• Our new ticketing site is now live! Using either this or the original site (both powered by TrainSplit) helps support the running of the forum with every ticket purchase! Find out more and ask any questions/give us feedback in this thread!

ScotRail HST derailment at Dalwhinnie (10/04/2021)

Status
Not open for further replies.

alxndr

Established Member
Joined
3 Apr 2015
Messages
1,694
I was under the impression that the point machine controls are normally inhibited if the track circuit over them is occupied though (clearly not, as this would have been raised in the report)
The signaller may be prevented from actively trying to swing the points with the track circuit over them occupied, but it appears that on these points if the detection is lost the points will motor try to achieve detection again.

With the way that the errors were made detection was still lost when one end was no longer fully closed, at which time the motor ran and managed to drive the points.
 
Sponsor Post - registered members do not see these adverts; click here to register, or click here to log in
R

RailUK Forums

GC class B1

Member
Joined
19 Jun 2021
Messages
460
Location
East midlands
The train took 25 seconds to accelerate up to 25 mph, so about 8 seconds to reach 33 mph, from the start of the points, to the moment the brake pipe fractured, and derailment. The red button should surely have been pressed, along with brake lever to emergency position, before the train actually stopped.

Playing the Monday morning quarterback is easy for sure, but lessons need to be learnt.
I think your calculation of the time between the front bogie of the leading power car lurching as it passed over points 13A until the brake pipes parted is too short at 8 seconds, as I have calculated it to be about 10 seconds. The distance between the leading bogie of the leading power car and the trailing bogie bogie of the last passenger vehicle is at least 125 metres. This would be around the same as the distance travelled by the train from the leading power car bogie being on the points (when the lurch would be felt) to the trailing bogie of the last passenger vehicle being sufficiently misaligned to part the brake pipes.
As the train was accelerating from 25 to 33 MPH i have taken the average speed over this distance to be 12.5 m/s and the time taken will be about 10 seconds.
 

Taunton

Veteran Member
Joined
1 Aug 2013
Messages
12,343
I am more surprised at what caused the points to move. Isn't the whole point of mechanical Facing Point Locks to act as a second backup to the main point mechanism and to prevent it moving? If the mechanism which operated the points when it got an 'out of correspondence' signal as the trailing points were run through released both the FPLs as well as operating the points, there seems little purpose in having it. I would have expected the design to be such that a mis-wiring in the point mechanism would not release the locks as well. In a mechanical signalbox like this (despite some items being motor-operated) there are two levers, one for the point mechanism and one for the FPL.
 

BRX

Established Member
Joined
20 Oct 2008
Messages
4,557
I'm not a train driver... but can imagine how disoriented I'd feel, having been given a clear signal and started forward, to find myself directed unexpectedly at the very first set of points. I can imagine that I would first question myself - have I got confused, are those tracks on the left just a siding that's always there, have we intentionally been put on the other line - before deciding that no, it's not me who's wrong here. I can well imagine that process taking 5 or 10 seconds.

Especially given the context of being in the middle of a series of slightly unusual moves rather than on a regular timetabled trip.
 

Railsigns

Established Member
Joined
15 Feb 2010
Messages
2,754
In a mechanical signalbox like this (despite some items being motor-operated) there are two levers, one for the point mechanism and one for the FPL.
The points in question were worked by lever 13 alone. There wasn't a separate FPL lever.
 
Joined
29 Oct 2021
Messages
180
Location
Newton Abbot
I'm not a train driver... but can imagine how disoriented I'd feel, having been given a clear signal and started forward, to find myself directed unexpectedly at the very first set of points. I can imagine that I would first question myself - have I got confused, are those tracks on the left just a siding that's always there, have we intentionally been put on the other line - before deciding that no, it's not me who's wrong here. I can well imagine that process taking 5 or 10 seconds.

