Guest Blog by A Transport Specialist: Hazard Monitoring and Risk Management Issues Raised by TfL’s Q1 Bus Safety Data

Introduction
TfL’s historic decision to publish Bus Safety Data every quarter gives the public an excellent opportunity to scrutinise TfL bus subcontractors’ safety performance on regular basis.  Based on discussions commenced on this blog as well on the Safer Oxford Street blog, both of us were presented with this Guest Blog by A Transport Specialist who has worked for decades in the UK Transport Sector.  It is no coincidence that A Transport Specialist presented this blog both to Tom Kearney and me: both Tom and I are victims of the flaws in TfL’s Bus Operations System that produce so many deaths and serious injuries in London.  My father was killed by a TfL Bus on Regent Street in July 1997 and Tom was nearly killed by a TfL Bus less than a kilometre away on Oxford Street in December 2009. 
The impetus behind the campaigning of Vision Zero London and Safer Oxford Street is to compel  TfL – paid professionals who have both the power to kill and seriously-injure and the power to change things – to take some accountability for bus collisions and to change things for the better.  Lives and livelihoods need not be destroyed from preventable collisions involving TfL buses.
A Transport Specialist offers some very compelling observations of how TfL might start changing things for the better.
Tom Kearney                                                                       Andrea Casalotti
Safer Oxford Street Blog                                                   Vision Zero London Blog
Guest Blog by A Transport Specialist: Hazard Monitoring and Risk Management Issues Raised by TfL’s Q1 Bus Safety Data
Having worked in the rail industry for decades, and taking a keen interest in the mechanisms/methodology of safety and how to deliver it (especially for cyclists), I am signed up for regular alerts from the Rail Accident Investigation Branch.  Based on my analysis of the TfL’s Q1 Bus Safety Data, here are some issues that immediately spring to mind.
1. What is TfL’s Q1 2014 Bus Safety Data Not Telling Us?
The Q1 Data released by TfL show 285 incidents involving its bus fleet where 283 people were sent to hospital (Serious Injury) and 2 people died on the scene (Fatals).  TfL decided to display this casualty data for individual subcontracting divisions as opposed to consolidating the data and showing totals for each Bus Holding Company.  I have consolidated and enhanced this data to make it easier to draw some initial conclusions about it.

The data published by TfL reflects information that has been filed by its Bus Subcontractor.  Where no information has been published (i.e., what I’m calling a “Nil Return”), I am assuming that no KSI incidents have taken place.   One of Arriva’s subsidiaries, Arriva TGM, has a Nil Return but it operates just one TfL contract (E10 – 8 buses – Heathrow). In addition, Community Transit (HCT Group) reports a single KSI and Transit Systems (a former Firstgroup operation, now controlled by the Australian Transit Systems group) has just 5 reports.
By taking TfL’s Q1 Bus Safety Data and linking it to the size of each Bus Company’s Fleet under contract to TfL (a crude measure but one to use such a marker in the absence of any other data being made available by TfL), one can now more readily show Q1’s worst and best performers.
Bus Company
KSI Incident Rate per Bus
RATP
1 KSI per 19 buses
Arriva
1 KSI per 20 buses
Stagecoach
1 KSI per 23 buses
ComfortDelgro
1 KSI per 25 buses
Abellio
1 KSI per 34 buses
Go-Ahead
1 KSI per 38 buses
CT Plus
1 KSI per 73 buses
Tower Transit
1 KSI per 74 buses
Sullivans
Nil Return = No KSI incidents?
Quality Line
Nil Return = No KSI Incidents?
London Sovereign
Nil Return = No KSI incidents?
  Source:  Transport for London Q1 results and bus contract listing
Whilst noting that Arriva stands out in this analysis as the worst performer of Bus Companies supplying more than 1000 buses to TfL (it supplies about 20% of the fleet but reports more than 27% of the KSI incidents), this fact has to be weighed against the number of contracts being performed by Arriva and the scale and specific location of those operations.  Perhaps Arriva is the main contractor in combined terms of the number of buses and routes on London’s busiest roads? 
Go-Ahead provides the largest number of buses under contract with TfL  (1828 buses or 23.6% of the total TfL fleet) but only reports 16.84% of KSI incidents in Q1.   This ranks Go-Ahead at 1 incident for every 38 buses operating, far better than any of the other 3 groups (Arriva, ComfortDelGro, Stagecoach) providing more than 1000 buses on TfL contracts.  Only Abellio comes close as a major operator.  Could Go-Ahead or Abellio be doing something differently to account for the lower figures?
Based on the information supplied by TfL, with the largest number of buses running around and many routes in Central London, Go-Ahead appears to be only being beaten by the much smaller operators. Might factors such as local routes (Sullivans routes are all in outer London) and a closer connection between management and front line staff be delivering a greater level of diligence and faster response to any issues (eg ‘rogue’ drivers)?  That being said, just KSI one incident would rank in Sullivans equal place with the overall worst performer for incidents per number of buses, RATP’s London United. 

