RAIB: Overspeed at Queen's Park

[455driver]

Yes they investigate near misses. Has it been described as an accident? The RAIB link says incident.

I think he is hung up on the A in RAIB!
Maybe it should have been called the Rail Accident, Incident, Near Miss and any Other Worthy Item Investigation Branch but then RAINMOWIIB is a bit of a mouthful!

 

[ainsworth74]

I think he is hung up on the A in RAIB!
Maybe it should have been called the Rail Accident, Incident, Near Miss and any Other Worthy Item Investigation Branch but then RAINMOWIIB is a bit of a mouthful!

Yet surprisingly still actually pronounceable as a word!

 

[Jamesb1974]

Deleted

 

[HMS Ark Royal]

I suppose the acronym for Total Ignorance Towards Safety can never be used instead

 

[455driver]

Yet surprisingly still actually pronounceable as a word!

Deliberately so, it took me ages to make it work!

 

[100andthirty]

Modern safety management is all about identifying and learning from incidents where there has been no loss but in only slightly different circumstances could havs been catastrophic - so called "near misses" or "near hits". This one is important for the reasons the RAIB outlined but didn't emphasise, namely that all the appropriate processes and actions were put in place to impose and communicate the TSR and yet it was still overlooked by experienced professional train drivers. Therefore they need to understand why and recommend improvements in process.

Few accidents or near misses happen because of a single error or failure. There are generally a number of layers of safety protection, albeit each one may not be perfect. It is only if the weakensses of each layer of safety coincide that you have an incident.

 

[tsr]

Deliberately so, it took me ages to make it work!

Part of your skills from when you were a guard?

 

[ComUtoR]

Part of your skills from when you were a guard?

Only if the acronym spelt KitKat

 

[tsr]

Only if the acronym spelt KitKat

Exactly the sort of comment I should expect from Lunatic Electric Vehicle Engineers Requiring Pay, Unlit Surroundings, Hours Exceeding Roster & Snacks.

 

[HMS Ark Royal]

Exactly the sort of comment I should expect from Lunatic Electric Vehicle Engineers Requiring Pay, Unlit Surroundings, Hours Exceeding Roster & Snacks.

LOL - lever pushers

 

[HLE]

Out pedanted by a pedant! Is this a first?

Ah I wondered who'd be the first to spot that!

 

[krus_aragon]

I suppose the acronym for Total Ignorance Towards Safety can never be used instead

Much like Arnold Rimmer's (Red Dwarf) Commitee for the Liberation and Integration of Terrifying Organisms and their Rehabilitation Into Society...

 

[LAX54]

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

BUt even in the 'old days' you only cautioned until the boards were out, having said that, it's 5mph so yes, trains would have been stopped and cautioned for at least 24 hours until it was known that the notice was in the late notice cabinet for Drivers, and that all had seem it, or could / should see it.

 

[ComUtoR]

having said that, it's 5mph so yes, trains would have been stopped and cautioned for at least 24 hours until it was known

Not sure how long you are cautioned for but very often when ESR's are imposed you can get checked down, verbally cautioned, and even asked to exceed the limit. You may even get asked to proceed at a specific speed between point a and point b because they are aware of a problem and the boards are not out yet.

My personal experience is that you get cautioned until the boards go up. The typically they open the road up again to "normal" running.

 

[carriageline]

Correct, that's how we've always done it. IE:

Driver reports rough ride, examine/and subsequently caution at 20mph until pway attend.

They attend, say it can be raised to 50, and they are going back to get boards. We caution at 50 mph.

Pway ring up, boards are in place at XYZ, "normal" running resumed

 

[Bayum]

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 ---


What is funny about that?

So it is probable that the TSR wasn't visible on that morning and the investigation will have to focus on whether it was in place properly, fallen down or there was poor visibility.

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.

Irregardless (not often I get to type an incorrect, double negative these days!) of whether the managers 'recieved' or 'saw' the emails on phones, surely the point of the matter is that the short notices board should have been checked prior to taking the train out into service? Whether they received or acknowledged the email or it's existence prior to being on the mainline is largely irrelevant in this case when notices should have been checked.