Especially given the context of being in the middle of a series of slightly unusual moves rather than on a regular timetabled trip.
Modern day driving standards require situational awareness and fast reactions, as per the psychometric standard. This was not a wrong route but a no route. I don't believe the red button was not pressed either. The competence standards put drivers on corrective supervision for missing the AWS cancel once in every blue moon, so what are the standards? No one wants the unfortunate driver's blood, just well promulgated learning from a well conducted report, that does not take over a year to produce and fall short of the mark.
 

MadMac

Established Member
Joined
13 Jun 2008
Messages
1,509
Location
Moorpark, CA
I don't ever recall seeing motor points with a separate FPL lever.
The FPL is integral to the machine/mechanism. Where it's a conversion from mechanical points, the old FPL lever will generally be retained "for interlocking purposes only" to avoid alterations to the mechanical locking.
 

Railsigns

Established Member
Joined
15 Feb 2010
Messages
2,754
The FPL is integral to the machine/mechanism. Where it's a conversion from mechanical points, the old FPL lever will generally be retained "for interlocking purposes only" to avoid alterations to the mechanical locking.
You beat to me to it, although I was going to add that this does not apply at Dalwhinnie.
 

MadMac

Established Member
Joined
13 Jun 2008
Messages
1,509
Location
Moorpark, CA
You beat to me to it, although I was going to add that this does not apply at Dalwhinnie.
It's about time I beat you to something 8-)

Dalwhinnie would have presumably been re-locked when the line was redoubled in 1976-ish and the necessary resources for that type of work were somewhat more plentiful.
 

alxndr

Established Member
Joined
3 Apr 2015
Messages
1,694
I am more surprised at what caused the points to move. Isn't the whole point of mechanical Facing Point Locks to act as a second backup to the main point mechanism and to prevent it moving? If the mechanism which operated the points when it got an 'out of correspondence' signal as the trailing points were run through released both the FPLs as well as operating the points, there seems little purpose in having it. I would have expected the design to be such that a mis-wiring in the point mechanism would not release the locks as well. In a mechanical signalbox like this (despite some items being motor-operated) there are two levers, one for the point mechanism and one for the FPL.
The FPL will "lock" the points physically in the closed position until such a time that the points are called to the other direction. As a feed was applied to the motor due to the other end of points losing detection and the points trying to motor back to their intended position (as designed), the points unlocked and moved as they would for any other swing.
 

Taunton

Veteran Member
Joined
1 Aug 2013
Messages
12,343
The FPL is integral to the machine/mechanism. Where it's a conversion from mechanical points, the old FPL lever will generally be retained "for interlocking purposes only" to avoid alterations to the mechanical locking.
Thank you. Learned something there.
 

Greybeard33

Established Member
Joined
18 Feb 2012
Messages
4,335
Location
Greater Manchester
This accident seems to have been very much a case of the holes in the Swiss cheese lining up. Except, thankfully, the very last hole - the mis-set points might have been encountered by a passenger service at 70mph rather than the ECS working at 25mph.

The report emphasises the human factors issues that resulted in the wiring error not being spotted during installation and testing of the replacement point machine. However, what stands out for me is the part played by the "grandfather rights" accorded to the legacy BR-era design of point machine. It seems that the replacement point machine was supplied with no technical documentation, nor warnings that the internal wiring would require modification for safe operation in a double-ended point installation. Removal of the unwanted jumper wire, which was the same colour as the other internal wires, would have required the factory-fitted cable ties to be cut off the internal wiring harness of the machine. Yet this type of point machine only had a single catalogue number to cover both of the two incompatible wiring configurations.

In the aviation industry, it is accepted that procedures and testing, however rigorous, are insufficient to guard against this type of maintenance error, when replacing a safety-critical part of a system. Where aircraft parts are physically interchangeable, but functionally different, they must be clearly identified by different part numbers. Where possible, the design must include "foolproofing" (e.g. different mounting arrangements) to physically prevent the part fitting in the wrong location. And/or the wiring must be designed so that the system will not function if the incorrect part is installed.
 

