Carmont (near Stonehaven) derailment - 12 August 2020

[yoyothehobo]

And in the failure to do that, we see the accountability come back to the client - Network Rail.

Sorry, i did miss out in my reply that there should have been checking of as builts and i believe the entire construction industry nationwide needs more integration between designs and construction with too many things being designed and then passed out the door.

 

[35B]

I don’t think comparisons to Ladbroke Grove are that useful.

I agree - and my point is that the test of criminal responsibility is not the consequence of an event, but the culpability for that event happening in the first place (excepting a few strict liability offences).

Sorry, i did miss out in my reply that there should have been checking of as builts and i believe the entire construction industry nationwide needs more integration between designs and construction with too many things being designed and then passed out the door.

Completely agreed - and working in an outsourced industry (not construction), I'm very conscious that accountability cannot be transferred, and that customers have an ultimate duty to ensure that what they have purchased is what they said they wanted to purchase.

 

[Wynd]

Hindsight much? In the time 1T08 waited to crossover to return north the weather cleared substantially. 1T08 had already traversed that section of line in the southbound direction with nothing amiss and a train had travelled north through the incident site prior to the derailment with nothing amiss. It’s a cruel situation but as a Driver myself, prior to the Stonehaven incident I am sure that I also would have felt comfortable to reach linespeed.
If I were in that exact scenario now, post Stonehaven, there would definitely be a major red flag that would influence my decision making. This is knowledge that no one on the day was privy to.

This is a very good point, well made.

To my limited knowledge, we had not seen any issues on that section of line prior to this incident. It was an odd situation, and the rain that day was like something out of a movie, im not sure iv ever seen the like in Aberdeenshire.

AIUI Sec 76 only states that a guilty plea is to be entered. As above, its the classic accountability/responsibilty situation. Due to the loss of life, its a challenge to see other paths. The buck ultimately stops with someone, harsh though that may be, in this instance. Consider any other business where life is lost and appraise similar outcomes.

The silver lining is that contracted work will be held to account more robustly going forwards, and NR are evidently doing all of the right things to ensure this doesnt happen again, here, or elsewhere.

 

[Falcon1200]

It would seem that the RAIB have addressed why and the answer appears to a route control overloaded by issues that morning and something slipping past them and a driver and signaller who were not required to proceed at caution and, with the information available to them locally, not aware that there may be any reason to suspect a problem.

Had I not retired in 2016, and declined Network Rail's invitation to return to work during Covid, I might well have been the RCM on duty in Glasgow Control during this terrible incident. IMHO the RAIB report understates just how overwhelmed Control was on that day; I experienced many extreme weather days, when phone calls requiring immediate action came in incessantly, leaving only time to react, and certainly not to stop and think. On this day the washout on the Edinburgh/Glasgow Queen Street line was already a major incident requiring Control's full attention. Bringing in additional staff may not have helped either, unless they were competent Controllers, as (from experience) the duty staff then have to divert from their own work to help and direct the assistants.

Hindsight much? In the time 1T08 waited to crossover to return north the weather cleared substantially. 1T08 had already traversed that section of line in the southbound direction with nothing amiss and a train had travelled north through the incident site prior to the derailment with nothing amiss.

Yes, a very good point indeed.

 

[bramling]

Had I not retired in 2016, and declined Network Rail's invitation to return to work during Covid, I might well have been the RCM on duty in Glasgow Control during this terrible incident. IMHO the RAIB report understates just how overwhelmed Control was on that day; I experienced many extreme weather days, when phone calls requiring immediate action came in incessantly, leaving only time to react, and certainly not to stop and think. On this day the washout on the Edinburgh/Glasgow Queen Street line was already a major incident requiring Control's full attention. Bringing in additional staff may not have helped either, unless they were competent Controllers, as (from experience) the duty staff then have to divert from their own work to help and direct the assistants.

This is always the big elephant in the room. I think it’s probably not an overstatement to say that few railway controls are fully resourced to deal with multiple simultaneous incidents. No one wants to pay to have the numbers of staff sitting around under-utilised for 95+% of the time. Which is fair enough (and there would be disbenefits in doing so as well), but the consequence is that when the brown stuff does properly hit the fan there has to be an expectation that control is going to be overwhelmed. No one really wants to admit that reality because of the implications which come with it.

