Collision Plymouth 03/04/16

[TheEdge]

Its RAIB Report day!

Summary
At 15:34 hrs on Sunday 3 April 2016, the 13:39 hrs passenger train service from Penzance to Exeter collided with an empty train which was already waiting in platform 6 at Plymouth station. The collision occurred at a speed of about 15 mph (24 km/h) and resulted in injuries to 48 people and damage to both trains.

The signaller intended that both trains should share the platform because the empty train was to form a service to London and some passengers from the Penzance service were expected to join it. Lift refurbishment work meant that without platform sharing, passengers would have needed to use the stairs and a subway when changing trains. Permissive signalling arrangements were in place at Plymouth to permit two trains to share the same platform.

The signaller misjudged the amount of space available behind the London train and wrongly believed there was room for the Penzance train. He was aware that the platform sharing arrangement required an unusual form of permissive working, but did not communicate this to the Penzance train driver, and the rules did not require him to do so.

The Penzance train driver incorrectly believed he would not be sharing a platform with the London train. There was insufficient distance to stop his train by the time he realised his mistake and had applied the emergency brake.

Great Western Railway, the operator of both trains, and Network Rail the owner of the infrastructure, had not identified the risk of a collision due to the combination of an unusual form of permissive working, the track alignment on the approach to Plymouth station, and an inexperienced driver.

Recommendations
The RAIB has made three recommendations. The first, addressed to Great Western Railway and possibly also relevant to other train operators, seeks improvements to the training and assessment of new drivers. The second, also addressed to Great Western Railway and possibly relevant to other train operators, arises from difficulties encountered during passenger evacuation and seeks improvements to emergency door release controls. The third recommendation, addressed to Network Rail and to be undertaken with the assistance of appropriate train operating companies, seeks a review of permissive working arrangements at stations.

Two learning points stress the care needed by drivers when undertaking permissive moves, and the value of preventing passengers boarding or alighting from trains when permissive movements are taking place in the same platform.

 

[2HAP]

Is there any reason why 2E68 could not have been routed into platform 5?

Edited to add: Found it, another train scheduled for platform 5.

 

[SpacePhoenix]

Are both the trains involved repaired and back in service?

 

[GB]

It is most surprising that the driver only realised where he was going at the very last few seconds. Whatever happened to route knowledge and "being prepared to stop short of any obstruction"?

While I acknowledge we all make mistakes, it seemed like he was relying on the lay of the points to determine where he was going rather than using the information displayed at the signal.

 

[theironroad]

It is most surprising that the driver only realised where he was going at the very last few seconds. Whatever happened to route knowledge and "being prepared to stop short of any obstruction"?

While I acknowledge we all make mistakes, it seemed like he was relying on the lay of the points to determine where he was going rather than using the information displayed at the signal.

I'd say these topics are covered at length in the report.

 

[pdeaves]

It is most surprising that the driver only realised where he was going at the very last few seconds. Whatever happened to route knowledge and "being prepared to stop short of any obstruction"?

As theironroad says, this is covered in the report. The driver understood that he was not going into the same platform as the HST, believing the obstruction to be further along the platform.

 

[Taunton]

How many more collisions at "permissive" platforming will there be (I can recall recent ones at Norwich and Kings Cross as well), which are well removed from the original concept of two trains fitting correctly into a long platform, but each of these three (maybe there have been more) were about bringing a second train into a platform which, by all normal measures, is already full up, and the second train doesn't fit (and the driver, having received a Proceed aspect, doesn't expect it to be so full).

 

[MichaelAMW]

As theironroad says, this is covered in the report. The driver understood that he was not going into the same platform as the HST, believing the obstruction to be further along the platform.

I think that's just what underlies GB's concern, and perhaps surprise: the driver wrongly believed that a position light in effect told him a minimum distance that would be clear, in this case the 4-car stop sign some way down the platform, and he discounted the possibility that the HST he could clearly see would constitute an obstruction, before which he would need to stop, on the grounds that it was too near to the west end of the station.