Epsom Coaches, which has operated as a clearly defined entity within the Transdev/RATP period, and MD Steve Whiteway are particularly worth a mention here, as they ran an interesting trial of operating their buses with the engine management system set to limit the top speed (but not engine power) to 30mph, on routes entirely within a 30mph limit.  This delivered some interesting results 

– reduced minor collisions,
– reduced driver stress,
– reduced fuel consumption.
What might we see if TfL’s Q1 report provided better detail. Why, for example is Route 109 featuring in 11 incidents, why a run of 4 passenger falls in the bus in Jan-Feb on route 205, or 4 each for falls outside the bus all in January on Routes 109 and 410?  Perhaps the last detail might be due to ice or snow conditions at bus stops given the time of year and specific locations on those routes.  That latter detail might perhaps identify a key intervention to deal with winter conditions but without detail and effective monitoring. Where do we start?
There were 13 bus drivers sent to hospital, but no identification on age or gender, or whether (in the cases, which were not assault) the incident was a crash with another vehicle or object, or being hit by another bus at a bus depot or station, and 5 incidents where the road user was taken to hospital but the type of ‘road user’ is not recorded.
The 3 operators with several contracts apiece who have no reported serious injuries, are not listed.  If the review is to be thorough they should be there – even with a nil return, these buses should be counted to provide the overall picture on London Buses contracted services. Reviewers can spot good performers and even trends (eg most reported ‘assaults’ in the period were in Lambeth – 4 in 9 reported incidents) and link this to internal and external factors.  What, when something is done differently delivers a reduction?   With that added detail, there can be opportunities to make significant progress in reducing that quarterly toll.
Of course all of this analysis is based on the data available as presented from the TfL record. These are base figures and rely on the full reporting of all incidents, and the analysis is equally basic, and would benefit from deeper testing of statistical validity of the small sample sizes. It would be of great value to have this data in the open and pulled together for a more thorough analysis of the detail.Only by really understanding a problem can you have any potential for fixing it properly.
2. TfL Might consider applying Safety Practices & Incident Investigation being used by the Rail, Maritime & Air Industries.
Our rail system is very safe.   Hardly one passenger a year is killed, and fatalities for staff at work are equally low. In one recent year, the prospect of no staff fatalities was cruelly cut-short by a worker killed in a road crash, heading for a site via the A9.   RAIB reports inform the Office of Rail Regulation (ORR), who then can order operators to deliver action on the way they operate or the equipment they use.  These reports are all based on a thorough objective and impartial investigations carried out and the results published online for full open access, so that the public can see what faults have been identified, and how those issues should be addressed.   A core element is the methodical review of all causal factors, without any placing of blame, and how these have combined to deliver the dangerous situation.

