UK railway suicides – 2017 update

The latest UK rail safety statistics were published on 23 November 2017, again absent much of the press fanfare we had seen in the past. Regular readers of this blog will know that I have followed the suicide data series, and the press response, closely in 2016, 20152014, 2013 and 2012. Again I have re-plotted the data myself on a Shewhart chart.

RailwaySuicides20171

Readers should note the following about the chart.

  • Many thanks to Tom Leveson Gower at the Office of Rail and Road who confirmed that the figures are for the year up to the end of March.
  • Some of the numbers for earlier years have been updated by the statistical authority.
  • I have recalculated natural process limits (NPLs) as there are still no more than 20 annual observations, and because the historical data has been updated. The NPLs have therefore changed but, this year, not by much.
  • Again, the pattern of signals, with respect to the NPLs, is similar to last year.

The current chart again shows two signals, an observation above the upper NPL in 2015 and a run of 8 below the centre line from 2002 to 2009. As I always remark, the Terry Weight rule says that a signal gives us license to interpret the ups and downs on the chart. So I shall have a go at doing that.

It will not escape anybody’s attention that this is now the second year in which there has been a fall in the number of fatalities.

I haven’t yet seen any real contemporaneous comment on the numbers from the press. This item appeared on the BBC, a weak performer in the field of data journalism but clearly with privileged access to the numbers, on 30 June 2017, confidently attributing the fall to past initiatives.

Sky News clearly also had advanced sight of the numbers and make the bold claim that:

… for every death, six more lives were saved through interventions.

That item goes on to highlight a campaign to encourage fellow train users to engage with anybody whose behaviour attracted attention.

But what conclusions can we really draw?

In 2015 I was coming to the conclusion that the data increasingly looked like a gradual upward trend. The 2016 data offered a challenge to that but my view was still that it was too soon to say that the trend had reversed. There was nothing in the data incompatible with a continuing trend. This year, 2017, has seen 2016’s fall repeated. A welcome development but does it really show conclusively that the upward trending pattern is broken? Regular readers of this blog will know that Langian statistics like “lowest for six years” carry no probative weight here.

Signal or noise?

Has there been a change to the underlying cause system that drives the suicide numbers? Last year, I fitted a trend line through the data and asked which narrative best fitted what I observed, a continuing increasing trend or a trend that had plateaued or even reversed. You can review my analysis from last year here.

Here is the data and fitted trend updated with this year’s numbers, along with NPLs around the fitted line, the same as I did last year.

RailwaySuicides20172

Let’s think a little deeper about how to analyse the data. The first step of any statistical investigation ought to be the cause and effect diagram.

SuicideCne

The difficulty with the suicide data is that there is very little reproducible and verifiable knowledge as to its causes. I have seen claims, of whose provenance I am uncertain, that railway suicide is virtually unknown in the USA. There is a lot of useful thinking from common human experience and from more general theories in psychology. But the uncertainty is great. It is not possible to come up with a definitive cause and effect diagram on which all will agree, other from the point of view of identifying candidate factors.

The earlier evidence of a trend, however, suggests that there might be some causes that are developing over time. It is not difficult to imagine that economic trends and the cumulative awareness of other fatalities might have an impact. We are talking about a number of things that might appear on the cause and effect diagram and some that do not, the “unknown unknowns”. When I identified “time” as a factor, I was taking sundry “lurking” factors and suspected causes from the cause and effect diagram that might have a secular impact. I aggregated them under the proxy factor “time” for want of a more exact analysis.

What I have tried to do is to split the data into two parts:

  • A trend (linear simply for the sake of exploratory data analysis (EDA); and
  • The residual variation about the trend.

The question I want to ask is whether the residual variation is stable, just plain noise, or whether there is a signal there that might give me a clue that a linear trend does not hold.

There is no signal in the detrended data, no signal that the trend has reversed. The tough truth of the data is that it supports either narrative.

