RAIB: Overspeed at Queen's Park

[nom de guerre]

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.

The worrying thing about Queen's Park is that it happened during daylight (unlike Nuneaton), with the speed restriction equipment apparently working correctly (unlike Nuneaton).

 

[ComUtoR]

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.

Happens all the time.

That kind of the point. They are Emergency speeds. Why they didn't act on the indicator is my only real concern. I'm not even that concerned as you miss them all the bloody time. Granted not 75 vs 5. In the week I first started there was 100 through a 20.

For the RAIB to get involved seems excessive so I reckon there is more than meets the eye. Hopefully it will show that email and notice cases are not reliable and hopefully it highlights that the admin side of the Drivers role does need looking at.
--- old post above --- --- new post below ---

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!

Which ones are those ? The only power reduction ones I know of are the coasting boards and the inverted triangle "notch indicator" boards. Both have been around for many moons. Do you have a link to the trial ones, I'd be interested to see them ? Cheers if you do (or don't).

 

[najaB]

If a ESR warning board comes as a surprise, something has gone wrong.

Happens all the time.

That kind of the point. They are Emergency speeds.

Sorry, I meant (and should have posted) "if it was posted before you started your shift". It goes without saying that ESRs imposed during your day may come as a surprise.

Edit for clarity: My earlier post was in reply to MichaelAMW saying it must be difficult to remember TSR/ESRs - naturally you can't remember something that you don't know about!

 

[scott118]

100 through a 20.

Yikes! what was the following action plan?

 

[ComUtoR]

Gotcha. Cheers for the clarification.
--- old post above --- --- new post below ---

Yikes! what was the following action plan?

Nothing. There was mitigating circumstances. Pretty much why I'm keeping an open mind to this. Many facts are missing.

 

[455driver]

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.

Yeah I suppose the boards are the primary way, the notices etc add additional information such as exact mileage.

Once we go through them once we will remember them for the next time so we can adjust our braking so we don't lose any more time than necessary if the boards are placed further away than ideal for the traction we are driving.

 

[SpacePhoenix]

For TSRs and ESRs where the difference between the normal line speed and the temp speed is greater then a certain amount, is an extra "advance warning" board/light placed in advance?

 

[driver_m]

For TSRs and ESRs where the difference between the normal line speed and the temp speed is greater then a certain amount, is an extra "advance warning" board/light placed in advance?

No, but there are reminders for instance if a station falls between the warning and the commencement board if it's more than a set distance away.

 

[colchesterken]

Anyone know if any other trains did the same thing ..At 0830 I would have thought that speed reduction from 75 to 5 would mean running on single yellows .due to congestion
That would mean running at about 30mph, so last min red button should have sorted it
I am waiting to see the report

 

[Boodiggy]

No this was the only train that ran through the ESR at line speed. All other trains from start of service ran through at the 5 ESR speed.
The restriction was placed at night following discovery of a rail defect in a crossing leading in to / out of Kilburn loop.
As it is under investigation I cannot say much but it was reported by Pway staff on site and it seemed the driver believed speed was for going into loop only.

 

[Jamesb1974]

Deleted

 

[455driver]

Sounds plausible, but surely if the ESR was for the loop, it would have had a directional arrow board underneath the '5'??

read the previous post properly!
It was on the points from the mainline to the loop so the 5 would relate to all trains whether looped or not.

 

[Jamesb1974]

Deleted

 

[theironroad]

No this was the only train that ran through the ESR at line speed. All other trains from start of service ran through at the 5 ESR speed.
The restriction was placed at night following discovery of a rail defect in a crossing leading in to / out of Kilburn loop.
As it is under investigation I cannot say much but it was reported by Pway staff on site and it seemed the driver believed speed was for going into loop only.

Wow! I guess there is going to be fall out from this if people who are supposed to be managing drivers can't work out what the trackside signage means.

 

[cool110]

Which ones are those ? The only power reduction ones I know of are the coasting boards and the inverted triangle "notch indicator" boards. Both have been around for many moons. Do you have a link to the trial ones, I'd be interested to see them ? Cheers if you do (or don't).

There's also the E boards used in the Merseyrail area, although those only appear at stations.

 

[TDK]

Looks quite clear to me...

Sorry I must have missed that bit
--- old post above --- --- new post below ---

Wow! I guess there is going to be fall out from this if people who are supposed to be managing drivers can't work out what the trackside signage means.

This is a silly statement, of course driver managers understand what the line side sinage means it's the fact that they didn't act on the sinage that is the problem here.

 

[Cliveblackpool]

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.