Taunton

Veteran Member
Joined
1 Aug 2013
Messages
12,343
Another surprising aspect was it was 9 months from installation before a service departed in that direction with such a combination of prior moves over the crossover and caused the points to be mis-set. But as far as I can see the issue was waiting for such a move and could have happened at any time previously.
 

edwin_m

Veteran Member
Joined
21 Apr 2013
Messages
28,767
Location
Nottingham
Another surprising aspect was it was 9 months from installation before a service departed in that direction with such a combination of prior moves over the crossover and caused the points to be mis-set. But as far as I can see the issue was waiting for such a move and could have happened at any time previously.
There could have been previous moves over the crossover where both ends went fully over so the lack of detection wasn't evident. On this occasion one end didn't move. This could have been for one of several reasons which RAIB didn't investigate, as the main safety issue was the latent fault in the detection allowing the signal to be cleared when for whatever reason the motor failed to move the points.
 

GC class B1

Member
Joined
19 Jun 2021
Messages
460
Location
East midlands
I have studied this report with interest and have noted an apparent anomaly. Using the details in the report of the speed at the time of derailment (about the same point where the air pipes parted) and the distance to point at which the train came to rest, I have calculated the deceleration rate to be about 9 to 10% g. From the details in the report I have calculated that the train travelled between 125 and 135 metres with an Emergency brake application and three bogies derailed to the point where it came to rest. As the deceleration rate in Emergency for an HST set from about 33 MPH should be at least 11% g this seems to be rather low, without taking into account the significant additional retardation force resulting from the three derailed bogies dragging in the ballast and causing the damage to the crossing as mentioned in the report. I would therefore have expected the train to have stopped from 33 MPH significantly earlier.
 

AndrewE

Established Member
Joined
9 Nov 2015
Messages
7,372
The FPL will "lock" the points physically in the closed position until such a time that the points are called to the other direction. As a feed was applied to the motor due to the other end of points losing detection and the points trying to motor back to their intended position (as designed), the points unlocked and moved as they would for any other swing.
This sounds as though a fault in a single wire (as well as the situation described above) can make points move under a train. Surely another wire from a fpl lever would be a good idea? How can a fpl be fail-safe if just trying to power the points back is enough to make them move?
 

scotraildriver

Established Member
Joined
15 Jun 2009
Messages
1,847
I have studied this report with interest and have noted an apparent anomaly. Using the details in the report of the speed at the time of derailment (about the same point where the air pipes parted) and the distance to point at which the train came to rest, I have calculated the deceleration rate to be about 9 to 10% g. From the details in the report I have calculated that the train travelled between 125 and 135 metres with an Emergency brake application and three bogies derailed to the point where it came to rest. As the deceleration rate in Emergency for an HST set from about 33 MPH should be at least 11% g this seems to be rather low, without taking into account the significant additional retardation force resulting from the three derailed bogies dragging in the ballast and causing the damage to the crossing as mentioned in the report. I would therefore have expected the train to have stopped from 33 MPH significantly earlier.
I suspect it's the time taken for the brake to apply on an HST - it's a good few seconds from application to anything actually happening. At Stonehaven the emergency brake was applied before it hit the landslip but made no discernible difference to the train speed by the impact point. It's a thing that makes driving an HST a very different art to other train types.
 

GC class B1

Member
Joined
19 Jun 2021
Messages
460
Location
East midlands
I suspect it's the time taken for the brake to apply on an HST - it's a good few seconds from application to anything actually happening. At Stonehaven the emergency brake was applied before it hit the landslip but made no discernible difference to the train speed by the impact point. It's a thing that makes driving an HST a very different art to other train types.
The specified Full Service brake application time for a full formation HST is 3-5 seconds and this would be slightly less for a 2+5 set. Venting the brake pipes will result in a quicker application and I have used 3 seconds application time in my calculation.