 

[Falcon1200]

No one really wants to admit that reality because of the implications which come with it.

A valid point, well made. We used to joke that there were two types of railway manager, those who saw Controllers chatting and drinking tea and thought 'great, the railway must be running well', and those who saw that and thought 'what are we paying all these people for?'

 

[bramling]

A valid point, well made. We used to joke that there were two types of railway manager, those who saw Controllers chatting and drinking tea and thought 'great, the railway must be running well', and those who saw that and thought 'what are we paying all these people for?'

That is so true.

 

[najaB]

That depe

And in the failure to do that, we see the accountability come back to the client - Network Rail.

That, of course, depends on how easy it would have been to identify that it wasn't built as designed.

 

[Horizon22]

This is always the big elephant in the room. I think it’s probably not an overstatement to say that few railway controls are fully resourced to deal with multiple simultaneous incidents. No one wants to pay to have the numbers of staff sitting around under-utilised for 95+% of the time. Which is fair enough (and there would be disbenefits in doing so as well), but the consequence is that when the brown stuff does properly hit the fan there has to be an expectation that control is going to be overwhelmed. No one really wants to admit that reality because of the implications which come with it.

When you say few I would say none. Certainly with an almost complete shutdown of multiple lines, as happened in this scenario. Although at this point the best thing would be to let nothing run, keep alltrains in stations and then work through each service methodically.

 

[ModernRailways]

When you say few I would say none. Certainly with an almost complete shutdown of multiple lines, as happened in this scenario. Although at this point the best thing would be to let nothing run, keep alltrains in stations and then work through each service methodically.

Would this realistically have changed the outcome of what happened though? 1T08 had already operated through the area southbound, with no signs of issue. 2B13, the 158, travelled north along the same section with no signs of issue, granted there was a few hours between these trains passing through the area but this very much is a situation where most (all?) control managers would say continue as normal back to x location, this could be at line speed or at the maximum speed for a severe weather event, whichever is the lesser.

Of course considering the events that took place I'd be hopeful that during severe weather where circumstances are similar, trains would be driven on a more line of sight approach to a point of safety.

 

[najaB]

Of course considering the events that took place I'd be hopeful that during severe weather where circumstances are similar, trains would be driven on a more line of sight approach to a point of safety.

In future, I'm almost certain that they will. But that's with the benefit of hindsight.

On that day, given that both the accident train and another had passed the site without observing anything unusual, plus the fact that the worst of the weather had passed some hours earlier and the sun was starting to shine, I don't think anyone would have given even a moment's thought to running at reduced speed.

 

[ModernRailways]

In future, I'm almost certain that they will. But that's with the benefit of hindsight.

On that day, given that both the accident train and another had passed the site without observing anything unusual, plus the fact that the worst of the weather had passed some hours earlier and the sun was starting to shine, I don't think anyone would have given even a moment's thought to running at reduced speed.

Which is precisely what I said if you quoted my whole post. On the day nobody would've thought twice, even if the control room had worked through each incident and each train one by one, 1T08 would've still be given the okay to continue as normal once crossed onto the usual running line in the usual direction of travel.

 

[najaB]

Which is precisely what I said if you quoted my whole post. On the day nobody would've thought twice, even if the control room had worked through each incident and each train one by one, 1T08 would've still be given the okay to continue as normal once crossed onto the usual running line in the usual direction of travel.

Sincere apologies. When I reworded my post I took out the "As you said" with which I had originally started my second paragraph.

I had intended to add to your post the fact that the weather had improved and the sun was starting to shine.

 

[snookertam]

A valid point, well made. We used to joke that there were two types of railway manager, those who saw Controllers chatting and drinking tea and thought 'great, the railway must be running well', and those who saw that and thought 'what are we paying all these people for?'

My worry is we’re increasingly seeing the latter. This attitude doesn’t just apply to control staff, but to many grades across the railway.

Ironically control staff numbers have increased (although not necessarily in the most relevant roles) but outside there are many grades that are being undermined thanks to the attitudes you mention.

== Doublepost prevention - post automatically merged: 23 Aug 2023 ==

That depe

That, of course, depends on how easy it would have been to identify that it wasn't built as designed.

