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RAIB discussion 18/02/2015 at 19:35 #69310
Jersey_Mike
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" 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?

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RAIB discussion 18/02/2015 at 19:49 #69311
TimTamToe
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Unauthorised entry on to a single line is hardly a minor incident, the possible outcomes of such an action don't bare thinking about. Just because there were no devastating effects this time doesn't mean there couldn't have been and by investigating they can find out the reasons why the incident occurred to prevent similar things occurring in the future.

I don't know how they do things in America but as a UK citizen I'm glad such things are investigated fully to help make all of our journeys safer

Gareth

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RAIB discussion 18/02/2015 at 19:51 #69312
Steamer
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" said:
" 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?
Railway companies still investigate things internally. The full guidance for what should and shouldn't be reported to the RAIB is available here, with a 'quick guide' here.

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.
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.

"Don't stress/ relax/ let life roll off your backs./ Except for death and paying taxes/ everything in life.../ is only for now." (Avenue Q)
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RAIB discussion 18/02/2015 at 20:02 #69314
Ron_J
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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.
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RAIB discussion 18/02/2015 at 20:15 #69315
Jersey_Mike
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" said:

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.
Ah, but a collision didn't happen. The system worked! B)

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).

Less severe incidents (like luggage trolleys being hit by trains) are left to the railroads and the labor unions to investigate.

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.

" said:
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.
We have a fireball going on right now. Since it made the national network newscast it will probably get a 5 page investigation report.

Last edited: 18/02/2015 at 20:17 by Jersey_Mike
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RAIB discussion 18/02/2015 at 20:42 #69317
Ron_J
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The way it works here is that the safety departments of the various railway undertakings have a statutory obligation to investigate incidents, accidents and near misses. The type and severity of the incident (which is derived from a risk ranking process) determines the level of internal investigation - "Local" or "Formal" - and these investigations are conducted to an agreed standard within a defined timescale. Incidents with a high risk ranking score and/or involvement of more than one company's staff are investigated by Network Rail. Railway undertakings have a duty to co-operate with each other and share evidence for the purpose of an investigation. Investigation reports are reviewed and any recommendations or local actions accepted or rejected at a "Recommendations Review Panel" attended by the great and the good of each company's Operations and Safety departments.

Independent of this process, certain incidents/accidents/near misses are required by law to be reported to the RAIB. The RAIB then seek further information before deciding whether to launch their own seperate investigation. The vast majority of occurrences which are reported to the RAIB are not subject to a full investigation by them. The RAIB also sometimes release very short summary reports of incidents to rail industry stakeholders which aren't uploaded to their website. Although the RAIB can make recommendations as a result of their investigation, it is the job of the Office of Rail Regulation to enforce their adoption.

I've seen the process from both sides, having sat on Investigation Panels both as a member and as Lead Investigator as well as being grilled by the RAIB after an incident. I can't recommend the latter as being a particularly enjoyable experience.

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RAIB discussion 18/02/2015 at 21:07 #69318
Danny252
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Honestly, it isn't worth arguing with Jersey_Mike over how (un)safe a railway should be - it's been done by many people on many forums (at least one of which he seems to have been banned from for his repetitive arguments), and he'll just keep coming back to say that your concerns are laughable!
Last edited: 18/02/2015 at 21:09 by Danny252
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RAIB discussion 18/02/2015 at 21:39 #69319
Steamer
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" said:

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).
There's no point waiting for someone to be killed or injured before writing a report. The idea with the RAIB is that they investigate anything that had the potential to be much more serious, thus reducing the chances of a serious accident occurring.

Quote:
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.
We tried 'profits before safety' in the Railtrack era, and it didn't work. Hopefully things have moved on. In the long run, it may be cheaper to investigate and prevent than the alternative of ignoring the near misses and then having to deal with the financial and political consequences of a fatal collision. Especially if it later transpired that the warning signs had been ignored.

"Don't stress/ relax/ let life roll off your backs./ Except for death and paying taxes/ everything in life.../ is only for now." (Avenue Q)
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RAIB discussion 18/02/2015 at 21:47 #69320
Ron_J
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If you read some of the NTSB reports in the link that Mike posted you'll see that the entire American approach to railway safety is absolutely insane. We certainly shouldn't be listening to lectures from the other side of the Atlantic on the value, or otherwise, of our RAIB investigations.
Last edited: 18/02/2015 at 21:47 by Ron_J
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RAIB discussion 18/02/2015 at 23:28 #69325
RainbowNines
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I'm a civil servant. Let me tell you - there are thousands of other parts of the civil service that could be pruned before we look at the RAIB, which is a very small agency of DfT and delivers on its objectives year on year.

It consists of just 42 staff (an insanely small number for the work they do) and the budget is £4.8m (source) - a tiny amount compared to the billions we (and the Americans) spend on defence, etc. and certainly less than the premiums some of the railway companies pay. The net cost to the Department for Transport is probably negligible, for a vital independent reporting body.

