Arbutus Technical Consulting

I have just finished watching the recording of Wim Coenraad’s IET presentation “Understanding the ‘English Disease…”. As one of the authors of the Yellow Book, the billing could not help but catch my eye:

“In recent years a safety case seems to have become synonymous with long delays, caused by consultants, aka “brains on sticks” inventing solutions for problems, drawing out assessments and costs spiralling out of control. In some places this is seen as “Yellow Book fever”, or “the English disease”. UK practices seem to be exporting the Yellow Book Philosophy and by putting procedures before brains, through largely unmanaged, ISAs as well as processes, in a stifling (legal) framework, which is dominated by fear of litigation and indemnity claims. It is not risk based but risk averse and clearly unsustainable and therefore a threat to the rest of us!”

So I watched the presentation with some apprehension. Was the Yellow Book going to be likened to ‘Mad Cow Disease” and its authors to football hooligans? In fact, Mr Coenraad’s criticisms of the content of the Yellow Book are mostly concerned with the presentation of Safety Cases where he makes some sensible and cogent proposals which, if adopted, would leave the majority of the Yellow Book untouched.

Mr Coenraad’s main criticism is reserved for the way in which the Yellow Book is used and in particular for a promotion of text which is clearly advisory guidance to mandatory requirements and its application in circumstances where it is not appropriate. Now I know that this happens and it is clearly a bad thing so it doesn’t seem unreasonable to refer to it as a ‘disease’.

So for the purpose of this article, I hope I am not straying too far from Mr Coenraad’s presentation if I define the ‘English disease’ to be an unthinking application of inappropriate advisory safety guidance.

As to whether it’s a fair name, I don’t know. It’s certainly not restricted to England but the English do seem to be rather prone to it. Whatever its name, it is worth of study. Let’s call it ED for now.

Mr Coenraad offers his analysis of the cause and consequences and of ED and some suggestions for remedies. I’d like to develop these further.

Causes

Mr Coenraad suggests two causes:

• A legal environment that causes people to feel that they must follow authoritative guidance, whether they believe that it is appropriate or not because, if an accident were to occur, they might find themselves in court with a lawyer waving the Yellow Book (or whatever) at them asking them why they had not followed the guidance on page such-and-such.

• Assessors who find it easier to check project processes and products clause-by-clause against a publication like the Yellow Book than to form a judgement from first principles as to whether the processes and products are suitable for their purposes.

My personal suspicion is that the first cause drives the second and that assessor’s behaviour is driven more by the threat of finding themselves in court than by laziness. So it is the first caysethat interests me.

Here I suspect that the problem, in the UK at least, may be traced back to clause 3 (i) of the Health and Safety at Work etc Act 1974 which reads:

“It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.”

For what it’s worth, I have always considered this to be a reasonable formulation of the duty of care which I believe that we owe to each other. However, the use of “reasonable practicability” as a test of legal guilt leads to a situation where it is extremely difficult to know whether one is breaking the law or not. That is a very uncomfortable position to find oneself in it and it is only human nature to try and remove this discomfort by finding some authoritative procedure to follow which one could then use as a defence in a court of law.

Consequences

Mr Coenraad suggests that the immediate consequences of ED are unnecessary activities and paperwork, leading to increased costs which divert resources from measures that would reduce risk and, he argues, threatening to making the railways economically unsustainable. I don’t have the knowledge to judge whether the consequences are quite as severe as this but, otherwise, I find the analysis logical and compelling.

But I think it is worse than that. As I have argued elsewhere, I think that having people carry out tasks in the name of safety which do not actually contribute to making anything safer is counter-productive in its own terms because:

• It breeds a cynicism which can in turn lead to passivity when faced with things that are not as they should be;
• It diverts a proportion of a limited pool of experienced, capable people’s time from other activities, some of which might have delivered increased safety; and
• It stifles people’s ingenuity.

If anything it is the last one that worries me most. A random transposition of vowels has contributed to a misunderstanding of engineering in the UK. People assume that “engineers” were originally people who mended engines and mix us up with technicians. “Engineer” is “ingenieur” in Dutch and German, “ingénieur” in French and “ingegnere” in Italian and, in all these languages, it is clearer that an engineer is someone who is paid to use their ingenuity. Railways are as safe as they are because of the accumulated consequences of any number of ingenious inventions. If we are going to replace that ingenuity with blind following of rules then that improvement is going to stop.

So I am convinced that, all other things being equal, the consequences of ED include rail travel that is less safe that it would otherwise have been.

Remedies

Mr Coenraad suggests resisting pressures to do things that you don’t believe contribute to safety. I agree with that but it does not seem to me to be a real cure. I think we need to try to attack some of the root causes.

Firstly, I do think that those who make and enforce health and safety law need to:

• Make sure that those who are subject to it can be sure in advance whether they are following it or not; and
• be quite clear that the law can be relied upon to distinguish between cutting corners and a principled, properly thought through and properly checked decision not to follow an established practice on the grounds that it is not appropriate to the circumstances at hand.

But the law changes slowly. In the meantime, I think that we need to look for other remedies. I was discussing this with a friend and ex-colleague Richard Tavendale. About 10 years ago, we wrote a paper together arguing that we should articulate the fundamental principles behind the Yellow Book. This idea was adopted and since issue 3 was published in 2000, the Yellow Book has been structured around a number of fundamentals.

Richard and I agree that the introduction of Yellow Book fundamentals was a step forward but neither of us thinks that this step has yet been fully exploited. Perhaps an injection of Yellow Book fundamentals might provide patients with some resistance to ED?

Yellow Book 4 contains the following text:

“If your organisation already has a systematic approach to managing safety, you should check that it puts all the fundamentals into practice. If you do not have a systematic approach yet, or if your approach does not yet put all the fundamentals into practice, you may find volume 2 useful. You do not have to use the approach described there and it is not the only effective approach, but it has been proven in practice.”

Mr Coenraad exhorts people to “engage their brains” before reading the book. Surely he must have something like this in mind.

I suggest a couple more remedies:

• Those of us who are doing Engineering Safety Management can turn down the corner of that page in the Yellow Book so that we can find it quickly the next time an assessor tells us that “you have to do this because it says so in the Yellow Book”.
• Those of use who are assessing others can bear this advice in mind as well. We can try to lift our assessment from checking the contents lists of Safety Plans to trying to judge whether or not the fundamentals are being effectively put into practice.

Then perhaps we can talk about the Yellow Book as a cure of ED rather than a means of infection.