Our airline & shipping industry is also very safe. The air and maritime regulators (Civil Aviation Agency [CAA] & Maritime & Coastguard Agency [MCA]) likewise receive reports both on the incidents where harm has occurred, and the incidents which MIGHT have caused a problem but the lucky card came in to play. The Health & Safety Executive  (HSE) does the same for factories. 
The gaping void is that we have no equivalent Highways Accident Investigation Branch.  Investigations do take place: the Police do them, generally with the objective of identifying the guilty parties, and so these may be slightly biased when measured against the premise of the objective and impartial RAIB system, and of course, even when the detail is provided to a Coroner, it is not published.  Insurers also investigate, but their objective is to establish the liability of one or more of the parties involved.
3. Should TfL Bus Drivers Have A Confidential Incident Reporting & Analysis System (CIRAS) like the Rail Industry?
Rolled out in Scotland, CIRAS is now an established part of the railway safety structure. It provides a fully confidential reporting system, which can be used to register individual concerns, about work colleagues, working  practices, and other activity which presents a safety hazard, or fails to apply good systems of risk management.  I believe it is now being considered for other industries, including, quite possibly, for bus and coach operations. This newsletter shows how the CIRAS system works.
4. Why Are Road Incidents Any Different?
The incident investigation duty for TfL and other roads authorities is covered by Section 39 of The Road Traffic Act 1988, but a few FOIA requests fired in around the UK reveal the inadequate material which is being delivered by way of ‘investigation’.  From these often weak listings of crash dates and locations, very little can be learned to prevent future crashes. TfL’s delivery is slightly more structured, and an increasingly-detailed resource is published, but getting access to this information often demands determined external and internal pressure from people like Tom Kearney, Andrea Casalotti and supportive GLA members. 
There also appears to be very little direction coming from DfT on what they expect to be delivered by Section 39 either, but a glimmer of hope came in the recent announcements about a roads regulator (below) who will be required when the Highways Agency is converted into a contracted supplier for roads infrastructure. That presents a whole new debate, but we have to move on from simply shrugging our shoulders and mumbling “**it happens” for every road crash.
5.  A Roads Regulator
A DfT announcement about a month ago hinted at plans to turn the Highways Agency into, essentially, a Railtrack for Roads.  The DfT noted that some of the parallel detail would be needed to provide the functioning that matched that for the rail network, with a roads equivalent of the Rail Regulator (although the thinking at present seems to be adding a section to ORR [Office of the Rail Regulator] rather than enhancing the existing ‘roads regulator’ function of the Traffic Commissioner, and Driver and Vehicle Standards Agency (DVSA).  If that regulator is to be effective it will have to possess Incident Investigation Capacity to the same standards as RAIB, and a Highways Accident Investigation Branch has to be part of that delivery. If we are to make a difference in delivering safer roads we cannot continue with the weak and flawed arrangements of Section 39.
6. Coroners Reports & Prevention of Future Death Orders: A New Change Agent for Road Safety? 
Though relatively new in the post, the Chief Coroner is encouraging his deputies to make greater use of their power using Rule 43 – better known as a Prevention of Future Deaths (PFD) Report. Although a PFD asks for answers rather than directs changes in its own right (because, for one thing, it lacks the technical expert detail of a rail accident report), the Coroner can only ask others to provide the answers in a PFD.  Since 2013, such answers are placed in a publicly-accessible online location.

