Wootton Bassett junction SPAD (07/03/15) RAIB Update released

[FordFocus]

The driver did not see signal SN43 and, therefore, was not aware that it was
displaying a caution aspect.

If you can't recall seeing the signal, especially as there wasn't a AWS clear/bell indication then I always assume it's most restrictive and react accordingly. Put the brake in and assume the next one is at danger in this case.


Poor show all round, I sympathise with the lack of visibility but that's it. Giving a signal to your fireman to isolate the AWS is a shocking and unsafe attitude.

 

[carriageline]

Personally, the fact the fireman knew what to do when signalled by the driver to isolate it, shows a shocking attitude towards safety on both their behalfs. The fact it's happened multiple times, looks very bad for WCR. Personally (and this is my view only), there should be serious thought about whether these peoples responsible should work a train ever again, before seriously looking at the operator.

When you see the recent incidents Tangmere has been involved in, it does make you wonder an awful lot

 

[Tw99]

I'm still unclear as to the likely reason for the AWS being disabled. Would someone like to speculate on that ?

 

[ilkestonian]

I'm still unclear as to the likely reason for the AWS being disabled. Would someone like to speculate on that ?

To prevent the train from coming to a halt.

 

[Tw99]

To prevent the train from coming to a halt.

Well, yes... But why would you want to do that ? Is AWS known for giving false positives, which might provide a reason (but not an excuse) for turning it off.

I'm not trying to defend what they did, just trying to understand why they might have done it.

 

[ilkestonian]

Well, yes... But why would you want to do that ? Is AWS known for giving false positives, which might provide a reason (but not an excuse) for turning it off.

I'm not trying to defend what they did, just trying to understand why they might have done it.

I think it's a reasonable assumption that the driver realised that the activation related to the temporary 85mph speed limit and therefore it didn't affect him, in so far as he didn't need to slow.

No false positives involved, just a realisation by the driver that he had failed to cancel the activation in time and he didn't want to stop, then do what he should have done; with the delays and possible sanctions that would have involved.

Edit

Just to add, it's a reasonable supposition that the actions involved in asking the fireman to disable the AWS relating to the TSR contributed to the crew missing the vital AWS warning for the junction signal. Strange though, because although it doesn't seem to have been mentioned,surely the train would already have passed a double yellow, so surely the restricted aspect of the missed signal should have been expected.

A classic "Red for Danger" scenario where a series of decisions rather than just one thing leads to an incident.

Further edit. I'm wrong about the above, sorry. It was SN43, the yellow before the junction whose warning wasn't cancelled, not the TSR magnet.

The driver having his head out of the cab may be relevant, ie not hearing the warning horn. However it begs the question why did his route knowledge not make him prepare for the horn.

I can't of course condone his actions, but I guess his reasoning for disabling the AWS was still to avoid having to report the activation to the signaller, but why he then failed to slow for the junction is puzzling.

 

[Zoidberg]

... just trying to understand why they might have done it.

Because they could?

A question for those on the know: Is it possible for those driving contemporary traction to over-ride safety mechanisms in a similar manner?

 

[louis97]

Just to add, it's a reasonable supposition that the actions involved in asking the fireman to disable the AWS relating to the TSR contributed to the crew missing the vital AWS warning for the junction signal. Strange though, because although it doesn't seem to have been mentioned,surely the train would already have passed a double yellow, so surely the restricted aspect of the missed signal should have been expected.

There isn't a double yellow aspect leading to the junction signal. Its just 3-aspect signalling.

 

[ilkestonian]

There isn't a double yellow aspect leading to the junction signal. Its just 3-aspect signalling.

Ah, thanks for the clarification. I saw in the report that SN43 was four aspect and assumed the previous signal would have been too.

 

[D1009]

21 During this 12 second period, a second AWS warning occurred. This was created by the fixed AWS magnet located around 275 metres on approach to signal SN43, which was displaying a single yellow caution aspect. This warning occurred around 2.5 seconds after the AWS warning from the TSR had been acknowledged; OTDR data shows that it was acknowledged by the driver within 0.5 seconds.

I thought the incident occurred because the AWS warning from the TSR was not acknowledged, and this was why the AWS was isolated to prevent the train coming to a stand.

 

[notadriver]

Because they could?

