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

[FordFocus]

With modern era stock, if you miss the AWS then the TPWS will bring the train to a stand with the brake in emergency. You can't override it, the train will have to stop as the appropriate train wire has been broken.

Out of interest, do we have any solid information on whether the other two people in the cab were qualified in any rules e.g. as drivers or guards? Reason I ask is during incident investigation at TOCs, one item they look at is potential distractions such as mobile phones, automated PAs or other people in cabs as contributory cause to incidents.

 

[D1009]

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!

I believe this is normal practice for any privately owned loco on the main line, not just steam.

 

[ilkestonian]

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.

I don't think anyone is trying to justify the unjustifiable. I'm simply trying to understand the thought process which could have lead to it.

 

[edwin_m]

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.

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?

RAIB's investigations are purely to learn lessons. It is illegal to use them as evidence to support a prosecution.

If there are grounds to think a prosecution may be necessary then ORR takes the lead in the investigation and RAIB does not publish until any legal proceedings are completed or dropped (they do pass on any urgent safety lessons to the relevant people though). At least that is what happened in the case of the Merseyrail guard.

Assuming the same process applies here, this implies that ORR has decided not to bring a prosecution and it would now be impossible for them to do so. In the wake of NR's suspension of WCR, ORR was also investigating them so I imagine the decision not to prosecute would have been made then.

 

[Chris M]

RAIB's investigations are purely to learn lessons. It is illegal to use them as evidence to support a prosecution.

Not illegal, just "inappropriate". From the preface to the Moston report:

The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose.

If there are grounds to think a prosecution may be necessary then ORR takes the lead in the investigation and RAIB does not publish until any legal proceedings are completed or dropped (they do pass on any urgent safety lessons to the relevant people though). At least that is what happened in the case of the Merseyrail guard.

Assuming the same process applies here, this implies that ORR has decided not to bring a prosecution and it would now be impossible for them to do so. In the wake of NR's suspension of WCR, ORR was also investigating them so I imagine the decision not to prosecute would have been made then.

I think it would now be unlikely for a prosecution to be brought regarding this specific incident, but still possible for one to be brought regarding underlying factors such as the safety regime and/or culture if further investigation identifies something that warrants it.

 

[SPADTrap]

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

RAIB report says SN43 is 4 aspect?

 

[snowball]

The driver in the Stafford SPAD was prosecuted and fined. That case was similar to this in showing a lax attitude to safety in a small private company.

www.railforums.co.uk/showthread.php?t=118609

 

[bramling]

The driver in the Stafford SPAD was prosecuted and fined. That case was similar to this in showing a lax attitude to safety in a small private company.

www.railforums.co.uk/showthread.php?t=118609

One note of caution, I don't think it's fair to conclude anything about the driver's behaviour without knowing what training he had, at this stage the investigation is not complete. The Stafford incident was different in that the individual concerned was also part of the company's management, if I understand correctly.

 

[carriageline]

One note of caution, I don't think it's fair to conclude anything about the driver's behaviour without knowing what training he had, at this stage the investigation is not complete. The Stafford incident was different in that the individual concerned was also part of the company's management, if I understand correctly.

I'm sorry, but I'm not the sort to jump down people's throats. But this shows a very lax view on safety, and that is inexcusable.

 

[TheEdge]

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!

I have a feeling it stems from the absolutely catastrophic slip of Blue Peter at Durham in 1994. Long story short, a crew who knew the theory of how to drive a steam engine but not how to drive Blue Peter with its foibles got it badly wrong and ended up blowing the cylinder heads off and destroying the motion and wheels.

https://www.youtube.com/watch?v=YjsNbzg1UaI

[YOUTUBE]YjsNbzg1UaI[/YOUTUBE]

 

[amcluesent]

There's really no place for amateurs with their kettles on the mainlines, stick to the heritage railways.

 

[CharlieSpotted]

I have a feeling it stems from the absolutely catastrophic slip of Blue Peter at Durham in 1994. Long story short, a crew who knew the theory of how to drive a steam engine but not how to drive Blue Peter with its foibles got it badly wrong and ended up blowing the cylinder heads off and destroying the motion and wheels.

[YOUTUBE]YjsNbzg1UaI[/YOUTUBE]

[YOUTUBE]jaRBHQlEu-o[/YOUTUBE]

 

[455driver]

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?

The role of the traction inspector is to ensure the loco is being driven correctly, ie to ensure it won't get damaged by mis-handling etc, he is nothing to do with anything else.

Owners representative would be a better title.