== Doublepost prevention - post automatically merged: ==

Another surprising aspect was it was 9 months from installation before a service departed in that direction with such a combination of prior moves over the crossover and caused the points to be mis-set. But as far as I can see the issue was waiting for such a move and could have happened at any time previously.
Yes at first glance I thought it unlikely that the crossover wouldn’t have been used for 9 months however the report shows that the crossover is only used for moves from the down to the up line when a disabled passenger wishes to alight at Dalwhinnie. The crossover cannot be used for moves from the up line to the down line so its use will be very infrequent.
 

alxndr

Established Member
Joined
3 Apr 2015
Messages
1,694
However, what stands out for me is the part played by the "grandfather rights" accorded to the legacy BR-era design of point machine. It seems that the replacement point machine was supplied with no technical documentation, nor warnings that the internal wiring would require modification for safe operation in a double-ended point installation. Removal of the unwanted jumper wire, which was the same colour as the other internal wires, would have required the factory-fitted cable ties to be cut off the internal wiring harness of the machine. Yet this type of point machine only had a single catalogue number to cover both of the two incompatible wiring configurations.
Very true. While it is easy to say "they should have checked" it is also worth asking, "why wasn't it made obvious?"

I also wonder if the move towards "plug and play" technology might have played a part. Both on and off the railway the trend is for things to just be replaced, rather than taking something apart for an internal repair or alteration. It would also be interesting to know whether the different possible configurations in the training material for those point machines. In the courses for other configurable equipment quite a bit of emphasis was made on the fact that it can be set up in different ways and that you must check. The SMTH states that a tester must "check that any configurable wiring or straps internal to the replacement item are correct", but when was the last time that they were made aware that the wiring was configurable in this manner?

This sounds as though a fault in a single wire (as well as the situation described above) can make points move under a train. Surely another wire from a fpl lever would be a good idea? How can a fpl be fail-safe if just trying to power the points back is enough to make them move?
The purpose of the FPL is to provide a mechanical means of ensuring that once the points are driven over to one position that they remain in that position until required otherwise. It means that you are no longer relying on positive pressure being applied to the points to prevent movement. You could strip everything else out of the point machine (motor, gears, drive rod, etc) and the points would not move as long as the FPL remained in place. It is the purpose of the interlocking to prevent the points from being moved under a train.

In any case, "another wire from an FPL lever" wouldn't really prevent the possibility of the motor becoming incorrectly energised due to a fault. The interlocking already prevents a signaller from calling a set of points under a train, so the risk of the scenario you describe really comes from a false feed to the motor.

As with most safety critical circuits the feed to the motor, and all the circuitry between the signallers' controls and the motor, is double cut. This means that there are contacts of the controlling relays present in both the positive and negative legs of the circuit. This means that one single fault won't falsely operate the circuit, two faults would need to occur to cause a fault scenario. It's not impossible, but providing things are maintained correctly to identify any developing faults (earth monitoring etc), and equipment is installed and tested correctly the risk is very small. Signalling circuits are very cleverly designed in this regard. The need for things to be tested correctly is vital though, which is why this report is so scary. The flaw at Dalwhinnie was not a deficiency in the design of the circuit, but a deficiency in the installation matching the designed circuit.

Yes at first glance I thought it unlikely that the crossover wouldn’t have been used for 9 months however the report shows that the crossover is only used for moves from the down to the up line when a disabled passenger wishes to alight at Dalwhinnie. The crossover cannot be used for moves from the up line to the down line so its use will be very infrequent.
The issue would not be apparent until a failure which caused one end not to move at all (and thus not loose detection) but the other end to complete its travel. Had the points managed to move at all then they would have correctly shown as being "out of correspondence". It's probably more typical for a point machine to manage to move at least partway before failing, but failures where they don't move at all isn't unusual, as we've seen and read here. With a typical maintenance regime the points would have been moved at least 2-3 times between the installation and the incident, but I suspect that they would have been operated more times than this.
 
Last edited:

edwin_m

Veteran Member
Joined
21 Apr 2013
Messages
28,767
Location
Nottingham
Checking back, the Greenhill near-miss in 2009 was also caused by incorrect wiring within the point machine.


The immediate cause of the incident was that the points were detected in the reverse position by the signalling system although the point ends were in the normal position. This allowed the protecting signal to clear to a proceed aspect for train 2N50 which subsequently trailed through the point ends.

