feeling involved and included in the change process. Good practice guidance from a range of
literature. It is common for people to have negative perceptions about a change that may affect their working
9 Employees hold positive attitudes towards the planned changes. Office of Planning and Analysis (2002) arrangements, their status or their social security, or they may be afraid of a higher workload. Change
Management Benchmark Study. managers need to keep in mind these obstacles and maintain morale through the active involvement and
8 Employees report negative attitudes towards the change process. (http://www.sc.doe.gov/sc- participation of staff. Employees who feel that they are involved and have power over the change will respond
5/whatwedo/com-benchmark.html) more positively about the change.
Good practice guidance from a range of
9 Employees have trust in management to implement an efficient and literature. A good indicator of a positive safety culture is that employees hold positive attitudes and trust for the
successful change. management to direct the change in a way that is of benefit to the organisation as a whole, as well as the
Office of Planning and Analysis (2002)
8 Employees are mistrustful of management’s ability to implement the
Management Benchmark Study.
employees within it.
change safely.
(http://www.sc.doe.gov/sc- The organisation should demonstrate that they have communicated the benefits of the change to employees.
5/whatwedo/com-benchmark.html)
HSG217 ‘Involving Employees in
9 Employees have the opportunity to report their thoughts on the change Health and Safety: Forming
programme. Evidence should be provided that employees are given clear opportunities, and are given encouragement to
partnerships in the chemical industry’
8 Employees do not have the opportunity to raise concerns about the report their concerns, comments or thoughts in relation to the change process.
change programme. Good practice guidance from a range of
literature.
8 Changes in roles and responsibilities are not understood.
(4) Active Response to Feedback
Evidence Points Main Reference Source
9 There are strategies in place for communicating the outcomes of the Good practice guidance from a range of The organisation should be able to demonstrate that there are mechanisms in place for providing feedback
consultation process. literature. following consultation exercises. Methods could include follow-up meetings, e-mail updates.
9 Every attempt is made to incorporate employees’ suggestions and HSE (2003) Organisational Change and Evidence should be available that the consultation exercises are used to feed directly in to the design or
comments into the design process. Major Accident Hazards. Information change process. Where contributions are taken-up, direct feedback should be passed to the person
Sheet. responsible. An explanation should be given in cases where suggestions are not practical to be used.
9 It is ensured that employees receive rapid feedback following comments Good practice guidance from a range of
and suggestions they have made. literature.
All consultation exercises should be followed by active feedback to employees about the outcome of any
8 Employees report not receiving adequate feedback following
suggestions made, or concerns identified. Employees should be able to track the handling of any
consultation.
contributions that they have made.
8 No feedback is provided to operational staff about the suggestions that
they have made.
54
Transfer of Information about Shift Duties Appendix A: Detailed Evidence Points
Key Issue “….the requirement for clear safety rules and responsibilities is plain.”
Ladbroke Grove Inquiry Part 2 pp.67