  • The upward trend is continuing and is stable. There has been no reversal of trend yet.
  • The data is not stable. True there is evidence of an upward trend in the past but there is now evidence that deaths are decreasing.

Of course, there is no particular reason, absent the data, to believe in an increasing trend and the initiative to mitigate the situation might well be expected to result in an improvement.

Sometimes, with data, we have to be honest and say that we do not have the conclusive answer. That is the case here. All that can be done is to continue the existing initiatives and look to the future. Nobody ever likes that as a conclusion but it is no good pretending things are unambiguous when that is not the case.

Next steps

Previously I noted proposals to repeat a strategy from Japan of bathing railway platforms with blue light. In the UK, I understand that such lights were installed at Gatwick in summer 2014. In fact my wife and I were on the platform at Gatwick just this week and I had the opportunity to observe them. I also noted, on my way back from court the other day, blue strip lights along the platform edge at East Croydon. I think they are recently installed. However, I have not seen any data or heard of any analysis.

A huge amount of sincere endeavour has gone into this issue but further efforts have to be against the background that there is still no conclusive evidence of improvement.

Suggestions for alternative analyses are always welcomed here.

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UK railway suicides – 2015 update

The latest UK rail safety statistics were published in September 2015 absent the usual press fanfare. Regular readers of this blog will know that I have followed the suicide data series, and the press response, closely in 2014, 2013 and 2012.

This year I am conscious that one of those units is not a mere statistic but a dear colleague, Nigel Clements. It was poet W B Yeats who observed, in his valedictory verse Under Ben Bulben that “Measurement began our might.” He ends the poem by inviting us to “Cast a cold eye/ On life, on death.” Sometimes, with statistics, we cast the cold eye but the personal reminds us that it must never be an academic exercise.

Nigel’s death gives me an additional reason for following this series. I originally latched onto it because I felt that exaggerated claims  as to trends were being made. It struck me as a closely bounded problem that should be susceptible to taught measurement. And it was something important.  Again I have re-plotted the data myself on a Shewhart chart.

RailwaySuicides4

Readers should note the following about the chart.

  • Some of the numbers for earlier years have been updated by the statistical authority.
  • I have recalculated natural process limits as there are still no more than 20 annual observations.
  • The signal noted last year has persisted (in red) with two consecutive observations above the upper natural process limit. There are also now eight points below the centre line at the beginning of the series.

As my colleague Terry Weight always taught me, a signal gives us license to interpret the ups and downs on the chart. This increasingly looks like a gradual upward trend.

Though there was this year little coverage in the press, I did find this article in The Guardian newspaper. I had previously wondered whether the railway data simply reflected an increasing trend in UK suicide in general. The Guardian report is eager to emphasise:

The total number [of suicides] in the UK has risen in recent years, with the latest Office for National Statistics figures showing 6,233 suicides registered in the UK in 2013, a 4% increase on the previous year.

Well, #executivetimeseries! I have low expectations of press data journalism so I do not know why I am disappointed. In any event I decided to plot the data. There were a few problems. The railway data is not collected by calendar year so the latest observation is 2014/15. I have not managed to identify which months are included though, while I was hunting I found out that the railway data does not include London Underground. I can find no railway data before 2001/02. The national suicide data is collected by calendar year and the last year published is 2013. I have done my best by (not quite) arbitrarily identifying 2013/14 in the railway data with 2013 nationally. I also tried the obvious shift by one year and it did not change the picture.

RailwaySuicides5

I have added a LOWESS line (with smoothing parameter 0.4) to the national data the better to pick out the minimum around 2007, just before the start of the financial crisis. That is where the steady decline over the previous quarter century reverses. It is in itself an arresting statistic. But I don’t see the national trend mirrored in the railway data, thereby explaining that trend.

Previously I noted proposals to repeat a strategy from Japan of bathing railway platforms with blue light. Professor Michiko Ueda of Syracuse University was kind enough to send me details of the research. The conclusions were encouraging but tentative and, unfortunately, the Japanese rail companies have not made any fresh data available for analysis since 2010. In the UK, I understand that such lights were installed at Gatwick in summer 2014 but I have not seen any data.