The causal factors were that extra wiring was incorrectly installed in the point machine which was not detected before installation on site at Greenhill Upper Junction; the site testing carried out at Greenhill Upper Junction on 18 January 2009 was not carried out correctly; the indications on the signaller’s NX panel were not correctly responded to during the out of correspondence testing; and the point ends were not switched back onto powered operation on 22 March 2009.
 

GC class B1

Member
Joined
19 Jun 2021
Messages
460
Location
East midlands
As BRX stated in post No. 124 this report did not state a clear sequence of events.
After much thought I think I now understand the sequence of events much better. I have studied the details in the report and hypothesise that the following may be the sequence of events during the incident. The front of the train ran through points 13B and as a result about this time points 13A started to move between the bogies of the last coach. The points take more time than the time between the bogies so only moved part way. As a result the points were split and the last three bogies ended up on the ballast with the left hand wheel of each wheelset inside the rails in the four foot of the up line, and the right hand wheel of each wheelset outside the rails in the six foot. This would have caused the train to slow significantly. The driver may have applied power at this time as he became aware that the train was slowing. The rear power car then pulled the right hand wheels of the trailing bogie of the last trailer car over the left hand rail some time after passing over points 13A. Because the power car was pushing, and not being dragged, the train stayed pretty much in line and the couplers didn’t part. The air pipes didn’t part until the misalignment between the last trailer car and the trailing power car became sufficient to part the air pipes. An Emergency brake application was initiated when the flexible Brake pipes parted and the Brake Pipe was vented. The train then stopped in about 70 metres or less.
This is the only scenario I can think of that explains what happened.
 
Last edited:
Joined
29 Oct 2021
Messages
180
Location
Newton Abbot
As BRX stated in post No. 124 this report did not state a clear sequence of events.
After much thought I think I now understand the sequence of events much better. I have studied the details in the report and hypothesise that the following may be the sequence of events during the incident. The front of the train ran through points 13B and as a result about this time points 13A started to move between the bogies of the last coach. The points take more time than the time between the bogies so only moved part way. As a result the points were split and the last three bogies ended up on the ballast with one wheelset inside the rails in the four foot of the up line, and the other wheelset outside the rails In the six foot. This would have caused the train to slow significantly. The driver may have applied power at this time as he became aware that the train was slowing. The rear power car then pulled the right hand wheelsets of the trailing bogie of the last trailer car over the left hand rail some time after passing over points 13A. Because the power car was pushing, and not being dragged, the train stayed pretty much in line and the couplers didn’t part. The air pipes didn’t part until the misalignment between the last trailer car and the trailing power car became sufficient to part the air pipes. An Emergency brake application was initiated when the flexible Brake pipes parted and the Brake Pipe was vented. The train then stopped in about 70 metres or less.
This is the only scenario I can think of that explains what happened.
This seems very credible, I will email RAIB via the enquiry option, asking what was the time from brake pipe vent to stopping?

== Doublepost prevention - post automatically merged: ==

No, the train continued to accelerate - he was already accelerating after leaving the platform having seen a signal telling him he was heading on the up line. Once the power controller is knocked off the train will still continue to accelerate until the power ramps down. If the RAIB had seen anything on the OTMR download they would no doubt have investigated further.
What do you mean by power ramp down? I found the amps drop away within 1 second or so, when off selected, I can understand: inertia or a falling gradient may influence to a small degree.
 
Last edited:

Taunton

Veteran Member
Joined
1 Aug 2013
Messages
12,343
There have been a number of accidents, Polmont being perhaps the most notable, where whatever the moment when everything was shut off at the front, or even derailed and overturned, a power unit at the back has kept on pushing for a few seconds to an extent, and added to the problems.
 