Edit-
Point already covered by other posters.

 

[talltim]

There's really no place for amateurs with their kettles on the mainlines, stick to the heritage railways.

These steam services are run by professionals. While in this particular instance the crew don't seem to have behaved professionally, it isn't just a case of some enthusiast rocking up with a loco and going 'gissa go'

 

[Dave1987]

These steam services are run by professionals. While in this particular instance the crew don't seem to have behaved professionally, it isn't just a case of some enthusiast rocking up with a loco and going 'gissa go'

Sorry but I'm afraid I cannot agree with that. If this was an isolated incident then I could accept that this might have been a rogue crew who were prepared to break the rules. But it would appear that isolating the AWS is a fairly common thing to happen or at least with this loco it is. Professionals would not be so blasé about isolating safety equipment and would certainly follow the correct procedures in doing so.

 

[najaB]

Professionals would not be so blasé about isolating safety equipment and would certainly follow the correct procedures in doing so.

They are professionals (in that they earn their living driving trains) but their actions haven't demonstrated any professionalism.

 

[D1009]

I have a feeling it stems from the absolutely catastrophic slip of Blue Peter at Durham in 1994. Long story short, a crew who knew the theory of how to drive a steam engine but not how to drive Blue Peter with its foibles got it badly wrong and ended up blowing the cylinder heads off and destroying the motion and wheels.

I was on that train and I can assure you the wheels were not destroyed. It was possible to move the engine once the tangled motion had been removed.

 

[TheEdge]

I was on that train and I can assure you the wheels were not destroyed. It was possible to move the engine once the tangled motion had been removed.

Maybe destroyed was an overstatement but I'm fairly sure they were not suitable as express locomotive wheels after that...

 

[HLE]

There is a picture somewhere online of the damage done to blue peter.

Let's just say that it certainly wouldn't buff out!! It took around a year to repair if I remember.

Back on topic, nothing much to add as its already been said, all I will say is that we all know that isolating the TPWS/AWS without having brought the train to a stand and contacting the box is a huge no-no, to be honest I'm more concerned with the fact that in the short space of time from isolating it to coming to a stand over the junction, no attempt was made to return the valve back to normal, even if the signal had cleared and the train had continued normally it would probably still have remained isolated, and by the sounds of it the 'relaxed'
attitude to isolating the TWPS on tangmere would have continued undetected.

It really is no wonder west coast lost their licence for a short while.

 

[Jamesb1974]

Deleted

 

[edwin_m]

Not illegal, just "inappropriate". From the preface to the Moston report:

Perhaps so, but they may find themselves in contempt of court by publishing a report:

(5)In performing a function in relation to an accident or incident the Branch—

(a)shall not consider or determine blame or liability, but

(b)may determine and report on a cause of an accident or incident whether or not blame or liability is likely to be inferred from the determination or report.

(6)The Branch may conduct an investigation and report whether or not civil or criminal proceedings are in progress or may be instituted (but this subsection is without prejudice to the operation of the law of contempt of court).

(7)The Chief Inspector of Rail Accidents may apply to the High Court or the Crown Court for a declaration that the making of a report in connection with a specified accident or incident will not amount to a contempt of court in relation to civil or criminal proceedings which have been or may be instituted in connection with the accident or incident.

Railways and Transport Safety Act 2003
http://www.legislation.gov.uk/ukpga/2003/20/section/7

 

[DaveNewcastle]

RAIB's investigations are purely to learn lessons. It is illegal to use them as evidence to support a prosecution.

I am sorry to have to advise you that this is not correct.

I think you have grasped the crucial distinction in your follow up elaboration :-

Perhaps so, but they may find themselves in contempt of court by publishing a report:
. . . .

In England & Wales, it is only duing the course of legal proceedings by way of a trial in a court of law, that any publication of the evidence which might come to the attention of a jury, and thereby might influence the decision of that trial, might be dissallowed, uner a complex mix of legislation and instructions by the Court, including the 1981 Contempt of Court Act S.4(2) & S.8, (with the allowances such as the right of anyone to report anything said while a jury is present during Crown Court proceedings unless expressly dissallowed), the 2003 Criminal Justice Act S.71, the 1933 Children & Young Persons Act S.49, or a Sexual Offences Prevention Order.

The BBC's internal guidance makes the neccessary distinctions clear quite concisely:

Once proceedings are ‘active’, anything which creates a substantial risk that the course of justice in these proceedings will be seriously prejudiced or impeded will be a contempt of court.