A question for those on the know: Is it possible for those driving contemporary traction to over-ride safety mechanisms in a similar manner?

Why would you want to know that ?

 

[ainsworth74]

Why would you want to know that ?

Curiosity?

 

[snowball]

I thought the incident occurred because the AWS warning from the TSR was not acknowledged, and this was why the AWS was isolated to prevent the train coming to a stand.

He acknowledged it but not in time.

17 At around 17:24 hrs train 1Z67 was approaching signal SN43 at 59 mph (95 km/h), when it passed over the portable AWS magnet associated with the TSR. Around a second after this, the AWS horn sounded and the orange light connected to it began to flash in the locomotive’s cab. Data from the locomotive’s On Train Data Recorder (OTDR) shows that it took the driver 4.2 seconds to acknowledge this warning, by which time the AWS system had already demanded a full brake application.

 

[TheEdge]

A question for those on the know: Is it possible for those driving contemporary traction to over-ride safety mechanisms in a similar manner?

You can isolate pretty much any of the safety systems if needed. Saying that is isn't something that would ever be done on the fly like this, especially for something like AWS/TPWS.

 

[Zoidberg]

Why would you want to know that ?

Because the contents of the report encourages one, well, at least this one, to beg that question.

You can isolate pretty much any of the safety systems if needed. Saying that is isn't something that would ever be done on the fly like this, especially for something like AWS/TPWS.

Thanks for the reply. I suspected that we'd ultimately be relying on professionalism to ensure safety.

 

[380101]

Because they could?

A question for those on the know: Is it possible for those driving contemporary traction to over-ride safety mechanisms in a similar manner?

All safety systems can be isolated. Required for various reasons such as a fault with a system. However almost all units post 2000 require you to leave the driving seat to do so due to position of the isolating switches...ie; the train would need to be at a stand to do this.

 

[Zoidberg]

All safety systems can be isolated. Required for various reasons such as a fault with a system. However almost all units post 2000 require you to leave the driving seat to do so due to position of the isolating switches...ie; the train would need to be at a stand to do this.

And thanks to you, too.

 

[SPADTrap]

Isn't it the role of the Inspector on the footplate to ensure that issues such as these are known to the driver?

I'm not sure what you mean? Who has the route knowledge on these steam specials? I don't think this crew were being 'piloted' over the route on this occasion? The driver is driving!

Does anyone know if the footplate crew are being prosecuted out of interest, interesting given what happened at Hitchin?

 

[Class 170101]

Does anyone know if the footplate crew are being prosecuted out of interest, interesting given what happened at Hitchin?

Presumably they still could be once the full report comes out? I thought RAIB were only meant discover the facts leaving the HMRI / HSE to decide on prosecution or not?

 

[SPADTrap]

Presumably they still could be once the full report comes out? I thought RAIB were only meant discover the facts leaving the HMRI / HSE to decide on prosecution or not?

That makes sense, thanks.
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It seems very likely to me that the second acknowledgement was subconcious - either he didn't think the first acknowledgement had been successful and was trying again or he wasn't even aware that he had acknowledged more than once

That isn't how AWS works, you either cancel the AWS horn in time or you don't. It is possible however to recieve AWS horns from track debry (such as rails in the four foot) every now and then and when it happens you're checking and double checking to ensure you haven't missed anything.

 

[Arglwydd Golau]

I'm not sure what you mean? Who has the route knowledge on these steam specials? I don't think this crew were being 'piloted' over the route on this occasion? The driver is driving!

Does anyone know if the footplate crew are being prosecuted out of interest, interesting given what happened at Hitchin?

Ok, sorry for my ignorance, but I thought the role of the Traction Inspector (or whatever they are called) was to ensure that correct procedure was carried out. I think there was one on the footplate? What was he doing whilst all this was going on?

 

[cf111]

Ok, sorry for my ignorance, but I thought the role of the Traction Inspector (or whatever they are called) was to ensure that correct procedure was carried out. I think there was one on the footplate? What was he doing whilst all this was going on?

My understanding is that in all situations the driver has ultimate responsibility for the safe running of the train. A traction inspector on a steam train running in the modern age is simply the representative of the locomotive's owner.

 

[ainsworth74]

Presumably they still could be once the full report comes out? I thought RAIB were only meant discover the facts leaving the HMRI / HSE to decide on prosecution or not?

