Safety concern regarding the implementation process of changes to procedures.
The reporter has raised a safety concern regarding the implementation process of changes to [Operator]'s procedures.
The reporter states that the business unit responsible for implementing the changes frequently disseminates poorly written and confusing documentation and does nothing to assist operational areas in determining what significant changes have been made to the procedures, nor how the changes apply to a particular operational area. In addition, there is no training or guidance given to staff, nor is sufficient time given for operational staff to review and understand the new procedures prior to the rules coming into effect.
The reporter provided the most recent procedural changes as an example:
- The release of the new version was advertised in safety notices published on 21 March 2022, to come into effect on 28 March 2022.
- A draft copy of the final version was requested by at least one operational area to ensure they had time to review and understand the changes, but the request to obtain a copy was denied.
- The new version came into effect on the day it was published.
- The published version contained changes that were not in the draft released for review, including significant changes around responses to temporary speed restrictions for conditions affecting the network and the management of track machine movements. Some of the changes made were not flagged in the version document history as changes, so were not readily identified.
- There was no opportunity given for any training, nor was any training material provided to ensure operational staff were aware of the new changes.
The reporter advises that it has taken days of closely comparing the old and new versions to identify changes and the operator does not appear to be concerned that operational staff have not been informed, trained, or even aware of the legal requirements that the rules of managing the network have changed without proper and informative notification. The reporter is further concerned that not all significant changes to operational procedures have been identified by staff.
While the implementation of this particular version of procedures may not pose any critical safety issues, the reporter is concerned that the processes and/or risk assessments for changing the procedures are inadequate, or are not being followed, which could lead to a critical safety issue being mismanaged in the future.
To put the claim and the most recent changes into context, the previous change came into effect in June 2021. This version was a result of more than 2 years’ work with end user representatives through the operator's working group 1, a subject matter expert (SME) writing group 2, and learning/training team representatives for the network control and infrastructure assets parts of the business.
A significant amount of communication was issued throughout the program to advise end users of impacts and training requirements. Due to the significance of the changes and impact assessments performed by the training teams, training materials were developed, and a transition training course and subsequent refresher workshops were provided to both protection officers and network control officers prior to implementation. These activities included protection planning/application scenarios and opportunities to ask questions and obtain clarification.
After implementation, performance monitoring and assurance activities were conducted over a period of 6 months, which informed a post-implementation review. The outcome of the review was a finding that no significant or material changes were required to be made.
During this process, a request for clarification on the proposed changes about temporary speed restrictions was received from a network control centre. A workshop with control centre senior management and respective union representatives was held to discuss the proposed changes. This was directed towards the proposed wording for temporary speed restrictions (TSR’s); essentially clarifying the requirement to post in-field TSR signs where it is known a restriction will be placed for works or because of defects, and not to rely on verbal notification to Rail Traffic Crew (noting there are exceptions for Conditions Affecting the Network [CAN’s] due to reasonable practicability), which is an existing requirement. As a result of the meeting, agreed minor alterations were made to the proposed wording to provide clarity on the requirements.
Following the closure of consultation, the rail safety team worked through all feedback received and finalised the document. It was determined in consultation with the training SMEs from the lines of business that the changes in procedures did not require transition or update training, and communication was required for awareness only. As a result, no specific training packages were developed for implementation. Advice was subsequently published in the Mandatory Safety Notices on 21 March 2022. The documentation was then provided to the Document Management Team for publication in the Policy Centre, at which time advice was provided that because the document had been notified to the Office of the National Rail Safety Regulator, an entire new version number was required. The changes in the document itself did not trigger the version number change. A Critical Safety Alert (CSA) re-affirming the changes was then issued on Friday 25th March. The CSA also made reference to the new version.
[Operator] acknowledges that a final draft was not issued to the business prior to publication. Normal process, when training delivery is not required prior to implementation, is to provide the final version (pre-publication) to the business training teams so that they can socialise the key changes, answer questions, provide clarification and update referencing in training materials. This did not occur on this occasion. This resulted in requests for clarification from stakeholders upon publication, who were immediately engaged to work through any issues. A critical safety alert was subsequently issued on 1 April 2022 to clarify wording changes, and [Operator] committed to a workshop with stakeholders to review and affirm consultation and change management processes for safeworking rules and procedures moving forward.
[Operator] has safety change management requirements in place, and a safety change management checklist was used to document steps and artefacts in the change management process. [Operator] acknowledges that, on this occasion, the full document was not provided as per usual processes. Note, however the above information contextualising the change of version following a significant change event, and subsequent assurance and post-implementation review of performance and associated risk.
ONRSR was notified of the changes to network rules and consultation was conducted in accordance with specified periods of time and relevant stakeholders.
ONRSR has reviewed the reporter’s concerns and notes the operator’s response. ONRSR is aware of this matter through stakeholder engagement meetings with the operator. ONRSR is monitoring the implementation of changes to the procedures through regulatory interactions with the operator.