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RAIB DLR

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RAIB DLR 05/03/2010 at 12:23 #807
caedave
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142 posts
Why does it take 3 companies to run this railway. From the RAIB report on other incidents, none of them seem to take much notice of RAIB recommendations.
They don't talk to each other, seem to have no idea on planning or system testing and regularly disregard there own rules.

Rather glad that I am not required to travel on it.

Dave M.

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RAIB DLR 05/03/2010 at 12:23 #7095
caedave
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142 posts
Why does it take 3 companies to run this railway. From the RAIB report on other incidents, none of them seem to take much notice of RAIB recommendations.
They don't talk to each other, seem to have no idea on planning or system testing and regularly disregard there own rules.

Rather glad that I am not required to travel on it.

Dave M.

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RAIB DLR 05/03/2010 at 18:31 #7101
ralphjwchadkirk
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275 posts
The RAIB have no legal power - apart from the powers to investigate it.

Stupidly there is no legal obligation for a TOC to take on the RAIB's recommendations. Only HMRI can do that.

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RAIB DLR 05/03/2010 at 20:39 #7108
caedave
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142 posts
As you say, and I think that is the correct way. Enforcement powers would almost certainly reduce there effective investigation ability
by having the companies trying to protect themselves.

It was just the offhanded way that the companies, having said they agreed with the recommendations when made in a prior report,
are found in this investigation to have done little or nothing about them and in fact repeated the same errors.

Example: The company that is doing the upgrade is Canadian, although it's got a UK arm it's reports have to come from Canada.
These are passed on the nod by one of other companies and not even sent to the actual operating company.

Dave M.

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RAIB DLR 06/03/2010 at 09:22 #7118
northroad
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Dave,
Got to agree with your conclusions on this report which now having read it I find quite daming in parts. Seems to me that assumptions were made as to what the Control Centre were and were not told about with the new layout. Surely it was up to the Control Centre to make decisions about what effects them or does not.
I seem to remember that parts of a system not being fully decommissioned during upgrading, with wiring removed or correctly isolated was what was to blame for Clapham all those years back.
Was anyone dismissed over this do you know? or at least stood down until further training had been carried out and passed.
As for the records not being up to date and receipt not being acknowledged as being in the hands of the correct people some time after changes were made. I might work in a different industry but let me tell you this is not uncommon.
One final point and what I find the most disturbing that all rail systems, maintenance etc, seem to be that fragmented these days that I am not suprised that the information trail takes so long to complete.

Thanks to Ken for the update on the report being issued.

Geoff

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RAIB DLR 06/03/2010 at 12:47 #7119
caedave
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142 posts
Yes, I have seen it too. Now retired, but was instructing in the Computer Aided Engineering field, where the Students where required to design and
build a self contained, fully Automated machine. They then had to make them work together in a work cell.

They soon found out the importance of documentation and communication.

On the current NR setup, I would have liked to see a grouping type arrangement. However, at least these days the TOC's and Signalers tend to be
sat alongside one another in the same control room, so both sides know what is happening.

Dave M.

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RAIB DLR 07/03/2010 at 02:15 #7132
clive
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2789 posts
Geoff,

I don't see any of the issues you mention as actually being significant in this case. What actually caused the accident was:

(1) The controller *ASSUMED* that the train was sitting on the track circuit locking the points, without bothering to check. So he didn't lock them himself and, of course, they were left free to move when the automatic route setting wanted them for another route.

(2) The PSA (driving the train) didn't check the points indicator as he reached it and so didn't notice it was unlit.

(3) The PSA then didn't notice the points were set wrong, even though that's a requirement for this sort of emergency shunting.

They're all errors that could have been made (and have been made) on an integrated railway.