(1) Safety Information Communication System
International Atomic Energy Agency
9 Safety related information is communicated at the start of a shift or (IAEA). 2002. Self-Assessment of
whenever there is a handover of duties. There is a formalised communication process to prevent distorted or ambiguous information being
Safety Culture in Nuclear Installations.
9 Safety information is communicated face-to-face by management to all communicated. Good practice guidance recommends that a variety of methods could be used to disseminate
levels and/or via notices, log books etc. HSE. 1997. Successful Health and this information daily, for example, posters, notices, face-to-face communication by management, and daily team
Safety Management. HSG 65. HSE meetings.
8 The communication system fails to prepare the individual to operate Books. ISBN 0 7176 1276 7.
their shift adequately and safely.
9 Managers are on hand to deal with safety related concerns or issues. HSC. 1993. ACSNI Study Group on
Human Factors. Third Report: Management should be easily visible or reachable by all staff to deal with safety concerns or issues at the start
8 Management have to be actively sought out, and/or staff are reluctant Organising for Safety. of the shift.
to approach them.
9 A range of safety issues are covered, including both personal safety and Good practice guidance from a range
major accident avoidance, and how to mitigate against these. of literature
Good practice guidance suggests that all areas in relation to safety (not just limited to ‘hot topics’ e.g. SPAD
8 Not all safety issues are covered (e.g. limited to one or two ‘hot topics’, management) are communicated to staff in a time-effective manner.
and neglecting other areas).
Good practice guidance from a range Good practice guidance recommends that an organisation should not only be responsible for identifying any
8 Risks are stated, however there is failure to communicate how to
of literature risks that are prevalent, but it should also actively provide workable solutions to prevent or mitigate further risks
mitigate against these.
from occurring.
9 The communication system is reviewed and monitored for its success. Good practice guidance from a range To ensure that the communication system is effective, it is recommended that it be reviewed in a timely manner.
of literature Any discrepancies identified should be mitigated to ensure the system is fully functioning.
8 The adequacy of the communication system is reviewed infrequently.
(2) Comprehension of Safety Information
9 Staff are proactive in their approach to safety information. Good practice guidance from a range of
A good indicator of a positive safety culture is that employees are enthusiastic and positive about their
literature
responsibilities for maintaining good safety knowledge.
9 Staff have all the necessary information to conduct their shift safely. Good practice guidance from a range of
Staff should be able to give an accurate overview of the safety issues affecting them, including temporary, long
literature
8 Staff are unable to give an overview of key safety information that term, and newly-arising issues. The staff should report feeling confident about their level of knowledge and have
applies to them. a good sense of preparedness for the shift ahead.
8 Approaches used to disseminate information are limited. Good practice guidance from a range of The organisation should demonstrate that effective systems for the dissemination of safety information are in
literature place, and that employees understand and can act on information that is provided at the right place and at the
8 The information communicated is ambiguous, or difficult to comprehend. right time.
(3) Employee Awareness of Accountabilities
9 All staff are aware of their safety responsibilities HSC Safety Case Assessment
Criteria. (Criteria 5.7)
8 Management and all operational staff fail to take responsibility for Staff should be able to give an accurate overview of their safety responsibilities, including temporary, long term,
communicating accountabilities and newly-arising accountabilities. There should be evidence for how health and safety responsibilities are
Arthur D Little, Managing Safety
allocated and communicated, which might be visible job profiles, performance reviews, or start of shift briefings.
8 Safety responsibilities are unclear and changeable Through Culture, Learning Package.
8 Temporary changes are not always considered
9 Regular checks are carried out to ensure that all staff are aware of their Good practice guidance from a range of
responsibilities (for instance via spot checks or briefing attendance literature The organisation should have a system in place to allow for the monitoring and review of staff.
signature records)
55
Time-Critical and Degraded Situation Appendix A: Detailed Evidence Points
Key Issue “…the noise around performance must be tempered to ensure it does not swamp the noise
around safety.” Ladbroke Grove Inquiry Part 2 pp.65
(1) Safety Prioritised Behaviour
9 Employees have the knowledge, skills and resources available to deal HSC. 2001. The Ladbroke Grove Rail
Inquiry. Part 2 Report. The Rt Hon In the words of Lord Cullen: “the noise around performance must be tempered to ensure it does not
with the situation, without compromising safety.
Lord Cullen PC. HSE Books. swamp the noise around safety” (HSC, 2001a, page 65).
9 Safety is put first throughout. The company should ensure that sufficient budget is allocated to safety, and that this is not outdone
Good practice guidance from a range of by the emphasis on performance.
9 Employees report that there is no pressure from management or peers literature.
In practice, safety should be put first during day-to-day operations.
to maintain performance standards at the cost of safety.
Employees should not feel pressured to compromise safety in order to meet performance targets.
8 Safety has been compromised at the expense of performance.
Employees need to be given the resources (in terms of skills and knowledge) to deal with a wide
8 Employees report a pressure to maintain performance standards, range of situations without compromising safety.
potentially at the cost of safety.
(2) Performance vs. Safety Management Priority

