Improved railway safety through the implementation of a confidential incident reporting and analysis system (CIRAS)
Submitting InstitutionUniversity of Strathclyde
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
The Confidential Incident Reporting and Analysis System (CIRAS), was
developed in response to concerns about the role of human error in UK
railway accidents. In 2008, CIRAS became an independently operated unit
within the Rail Safety and Standards Board and is now available to
everyone working in the UK rail industry; it codes reports about health
and safety concerns and then facilitates a resolution between the
individual and the relevant company or companies. 2.75 million passengers
and 400,000 tonnes of freight use the railways in Great Britain every day
and CIRAS impacts on the safety of all railway staff and passengers by
ensuring that there are no barriers to reporting and resolving potential
problems and hazards. It has also led to the construction of a database
allowing safety issues to be classified and resolved before they can
occur. Between 2008 and 2012 CIRAS received 2228 reports; 45% of these
resulted in tangible safety improvements and approximately 33% contained
important information about safety that was new to the company concerned.
CIRAS has directly influenced the development of a confidential reporting
system used in the USA.
Context: Rail crashes such as those that happened at Potters Bar,
Hatfield, Ladbroke Grove and Southall cost hundreds of lives. Following
the Greenock rail crash in 1994, Scotrail set about investigating ways to
improve rail safety. A report, commissioned by Scotrail, showed that many
unsafe incidents were associated with human factors and human error.
Subsequently, Scotrail awarded a grant to Professor John Davies at the
University of Strathclyde's Centre for Applied Social Psychology to
undertake research into the role of human factors in near misses,
accidents and incidents on the railway network. A key problem that had
been identified initially by Scotrail was the number of signals passed at
danger (SPADs), which had been identified as contributing to many of the
crashes and near-miss situations.
Key findings: The Strathclyde team undertook a series of
laboratory-based studies on the subjective experiences and attentional
lapses that occur during sustained attention tasks [1, 2] and this work
gave the team insights into why SPADs may occur and the conditions for
drivers that were more likely to lead to errors in train operation.
However, from the data in a qualitative study where the team asked train
drivers about SPADs , a further problem became apparent: detrimental
working conditions were not being reported. This led Professor Davies'
group to taking a new approach to assessing human factors in railway
accidents. Previous approaches to accident prevention and safety had
tended to focus on technical fixes rather than looking at the role of
human input. However, the Strathclyde team's research indicated that,
while staff were often aware of dangers and hazardous situations and
practices, they were sometimes reluctant to report them, for fear of being
implicated or because of the pressure to meet targets or reduce costs. In
addition, the sheer number of different kinds of errors meant that a
robust method of classification was needed to analyse and address problems
at their source, rather than dealing with the symptoms. The Strathclyde
team's studies led to the identification of the factors that prevented
people from reporting safety issues , and they then used hermeneutics,
in which the verbal accounts of drivers were analysed, to develop a
taxonomical classification system. This method of classifying reports
provided detailed analyses of the frequency and seriousness of different
problems . From this work, the team then developed a method for a
confidential reporting system (CIRAS) [5, 6]. The system works by taking
written or verbal reports of issues and incidents and coding them using
the event coding model  developed by Professor Davies'
team. The taxonomy is unique to this system and the power of the system
increases the more it is used, as the data help to define specific error
types. This makes problem solving more straightforward, since it can be
seen that, for example, two problems are linked by a single underlying
cause. Additionally, the confidential (but not anonymous) nature of the
system meant that people would be more willing to report issues, even in a
working climate that was sometimes characterised by fear and mistrust (in
both directions) between rail workers and management. Initial evaluation
of the system showed that it was picking up some serious and critical
safety issues that had not been identified using standard safety
management practices .
Key Researchers: Professor John Davies, Professor in the Centre
for Applied Social Psychology at the University of Strathclyde at time of
research (2000-2006) led the research team comprising Alastair Ross,
Research Fellow 1997 to 2011, Brendan Wallace, Research Fellow 2000 to
2004 and Linda Wright, Research Fellow 1995 - 2001.
References to the research
1. Smallwood, J., Davies, J. B., Heim, D., Finnigan, F., Sudberry, M.,
O'Connor, R., & Obonsawin, M. (2004). Subjective experience and the
attentional lapse: Task engagement and disengagement during sustained
attention. Consciousness and Cognition, 13(4), 657-690. doi:
10.1016/j.concog.2004.06.003. Note on quality: This peer reviewed
journal has an impact factor of 2.03.
2. Smallwood, J., Riby, L., Heim, D., & Davies, J. B. (2006).
Encoding during the attentional lapse: Accuracy of encoding during the
semantic sustained attention to response task. Consciousness and
Cognition, 15(1), 218-231. doi: 10.1016/j.concog.2005.03.003. Note
on quality: same as 1.
