RAIB: Overspeed at Queen's Park

[Dave1987]

The correct line-side signs and warnings had been placed on the approach to the speed restriction

According to the RAIB the boards were in place. Yes there are new rules in place as of the December rule book update regarding ESRs when the boards are not in place but the boards were in place in this case so none of that applies here.

 

[misterredmist]

It's instructive to note how many airline accidents have had either a pilot under instruction or a senior instructor involved. KLM at Tenerife was the worst, but in recent history there was Turkish Airlines at Schiphol and Asiana at San Francisco among others.

Indeed , van Santen was a law unto himself at Los Rodeos, with a lack of hours at the "wheel" due to being based in the SIM centre at Schiphol, and his poor crew, who over-ruled him once on his first attempted take off , didn't dare interrupt him again - and every body on board and many PA pax and crew paid the price too....

Anyway, back on topic, I know the enquiry will get the reasons, could this overspeed situation have been a result of both of the DM's assuming the other was keeping their eye open / had read the Notices etc. etc... ???

 

[SPADTrap]

so does anyone know how that it was discovered that the train did not adhere to the speed restriction?

More than likely pway working in the vicinity reporting it?

 

[misterredmist]

Normally,yes, but the left seater was essentially a student with the PIC sitting in the right seat with the FO in the jump.

OK thanks for the info......

 

[HLE]

Why not? For an ESR laid out correctly you would have two AWS warnings for it and service braking distance which is the braking distance for the longest heaviest type train, a distance which a modern EMU would not need in order to be at the correct speed.
These things happen, and can happen to anyone as this clearly shows. Its impossible to know what happened in the cab at this time as none of us were there. There by the grace of god...

Well said that man.

It's just slightly amusing (if that's the right word) that it involves two DSM's.

 

[Islineclear3_1]

Well forgive my naivety, in my day I would have placed all signals at danger and cautioned trains through

 

[GadgetMan]

Sorry but you are not understanding how this works. It does not matter if you have seen the notice or not. As you are going along there are two very very bright strobe lights flashing that you can't miss along with two AWS magnets on the track that you need to acknowledge so unless you are not paying any attention to what you are doing it doesn't matter if you have not seen the notice you cannot fail to know about the ESR if it is boarded correctly.

on that day they were very dull, batteries may have been low. Both boards were placed in positions where they could be easily missed if you're passing at 75mph and not expecting them. The train would also have just exited a tunnel and so their eyes may not have quite adjusted from darkness to bright day light...

However none of the above are an excuse as the AWS magnets should've grabbed their attention.

 

[CC 72100]

and Asiana at San Francisco among others.

Somebody watched Air Crash Investigation last night!

 

[carriageline]

Well forgive my naivety, in my day I would have placed all signals at danger and cautioned trains through

What?! Why? If the boards are out, then there is no point and serves no purpose. That just causes a lot extra delay for no reason.

Another reason why the old days certainly were not the best.

 

[Jamesb1974]

Deleted

 

[Dave1987]

Well forgive my naivety, in my day I would have placed all signals at danger and cautioned trains through

There is no need to now. With the new addition of the GSMR V3.5 the signaller doesn't even need to stop you and caution you for a lot of things any more with the new 'safety broadcast message'. The way ESR's are set up even if you don't know about the speed order before hand, you certainly know about it when you approach the boards (if they are set up correctly)

 

[theironroad]

75 over a 5 is serious stuff. 5mph restrictions are pretty rare and used so that the line doesn't have to be closed altogether.

As raib have stated the appropriate warnings were all in place, one possibility and only that, a possibility, is that the manager driving cancelled the magnets for the warning and as it would have been some distance away from the commencement probably carried on chatting to his or her colleague and forgot about it. However, if the train was doing line speed as reported by raib, then it is incredulous that no attempt was made to reduce speed when they saw the commencement board. Hopefully the raib will get to the bottom of it and both these managers are honest about what was going on in the cab as the manager driving doesn't seem to have been concentrating on the road ahead, which makes a mockery of the assessing part of it.

 

[carriageline]

There is no need to now. With the new addition of the GSMR V3.5 the signaller doesn't even need to stop you and caution you for a lot of things any more with the new 'safety broadcast message'. The way ESR's are set up even if you don't know about the speed order before hand, you certainly know about it when you approach the boards (if they are set up correctly)

Unfortunately you misunderstand the new system. Trains will still be stopped and cautioned for an emergency speed. Anything safety of the line cannot be used with the new broadcast system. Infact, I think there is 6(?) precise events when you can use the berth triggered messages.

 

[najaB]

Somebody watched Air Crash Investigation last night!

I did. But knew about it already - still learned some new stuff though.

 

[RichmondCommu]

Perhaps the DM's hadn't seen the emails considering how late they were sent. Is it normal practice for DM's to log onto PC's when booking on - they may not have had the time to do so? The reason I ask is in my line of work, we are often too busy doing other (important) things before they get time to check (and respond to) our emails. Because of this, anything important/time sensitive is communicated via bleep or mobile phone.

I dare say I'm missing something here but surely the train drivers would have known that they had received an email simply by checking their phones?
--- old post above --- --- new post below ---

They were BOTH DSMs...? Good grief, this is almost too funny

What is funny about that?