A PFD Report Order was issued by North London (Camden) Coroner Mary Hassell for the second fatal crash in 5 years of a large vehicle turning left from Vernon Place into Southampton Row. In both cases, the large vehicle approached the junction in a lane marked for traffic going straight ahead and forced a conflicting priority over the traffic using the nearside lane, negligent of the fact that it was being used by a cyclist at that time. Quite simply, the left turn with a substandard corner radius (of around 4 metres instead of 6), and an angle greater then 90 degrees cannot be safely negotiated by a large vehicle with traffic moving in the nearside lane.  The immediate and blindingly simple remedy is to ban the drivers of such vehicles from making the left turn here and send them round via Theobalds Road, Proctor Street and High Holborn making right turns with the road space to do this in a safer way.  As yet Camden Council and TfL’s responses have not yet been made public. 
Frankly, some of the language produced in the answers does very little to deliver any convincing action to prevent future deaths (Bow Roundabout proved this with a further death after the safety improvements were made).   To get substantive answers, Coroners might look to the mandate which is placed on the roads authority to investigate crashes, and from those investigations direct itself on what measures may be required to promote safety or alter the design and management of the roads over which it has control.  The major flaw here has to be repeated – for Section 39 – Who will Watch the Watchman? (quis custodiet ipsos custodes)
7. Some Positive Trends in Monitoring Bus Driver Behaviour
In March 2014 Stagecoach London went fully active with the Green Road system of monitoring driver performance, which they initially tested at their Barrow-in-Furness depots few years ago. The system ranks driving by logging severe braking and acceleration, and other parameters, giving a green light for smooth and fuel efficient driving through to a red light for the opposite extremes.  The initial trial doubled the average mileage between crashes from 29,000 to 58,000 and cut fuel consumption by 4%. Stagecoach is rewarding drivers who get consistent ‘green light’ scores, and has a healthy staff buy-in for the system. We need to wait for Q2 results but there has been an interesting change in the type of incidents from February onwards.  
Other big groups also subscribe to Green Road and similar ‘traffic light’ performance monitoring, and Stagecoach makes a great show of the rewards offered to drivers achieving solidly green-light reports, as this system encourages driving with good anticipation of hazards, and financial incentives of lower fuel consumption, and reduced wear and tear on the vehicles.
A wider scheme is applied by the Traffic Commissioners, (London being Metropolitan & SE Traffic Area – Nick Denton) but with the greater focus on HGV use, for their Operator Compliance Risk Score (OCRS), where points are racked up for various ‘offences’ and other performance ratings, and generate a red, amber or green ranking for an operator and their vehicles. With a red ranking the operator can expect to be more closely watched than a green ranked one.  This is primarily a means of monitoring that the named Transport Manager, required as a licence condition for any Operator with a UK Domestic or International Operators Licence (LGV or PCV), is doing the periodic check on the validity of their drivers’ licences, getting a minimum number of annual vehicle test failures, with no roadside prohibition notices, and other required administration.  
The Annual Report by the Traffic Commissioners (in my view greatly under resourced for their task of “Reducing harm” from the commercial use of the UK’s road system) is well worth a read, especially if you can begin to pick up the nuances buried in the official statements.  The now-retired Bgdr. Tom McCartney neatly commented that he felt the small number of driver disciplinary interviews did not reflect the true need for them, and equally highlighted the informal way in which his office was receiving key intelligence from other agencies on driver and operator behaviour.  This perhaps highlights the notion that the best form of Policing is perhaps free and open access to information.

8. Some Upcoming Trends in Regulating Bus Driver Behaviour
Bus Driver X highlights a number of interesting issues that apply to both Bus Driving generally and Bus Driving in London.  Here are a few items to mull over:
The Conduct Regulations 1990 and the 2002 amendments relating to DDA issues.
The full title is the Public Service Vehicles (Conduct of Drivers, Inspectors, Conductors and Passengers) Regulations 1990. This legislation, with a serendipitous foresight actually made the use of mobile phones by PCV drivers illegal from well before their use was widespread. Essentially for that part of the regulations ensures that when the vehicle is moving the driver’s sole activity should be driving it and that means:
  • no non-essential use of microphones (that sign on a tour coach, and why sightseeing buses have a separate tour guide)
  • no non-essential conversation with anyone (why you use a bell-push to stop the bus and do not stand in front of a marked line on the front platform
  •  a vain hope on some buses where the statutory limit on standing passengers, displayed by law inside the bus in 1″ lettering is well exceeded).