In most criminal cases, proceedings become ‘active’:
•On the arrest of a suspect
•When an arrest warrant is issued
•On the issue of a summons (in Scotland a complaint) or indictment. This may be well before a person in charged
•When a person in charged.

I would only add the additional protection given to children and young persons and in sexual offences.

To present evidence from RAIB report in the course of a criminal prosecution where the defence challenged somethin crucial in that RAIB report, would require evidence to be provided in the form of Witness Statements and oral statements in Court which could be tested for reliability, authority and relevance under cross-examination.

 

[bramling]

I'm sorry, but I'm not the sort to jump down people's throats. But this shows a very lax view on safety, and that is inexcusable.

Yes maybe, however let's wait for the investigation to be completed before making judgements about an individual's conduct.

Copying & pasting from the RAIB bulletin, the following paragraph is relevant:

"The RAIB’s investigation will also continue to examine other possible factors that led to signal SN45 being passed at danger. These will include;
~ the competence of the train crew involved and how this was managed by WCRC;
~ how AWS system isolations were managed by WCRC;
~ the design (including ergonomics) and certification of the AWS and TPWS systems on Tangmere and how these systems were maintained and inspected by WCRC;
~ the way in which the TSR was designed and implemented by Network Rail; and
~ any relevant underlying factors, such as safety management and safety culture."


Two bits from within the RAIB bulletin ring alarm bells:
"Witness evidence suggests that the AWS isolating cock was not sealed before the fireman opened it."

"The evidence available to the RAIB indicates that the SPAD at SN45 was not the only occasion on which the AWS isolating cock was used by a train crew operating Tangmere in order to by-pass an AWS brake demand. The extent of this practice continues to be the subject of further investigation."


This suggests that the unsafe practices which culminated in this incident run deeper than just the individual driver concerned. Had this involved a franchise TOC, there are processes in place (e.g. random OTMR download and competence assurance assessments) designed to identify and correct bad practice.

It's unfair to criticise an individual without knowing what training he received - we don't know that at this stage.

 

[najaB]

It's unfair to criticise an individual without knowing what training he received - we don't know that at this stage.

I agree totally with that, but it really is very concerning that a mainline qualified driver could see isolating the AWS/TPWS as 'normal' in any circumstance. What were these guys doing in their day jobs? Or are they now retired from TOC or FOC driving?

 

[BestWestern]

I agree totally with that, but it really is very concerning that a mainline qualified driver could see isolating the AWS/TPWS as 'normal' in any circumstance. What were these guys doing in their day jobs? Or are they now retired from TOC or FOC driving?

I understand that common practise is for retired Drivers to be engaged on 'zero hours' contracts, used and paid where required. This in particular has led to concerns arising over the 'employer' having the ability to appropriately assess and train their Driving staff to the relevant standards.

 

[FordFocus]

I doubt you can properly manage 'zero hour' contract drivers competency. No rostered turns over certain lines and you would struggle to maintain route knowledge especially now that some TOCs refuse access unless you have something in writing or a route learning ticket or pass.

 

[61653 HTAFC]

I doubt you can properly manage 'zero hour' contract drivers competency. No rostered turns over certain lines and you would struggle to maintain route knowledge especially now that some TOCs refuse access unless you have something in writing or a route learning ticket or pass.

As a layperson, could I ask how long a driver's route knowledge over any given stretch of track lasts before a refresher run is required?

 

[Crossover]

As a layperson, could I ask how long a driver's route knowledge over any given stretch of track lasts before a refresher run is required?

6 months or so, I think

 

[HLE]

As a layperson, could I ask how long a driver's route knowledge over any given stretch of track lasts before a refresher run is required?

6 months is the normal timeframe

 

[GadgetMan]

It seems that he was unaware that he received two warnings, and hadn't seen that the signal was displaying a restrictive aspect (for whatever reason) so he would not have been expecting two warnings - only the one for the TSR. As the TSR was greater than the maximum permitted speed for the train he was driving, he would not be expecting to do anything for the restriction other than acknowledge it. 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*.

I suspect the first AWS warning caught the Driver off guard so he was late canceling it. He then got a second AWS warning and saw the TSR warning board. It is perfectly possible that his brain was trying to make sense of the situation and he convinced himself that it was in fact an ESR (Emergency Speed Restriction) which has TWO AWS temporary magnets associated with it and he wrongly assumed he must have missed sight of the flashing board.

Couple the above with (possibly) poor route knowledge/not reading WON properly and poor vision out the tiny window and it might just explain why they did what they did. Not that there can be any justification for disabling safety systems without following the correct procedures.