 

[Dave1987]

Unfortunately you misunderstand the new system. Trains will still be stopped and cautioned for an emergency speed. Anything safety of the line cannot be used with the new broadcast system. Infact, I think there is 6(?) precise events when you can use the berth triggered messages.

Sorry you misunderstood me. I'm not saying you can use the safety broadcast system for speed orders if the boards aren't set up. But for instance the signaller would no longer need to stop and caution you if the lights in an emergency indicator are not flashing as long as you press the 'ST' button after receiving his/her safety broadcast message.

 

[GB]

I'm pretty sure sending such information via email is not an industry recognized standard of communication....that is what late notices cases are for.

However, I think we are getting far to hung up on whether they received information prior to starting their shift or not. Its whats on the ground that counts and the reasons why in this instance, the train/driver failed to adhere to it.

Its entirely possible to get an ESR after you have started your shift which is why we have boards and magnets and why they are important.

 

[scott118]

Well forgive my naivety, in my day I would have placed all signals at danger and cautioned trains through

Bonkers!

That aside..75mph in a 5mph ESR - that over speed is proportionately the same, as doing 450mph in a 30mph zone.
One might reasonably say, it was horrendous negligent. As such when the RAIB has concluded its report are there any grounds for a criminal case to be brought? Is it in the public interest to prosecute? Or was the WCR somehow different, as safety equipment had been isolated prior, as opposed to 'not being acknowledged'..

 

[ComUtoR]

Its entirely possible to get an ESR after you have started your shift which is why we have boards and magnets and why they are important.

Indeed.

It's worth adding that if you see an emergency speed restriction in place and you haven't been previously informed then you should assume it will be 20mph and less than a mile and a quarter. At the least they should have had the brake in.

 

[6Gman]

Without commenting on this specific incident (though the report will make interesting reading) it is intriguing that in the early days of dieselisation having a second man on the footplate was considered to enhance safety; now it's widely viewed as a hazard to safety.

 

[Domh245]

Without commenting on this specific incident (though the report will make interesting reading) it is intriguing that in the early days of dieselisation having a second man on the footplate was considered to enhance safety; now it's widely viewed as a hazard to safety.

Would that not be because in the days of secondmen, they were there to act as a safety mechanism. Nowadays, a second person in the cab usually isn't acting as a safety mechanism unless they are a pilotman (or similar)

 

[matchmaker]

Pendant here, but it was an ESR, not a TSR.

Pedant here, but it's pedant

 

[Jamesb1974]

Deleted

 

[Cherry_Picker]

Everyone seems to have missed this paragraph:

Quote:
The maximum speed generally permitted at this location is 75 mph (120 km/h), but an emergency speed restriction had been imposed during the previous night after a cracked rail was found at a set of points near the east end of Queen’s Park station. The correct line-side signs and warnings had been placed on the approach to the speed restriction, and a notice warning of the speed restriction had been correctly displayed on the late notices board at the drivers’ depot. In addition, emails relating to the speed restriction had been sent to various London Midland managers, including the driver-managers involved in the incident.

Not at all, I certainly didn't miss the paragraph but I've also been around the block often enough to know that just because the report found that the the correct warnings were placed in the notice case and at trackside before the incident happened that doesn't necessarily mean that they were in place at the time of the incident. While I agree it's highly unlikely to have happened it's still possible that the ESR in the notice case could have been removed or obscured and/or the trackside equipment may have fallen over in the wind or something.

The RAIB are pretty thorough in their investigations and while I'm sure plenty of us have our own theories about why the overspeed happened not all of us (particularly the drivers amongst us) want to start throwing mud and spreading rumours about it.

 

[Jamesb1974]

Deleted

 

[Cherry_Picker]

Yeah, that's where the area of confusion might creep in. The language used says that RAIB can confirm that boards and notices had been placed correctly, it doesn't state whether they were still there at the time of the incident.

I'm sure we both agree it's unlikely they weren't there, but of the odds of them not being there are 1000/1 and a thousand trains pass the ESR over the duration it's in place then there is still a slight chance of it being the cause.

 

[Mag_seven]

Can someone explain to me why this is an "accident"? Surely its an "operating incident" or a "near miss"? Do the RAIB investigate "near misses"?

 

[Jamesb1974]

Deleted

 

[Zoidberg]

Can someone explain to me why this is an "accident"? Surely its an "operating incident" or a "near miss"? Do the RAIB investigate "near misses"?

From the RAIB leaflet at

https://www.gov.uk/government/uploa...ile/479856/151125_Leaflet_01_Introduction.pdf

What is the RAIB?

The Rail Accident Investigation Branch (RAIB) is the independent railway accident investigation organisation for the UK. The RAIB is concerned with the investigation of accidents and incidents ...

Note the inclusion of incidents

 

[ainsworth74]

Can someone explain to me why this is an "accident"? Surely its an "operating incident" or a "near miss"? Do the RAIB investigate "near misses"?

From this information leaflet published by the RAIB themselves:

What accidents do the RAIB investigate?

The RAIB must by law investigate all rail accidents involving a derailment or collision which result in, or could result in:

• the death of at least one person;
• serious injury to five or more people; or
• extensive damage to rolling stock, the infrastructure or the environment.

The RAIB may also investigate other incidents which have implications for railway safety, including those which under slightly different circumstances may have led to an accident.

The part in bold is the key bit me thinks.