3. Ross, A. J., Davies, J. B., & Plunkett, M. (2005). Reliable
qualitative data for safety and risk management. Process Safety and
Environmental Protection, 83(B2), 117-121. doi: 10.1205/psep.04239.
Note on quality: This peer reviewed journal has an impact factor
4. Wallace, B., Ross, A., & Davies, J. B. (2003). Applied
hermeneutics and qualitative safety data: The CIRAS project. Human
Relations, 56(5), 587-607. doi: 10.1177/0018726703056005004. Note
on quality: This peer reviewed journal has an impact factor 1.93.
5. Wallace, B., Ross, A., Davies, J. B., Wright, L., & White, M.
(2002). The creation of a new minor event coding system. Cognition,
Technology and Work, 4, 1-8. url: http://link.springer.com/article/10.1007/s101110200000.
Note on quality: This peer reviewed journal focuses on the
practical issues of human interaction with technology, in particular, how
human cognition affects, and is affected by, work and working
Grant funding: Between 1996-2001 Professor Davies tendered for and
won a total of 13 grants to study human errors and develop CIRAS. The
total value was £1.75 millon and included:
• Davies, J.B. (1996-1998) Scotrail, Railtrack, HSE, British Rail Board:
Study of Human Factors Errors, £139,000.
• Davies, J.B. (1997-1999) Great North Eastern Railways: Enrolment of
Safety Critical Staff to CIRAS programme, £40,000.
• Davies, J.B. (1998-1999) Railtrack (Scotland Zone), Jarvis, Bovis,
Semple-Cochrane, Scott Wilson Railways, Rigblast, Westinghouse Signals,
Adtranz: Enrolment of contracting staff to CIRAS programme, £42,000.
• Davies, J. B. (1998-2000). First Engineering: Enrolment of staff in
CIRAS programme, £40,000.
• Davies, J.B. (1999-2000) Railtrack: Enrolment of staff in CIRAS
• Davies, J.B. & Human Factors Analysts Limited (2000-2001) GT Rail
Maintenance: Enrolment of staff in CIRAS programme, £45,000.
• Davies, J.B. & Human Factors Analysts Limited (2000-2001) Railtrack
(Safety and Standards Division): Set up and run a mandated national CIRAS
system for the UK train operating companies, £1.2 million.
Details of the impact
Process: From research to impact. Following initial experimental
work arising from the grant funding from Scotrail in 1996, Professor
Davies' team developed a prototype CIRAS system which was designed to
classify the reports received into technical codes or human action codes
based on the narratives from train drivers, conductors, signalling staff,
maintenance staff and railway management. Over the next three years, staff
operating trains in Scotland (Scotrail, Virgin Trains, GNER, Railtrack
Scotland and GT Engineering) were enrolled into the CIRAS programme.
Following the Ladbroke Grove rail crash in 1999, the Government took the
decision to extend the CIRAS system to cover train operators in England
and Wales. In fact, CIRAS was specifically mentioned in the Cullen Report
into this accident. Paragraph 9.61 notes that "A confidential reporting
system, CIRAS, is now in place across the industry. This allows employees
to report safety-related incidents confidentially. It undoubtedly enables
"near miss" incidents to be reported and receive attention. It also
enables incidents to be categorised by type and location, and to measure
trends. It has great merit. It is to be hoped that in the longer term the
culture of the industry would be such as to make confidential reporting
unnecessary. I accept that this situation may be a long time in coming to
pass in the industry. In the meantime I fully support and encourage the
further use of the CIRAS system" (Source G).
CIRAS continued to operate as a Charitable Trust until 2008 when,
following extensive consultation, the Railway Safety and Standards Board
took over its management and governance. They expanded its remit
immediately and significantly. The system was opened up so that everyone
working in any capacity on the railway network in England, Scotland and
Wales could use it. The coding system was significantly modified and
expanded to take into account a much wider variety of safety issues, and
changes were made to the screening of reports ensuring that the focus was
on detecting and processing only safety critical reports. Additionally,
once the CIRAS team had resolved problems through consultation with the
relevant companies, any key safety lessons learned were shared with all
users of CIRAS publications. A significantly expanded database was
introduced during 2011, building on the 16 years of data that the
taxonomic system had already accumulated and increasing the ability to
diagnose and resolve source problems. The CIRAS website was also rebuilt,
making it more user-friendly and accessible to use with mobile devices.
This case study concerns the impact of the expanded CIRAS system.
Types of impact: The research on human factors in the railway
industry has led to:
- The adoption and use of a confidential reporting system across the UK
- The construction of a database to classify and resolve safety issues
before they occur
- Sharing of best practice on safety within the UK railway industry
- Enhancements to passenger and freight transport safety
- Influence on the development and implementation of a reporting system
in the US and Canada
Adoption of CIRAS: Since 2008, the number of companies using CIRAS
has grown steadily. There are now over 300 companies registered (Source
F), although the number of companies involved fluctuates as maintenance
and operation contractors change. The safety service that CIRAS provides
is open to train and freight operators, Network rail and its suppliers,
London Underground, Heritage Rail and Light Rail.