GC class B1

Member
Joined
19 Jun 2021
Messages
460
Location
East midlands
There have been a number of accidents, Polmont being perhaps the most notable, where whatever the moment when everything was shut off at the front, or even derailed and overturned, a power unit at the back has kept on pushing for a few seconds to an extent, and added to the problems.
Polmont was a push-pull train with the heavy locomotive trailing and a much lighter vehicle (DBSO) at the front. The DBSO at the front of the train was pushed by the inertia of the rest of the train and therefore the deceleration effect from the derailed vehicles would not have been anything like as much as the Dalwhinnie incident. In the Dalwhinnie incident derailed vehicle bogies were pulled and possibly pushed through ballast and remained coupled and largely in line. From memory the speed involved at Polmont was much higher and therefore the inertia would be much more.
 

computerSaysNo

Established Member
Joined
14 Dec 2018
Messages
1,669
What do you mean by power ramp down? I found the amps drop away within 1 second or so, when off selected, I can understand: inertia or a falling gradient may influence to a small degree.
I think this is referring to how quickly the power is cut.
It's my understanding that a power setting is selected on the controller, then followed by a short delay before the engine responds. If decreasing the throttle from a higher setting to a lower setting but not zero, the system will keep supplying the electric motors with all the energy available from the diesel engine; therefore the applied power will decrease gently as the engine revs down. If decreasing the throttle from any power setting into zero, the system will immediately cut the power to the motors (after the aforementioned delay), before the diesel engine fully revs down to idle.
 
Joined
29 Oct 2021
Messages
180
Location
Newton Abbot
I think this is referring to how quickly the power is cut.
It's my understanding that a power setting is selected on the controller, then followed by a short delay before the engine responds. If decreasing the throttle from a higher setting to a lower setting but not zero, the system will keep supplying the electric motors with all the energy available from the diesel engine; therefore the applied power will decrease gently as the engine revs down. If decreasing the throttle from any power setting into zero, the system will immediately cut the power to the motors (after the aforementioned delay), before the diesel engine fully revs down to idle.
You may well be correct, however I would say it is insignificant. We must be talking milliseconds?
 

computerSaysNo

Established Member
Joined
14 Dec 2018
Messages
1,669
You may well be correct, however I would say it is insignificant. We must be talking milliseconds?
If going from "full power" to "off' I'd guess it might be around two seconds, not including human thinking time. That's allowing half a second to move the lever its entire range from full to off, one second delay on the controls, and half a second for the system to respond by cutting the electrical current.
I could be hugely off but that's roughly what I'd guess.
As I side note, I'm not sure if the Big Red Button also has such delays on it? The human thinking time would be longer plus they've got to move their hand from the controls to the button; but then I'd imagine they'd be no "control delay" on that button and there's the benefit of cutting power and applying brakes in one go.
 
Joined
29 Oct 2021
Messages
180
Location
Newton Abbot
If going from "full power" to "off' I'd guess it might be around two seconds, not including human thinking time. That's allowing half a second to move the lever its entire range from full to off, one second delay on the controls, and half a second for the system to respond by cutting the electrical current.
I could be hugely off but that's roughly what I'd guess.
As I side note, I'm not sure if the Big Red Button also has such delays on it? The human thinking time would be longer plus they've got to move their hand from the controls to the button; but then I'd imagine they'd be no "control delay" on that button and there's the benefit of cutting power and applying brakes in one go.
Just to clarify, I refer to the red button as being the GSRM emergency call facility, stopping all trains. The driver clearly would have been subject to startle for a number of seconds, before realising a no route? When the brake pipe is vented the power is automatically cut. The cab operated emergency brake selection, is either by plunger or brake control lever. ATP data states 2 seconds for full rate of deceleration to establish. The truth is just less than 5 seconds for a 2 plus 8, and lessor for a 2 plus 5. This is proved by the timeline within the RAIB Didcot report 23/2008 page 59 and 60. There is definitely no further acceleration regarding any delay function.

Hopefully RAIB will answer the question regarding time and distance to stop from brake pipe vent. GC class B1 makes a very valid hypothesis. The RAIB report regarding stopping distance is not logical, unless 3 bogies in the ballast produces no resistance, which it certainty will.
 
Status
Not open for further replies.

Top