Observation of the details in sections 4 and 5 of the Conduct Regulations will reveal that it is regularly not rigidly observed on a daily basis, and there is some degree of common-sense in enforcement.
General driving laws also make the use of a display screen when the vehicle is being driven illegal, but with (last I checked) 3 exceptions, where the screen for example provides the equivalent of a mirror showing an external view.  Amazingly some bus operators needed to be convinced of this when early CCTV cameras were being fitted to monitor bike racks, and trailers at the back of buses 20 years ago.
The position on iBus and the apparent requirement for the bus driver to deal with text messages when driving would appear to be a new area to get guidance on, and perhaps this prompts a call to carry out an objective assessment of the use of this new technology and the legislation framed nearly 25 years ago.
9.  Putting everyone in the Picture
If you are going to sort a problem out properly you need to get a clear picture of what the problem is.  The brilliant blogpost by Mark Treasure on the failure to deliver Placemaking for the public realm in London and many UK cities because they have not grasped the fact that a place for people to interact cannot also be a place to move a massive volume of traffic through at the same time, and so the term Placefaking has been coined for all those schemes that miss that point so badly. 
I hope I’ve highlighted why our rail, air and maritime transport operations see so few fatal and serious injury incidents.  Investigation of any serious crash – or even a potentially serious crash which was avoided by pure luck of not having every element quite lined up for a disastrous outcome – is delivered by an independent and impartial agency, and the results published in full.  There are regulators ORR, CAA, MCA who – based on the recommendations made by the investigation – can then order the rail, air and maritime organisations they regulate to take action within a defined time.

We do have a regulator for commercial use of the roads, the Traffic Commissioners, supported by the DVSA, who require licensed operators to meet standards, including the catch-all requirement of being of good repute.  To aid them in directing limited resources to the most wayward operators, there is an Operator Compliance Risk Score (OCRS).
But the compliance with vehicle testing and operation standards does not always have formal or robust links back to the wider spectrum of driver and vehicle operation.  Traffic Commissioners can revoke a vocational drivers licence if they feel that driver is not fit to drive a Passenger Carrying Vehicle (PCV) or Light Goods Vehicle (LGV), yet the tragic records of many fatal crashes with ‘HGVs’ in particular reveal drivers with a trail of traffic offences, and clear warnings that they are unfit to be behind the wheel of a large and dangerous vehicle – some have been able to kill twice before they are stopped. Clearly, we need both better detail, and a more effective way to use that detail “to prevent harm” (a useful phrase repeated by one of the Commissioners in a speech she made to define the basic mission of her office in managing the commercial use of the roads). Reading between the lines of past annual reports, one senses an awareness that the Commissioners might be calling more drivers and operators in for a formal interview if intelligence and the resources to handle it were more readily available.
10. TfL’s Construction Logistics and Cycle Safety Project can serve as a Model for Improving TfL Bus Safety
TfL has taken up the baton with Construction Industry to get a better regime for monitoring and management, delivering a far more effective solution than the sticking plaster approach of adding secondary systems and technological gizmos.  These basically deal with the failings of current truck designs to provide clear direct vision between the driver of the truck and other road users sharing the road space around it rather than providing that direct vision, and managing the truck use to avoid those hazardous situations in the first instance. 
TfL’s Transport Commissioner Peter Hendy recently had a working breakfast with key CEO’s on how the next stages of work for the Construction Logistics and Cycle Safety (CLOCS) project might move forward, with its next full meeting on 10th July 2014.  The Transport Commissioner is clearly rattled by the legal loopholes which permit relaxed operator’s licence conditions for certain types of truck used solely for the owner’s business, and even the mobile plant category which allows what to all appearances is a 40 Tonne truck to be driven on a standard driving licence. 
Reputable operators do apply appropriate standards, but with the legal loopholes it only takes a few to exploit the position to raise the risks.  In the context of bus operations a watershed in another area came a few years ago when the growing use of stretch limousines carrying more than 8 passengers, but not meeting several bus and vehicle safety criteria was reined in, but this (and Tom Kearney might certainly observe) is only tinkering at the edges of a bigger operation.
  
Much of what is being worked on for CLOCS could be transferred to the bus operations.  This fact strikes me as something that can be broached with those high up in TfL and those within the campaigning community who are already backing CLOCS.    Whilst there is a desire to see the bus safety issue delivered directly and with a due sense of urgency, the progress being made in CLOCS can be an opportunity to start with another sector and feed out from the lessons learned and systems proven.  Delivery on a smaller scale (with construction traffic, or as Tom has focussed, on just Oxford Street’s bus routes) will give us the opportunity to fine tune and align the delivery of road safety for all sectors to a common standard and, in turn, will make wider analysis and actions to improve safety easier to deliver.

– A Transport Specialist

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