All that said, I must say I was rather surprised by their decision to produce a full report on this - but there again, the failure (or potential failure) of the One Train in Steam principle clearly retains (rightly) a fearsome reputation in the industry, especially with passenger trains involved.

It was actually a really good report for people interested in signalling.

Last edited: 18/02/2015 at 23:29 by RainbowNines
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RAIB discussion 19/02/2015 at 00:53 #69331
belly buster
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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.

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RAIB discussion 19/02/2015 at 04:28 #69332
Jersey_Mike
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" 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.

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RAIB discussion 19/02/2015 at 08:59 #69335
RainbowNines
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Suggest you go through the Railway Archive accident archive and acquaint yourself with the way we do things over here. From almost the year dot of railways we have had some sort of reporting on accidents, all of which report on multiple potential aspects of the incident.

We dragged ourselves kicking and screaming out of a cowboy operation to an unparalleled level of safety using sophisticated safety techniques.

Even into the 80s, fatalities were common - the Railway Archive documents for 1984 lists 11 fatalities in collisions before you even consider Polmont, which claimed another 13 lives.

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.

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RAIB discussion 19/02/2015 at 09:23 #69336
kbarber
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" 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!

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RAIB discussion 19/02/2015 at 09:58 #69337
Peter Bennet
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" 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

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RAIB discussion 19/02/2015 at 10:42 #69341
Ron_J
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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.

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RAIB discussion 19/02/2015 at 10:48 #69342
belly buster
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" 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.

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RAIB discussion 19/02/2015 at 10:50 #69343
RainbowNines
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271 posts
" said:
" 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!
You've summed it up very nicely. I'm sure it's indicative of having no hope of a life, but I've been slowly working my way back through the reports on the Railway Archive for some months as bedtime reading! I'm now at 1947. Pre nationalisation reports are subtly different, in that they offer opinions such as "it seems x should not have been considered responsible enough for the role of signalman" whereas those in the BR era don't.

The Clapham report is indeed fascinating - Hidden refers to signals as sentries, and that the failed signal that was at the centre of the disaster failed in its duty. makes it simpler to understand, anyway.

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RAIB discussion 19/02/2015 at 10:54 #69344
Peter Bennet
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" said:
" 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.
That's what I feared: so the EU now tells us what we can and can't investigate.

Peter

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RAIB discussion 19/02/2015 at 11:50 #69347
RainbowNines
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Well, it sets parameters over which they must be notified, but I doubt that figure makes much difference. If there's 2 million euro of damage (or the potential for) RAIB would almost certainly be investigating it regardless of that limit being in place! It's still nearly £1.5m.

As an aside, I have a long held ambition to work for RAIB. Small government agencies tend to be extremely good employers (super focused development opportunities coupled with usual government perks). But with no relevant technical experience I could never be an investigator!

Last edited: 19/02/2015 at 11:50 by RainbowNines
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RAIB discussion 19/02/2015 at 16:03 #69352
Jersey_Mike
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The original thrust of my question was if there had been some sort of centralization of railway incident investigation because it does seem a bit odd that the Central Government would be investigating things like an impact between a train and a luggage trolley in a rail terminal (I'm on the RIAB e-mail list BTW). 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.

In the US minor incidents are investigated by the railway or union or both as part of the collective bargaining agreement. Furthermore railroads are required by the government to report a wide range of safety incidents and have processes to combat them. This generally creates a robust internal investigation system that assigns blame and works to <a href="https://www.acm.jhu.edu//~sthurmovik/Railpics/14-04-28_SOUTHERN_MIDLAND/NS_Gainesville-Sta-injury-days-5-14.html">reduce incidents in the future</a>. Grade crossing accidents and accidents that involve injury or property damage will also trigger investigations by local police or the lawyers of the injured parties even if the Federal government does not get involved.

" said:

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.
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.

" said:
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.
The fundamental error was that the conductor forgot his train was on the siding instead of the main track. I guess that's a human factors problem, but short of spending tens or hundreds of millions of dollars to install CTC on a low density line, it's hard to account for major mental lapses such as that. If you are interested here is what the procedure looks like when performed properly.

https://www.youtube.com/watch?v=59SmBUGAlpA

In this case the conductor on the ground is in communication with the freight that he has opened the switch and was previously in communication with the freight when it passed the preceding signal. Maybe having those informal procedures codified as rules would have helped in this case...but on the other hand so would turning around and seeing that one's train is on the siding and not the main track.

" said:

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...
You know the report was only 5 pages long so you should have read it more closely

The line in question was signaled under single track TWC-ABS, which basically means automatic block signals in both directions with manual traffic control via track warrants. Points are detected, but not electrically locked, however the approaching train was past the approach signal. The detector readout informed the conductor of the approaching train, nothing more. That simply triggered the conductor's own mental cue that it was time to line the approaching train for the siding as he had done the past few times. Finally all mandatory directives require a readback before they become effective.