Braking hard at this point could have put a lot more strain on the broken rail?

 

[SPADTrap]

Braking hard at this point could have put a lot more strain on the broken rail?

I think there is something to the argument there, possibly a shift in the centre of gravity of the unit as the brakes apply hard might have an effect?

 

[ComUtoR]

I think there is something to the argument there, possibly a shift in the centre of gravity of the unit as the brakes apply hard might have an effect?

If you were going linespeed and missed a 5mph speed restriction, which was one of those annoying ones that are barely a few feet long. Would you hit the brakes or just go 'bugger' and continue.

If its true what was said up thread about they believing it was for the crossover into the loop and not the mainline then I'd say its just a simple and easy error to make.

 

[TDK]

Braking hard at this point could have put a lot more strain on the broken rail?

I doubt that the driver would even think or know why the ESR was in place if he missed it.

 

[theironroad]

Sorry I must have missed that bit
--- old post above --- --- new post below ---


This is a silly statement, of course driver managers understand what the line side sinage means it's the fact that they didn't act on the sinage that is the problem here.

Why is it silly? The poster below says that it seems the driver (driver-manager) thought the speed was going into loop only. He knew it was there, so didn't act on it because he didn't think it applied to him or her, so there is a discrepancy here in application of the rule book.

So we have RAIB (and presumably NR) laying out the speed correctly for all traffic (RAIB say it was laid out correctly) and a driver-manager driving the train who thinks it only applies to traffic entering the loop. It is not silly, either NR (and RAIB) are right or the driver-manager is right. We'll probably have to wait many months to find out.....

Note: the bold emphasis in post below is mine and not the original poster's.

No this was the only train that ran through the ESR at line speed. All other trains from start of service ran through at the 5 ESR speed.
The restriction was placed at night following discovery of a rail defect in a crossing leading in to / out of Kilburn loop.
As it is under investigation I cannot say much but it was reported by Pway staff on site and it seemed the driver believed speed was for going into loop only.

 

[ComUtoR]

Why is it silly? The poster below says that it seems the driver (driver-manager) thought the speed was going into loop only. He knew it was there, so didn't act on it because he didn't think it applied to him or her, so there is a discrepancy here in application of the rule book..

I don't think there was a discrepancy in application of the rule book. I would say this is an error and not a violation.

The mistake was not believing it applied to the main line. The Driver applied the rules in that they believed that the restriction was in place but didn't apply to them, rightly they didn't apply any brake. That is very much human error.

IF they find that the Driver didn't understand that you need a directional arrow or that even if the commencement board was a few feet prior to the loop so you would still need to slow down then it becomes something more.

It is incidents like this that make it to the next LADD briefing.

Thankfully the RAIB do go into depth and the facts will come out.

 

[TorqueOfTheDevil]

Another factor to 214's accident was the fact he did not know what he was doing, but didn't want to bother the senior pilot due to a cultural thing. Long and short of the matter is that he was a dangerous and unsafe pilot to be working that flight

Unfortunately the statement in bold is not only simplistic but also wrong. How would any new pilot (or train driver) become safe to operate by themselves without a period of on-the-job training? The whole point is that the training captain/instructor is meant to monitor closely the performance of the individual under training, precisely because the latter is very likely to make mistakes or have gaps in their knowledge/understanding.

To accuse the co-pilot of being dangerous and unsafe is unfair because he was no more dangerous or unsafe than any other typical trainee. Like it or not, the Captain has overall responsibility for the safety of a flight and this includes noticing and correcting mistakes, including serious ones, by junior members of the crew. The only time that a Captain would not shoulder blame for an accident caused by the flight crew is some kind of freak situation like the Germanwings crash, which fortunately is rather rare.

 

[Class 170101]

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!

Is this only for things like coasting or if there are emergency feeding arrangements in place?

I heard of one example where there was a fire on a site adjacent to a feeder station so this was switched off but the OLE was still live being fed from feeder stations either side of the one affected. This led to an instruction for Class 90s to reduce power consumption by not using notch four on ther power controller.

 

[theironroad]

Is this only for things like coasting or if there are emergency feeding arrangements in place?

I heard of one example where there was a fire on a site adjacent to a feeder station so this was switched off but the OLE was still live being fed from feeder stations either side of the one affected. This led to an instruction for Class 90s to reduce power consumption by not using notch four on ther power controller.