 

[TheEdge]

It is most surprising that the driver only realised where he was going at the very last few seconds. Whatever happened to route knowledge and "being prepared to stop short of any obstruction"?

While I acknowledge we all make mistakes, it seemed like he was relying on the lay of the points to determine where he was going rather than using the information displayed at the signal.

The report says the driver believed he would not be going on top of the HST as he hadn't been warned of such an unusual move and also believed incorrectly that when signalled into a permissive platform he would still be able to stop at the correct stopping position for his length of train.

How many more collisions at "permissive" platforming will there be (I can recall recent ones at Norwich and Kings Cross as well), which are well removed from the original concept of two trains fitting correctly into a long platform, but each of these three were about bringing a second train into a platform which, by all normal measures, is already full up, and the second train doesn't fit.

The report suggests that the signaller incorrectly believed the 4 car 150 would fit into the available platform space so its not quite the same situation.

 

[superalbs]

Are both the trains involved repaired and back in service?

43160 is, but 150219 is still part of 150938.

 

[theironroad]

Waterloo has a similar problem as Plymouth as well as a number of other stations in that curvature between the signal controlling the movement into the platform and the actual platform obscure any mk1 eyeball sight of what's in the platform already.

As a driver, especially busy areas like Waterloo, you have to trust that the signaller has got it right in terms of whether the platform will accomodate all the trains. It is often unrealistic to verbally check with the signaller every time, though once in a while signallers do call drivers to confirm formation lengths. It has been know at Waterloo for a train to be signalled into an occupied platform only to find that the available platform length is too short to accommodate the train.

It can cause considerable disruption as it might block access to other platforms and then the driver will have to change ends and do a Waterloo throat shunt move which will take time.

 

[GB]

As a driver, especially busy areas like Waterloo, you have to trust that the signaller has got it right in terms of whether the platform will accomodate all the trains. It is often unrealistic to verbally check with the signaller every time, though once in a while signallers do call drivers to confirm formation lengths.

This is what I don't necessarily understand nor agree with. You shouldn't have to "trust" a third party in such circumstances. Sure its nice to get verbal confirmation if only to avoid service disruption, but it should not be necessary to avoid potential collisions. As you've said yourself, its unrealistic for the signaller/driver to confirm every time which is why the calling on exists and why there is a rule about stopping short of any obstructions.

I think that's just what underlies GB's concern, and perhaps surprise: the driver wrongly believed that a position light in effect told him a minimum distance that would be clear, in this case the 4-car stop sign some way down the platform, and he discounted the possibility that the HST he could clearly see would constitute an obstruction, before which he would need to stop, on the grounds that it was too near to the west end of the station.

exactly

 

[theironroad]

This is what I don't necessarily understand nor agree with. You shouldn't have to "trust" a third party in such circumstances. Sure its nice to get verbal confirmation if only to avoid service disruption, but it should not be necessary to avoid potential collisions. As you've said yourself, its unrealistic for the signaller/driver to confirm every time which is why the calling on exists and why there is a rule about stopping short of any obstructions.



exactly

Everyone in the safety critical railway has to have faith in and trust what others do. Passengers rightly expect and trust I, as a driver, don't f*** up in my job and I have to have that faith in the people who maintain the track, signallers who tell me when they've blocked an adjacent line etc.

An interesting discovery for me from this raib report is that some signaller displays show how much of the platform is occupied by the red dashes. As signalling gets more digital I guess incidents of too long trains entering short available platforms will be rarer, though to complicate things I see that part of that available platform had been deemed unsuitable for the stock because of the pti gap.

However, you're right that there is a rule about stopping short of obstructions and every driver knows it, but as the report notes, the driver was relatively inexperienced and allowed prior experience at this station (going to the 4 car mark) to outweigh the basic rule book instruction of being prepared to stop short of any obstruction.

 

[G0ORC]

I normally find the RAIB reports very interesting reading and rarely are there any statements in them that are questionable - but this one is different.