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RAIB DLR 07/03/2010 at 02:18 #7133
clive
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The frightening bit was a note about a near-miss a few months later: the controller had reserved the points for a train in emergency mode (the equivalent of keying them to a position in ordinary signalling), but when the train crossed a loop boundary (which, I think, corresponds to a track circuit boundary) the system automatically cancelled the reservation even though the train was still heading towards the points!
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RAIB DLR 07/03/2010 at 03:45 #7134
northroad
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Clive.
You hit the nail on the head with the word 'ASSUMED' and whilst I was not saying that the points I raised 'directly' resulted in the incident they were all part of the process which contributed to an underlying problem that was inherant with the system. The report does find that several things were of concern in the Control Centre " non-compliance with procedures " - " poor dissemination of information to operating staff " and " inadequate reporting systems and processes ". The fact that the operation of the points had been changed and had not been relayed to them I would have thought just a bit of a concern so that they fully understood the workings of the operating system.

Overall I think we should be grateful that no-one was hurt and from the 'RECOMMENDATIONS' made it will lead to a safer railway.

Geoff.

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RAIB DLR 07/03/2010 at 12:02 #7136
caedave
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142 posts
clive said:
The frightening bit was a note about a near-miss a few months later: the controller had reserved the points for a train in emergency mode (the equivalent of keying them to a position in ordinary signalling), but when the train crossed a loop boundary (which, I think, corresponds to a track circuit boundary) the system automatically cancelled the reservation even though the train was still heading towards the points!
Clive. Loop equals TC was my reading too. On the actual direct reason for the incident (Forgetfulness, Breach of rules, Communication,etc)
and that the Loops (TC's) requirements are somewhat different for the DLR, I was surprised that no comment was made on the shortness
of the protection on the approach to these points compared to what would be expected on a normal railway.

Also I thought that compared to the displays we see in SimSig that the DLR display was confusing.

Dave M.

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RAIB DLR 13/03/2010 at 12:21 #7265
BarryM
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2158 posts
Why are the points that derailed the train, not trail-able?

BarryM

Barry, Sydney, New South Wales, Australia
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RAIB DLR 13/03/2010 at 18:16 #7269
AnyFile
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101 posts
BarryM said:
Why are the points that derailed the train, not trail-able?

BarryM
and I would add, why if a train pass from the wrong trailing direction over a non-trailable point, should a train derail?

From what I remember (with rather old non-trailable point on Italian railway) what should happen is that the point is eventually changed by the train, the train do not derail, but the point is damaged. I think that is better to have a point that can not be locked until repair than a derailed train.

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RAIB DLR 13/03/2010 at 19:14 #7271
GeoffM
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6376 posts
Possibly clamplock points which, as the name suggests, clamps the rails together so even a heavy train won't force them open. But as the report says, the DLR trains are light and would have easily ridden up over the rail even if the points would have opened under a heavy train.
SimSig Boss
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RAIB DLR 13/03/2010 at 21:32 #7279
postal
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Geoff

As you suggested. RAIB Report states:

1125 points

The type of points involved are known as ‘clamp lock’. Clamp locks are machines
operated by hydraulic pressure that mechanically lock, and detect, both open and
closed switch rail positions.

Clamp lock type points were introduced onto British Rail infrastructure in the
1970s and are still in use by Network Rail today.


JG

“In life, there is always someone out there, who won’t like you, for whatever reason, don’t let the insecurities in their lives affect yours.” – Rashida Rowe
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RAIB DLR 13/03/2010 at 21:41 #7281
kbarber
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1742 posts
Don't recall the paragraph but the report explicitly says that the lightweight DLR vehicle was not heavy enough to trail through the clamplock machines.
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RAIB DLR 14/03/2010 at 03:02 #7286
northroad
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872 posts
That's easy,
Page 36 Para 174 "As the train approached 1125 points in the trailing direction the flange of the right-hand wheel of the first bogie hit the back of the switch rail where it was hard against the stock rail. The flange was unable to ‘push through’ and split the switch rail from the stock rail because of the light weight of the train in relation to the force exerted by the clamp lock points (3.3 kN). As a result, the flange climbed the rail, rode along the top of the stock rail and dropped off into the gap between the right-hand rail and the derailment containment kerb"

:lol:

Geoff

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