A huge amount of sincere endeavour has gone into this issue but further efforts have to be against the background that there is an escalating and unexplained problem.

Things and actions are what they are and the consequences of them will be what they will be: why then should we desire to be deceived?

Joseph Butler

UK railway suicides – 2014 update

It’s taken me a while to sit down and blog about this news item from October 2014: Sharp Rise in Railway Suicides Say Network Rail . Regular readers of this blog will know that I have followed this data series closely in 2013 and 2012.

The headline was based on the latest UK government data. However, I baulk at the way these things are reported by the press. The news item states as follows.

The number of people who have committed suicide on Britain’s railways in the last year has almost reached 300, Network Rail and the Samaritans have warned. Official figures for 2013-14 show there have already been 279 suicides on the UK’s rail network – the highest number on record and up from 246 in the previous year.

I don’t think it’s helpful to characterise 279 deaths as “almost … 300”, where there is, in any event, no particular significance in the number 300. It arbitrarily conveys the impression that some pivotal threshold is threatened. Further, there is no especial significance in an increase from 246 to 279 deaths. Another executive time series. Every one of the 279 is a tragedy as is every one of the 246. The experience base has varied from year to year and there is no surprise that it has varied again. To assess the tone of the news report I have replotted the data myself.

RailwaySuicides3

Readers should note the following about the chart.

  • Some of the numbers for earlier years have been updated by the statistical authority.
  • I have recalculated natural process limits as there are still no more than 20 annual observations.
  • There is now a signal (in red) of an observation above the upper natural process limit.

The news report is justified, unlike the earlier ones. There is a signal in the chart and an objective basis for concluding that there is more than just a stable system of trouble. There is a signal and not just noise.

As my colleague Terry Weight always taught me, a signal gives us license to interpret the ups and downs on the chart. There are two possible narratives that immediately suggest themselves from the chart.

  • A sudden increase in deaths in 2013/14; or
  • A gradual increasing trend from around 200 in 2001/02.

The chart supports either story. To distinguish would require other sources of information, possibly historical data that can provide some borrowing strength, or a plan for future data collection. Once there is a signal, it makes sense to ask what was its cause. Building  a narrative around the data is a critical part of that enquiry. A manager needs to seek the cause of the signal so that he or she can take action to improve system outcomes. Reliably identifying a cause requires trenchant criticism of historical data.

My first thought here was to wonder whether the railway data simply reflected an increasing trend in suicide in general. Certainly a very quick look at the data here suggests that the broader trend of suicides has been downwards and certainly not increasing. It appears that there is some factor localised to railways at work.

I have seen proposals to repeat a strategy from Japan of bathing railway platforms with blue light. I have not scrutinised the Japanese data but the claims made in this paper and this are impressive in terms of purported incident reduction. If these modifications are implemented at British stations we can look at the chart to see whether there is a signal of fewer suicides. That is the only real evidence that counts.

Those who were advocating a narrative of increasing railway suicides in earlier years may feel vindicated. However, until this latest evidence there was no signal on the chart. There is always competition for resources and directing effort on a false assumptions leads to misallocation. Intervening in a stable system of trouble, a system featuring only noise, on the false belief that there is a signal will usually make the situation worse. Failing to listen to the voice of the process on the chart risks diverting vital resources and using them to make outcomes worse.

Of course, data in terms of time between incidents is much more powerful in spotting an early signal. I have not had the opportunity to look at such data but it would have provided more, better and earlier evidence.

Where there is a perception of a trend there will always be an instinctive temptation to fit a straight line through the data. I always ask myself why this should help in identifying the causes of the signal. In terms of analysis at this stage I cannot see how it would help. However, when we come to look for a signal of improvement in future years it may well be a helpful step.

The dark side of discipline

W Edwards Deming was very impressed with Japanese railways. In Out of the Crisis (1986) he wrote this.

