Talking reports: looking for the 'why' with RfLI

09 May 2024

Our reporting analyst, Helen, and Jane Jemmett, senior SHE business partner at Transport for London, discussed a concern about a potential fire hazard at a Rail for London Infrastructure (RfLI) depot and the positive impact of the CIRAS report.

RfLI took several actions to resolve the issue as a result of the concern.

London Overground infrastructure and lights

Summary of the reporter's concern

We listened to a concern about a fire hazard at Plumstead sidings due to cleaners propping open fire doors. The reporter said the issue was ongoing and consistent. They were also concerned that other staff were not removing the items used to keep the fire doors open.

Underlying cause

Reporter’s view: They believed that the doors were propped open by cleaners trying to dry floors quickly after mopping, to prevent a slip hazard.

Company’s view: RfLI confirmed that doors were being propped open to help the wet floors dry. In our conversation with Jane, we also discovered that during its investigation, RfLI found there was confusion at the depot about whether the doors were fire doors or not, and so whether keeping them open was a fire hazard.

How the company responded

RfLI was very proactive, showing that it took the concern seriously. The company worked to resolve the issues with a multi-pronged approach. This included:

Infrastructure

Changing the doors to meet the criteria for fire doors.

Review of other doors.

Process

Changing the cleaning process so cleaners dry-mop the floor after wet-mopping, removing any slip hazard.

Equipment

Putting in place new signs so staff and stakeholders are aware of the cleaning process taking place and/or the hazard of a drying floor.

Delving deeper into the reasons

At CIRAS, we are always interested to know how our reports impact our members, so we asked Jane what she felt was most useful about receiving the report.

‘It caused us to ask questions, because when we went to inspect the door… [the issue] ended up being much bigger.’

RfLI discovered that although the door had fire signage indicating it was a fire door, it also had a large ventilation panel at the bottom, and no intumescent strips. This meant that depot staff and contractors seeing this door received mixed messages about its purpose. ‘There was a clear design failure.’

What initially appeared to be an issue about rules and process had another layer. The cleaners had possibly thought it was not a fire door because of the ventilation panel, and the reporter had thought it was one because of the signage.

Jane explained that when the sidings moved from Crossrail to TfL when the Elizabeth Line launched, it was a time of transition, and snagging issues emerge.

‘So, the more that people can report stuff, the better, because we can’t be everywhere all the time. We need everybody to be our eyes and ears. I think that’s what was really good about the report: it flagged something that people hadn’t really considered before.’

As a result, one of the company’s actions was to consult with the fire engineering team and change the doors to solid ones. It also prompted a review of doors at other locations.

Encouraging people to ask why

The report mentions that ‘staff at this location have not been proactive in removing this hazard when noticing it’.

We asked Jane for her advice to other health and safety professionals for creating a culture that encourages staff to challenge unsafe behaviours. She said, ‘I advocate a “why” culture. I encourage people to ask the question, “Why?”’

Asking why leads to further understanding, including about the thought processes behind behaviour.

RfLI’s investigation into the CIRAS report began: ‘Why is that door being propped open? Because people don’t set out in the morning when they go to work to be unsafe or do things that are unsafe. It makes sense to them at the time.’

By propping the doors open, the cleaners were hoping to make the floors dry quicker, because someone might slip on them when they are wet. They also thought there was no issue with propping open this door because it had a ventilation panel, so it did not look like a fire door. The next question is why there was a ventilation panel. ‘So, there is something wrong with the design that has led to that unsafe behaviour.’

The focus on ‘why’ illustrates Jane’s approach to encouraging others to raise concerns. ‘You’re not “dropping anyone in it”. What you’re doing is you’re flagging [an issue]. You’re saying: something’s wrong here, and we need to find out why.’

Replacing one hazard inadvertently with another

As the report focused on a hazard being introduced inadvertently while trying to fix another hazard, we asked Jane whether she had experience of this before. ‘That’s a good question,’ she said. ‘I’m sure I have…, because it’s not uncommon where you solve one problem and create another.’

She gave the example of, ‘[trying to prevent] a slip hazard and then [creating] a trip hazard if it’s not the correct type of matte rubber-backed mat. You put a mat down to try to stop the slip hazard and you create a trip hazard.’

Asked what can be done to prevent this, she adds, ‘People thinking through the consequences of their actions … To think, if I do this, what will the domino effect be?’

RfLI therefore seeks to have a work environment that promotes this behaviour and culture through active engagement. ‘When we do our safety briefings, when we [directly engage] with teams, when we do safety stand downs, we talk about consequences of actions. So, if you do X, will Y happen?

‘It’s about changing people’s behaviour, to get them to stop and think. And not just about what they’re doing here and now, but that domino effect,’ such as where it fits in with what other people are doing, and their own tasks.

Excellent listening

We find safety in listening, and we build a strong listening partnership with our members to improve safety, helping them to listen to the concerns that might otherwise stay hidden.

Discussing what excellent listening looks like at RfLI, Jane explains, ‘I go back to the why, rather than jump into the blame or the defensiveness.

‘Someone’s taken the time [to raise a concern]. They haven’t walked by…. [There are] several levels of raising concerns.:

Someone walks by and thinks, “Someone else must have reported that. It’s so obvious.”
Someone mentions it to somebody.
Someone has taken the time to fill out a CIRAS form or close call form.

‘We’ve got to say, “Thank you. You’ve done exactly what we wanted you to do. You’ve taken responsibility for your own safety, getting yourself home safe, but you’ve also shown that you care for others.”

‘I see reporting things like this as someone who cares about others, and it’s our job to then do something about it.’

CIRAS’ role

CIRAS helps organisations to act on information that might otherwise stay hidden, and this was clear in the conversation. As Jane said, ‘CIRAS is brilliant because rail organisations are so vast. How can anyone know exactly who to report to? If there’s an issue at a station, who would you raise it to? Station customer service desk? Station manager? Network Rail? A TOC? Which TOC? If you submit a CIRAS concern, then you know the concern will get raised to the appropriate company.’

Conclusion

We finished our discussion by asking Jane what her biggest takeaway was from the report. She said, ‘…that CIRAS is a force for good. It’s another stream to find out things that are wrong so we can fix them.

‘The Elizabeth line has 10 stakeholders, and each of those are huge organisations in their own right. It can be hard to know who to tell, and that’s what CIRAS is good for.’