9 Management stipulate clearly and repeatedly to operational staff that HSC. 2001. The Ladbroke Grove Rail
Organisations in the Rail Industry should be expected to demonstrate that they have in place, and implement, a
safety is the first priority, using methods such as: Inquiry. Part 2 Report. The Rt Hon
system to ensure that senior management visibly and repeatedly demonstrate their commitment to safety.
Lord Cullen PC. HSE Books.
• Verbal communication (safety tours, briefings, safety days). Increasing management presence in frontline locations through scheduled management safety tours are a
HSE (1999). Reducing Error and powerful means for management presence and provide the opportunity to ‘walk the talk’.
• Written communication (notices, within job profiles, safety
publications and newsletters. Influencing Behaviour, HS(G)48.
9 Management demonstrate/promote the commitment to safety to Good practice guidance from a range of Leadership is about causing people to share visions and share passions to achieve things.
customers and clients. literature.
8 Evidence that safety could be over shadowed by performance e.g. hard It is recommended that the safety commitment is strongly and repeatedly mentioned in company bulletins and
hitting performance campaign. communications. Specifically this commitment must be visible and credible to every individual at every level of
8 Commitment to achieving performance targets is greater than that the organisation.
demonstrated for safety.
8 The emphasis placed upon performance at the expense of safety is not
mentioned, and there is no “buy in” to this message. All staff should believe that all their managers place safety issues at a top priority.
(3) Safety Accountability
9 Everyone is clearly informed and made aware of their roles and Paul, M. 1997, Moving from Blame to The organisation should demonstrate that they have in place clear rules, responsibilities and
responsibilities in a time-critical and degraded situation. Accountability. The Systems Thinker accountabilities for safety (including clear contractual responsibilities and ownership of rules), which are
Newsletter, Pegasus Communications. understood by employees.
8 Clear roles and responsibilities are not communicated adequately or
understood by all staff in a time-critical and degraded situation. Whittingham, R.B. 2004. The Blame Accountability refers to assigning responsibilities for a situation in advance and requires clear
Machine. Why Human Error Causes communication to discuss common difficulties. The process of making individuals accountable recognises
Accidents. Elsevier that everyone makes mistakes and views them as opportunities for learning and growing.
9 Management take responsibility for the consequences when they Good practice guidance from a range of
The organisation should ensure that the system, organisation or management process is recognised as often
prioritise performance over safety. literature.
being a root cause of errors or incidents, rather than only blaming the individual involved in the situation.
8 Management do not take responsibility for consequences when they
prioritise performance over safety.
56
Incident Management
Key Issue “…. Continuously learning the lessons of accidents and incidents in order to prevent them from re- Appendix A: Detailed Evidence Points
occuring, and having clear and consistent processes to enable that to happen”.
Ladbroke Grove Inquiry Part 2
(1) Incident Investigation System
9 A thorough root cause analysis investigates all possible underlying The incident investigation reports show evidence that all issues, including human factors, are covered. It
causes to events leading to the incident. HSE (2004) Leadership for the major ensures that immediate, as well as underlying management-related causes are identified.
hazard Industries. ISBN 0 7176 2905 9
8 The investigation focuses on local, or obvious, faults and neglects other The company can acknowledge that people make mistakes, but incident investigation reports that identify
‘hidden’ factors e.g. industry or company wide processes. 'human error' as the sole cause of an accident should not be accepted.
9 A key individual (or group of individuals) is designated to manage and Good practice guidance from a range of Management and supervisors are provided with incident investigation training to enable them to conduct
supervise the process. literature. thorough root cause analyses to investigate all the possible underlying causes that may have lead to the
incident.
9 A preventative and corrective action plan is developed to prevent re- Ladbroke Grove Inquiry (Part 2
Recommendations are prioritised and implemented in a strategic and controlled manner. A set of reliable
occurrence. Report) page 73-74
procedures are created to ensure that recommendations are carried out. Corrective actions are followed
8 No efforts are made to ensure the incident does not occur again. through, rather than starting with enthusiasm and then dropped.
9 The investigation process is completed within a sensible (usually Good practice guidance from a range of
prompt) time. literature. The organisation should be able to demonstrate that investigations are usually completed within an appropriate
length of time. Shorter investigation processes mean reduced stress for employees and members of the public
8 The investigation does not commence immediately, or is drawn out
involved in the incident, and prevents important information from being lost. Actions should be implemented as
over an inappropriate length of time (e.g. over several months).
soon as possible to prevent re-occurrence and ensure that lessons are learnt.
8 The immediacy of responding is inadequate
(2) Fault Allocation Process
Evidence Points Reference Source Details
9 Care is taken not to apportion fault before the root cause analysis is Ladbroke Grove Inquiry (Part 2 Report) The individuals involved are viewed as innocent until proven guilty. The incident investigation process
complete. page 69.
should consider the root cause of the incident prior to determining what or who was to blame for the
incident.
8 Blame is apportioned or insinuated prior to any investigation commencing.
A blame culture inhibits reporting, prevents thorough examination of incidents, prevents learning, and has a
negative effect on staff motivation.
9 The purpose of the situation is to learn from the incident, rather than to Ladbroke Grove Inquiry (Part 2 Report)
apportion blame page 70-74. DuPont Report p 73 LG). The organisation should avoid the tendency to look for the guilty party rather than the act and the reasons
behind it. The purpose of the situation should be to learn from the incident, rather than apportion blame.
8 Blame is apportioned or insinuated prior to any investigation
commencing.
(3) Disciplinary Process Details

Evidence Points Reference Source
Good practice guidance from a range of A more positive approach would be to develop a management plan to address the individual’s personal
9 The procedures distinguish clearly between different degrees of
literature.
culpability (e.g. blameless, system induced or reckless errors) weaknesses, and use the information gained from the incident to improve training schemes
8 Disciplinary procedures are limited to distinguishing between different
degrees of blameworthiness.
8 There are no clear procedures for deciding relevant disciplinary actions
57
Incident Management
(Continued…..)
Evidence Points Main Reference Source Details