 

[RichardN]

Irregardless (not often I get to type an incorrect, double negative these days!) of whether the managers 'recieved' or 'saw' the emails on phones, surely the point of the matter is that the short notices board should have been checked prior to taking the train out into service? Whether they received or acknowledged the email or it's existence prior to being on the mainline is largely irrelevant in this case when notices should have been checked.

Our investigation will include examination of:

the actions of staff involved
the information they each received
any underlying management issues.

Would encompass those points I would think.

 

[TDK]

RAIB are looking into this:



https://www.gov.uk/government/news/overspeed-at-queens-park

On the face of it, pretty shocking, especially given that both of the people in the cab are described as "Driver Managers"?

Actually reading this statement again it doesn't seem to say that driver managers were driving only that they are involved in the incident so in reality it may have not been dm's in charge of the train.

 

[221129]

Actually reading this statement again it doesn't seem to say that driver managers were driving only that they are involved in the incident so in reality it may have not been dm's in charge of the train.

It was being driven by a driver-manager who was being assessed, as part of a routine competence management process, by a second driver-manager travelling in the driving cab.

Looks quite clear to me...

 

[ComUtoR]

(...) when notices should have been checked.

What it depends on is when they booked on and when the notices were posted.

• I book on for duty at 0530 and check the notice case as required but the information has not been posted.
• I go take the unit into service.
• At 0630 the notice is posted in the Late Notice Case and emails are sent out etc.
• At 0830 I have the incident.

Not once did I read the notice or emails. The timeline of events will be clearly laid out to find out what went wrong. The RAIB will investigate every little detail.

I see more ESR's on approach than I read in the late notice case. As always there is a lot of missing information.

 

[SPADTrap]

I can see the scenario playing out something like:

- Units proceeding at line speed on greens
- AWS acknowledged for Emergency Indicator
- Emergency Indicator noted
- AWS for Warning Board acknowledged
- Warning Board's speed noted
- Braking distance is lengthy owing to the freight traffic that runs about the WCML - a 350 wouldn't likely need to get the brakes on passing the warning board in these circumstances but that is down to how each individual driver drives.
- Something happens in that time that distracts the crew up front, leading to them forgetting about putting the brakes on for the commencement
- Commencement board either missed or noticed too late to act to control the train's speed sufficiently
- PWAY working nearby on the track defect note train's alarming speed and report the incident

A total guess but no driver sets out to make a mistake like this, something was at play therefore it is vital the find the cause. It may cause hysteria because they were managers but no one is infallible, especially since manager's get much less 'stick time'.

 

[MichaelAMW]

Modern safety management is all about identifying and learning from incidents where there has been no loss but in only slightly different circumstances could havs been catastrophic - so called "near misses" or "near hits". This one is important for the reasons the RAIB outlined but didn't emphasise, namely that all the appropriate processes and actions were put in place to impose and communicate the TSR and yet it was still overlooked by experienced professional train drivers. Therefore they need to understand why and recommend improvements in process.

Few accidents or near misses happen because of a single error or failure. There are generally a number of layers of safety protection, albeit each one may not be perfect. It is only if the weakensses of each layer of safety coincide that you have an incident.

Indeed. I am reminded of this accident at Nuneaton in 1975

http://www.railwaysarchive.co.uk/docsummary.php?docID=272

where failure to slow for a TSR led to four deaths. It was fortunate that this time there was no damage done but it might have been different, so finding out why is vital.

 

[theironroad]

You're right! I did wonder...:roll:

Actually reading this statement again it doesn't seem to say that driver managers were driving only that they are involved in the incident so in reality it may have not been dm's in charge of the train.

Seems very clear to me who was driving:

The London Midland service, reporting number 2B14, consisted of three class 350 electrical multiple units coupled together; a total of 12 coaches. It was being driven by a driver-manager who was being assessed, as part of a routine competence management process, by a second driver-manager travelling in the driving cab. No injuries or damage resulted from the incident, and the train continued normally to its destination.