That makes sense, thanks.

The ORR are also in the midst of an investigation so any action will probably have to wait until that is also finished.

I can't help but wonder if they won't be eyeing up bigger fish than just the footplate crew in terms of bringing about a prosecution? From what the RAIB said in paragraph 26 it sounds like isolating the AWS might have become 'custom and practice' to crews operating Tangmere in which case I can't help but wonder if they wouldn't be after WCRC management (if it was their crews doing it).

After all there were question marks raised over their SMS and culture towards safety during the period when they were banned from operating on NR LNE metals a couple of years ago. That boiled down to NR losing confidence in their ability to manage safety.

I wouldn't be surprised if there was a certain amount of drive to haul them over the coals if it turns out that their management, once again, was inadequate and this time caused a near miss with potentially horrific consequences.

 

[Arglwydd Golau]

My understanding is that in all situations the driver has ultimate responsibility for the safe running of the train. A traction inspector on a steam train running in the modern age is simply the representatives of the locomotive's owner.

Really? I'm surprised...I always thought that they were either from the TOC or NR!

 

[ilkestonian]

Ok, sorry for my ignorance, but I thought the role of the Traction Inspector (or whatever they are called) was to ensure that correct procedure was carried out. I think there was one on the footplate? What was he doing whilst all this was going on?

DBS operated steam always have a third DBS qualified man on the footplate, and this strikes me as a sensible idea, to assist with signal sighting etc.

Tangmere at Wootton Bassett had the driver, fireman and two owners reps on the footplate, but, according to the RAIB interim report, no other WCRC personnel present on the footplate. Not sure if this has changed since their hiatus.

 

[Arglwydd Golau]

DBS operated steam always have a third DBS qualified man on the footplate, and this strikes me as a sensible idea, to assist with signal sighting etc.

Tangmere at Wootton Bassett had the driver, fireman and two owners reps on the footplate, but, according to the RAIB interim report, no other WCRC personnel present on the footplate. Not sure if this has changed since their hiatus.

Thanks for that clarification. I wonder what the owners reps role is then, if it is to ensure the safe running of their engine, then they clearly weren't on the ball either.

 

[SPADTrap]

Thanks for that clarification. I wonder what the owners reps role is then, if it is to ensure the safe running of their engine, then they clearly weren't on the ball either.

I didn't know the loco had a travelling rep on the owner's behalf, like you I'm curious as to their role and why they come along!

 

[ilkestonian]

Thanks for that clarification. I wonder what the owners reps role is then, if it is to ensure the safe running of their engine, then they clearly weren't on the ball either.

I suspect their role is somewhere between keeping an eye on the loco, as they will hopefully know it's foibles, and having a pleasant time experiencing a steam loco as only a driver and fireman usually can

They won't have route knowledge and in a situation such as the incident here, I doubt they'd have appreciated the nature of the situation.

 

[Dave1987]

Guys can I make something clear, isolating the AWS so you don't have to report a brake application to the signaller because you have not cancelled the AWS warning in time is a blatant breach of the rules in itself let alone the resultant SPAD. You NEVER isolate ANY equipment without authority and you DO NOT move until you have authority from the signaller to do so. Some people seem be trying to justify the isolation by trying to stop a brake demand for a TSR that didn't apply to the train.

 

[SPADTrap]

I suspect their role is somewhere between keeping an eye on the loco, as they will hopefully know it's foibles, and having a pleasant time experiencing a steam loco as only a driver and fireman usually can

They won't have route knowledge and in a situation such as the incident here, I doubt they'd have appreciated the nature of the situation.

Whatever knowledge they have about locomotive foibles should be known to those who operate it. A pleasant time observing a crew taking the entire train and others into danger.
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Guys can I make something clear, isolating the AWS so you don't have to report a brake application to the signaller because you have not cancelled the AWS warning in time is a blatant breach of the rules in itself let alone the resultant SPAD. You NEVER isolate ANY equipment without authority and you DO NOT move until you have authority from the signaller to do so. Some people seem be trying to justify the isolation by trying to stop a brake demand for a TSR that didn't apply to the train.

They were below the 85mph but the speed following AWS/TPWS isolation also applied so there is little weight behind anyone's argument of 'the 85 didn't apply to them' not to mention the other rulebook requirements following such action as you alluded to.