I find it a little strange that the report clearly states that permissive platform working has been in operation for "many years" at Plymouth (and hundreds of other stations too) yet it also stresses that it is an "unusual move". I certainly would not consider the move in question to be an unusual move, even at Plymouth. As the report also says, this sort of move occurs thousands of times a day across the network. How can this be an unusual move?

Sadly the inexperienced driver believed the subsidiary signal meant that there was room in the occupied platform up to the normal 4-car stopping point and not the rule book meaning of "be prepared to stop short of any obstruction."

When I worked in Derby PSB, the track circuits in the through platforms were split in the middle so it could be seen that a short train (usually a DMU) was either at the north end or the west end, but that did not absolve the signaller from ascertaining from the platform supervisor that there was also room for another train to be accommodated before setting a route into the occupied platform, even though it may have been a "booked" move.

 

[TheEdge]

I find it a little strange that the report clearly states that permissive platform working has been in operation for "many years" at Plymouth (and hundreds of other stations too) yes it also stresses that it is an "unusual move". I certainly would not consider the move in question to be an unusual move, even at Plymouth. As the report says, this sort of move occurs thousands of times a day across the network. How can this be an unusual move?

It was the presence of the HST. The report would suggest that driver's would not expect to be put on top of an HST. It appears from a report that both the TOC and NR agree that it is unusual to perform such permissive working involving a HST. It looks like the driver has not expected to go behind an HST, much more likely a unit, so discounted in his mind he would be going onto the platform occupied by the HST

 

[AndyPJG]

Unusual, insofar as a non-timetabled movement rather than a normal timetabled (and hence expected) permissive movement.

 

[ainsworth74]

It was the presence of the HST. The report would suggest that driver's would not expect to be put on top of an HST. It appears from a report that both the TOC and NR agree that it is unusual to perform such permissive working involving a HST. It looks like the driver has not expected to go behind an HST, much more likely a unit, so discounted in his mind he would be going onto the platform occupied by the HST

Plus, there wasn't actually room for the unit to be put on top of the HST. The unit was 81 meters long and the driver was required to stop two meters short of the train in front so 83 meters was required. But there was only 61 meters of platform available on top of the HST.

So surely the other element that makes this unusual is that the unit was being put on top of another train when there isn't actually room for it! Something else that the driver, I would assume, wouldn't be expecting...

 

[daikilo]

One element in the report which I see as a concern, yet is not restated in the findings or summary, is that at least 1 coach length at the western end of platform 6 is considered not usable due to the lie of the track relative to the platform edge (photo on page 21 and para 53 on page 22).

Even if the driver had stopped in the correct position relative to the HST he would have been faced with this problem which would effectively have meant that doors should not be opened on the rear unit and possibly part of the front unit

 

[CharlieSpotted]

Given that there wasn't actually space on the platform for his train, if he had stopped short of the HST, would the rear of his train be over the points?

 

[louis97]

One element in the report which I see as a concern, yet is not restated in the findings or summary, is that at least 1 coach length at the western end of platform 6 is considered not usable due to the lie of the track relative to the platform edge (photo on page 21 and para 53 on page 22).

Even if the driver had stopped in the correct position relative to the HST he would have been faced with this problem which would effectively have meant that doors should not be opened on the rear unit and possibly part of the front unit

Indeed, I thought this as soon as I heard about the collision, would of thought the signaller would of been aware of this.

Given that there wasn't actually space on the platform for his train, if he had stopped short of the HST, would the rear of his train be over the points?

Yes, the report mentions that the signaller was aware of this and that Platform 7 and 8 were not required whilst the unit was at the station.

 

[DY444]

All the stuff about whether the train would fit etc is irrelevant. If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened. Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

 

[Phil.]

All the stuff about whether the train would fit etc is irrelevant. If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened. Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

Oooh that's fighting talk. You're not supposed to say things like that on here. Stand by for incoming.

 

[ainsworth74]

All the stuff about whether the train would fit etc is irrelevant. If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened. Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

I don't see how it is? You're right that he should have driven such that he could stop short of an obstruction. But equally his train should never have been signalled into platform which didn't have sufficient space for his train to even fit fully into it! Both elements are surely concerning? 1) That the driver's knowledge of the relevant part of the rule book wasn't good enough and 2) That the signaller signalled a move which couldn't be safely completed in the space available.

