Chief Inspector’s review
by Richard Hines
HM Chief Inspector of Railways and Director of Railway Safety
A healthy and safe railway is not created by systems alone. It is built every day through the judgement, decisions, and actions of those who design, operate, and maintain it. Systems matter, but safety ultimately depends on how effectively they are delivered across the railway and embedded in day-to-day operations.
This report sets out our assessment of health and safety performance across Great Britain's railway during 2025 to 2026. The year has been characterised by continued change alongside broadly stable overall outcomes. While there has been good progress in several areas, our findings show that the management of risk is not yet delivering the overall level of control and assurance required.
This challenge comes at a time of increasing complexity. Industry reform, financial pressures and evolving operating models are placing greater demands on systems, people, and organisational interfaces. Maintaining high standards requires strong leadership, clear accountability and assurance that is grounded in operational reality, underpinned by active engagement with the workforce. Trade unions and workforce representatives continue to play an important role in identifying hazards, raising concerns, challenging unsafe practices, and supporting the management of risk.
The creation of Great British Railways (GBR) presents a significant opportunity to strengthen system leadership, simplify accountability and improve the management of shared risks. If delivered effectively, reform can help address longstanding weaknesses at organisational interfaces and support a more coherent approach to health and safety across the railway.
Although outside the period covered by this report, the recent passenger train collision at Bedford is a sobering reminder that, despite the railway's strong safety record, the consequences of a major accident can be severe. Our thoughts remain with the family, friends and colleagues of the driver who lost their life, and with all those injured or affected by the accident. The causes of the collision remain under investigation.
Drawing on evidence from inspections, investigations and Risk Management Maturity Model (RM3) assessments, this report provides a comprehensive view of performance across the sector. My key reflections from the past year are set out below.
Network Rail
Network Rail's safety performance remains stable, with progress evident in a number of areas. However, RM3 assessments continue to identify differences in performance across regions and functions, particularly in asset management, workload planning, and the implementation of safe systems of work.
There has been good progress in addressing previously identified gaps in structures management. A significant programme of assessments has provided a better understanding of asset risks and increased assurance over the management of structural risk.
Track worker safety remains a key concern. While progress has been made in reducing higher-risk working practices, recent incidents, including a fatal incident at Radlett, demonstrate that planned protections are not always delivered as intended. Ensuring established safeguards are applied reliably, every time, remains essential.
Level crossing risk has increased, with rising fatalities indicating that existing controls are not always achieving the intended outcome. Incidents such as the Shap derailment also underline the importance of robust infrastructure management in the face of environmental pressures and changing asset conditions. Further improvement will require stronger assurance and greater discipline in the management of known risks.
Mainline operators and freight
The transition of many passenger operators into public ownership increases the importance of clear accountability and effective safety management across the rail industry.
Overspeeding remains one of the most significant and insufficiently controlled risks on the railway. The causes are well understood, yet progress has been too slow. The challenge is not one of knowledge, but of execution and system leadership. The industry must now move decisively from analysis to action, focusing on known high-risk locations and deploying effective controls at pace. I expect to see far greater urgency and demonstrable improvement in this area.
Workforce risks are also becoming more prominent. Violence and harassment, together with weaknesses in fatigue management and welfare provision, require a more systematic response. Improved cooperation across the industry must now translate into better protection and outcomes for the workforce.
The Freight Safe Wagon Condition Programme demonstrates how coordinated industry action can deliver meaningful improvements in risk management.
Non-mainline railways
Safety performance across non-mainline sectors remains broadly stable, but differences in management maturity and risk control capability continue to be evident.
Across Transport for London networks, governance arrangements are generally strong. However, operational delivery remains uneven in some areas, particularly in relation to ageing assets, platform-train interfaces, and occupational health arrangements.
In the tram sector, serious incidents remain rare, but weaknesses persist in the management of risks at public interfaces.
Heritage railways continue to rely heavily on individual competence and experience, which can limit organisational resilience.
Strategy, policy, and regulatory delivery
We have continued to strengthen the regulatory framework while delivering our core statutory functions. This includes progress in modernising train driver licensing, reviewing key legislation such as the Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS), and improving the railway standards framework.
We have delivered a substantial programme of inspections, approvals, and enforcement activity, taking action where necessary to address risk and secure compliance.
Our work with industry, government and international partners continues to promote learning and improvement across the sector. We are also investing in our own capability to ensure we remain an effective regulator of an increasingly complex railway system.
Themes for the year ahead
Britain's railway continues to operate in an environment of increasing complexity. Our findings point to three priorities that require sustained attention during the coming year.
1. Control of risk through transition
Many parts of the railway will continue to experience organisational and operational change. Duty holders must demonstrate that control measures remain effective as responsibilities evolve, interfaces change and operating models develop. Accountability for managing risk must remain clear at all times. We will work constructively with industry while taking a firm approach where change weakens control or creates uncertainty in risk ownership.
2. Assurance grounded in operational reality
Assurance should provide a clear and tested understanding of health and safety performance. Too often, assurance demonstrates that arrangements exist on paper but provides limited evidence that they are being delivered effectively in practice. Duty holders should ensure assurance is grounded in operational reality, informed by frontline activity and capable of identifying emerging weaknesses before they result in harm. We will challenge assurance arrangements that fail to provide an accurate picture of risk.
3. Leadership of system risk and interface failure
Some of the most significant risks arise at organisational interfaces between operators, infrastructure managers, and the wider supply chain. These risks require active leadership, not coordination alone. Leaders must take responsibility for shared risks, align action across organisational boundaries, and address emerging weaknesses before they escalate.
Delivering a healthy and safe railway is a shared responsibility. I would like to thank my colleagues across ORR for their professionalism, expertise and commitment throughout the year, and the many duty holders, workforce representatives, trade unions and industry partners who have worked with us to address risks, share learning, and drive continuous improvement.
The challenges outlined in this report are significant, but they are not insurmountable. The railway has repeatedly demonstrated its ability to learn, adapt and improve.
By maintaining clear accountability, strong leadership, and an unwavering focus on the effective management of risk, we can continue to build a railway that is both safer and healthier for passengers, the workforce, and the communities it serves.
I look forward to working with you in the year ahead.