The economy of a single plan that will work is obvious. As an example, may I cite a proposed itinerary in Japan:

          1725 h Leave Taku City.
          1923 h Arrive Hakata.
Change trains.
          1924 h Leave Hakata [for Osaka, at 210 km/hr]

Only one minute to change trains? You don’t need a whole minute. You will have 30 seconds left over. No alternate plan was necessary.

My friend Bob King … while in Japan in November 1983 received these instructions to reach by train a company that he was to visit.

          0903 h Board the train. Pay no attention to trains at 0858, 0901.
          0957 h Off.

No further instruction was needed.

Deming seemed to assume that these outcomes were delivered by a capable and, moreover, stable system. That may well have been the case in 1983. However, by 2005 matters had drifted.

Aftermath of the Amagasaki rail crashThe other night I watched, recorded from the BBC, the documentary Brakeless: Why Trains Crash about the Amagasaki rail crash on 25 April 2005. I fear that it is no longer available in BBC iPlayer. However, most of the documentaries in this BBC Storyville strand are independently produced and usually have some limited theatrical release or are available elsewhere. I now see that the documentary is available here on Dailymotion.

The documentary painted a system of “discipline” on the railway where drivers were held directly responsible for outcomes, overridingly punctuality. This was not a documentary aimed at engineers but the first thing missing for me was any risk assessment of the way the railway was run. Perhaps it was there but it is difficult to see what thought process would lead to a failure to mitigate the risks of production pressures.

However, beyond that, for me the documentary raised some important issues of process discipline. We must be very careful when we make anyone working within a process responsible for its outputs. That sounds a strange thing to say but Paul Jennings at Rolls-Royce always used to remind me You can’t work on outcomes.

The difficulty that the Amagasaki train drivers had was that the railway was inherently subject to sources of variation over which the drivers had no control. In the face of those sources of variation, they were pressured to maintain the discipline of a punctual timetable. They way they did that was to transgress other dimensions of process discipline, in the Amagasaki case, speed limits.

Anybody at work must diligently follow the process given to them. But if that process does not deliver the intended outcome then that is the responsibility of the manager who owns the process, not the worker. When a worker, with the best of intentions, seeks independently to modify the process, they are in a poor position, constrained as they are by their own bounded rationality. They will inevitably by trapped by System 1 thinking.

Of course, it is great when workers can get involved with the manager’s efforts to align the voice of the process with the voice of the customer. However, the experimentation stops when they start operating the process live.

Fundamentally, it is a moral certainty that purblind pursuit of a target will lead to over-adjustment by the worker, what Deming called “tampering”. That in turn leads to increased costs, aggravated risk and vitiated consumer satisfaction.

Sad news on railway suicide statistics

I recently blogged about statistics of suicides on British railways here and here. Some very worthwhile programmes had been put in place with the objective of reducing these tragic deaths. However, my view at the point of my earlier posts was that this was a stable system of trouble, that there was neither a deteriorating trend nor any sign of improvement.

I now have the statistics for 2012/2013 to hand, released without any framing press notice. Here is the updated process behaviour chart.
RailwaySuicides2

Readers should note the following about the chart.

  • Some of the numbers for earlier years have been updated by the statistical authority.
  • I have recalculated natural process limits as there are still no more than 20 annual observations.
  • There is still no signal of improvement or deterioration.

I fear that this is the tough discipline of the chart. It confronts us with current reality and deprives us of the opportunity to find comforting messages. Only a signal on the chart would be evidence of improvement. Statistics are not there to be selectively reported only when they fit our wishes and hopes. Statistics are to be charted, and reported, and discussed, and used as a basis for managing any operation; year in, year out.

Remember that in leading any operation the manager is confined to the retreating picture in the rearview mirror. Without the process behaviour chart, the manager is deprived even of that rear view.

It is a sad picture but improvement only comes from confronting current failure and finding new ways to intervene and redesign. Nobody will benefit from an ultimately vain quest for comforting messages.