Not a coasting board, we still have those though not rigoursly used. Since desiro were introduced on Swt, the dc power supply has issues at times providing enough current and when too many trains in a close area, the supply can't cope and power reduction is imposed. Often this is a temporary issue with the supply at may only last until rectified. Im only aware of one place where there is a requirement for permamnet power reduction in limited scenarios. On desiros (444/450 at least) there is a power reduction button in cab and when operated cuts the traction motors demand by 50%.

I'm not really that clued up about the reasons why power reduction is needed, just have to apply it. We had it for years, just previously was advised via late notice or call from signaller, the boards are a trial.

 

[nom de guerre]

Unfortunately the statement in bold is not only simplistic but also wrong... To accuse the co-pilot of being dangerous and unsafe is unfair because he was no more dangerous or unsafe than any other typical trainee.

I don't necessarily agree with the poster you were responding to, but equally, I have to disagree with your statement.

The FP was nervous about performing a relatively challenging, visual 'Slam Dunk' approach because he had never previously landed a Boeing 777 'by hand'. He was struggling to acclimatise to the Boeing control interface, having accumulated most of his career hours on the A320. His previous 777 training landing had not gone well (the IP on that flight stated that the FP was "not well organised or prepared", "deviated from multiple standard operating procedures" and "[did not take] his feedback seriously enough"). It was also the first time the IP supervising him had ever performed this role.

This unfortunate combination of factors meant that the FP represented a greater risk than a "typical" trainee for this particular landing.

 

[zn1]

until the investigation is concluded all this assumption etc is superflous..none of us were there....simple as that

 

[TorqueOfTheDevil]

The FP was nervous about performing a relatively challenging, visual 'Slam Dunk' approach because he had never previously landed a Boeing 777 'by hand'. He was struggling to acclimatise to the Boeing control interface, having accumulated most of his career hours on the A320. His previous 777 training landing had not gone well (the IP on that flight stated that the FP was "not well organised or prepared", "deviated from multiple standard operating procedures" and "[did not take] his feedback seriously enough"). It was also the first time the IP supervising him had ever performed this role.

This unfortunate combination of factors meant that the FP represented a greater risk than a "typical" trainee for this particular landing.

Fair point, but surely there will always be a range of acceptable ability levels for any group of trainees in any field? Had this individual's ability been well below the norm, he would have been suspended from training or sacked outright, so the fact that he was being given another chance shows that he was still in the right ballpark, even if at/near the "bottom of the class". Perhaps my previous post should have stated "He was not significantly more dangerous or unsafe...".

And the concerns about the FP's performance which you have highlighted demonstrate that the IP failed in his duty: namely, to monitor the trainee's actions closely and intervene before the situation became irrecoverable. Please understand that I don't envy the brand-new IP - speaking as a fairly experienced instructor myself, it was not an easy situation to manage, but that's the nature of the job!

As with most things, there was far more to it than simply "The trainee f**ked up". The root of this goes back to the decision by the roster planner to crew a weak trainee with a brand-new IP. Of course the FP must shoulder some of the blame, as does the planner, but the captain/instructor is primarily at fault.

 

[Zoidberg]

The RAIB has published its report linked to from:

https://www.gov.uk/raib-reports/overspeed-incident-at-queen-s-park

Summary:

At 08:28 hrs on 5 January 2016, a London Midland train estimated to be carrying around 2000 passengers travelled at 75 mph (121 km/h) through a 5 mph (8 km/h) emergency speed restriction at Queen’s Park in north-west London. The train was the 07:39 hrs service from Bletchley to London Euston and was being driven by a driver manager who was being assessed by another driver manager. The emergency speed restriction had been imposed due to a track defect. There were no injuries, no further damage to the infrastructure and no damage to the train which continued its journey to Euston.

The driver manager who was being assessed did not slow the train for the emergency speed restriction as he had misunderstood details of the restriction given in an email. Details of the restriction were also given on a notice displayed at his booking-on point, and lineside warnings were provided on the approach to the restriction. These did not correct the driver’s misunderstanding. The assessing driver manager’s knowledge of the emergency speed restriction was insufficient to notice the driver’s error.

The RAIB has made three recommendations to London Midland seeking to improve the ongoing training of driver managers, improve the communication of safety critical information and to implement a means of quickly identifying the driver of any train. The RAIB has also identified three learning points concerning the importance of managers fully preparing before driving trains, the need for driving assessors to prepare as if they were driving the train and the use of unambiguous words in safety communications.

 

[Phil.]

The RAIB has published its report linked to from:

https://www.gov.uk/raib-reports/overspeed-incident-at-queen-s-park

Summary:

Sounds like the blind leading the blind. What a terrible indictment of London Midland's management when the people given the task of ensuring standards can't even manage them themselves.