" said:

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.
That an employee can have such a major mental lapse is a risk inherent in the system. Safety remedies are well known, but are not economically practical. The robust construction of the locomotives protected the crew from harm and the property damage is simply a cost of doing business. What the brief report acknowledges is that the event that is expected to happen occasionally, happened. If you liked this report where a METRA commuter train hit a road vehicle at a level crossing, killing the driver of the road vehicle. A local newspaper called the NTSB to see if there would be an accident investigation and were told by an NTSB official that the cause was driver error and the NTSB would not be investigating.

At the end of the day rail passengers and workers in BOTH the US and the UK can expect to ride the rails from now until the day they die from heart disease without being hurt in a accident.

Last edited: 19/02/2015 at 20:20 by Jersey_Mike
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RAIB discussion 19/02/2015 at 16:58 #69357
RainbowNines
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I'd say an annual amount of £4.8m isn't a great deal to commit to a central investigatory board.

RAIB will equally not investigate if someone trespasses on the railway, although will usually look into crossing misuse of it results in a road vehicle collision.

Clearly the UK strives for continuous improvement. Again, £5m isn't a lot to ensure the exemplary safety standards of our railways are maintained.

Last edited: 19/02/2015 at 16:58 by RainbowNines
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RAIB discussion 19/02/2015 at 17:52 #69360
Steamer
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" said:
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.
That's probably the case- with multiple companies directly involved, an independent investigation body reduces the risk of bias.

Quote:
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.
You don't even have to save a life. Provided they prevent one moderately serious derailment a year, they've paid for themselves. I reckon a freight train derailment that writes off a couple of wagons, churns up half a mile of track and shuts the line for a couple of days while it's repaired would cost £5 million (at least), especially if signalling or pointwork is damaged.

"Don't stress/ relax/ let life roll off your backs./ Except for death and paying taxes/ everything in life.../ is only for now." (Avenue Q)
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RAIB discussion 19/02/2015 at 19:42 #69361
GeoffM
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" said:
The person at fault in that incident was the driver, full stop.
It would be wrong to just say "oh, he went past a signal, must be his fault" for incidents like this. Why did he go past that signal? Is there a past history of drivers passing that signal? If so, why do they keep going past? Once you determine that, perhaps you can reduce the risk of future drivers passing that signal. After all, that is the aim of inquiries.

One thing that struck me about the Metro North derailment was that it blamed a joint bar that failed - fair enough, direct cause. But it completely neglected the reasons why it failed (fatigue is not a "why" but a "what happened"). The only conclusions it could come up with was to do a visual check a bit closer than up to 39(?) feet away - and you can't check for even visible cracks more than a couple of feet away, so what they're really saying is "look for obviously broken joint bars" rather than "detect breaks before they happen".

SimSig Boss
Last edited: 19/02/2015 at 19:42 by GeoffM
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RAIB discussion 19/02/2015 at 19:45 #69362
Stephen Fulcher
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First thing I will say on this thread is that it may be worth Peter or Geoff considering whether the last few pages should be split off from the main thread as it relates to differences of investigation procedure across continents rather than the original purpose that Tallington intended when he started the thread all those years ago.

Now for my main point. Britains railways are amongst the safest in the world. A lot of the safety innovations are reactive, and are introduced as a direct result of the reports produced by the investigative authorities (whether they be Officers in the Royal Engineers, HMRI Inspectors, Queens Counsel, High Court Judges or, as today, RAIB Investigators) following major incidents. Accidents have always been investigated thoroughly in this country, and this will always be so.

TPWS for instance was installed nationwide as a result into the report by Lord Cullen into the Ladbroke Grove crash in October 1999. I will leave aside the argument that successive enquiries had recommended nationwide adoption of ATP systems (including at Clapham where the system would have been useless), but it is safe to say that had Lord Cullen simply written three pages stating that Thames Turbo 1K20 passed signal SN109 at red and ran into the path of First Great Western HST 1A09 leading to a head-on-collision, which are the basic facts of the matter, then nothing positive would have come from it safety wise.

That self-same TPWS should have stopped the Chiltern Turbo at Greenford, but did not do so because it was isolated. The fact that the RAIB concluded that isolation of TPWS in the circumstances was fairly common-place is worthy of note, because measures will now be taken to stop it happening in the future. Again, a half-hearted investigation would not have looked at this. It also shows that the incident was not, as has been suggest above, a simple violation of the rules. The investigation also uncovered a shortcoming of the new GSM-R radio system, which will also be improved as a result.

In conclusion, the reason for the inherently safe railways in this country is precisely because incidents, which on the surface may be considered trivial, have been thoroughly investigated for nearly two hundred years. Rarely is something simple "black and white".

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