Database of safety issues: Currently, the CIRAS Report Library
(Source B) contains 17 categories of health and safety
concerns, including fatigue, infrastructure, security, signalling,
stations and platforms, training and workloads. Companies value CIRAS for
bringing safety issues to light which could otherwise have been undetected
Sharing best practice and improvements to passenger safety: In
addition, companies are able to share safety lessons via CIRAS
publications. In 2008-9, more than 300 reports were made to CIRAS,
resulting in 32 instances where CIRAS was able to negotiate tangible
changes (Source C). For example, a CIRAS report from that year raised a
signal passed at danger (SPAD) risk at platform 9, Liverpool Street
station. As a result of CIRAS' intervention, a review was undertaken of
the signal controls at this junction and subsequently train operating
procedures were changed (Source B). The estimated level of SPAD risk in
March 2012 was 69% lower than September 2006. The number of potentially
severe SPADs occurring fell from 43 in 2003-2004 to nine in 2011-2012
(Source K). In 2009-10, the number of reports to CIRAS grew to 561, with
117 positive actions. Eighty five of these processed reports contained
information which was new to the company concerned. One report revealed
that train drivers had spotted a loophole in the rules associated with
emergency speed restrictions allowing them to drive above the speed limit.
The positive action taken by the company was that The Rule Book and
Railway Group Standard were changed so as to prevent a derailment through
inappropriate speed. The Rail Safety & Standards Board's annual board
meeting reported that the implication of this report to CIRAS was that
potential accidents had been prevented (Source D). In 2010-11, the number
of reports made to CIRAS continued to grow to 679 (Source E), and in
2011-12 the number had risen to 855 with 50% of all reports resulting in
positive action and 30% of reports containing new information to the
company concerned (Source F).
The CIRAS system works constantly behind the scenes, making sure that no
safety issues are overlooked or unreported, and helps to improve future
railway safety performance through gathering data on types of errors,
faults and their causes (Source A). The Rail Safety & Standards
Board's annual safety and performance report for 2011-12 (Source I)
reported that: between 2008 and 2012 there were no passenger or workforce
fatalities resulting from train crashes on Great Britain's mainline
railway; in 2011-12 the ten-year average for the number of train accidents
resulting in passenger or workforce fatalities was less than one every two
years for the first time ever; the number of passenger fatalities was the
lowest level on record; the total number of public fatalities in 2011-12,
excluding trespass and suicide, was eight (lower than in previous years).
A Workforce Risk Review published in 2012 (Source J) presented the
recurrent themes arising from the Office Rail Regulation (ORR)
inspections, Rail Accident Investigation Branch (RAIB) investigations and
CIRAS reports. Nine out of the ten recurrent themes were raised by CIRAS
reports, whereas ORR inspections highlighted four and RAIB investigations
highlighted six of the recurrent themes, respectively.
International influence: Beyond its extensive use in the UK, CIRAS
has also impacted on the development of other confidential reporting
systems, such as C3RS, the Confidential Close Call Reporting
system launched by the Federal Railroad Administration in the USA (Source
L). Primary C3RS stakeholders include the US Department of
Transport, Amtrak, Canadian Pacific Railway and the Association of
American Railroads. The Federal Railroad Administration stated that they
used lessons learned from CIRAS when developing and implementing their
system and that previously unknown safety issues are being discovered,
with resulting actions having a positive impact on safety (Source L) "The
FRA implementation team benefited from the existing literature on
confidential close call reporting systems ... (including the) United
Kingdom's Confidential Incident Reporting and Analysis System (CIRAS);
Davies et al., 2000."
Sources to corroborate the impact
A. A Letter from Maurice Wilsdon, Head of National Programmes, Railway
Operations and CIRAS, 21st March 2012.
B. CIRAS Report Library (http://www.ciras.org.uk/report-library/)
C. CIRAS Committee Annual Stewardship Reports 2008/9
D. CIRAS Committee Annual Stewardship Reports 2009/10
E. CIRAS Committee Annual Stewardship Reports 2010/11
F. CIRAS Committee Annual Stewardship Reports 2011/12
G. Cullen Report: The Ladbroke Grove Rail Enquiry. Paragraph 9.61. http://www.rail-reg.gov.uk/upload/pdf/incident-ladbrokegrove-lgri1-optim.pdf
H. Britain's Growing Railway: Association of Train Operating Companies
I. Rail Safety & Standards Board Annual Safety Performance Report and
Workforce Risk Review 2011/12 http://www.rssb.co.uk/SPR/Documents/ASPR_2011-12_FullReport.pdf
K. SPAD and TPWS activity report, Quarter 3 - 2012-2013
L. Developing an effective corrective action process: Lessons learned
from operating a confidential close call reporting system.