RAIB discussion

Rail Accident Investigation Branch (RAIB) has released its report into the unauthorised entry of a train onto a single line at Greenford.

RAIB has made three recommendations and identified two learning points.

Click here to read more on the Rail Accident Investigation Website.

141222_R292014_Greenford.pdf (6,208.44 kb)

" said:

Rail Accident Investigation Branch (RAIB) has released its report into the unauthorised entry of a train onto a single line at Greenford.

RAIB has made three recommendations and identified two learning points.

Click here to read more on the Rail Accident Investigation Website.

141222_R292014_Greenford.pdf (6,208.44 kb)

I have long wondered how the RIAB has the resources to investigate all manner of what appear to be minor incidents and rulebook violations. Did the railway operating companies somehow divest their own internal compliance departments?

Accidents or incidents which could have lead to deaths or serious injuries or 2m euros worth of damage to trains, infrastructure or environment, had the circumstances been slightly different.
If in doubt notify.

Personally, I'd class a SPAD onto a single line as significantly more than a 'minor rulebook violation'. Had a train been heading the other way, a head-on collision involving at least one passenger train would have resulted.

I've always had the impression that the Americans just accept head-on collisions on single lines and the resultant fireballs/toxic gas clouds as being a routine part of railway operation.

I actually looked up the number of railroad related National Transportation Safety Board investigations and it averages ~10 a year (many of which are 10 pages or less). It's sort of getting a best picture nomination since due to budget and staff constraints they only investigate incidents involving a collision, passenger/employee fatality or serious derailment (serious appearing to mean hazardous waste spill or explosion).

As much as I love reading the reports I am aware of the significant amount of polish that's been put into them and it made me wonder how it's avoided budget cuts in this age of austerity.

The quality of the RAIB reports are very good. Clear, technical where necessary, well structured and objective.

A lot of organisations, both public and private, would do well to mirror this quality of report.

" said:

The quality of the RAIB reports are very good. Clear, technical where necessary, well structured and objective.

A lot of organisations, both public and private, would do well to mirror this quality of report.

After reading through some of the NTSB reports I have a bit of a feeling that less might be more. Each of these reports go into so many different casual factors, contributing factors and lessons learned that I feel there can be a diffusion of responsibility. The person at fault in that incident was the driver, full stop. He not only disregarded two(?) stop signals, but also departed his initial terminal with a critical safety system disabled. Going into issues with pulling up the intermediate signal too soon creates the impression that drivers are not responsible for passing Stop signals and running with TPWS disabled.

There are many lessons that can be learned from any event, but too many lessons at any one time creates fatigue and allows every named party to feel that they aren't the ones responsible and don't really need to act. In this case I would have issued the GSM-R problems as a stand alone safety alert so that it doesn't distract from the causes of the incident and doesn't get buried.

This incident would fall under Schedule 1 (notify immediately) section 9

Quote:

Accidents or incidents which could have lead to deaths or serious injuries or 2m euros worth of damage to trains, infrastructure or environment, had the circumstances been slightly different.
If in doubt notify.

" said:

This incident would fall under Schedule 1 (notify immediately) section 9

Quote:

Accidents or incidents which could have lead to deaths or serious injuries or 2m euros worth of damage to trains, infrastructure or environment, had the circumstances been slightly different.
If in doubt notify.

Good grief: why measure damage in the UK in euros?

Peter

" said:

" said:

The quality of the RAIB reports are very good. Clear, technical where necessary, well structured and objective.

A lot of organisations, both public and private, would do well to mirror this quality of report.

After reading through some of the NTSB reports I have a bit of a feeling that less might be more. Each of these reports go into so many different casual factors, contributing factors and lessons learned that I feel there can be a diffusion of responsibility. The person at fault in that incident was the driver, full stop. He not only disregarded two(?) stop signals, but also departed his initial terminal with a critical safety system disabled. Going into issues with pulling up the intermediate signal too soon creates the impression that drivers are not responsible for passing Stop signals and running with TPWS disabled.

There are many lessons that can be learned from any event, but too many lessons at any one time creates fatigue and allows every named party to feel that they aren't the ones responsible and don't really need to act. In this case I would have issued the GSM-R problems as a stand alone safety alert so that it doesn't distract from the causes of the incident and doesn't get buried.