(4) Feedback Systems
9 There are strategies in place for communicating the outcomes of the Ladbroke Grove Inquiry (Part 2 Report)
investigation e.g. briefings, newsletters, articles in corporate magazines, page 74
notices. Lessons learnt from the incident should be communicated to the individual involved in the incident, and efforts
8 The information communicated is difficult to comprehend, and fails to should be made to disseminate this information to the rest of the organisation, if required. Efforts should also be
serve its purpose. made to communicate mitigation measures to inform staff how to prevent the incident from occurring again.
8 Communication does not target all safety-critical employees and is Lessons should be learnt from the industry and shared with the employees in the organisation. Employees
limited to certain areas. should also know where to go to ascertain information of this nature.
8 There is no personal feedback to those involved in the incident.
9 Preventative campaigns are installed throughout the organisation to Work undertaken on behalf of the Rail
Industry knowledge is widely available and this information should be communicated throughout organisations.
raise awareness of the factors contributing to the incident For example, information is available on the RSSB website about work that has been undertaken to research
Standards and Safety Board (RSSB) by
the many underlying factors that contribute towards incidents, such as SPADs.
9 Hard (equipment) as well as soft (training and procedures) actions are Human Engineering Limited (HEL).
highlighted. Reference HEL/RSSB/041106/RT01.
58
Printed and published by the Health and Safety Executive
C30 1/98
Printed and published by the Health and Safety Executive
C1.10 07/05
ISBN 0-7176-6142-3
RR 365
£35.00 9 78071 7 661 428

Ranking of Process Safety Cultures For Risk-Based Inspections Using Indicative Safety Culture Assessments

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ranking of Process Safety Cultures For Risk-Based Inspections Using Indicative Safety Culture Assessments

Uploaded by

Copyright:

Available Formats

HSE

Health & Safety

Development and validation of the HMRI

Prepared by Human Engineering for the

RESEARCH REPORT 365

Development and validation of the HMRI

First published 2005

ISBN 0 7176 6142 3

All rights reserved. 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

HMRI Her Majesty’s Railway Inspectorate

Defining the Requirements of the Toolkit

Development of the Toolkit

Summary of Findings for the Validation Visits

Conclusions and Recommendations

1.2 REQUIREMENTS ...................................................................................................... 1

1.3 AIM AND OBJECTIVES ............................................................................................. 2

1.4 STRUCTURE OF THE REPORT ................................................................................ 2

2. DEFINING THE REQUIREMENTS...............................................................................4

2.2 BACKGROUND RESEARCH ..................................................................................... 4

Consultation With Rail Stakeholders ........................................................................... 4

2.3 IDENTIFICATION OF THE TOOLKIT COMPONENTS ................................................. 5

3. DEVELOPMENT OF THE TOOLKIT ............................................................................6

3.1 REQUIREMENTS OF THE TOOLKIT ......................................................................... 6

Applicability to a Variety of Rail Organisations ............................................................. 6

Health and Safety Management Framework ................................................................ 6

Vertical Slice Approach .............................................................................................. 6

3.2 TOOLKIT FEATURES ................................................................................................ 7

Colour Coding to Represent the Five Indicators ........................................................... 7

Assessment Criteria ................................................................................................... 7

Scenario Based Approach.......................................................................................... 8

3.3 VALIDATION OF THE TO OLKIT ................................................................................ 8

4. THE QUESTION SET ....................................................................................................9

4.1 INITIAL DEVELOPMENT........................................................................................... 9

Assessment Criteria ................................................................................................... 9

Scenario Based Approach........................................................................................ 11

Format of the Question Set ....................................................................................... 12

4.2 EVOLUTION OF THE QUESTION SET .................................................................... 12

Edits Made to the Wording ....................................................................................... 12

Expansion of the Scenario Approach and Assessment Criteria ................................... 12

Expansion of the Evidence Points ............................................................................. 14

Questions as Memory Prompts................................................................................. 15

Amendments to the Format and Layout of the Question Set ....................................... 15

4.3 FINAL VERSION OF THE QUESTION SET .............................................................. 16

5. THE POCKET CARD...................................................................................................17

5.1 INITIAL DEVELOPMENT......................................................................................... 17

5.2 EVOLUTION TO THE FINAL VERSION OF THE POCKET CARD.............................. 17

6. THE OVERVIEW DIAGRAM .......................................................................................18

6.1 INITIAL DEVELOPMENT......................................................................................... 18

6.2 EVOLUTION TO THE FINAL VERSION OF THE OVERVIEW DIAGRAM ................... 18

7. THE INSPECTORS’ GUIDE........................................................................................19

8. SUMMARY OF THE DEVELOPMENT OF THE TOOLKIT........................................20

9. SUMMARY OF FINDINGS FOR THE VALIDATION VISITS.....................................21

9.2 COMPANY A.................................................................................................................. 21

Summary of the Main Strengths ..................................................................................... 21

Specific Issues ............................................................................................................... 21

9.3 COMPANY B.................................................................................................................. 22