 

[455driver]

Whether they have read the email or late notice case (LNC) is irrelevant in this case, the fact they didn't notice/forgot about/disregarded the dalek and warning boards are what is important.
ESRs can be imposed after a driver has signed on for duty and the ESR therefore wouldn't be in the late notice case or notices, the LNC is only an aid and gives the drivers a heads up on what they are going to encounter, it isn't/can't be taken that everything is going to be posted on the LNC.

 

[nom de guerre]

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.

There is no rulebook requirement to stop and caution for a defective emergency indicator - just to stop and advise.

It's been lumped in with auto-cautioning but isn't actually a caution.

 

[MichaelAMW]

Whether they have read the email or late notice case (LNC) is irrelevant in this case, the fact they didn't notice/forgot about/disregarded the dalek and warning boards are what is important.
ESRs can be imposed after a driver has signed on for duty and the ESR therefore wouldn't be in the late notice case or notices, the LNC is only an aid and gives the drivers a heads up on what they are going to encounter, it isn't/can't be taken that everything is going to be posted on the LNC.

Presumably it can be pretty difficult to actually remember accurately all of the speed restrictions on your "patch" - temporary or emergency ones, I mean - so are the warning boards in practice the primary way you know about them? I think that's essentially what you're saying here, but I'm just asking the question from a different angle.

 

[najaB]

Presumably it can be pretty difficult to actually remember accurately all of the speed restrictions on your "patch" - temporary or emergency ones, I mean - so are the warning boards in practice the primary way you know about them?

I risk incurring the wrath of 455driver and others, but that's what drivers are paid the big bucks* for. If a ESR warning board comes as a surprise, something has gone wrong. It might be the driver's fault, the signaller's or NR's but it shouldn't happen.

It's testament to the multiple layers of redundancy built into the system that even when people do get thing wrong it's usually an incident rather than an accident but it needs to be investigated and lessons learned so that it doesn't happen again (without apportioning blame). That's what keeps us all safe on the railway.

*Used purely as a literary device and not a criticism of salaries!

 

[scott118]

Presumably it can be pretty difficult to actually remember accurately all of the speed restrictions on your "patch" - temporary or emergency ones, I mean - so are the warning boards in practice the primary way you know about them? I think that's essentially what you're saying here, but I'm just asking the question from a different angle.

Even if you can't remember all the esr/tsr speeds within, you get a speed reminder when the aws goes off, which needs to be acknowledged by the driver. In some cases, where an esr has just been been placed on the route, a driver will be prewarned, should it not have been visible to them upon signing on. The warning comes in the form of, signaller contact, or in worst cases, the esr warning board itself. In any case, the driver would have been made aware of any restriction ahead

 

[theironroad]

My TOC no longer publishes ESR notices for display at signing on points and we don't have tablets either. The first we know about an ESR is either when someone mentions it in the messroom if it is unusual or when we see the dalek. It's no big deal not having it in the notice case, except one thing that was useful was that the notice published the mileage of the ESR which was useful when the dalek was positioned a long way before commencement.

The new thing they are trialling is having power reduction boards line side to indicate where power reduction has to be applied. Currently this is via late notice case or signaller and there is no lineside indications until you blow the juice!

 

[Dave1987]

Guys if there is an ESR imposed on my route after I have signed on I will know about it via two ways:

1) The signaller will stop me at the stop signal protecting the relevant piece of track and inform me there is an ESR in place and tell me what maximum speed he/she requires me to comply with over the block section.

2) The ESR boards are put in place properly, I get two AWS warnings along with a very bright flashing Emergency indicator and speed warning board. I should then have ample breaking time before I get to where the speed order applies, especially if I am in any kind of passenger train.

It should not matter if I have received an email (which I don't get) or seen the Late notice case. These are measures that added on top so that you are expecting the speed restriction.

As SPADTrap has said something must have happened between them seeing the ESR warning boards and getting the AWS warnings and them reaching the ESR. The RAIB will no doubt find out why they failed to break for it.