Surely we shouldn't just be relying on the driver's knowledge to keep the train safe in this situation? The signaller has a role to play to surely? Therefore both parts are very relevant?

 

[theironroad]

All the stuff about whether the train would fit etc is irrelevant. If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened. Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

While that is essentially true, we are fortunate that the raib report goes into more depth than your blunt blame statement.

The raib aren't there to apportion blame but to identify lessons that can be learnt to help prevent a recurrence.

While the crash itself is down to the driver, as I described earlier he or she could have been in a position where they had stopped 6 feet from the stationary train and then found that the train was not accomodated in the platform and was overhanging the platform and fouling the points.

There is a lot of information in that report that could help to prevent a similar incident rather than your claim it's all irrelevant and let's just blame the horrible driver.

 

[Flying_Turtle]

Thank you for reminding us of the drivers duties! Now, can we go back to the discussion about the report and real world facts (as opposed to how the real world should run) ?

 

[ComUtoR]

Oooh that's fighting talk. You're not supposed to say things like that on here. Stand by for incoming.

Deep inhale...

If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened.

Totally agree. This is certainly something I can't quite grasp. This incident should not have happened. There was a series of unfortunate events that led to the collision but the Driver should have stopped short.

Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

Not sure I agree with this part. I see this as more a series of assumptions that were incorrect. Route knowledge appears lacking as he had to count the platforms rather than knowing he was routes into 6 and the HST.

Training I'm not so sure on. I know the requirements that are needed (at least my TOC) and that there are many opportunities that require permissive working. He assumed the location of where he was expected to stop and drove accordingly. He aimed for a place that he assumed he was going to stop at rather than going at caution.

The only defence of the Driver I can think of is that it takes a few seconds to realise what is about to happen. When this happened to me at Victoria I came round the corner into the platform and the platform was occupied with a unit I wasn't expecting to be there (much longer than advised)

My mindset was :

'Are you forking kidding me..'
'seriously signaller wtf..'
'ahh crap this is gonna end badly..'
'better make an announcement'

Only because I was at caution did I manage to stop. Its very easy to doubt when your new and you are reliant on training and 'normal' workings. Its also very easy to say out of experience and I have no doubt that this Driver will change his approach to permissive working.

 

[daikilo]

All the stuff about whether the train would fit etc is irrelevant. If the driver had driven the train such that he could stop short of any obstruction as required by the rulebook then the incident would not have happened. Basically he didn't understand permissive working and what was required of him by the rulebook because the training he received was inadequate in this respect.

I don't disagree, but in addition, basically the signaller called-on the train into a platform where it would not fit, and without warning the driver this may happen and not to open the doors of at least the last vehicle. Not saying this is a bigger or smaller issue than the above, but both are mentioned in the report.

 

[GB]

I don't see how it is?

Had the train been a two car it would have fit yet the collision would have still probably occurred. So yes I agree with DY444, it is largely irrelevant (in my opinion).

Edit: Having said all the above, I hope the driver is doing ok without any lasting repercussions.

 

[scott118]

I was always taught when i was training, never to trust the signaller. Upon receiving a signal, into an occupied platform, i would always call the signallers to ask, what, i was being 'called onto'. I would also, always, state my train length, then ask again, if it was safe to proceed? Calls to the signallers are recorded, hence should there be any need to request them, I will be in no doubt, hopefully, 'safe'.

On one occasion, this prevented an issue for us both. A quick PA, explaining "awaiting platform allocation", whilst the route was reset, then onwards with the minimum of delay. Taught me a valuable lesson, and reiterated what was drummed into me, during my training.

Both signallers and drivers, have different responsibilities. These seem to have been overlooked on this occasion, sadly.

 

[TEW]

Although in this case even if the driver had called up and queried the route, the train may still have been routed in to the platform. The signaller incorrectly believed there was sufficient room for both trains. The driver would however have been expecting an HST in his platform so would have known that's what he was stopping short of.