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From all the reports and recommendations released at the end of February two words recurred: safety culture. The trouble is that like all corporate cultures, safety culture is an intangible. As with esprit de corps, or morale or customer focus, a safety culture is obvious when it exists, but if you have to try and identify its present you probably haven't got it.
What we do know is that strong cultures in organisations occur when top down leadership meets bottom up commitment. It needs only a few strong managers to set the tone. When the workforce shares this commitment, the ethos of the organisation takes shape.
Take a simple example. In the drives to reduce deaths among track workers, strict safety procedures were established. This included a safety briefing before going onto a worksite.
At first, on press facility visits, these briefings often seemed statements of the blindingly obvious. All we were going to do was walk a few years along the track, But in a culture of safety, you do not, cannot, differentiate between a couple of journalists looking at a new point motor, say, and a contractor with plant and machinery taking over a possession. Your instinctive reaction must be to do it right every time.
Thus the basis of a safety culture is discipline. This is, of course, an unpopular word in these days of empowerment and devolution of responsibility. But we have to get back to doing operational things by the rule book.
When you do things by the book you do the basics automatically. In the howling chaos of the aftermath of a major accident, senses ands bodies shocked, staff need to do the right things in the right sequence immediately. And be able to trust your colleagues to carry out their tasks while you get on with yours.
And because you don't have to work out what to do immediately, while training is carrying you through the immediate aftermath, you have time to thinks about what to do next.
But, of course, safety culture is not about the rare major accident it is about the daily running of the railway. Because the lesson of accident investigation in all modes of transport is that major accidents generally follow the pattern of the old nursery rhyme which starts for the sake of a nail a horseshoe was lost' and builds up to the loss of a kingdom.
So when something goes wrong, say a land slip blocking one line, the rule book tells you and your colleagues on the spot how to work round the problem safely. Reversion to manual control for emergency tasks such as wrong line working, is frowned on by the safety establishment and this may reflect a weakening of old railway knowledge of the rule-book in these days of Integrated Electronic Control Centres. But proper safe procedures, followed by everyone, can keep the railway running.
Of course, doing it by the book can be incompatible with customer focus. We recall a case where a commuter train had a failure in the sliding door interlock system in the evening peak. The driver detrained a full and standing passenger load and was roundly abused for his pains as he went down the train.
That was safety culture in action, when the driver could have opted for a quiet life and taken the slight risk that no one would play with the button on the offending door. But a safety culture should not include scope for freelance on the spot quantified risk assessment and the driver knew that his old school railway manager boss would back him up.
Overall, a commitment to true safety culture is going to make the railway more difficult to operate and annoy more passengers. So be it.
There are too many blind eyes being turned to passenger behaviour. When was the last time the BT Police arrested someone for opening a slam door as an incoming train hit the ramp at Waterloo or Victoria ? This sort of event leaves a trail of injuries every year but no one seems to care. Yes, Mk 1 stock having to be withdrawn, but why no sound from the Health & Safety Executive on ameliorating risk from slam doors over the next two years, which is surely required under the safety cases of Railtrack, as major station operator, and the Train Operating Companies?
Living with a genuine safety culture is going to be very uncomfortable. But this should prove a spur to further improvement.
Japanese style operation, another current mantra, is all about regulation to the second and equipment not going wrong, or if it does, having a redundant system to take over. And when things don't go wrong you have a much safer railway.
But, a safety culture is not something you can bolt on or get the consultants in to create. It has to come from within the railway itself and this will depend on strong, committed and above all experienced railway managers setting the tone, and backing up staff who do it by the book, even if this causes big problems in the early days.