That sort of thing might happen across the Pond. Over here, the reverse is true - every party to whom a recommendation or learning point is directed would be expected to (and would, as a matter of course, in any case) take on board any part of the whole situation that was their responsibility. That is our culture. And it has been since the 'good old days' of the Railway Inspectorate, staffed with retired Royal Engineers who always "..ha[d] the honour to report, for the information of the Secretary of State, the results of my enquiry into [accident details] in accordance with your order of [date] in which, I very much regret to say, X persons lost their lives" and signed off with:
"I remain, sir,
Your obedient servant,
N______________"

Incidentally, if you want a good read, the old Inspecting Officers' reports are a delight, a combination of absolutely correct (often archaic) English with penetrating technical understanding and awareness of human factors.

It is those reports and their RAIB successors, going beyond the proximate causes to the underlying factors, that have led to the enviable safety record railways have in this country. That wouldn't have happened if they hadn't looked more deeply into contributing factors.

Oh, and if you want to see what going in to too much detail could look like, read the Hidden Report (the investigation into the Clapham Junction collision of 1988). Sir Anthony Hidden QC is a lawyer (now a High Court judge) and his report is exhaustive. It is also clearly not written by someone who understands railways. His description of the operation of track circuits and the controls for WF138 signal are exemplary, comprehensible to the least technically-minded. But when I read it, I can't help getting the impression of this brilliant legal mind so able in the matters of words and their meanings struggling to get to grips with the operation of this technical apparatus. Delicious!

" said:

" said:

This incident would fall under Schedule 1 (notify immediately) section 9

Quote:

Accidents or incidents which could have lead to deaths or serious injuries or 2m euros worth of damage to trains, infrastructure or environment, had the circumstances been slightly different.
If in doubt notify.

Good grief: why measure damage in the UK in euros?

Peter

Probably an EU directive.

As safety improves more and more, the role of the reporting body has subtly changed from making great leaps in policy and training matters to finding failures in a now well honed system. So no longer are we seeing reports into the deaths of railwaymen due to terrible collision protection, now we are trying to avoid the collision in the first place by investigating near misses, etc.

Compare those 24 fatalities with the zero last year (in fact I don't think there's been a fatality due to a train crash since Grayrigg?) - I'd say you probably can't critique the way the UK industry reports on incidents.

A good illustration of the difference between the UK and US mindset can be seen if you read the first report on the linked NTSB site - ​"Collision of BNSF Railway Company and Union Pacific Railroad Trains Near Keithville, Louisiana"

Two trains are booked to pass on a single line in the early hours of the morning. The first train goes into the loop and the conductor on the train sets the hand points for the main line. Then a second conductor following the looped train in a van (to help the crew) arrives nearby and hears another train approaching the location on the open channel radio; he gets out of the van sets the hand points for the loop. As the other train is approaching, the second conductor realises his error but runs away instead of trying to correct it. The second train is diverted into the loop and collides head on with the first train.

This an interesting accident which throws up all sorts of human factors stuff and questions about the railway's operating practices. The initial wrong assumption was made because of something overheard on Mike's beloved open channel radio. The signaller was unaware of any of this because there are no signals and the points are hand operated and undetected. One of the most interesting things for me was that the signaller had already issued the crew of the looped train with authority to move "after the southbound train passes" which surely invites disaster if the radio cuts out before the vital last part. Put simply there's plenty of meat there for an investigation to get stuck into...

The NTSB conclusion is that the train was derailed because the second conductor incorrectly operated the hand points. That's it. Just a bald narrative of the accident with no discussion and no reccomendations. It could happen again tomorrow and no one would bat an eyelid.

If this had happened over here on either of the remaining RETB lines, people would be in jail and the RAIB report would be about a thousand pages long. But at least it would only happen once. I'll stick with the UK way of doing things please.

I'm not expecting such events to go un-investigated, just that said investigations would be undertaken by Network Rail or some other responsible authority. I figured this could be a side effect of the semi-privatization scheme and the desire for some neutral investigator.

Well beyond a certain point one starts getting diminishing returns. The cost of preventing the last few deaths a year is much higher than the first hundred. We live in a world of limited resources so if something like a whistling teapot was identified in a report as having distracted a signalman, then efforts to enforce the new teapot policy might replace enforcement of something more critical. Moreover the money spent on the new teapot policy (or other such policies) might be better spent on employee wellness programs due to the shift from mechanical lever frames to video displays raising the level of obesity.

The person at fault in that incident was the driver, full stop.