I would have thought a standard inspection of the work carried out should reveal this.

 

[Morayshire]

I would have thought a standard inspection of the work carried out should reveal this.

That assumes that the designer had someone on site or there was an independent checker (aka a clerk of works). But I think the contractor was responsible for ensuring work was done as per the design. And the RAIB report also concludes the site team didn't bother with the change control process.

Post construction, part of the problem was that there were no as-builts to feed into the asset management system so no one knew they had drainage to inspect. Plus once the drain is in, without digging it back up, all you would see is a line of stone with the odd catchpit cover.

It will be interesting to see exactly what is on the charge sheet though.

 

[35B]

That depe

That, of course, depends on how easy it would have been to identify that it wasn't built as designed.

Only if the thing had been inspected in the first place - my memory of the report is that there was an acceptance process which was not used.

 

[najaB]

I don’t think comparisons to Ladbroke Grove are that useful.

Interestingly, the most apt comparison is the 737 Max, where the FAA gave Boeing the responsibility to "mark their own homework" and Boeing, in an effort to avoid the retraining requirements for their biggest customers implemented a change that should really have invalidated the grandfather rights to the original 737 type certificate.

 

[Nicholas Lewis]

That assumes that the designer had someone on site or there was an independent checker (aka a clerk of works). But I think the contractor was responsible for ensuring work was done as per the design. And the RAIB report also concludes the site team didn't bother with the change control process.

Post construction, part of the problem was that there were no as-builts to feed into the asset management system so no one knew they had drainage to inspect. Plus once the drain is in, without digging it back up, all you would see is a line of stone with the odd catchpit cover.

It will be interesting to see exactly what is on the charge sheet though.

Surely they can only charge the corporate entity NR and fine them if it was anymore ORR and BTP would have acted before now. So what is iot going to achieve?

It would be far better for ORR to have done a swathe of unannounced audits to determine if NR have remedied the situation on site works. Im pretty sure implementing restrictive operating during bad weather has been acted upon as on several occasions this year ive been on trains told to run at reduced speed due to heavy rainfall.

 

[Wynd]

Interestingly, the most apt comparison is the 737 Max, where the FAA gave Boeing the responsibility to "mark their own homework" and Boeing, in an effort to avoid the retraining requirements for their biggest customers implemented a change that should really have invalidated the grandfather rights to the original 737 type certificate.

Its funny that you should mention that, becasue I know of at least one aerospace company where this incident, is a subject of some mandatory annual training.

 

[InOban]

In future, I'm almost certain that they will. But that's with the benefit of hindsight.

On that day, given that both the accident train and another had passed the site without observing anything unusual, plus the fact that the worst of the weather had passed some hours earlier and the sun was starting to shine, I don't think anyone would have given even a moment's thought to running at reduced speed.

Whenever heavy rain or storm winds are forecast in Scotland, trains are, since Carmont, instructed to proceed on sight over all vulnerable sections. As you can imagine this causes major delays on single track routes such as the WHL. The decisions are made by a joint NR /Met Office group.

 

[Tim_UK]

Whenever heavy rain or storm winds are forecast in Scotland, trains are, since Carmont, instructed to proceed on sight over all vulnerable sections. As you can imagine this causes major delays on single track routes such as the WHL. The decisions are made by a joint NR /Met Office group.

I don't think it is just in Scotland. On the 3rd of August my LNER from Doncaster to Wakefield Westgate was slowed because of a thunderstorm. I think it was 30 mph. The driver said it was an instruction from the signaller. Might have a bit more than 30, but pretty slow.
We didn't get rained on really, but a massive amount of rain fell maybe 10 miles to the West. You could see it, and I had a very slow drive home after.

 

[chuff chuff]

Blanket speed restrictions are placed on certain areas during expected bad weather,usually 40 mph is the top end.

 

[The Puddock]

Whenever heavy rain or storm winds are forecast in Scotland, trains are, since Carmont, instructed to proceed on sight over all vulnerable sections. As you can imagine this causes major delays on single track routes such as the WHL. The decisions are made by a joint NR /Met Office group.

That’s not entirely correct. Trains aren’t instructed to “proceed on sight” (which incidentally is a tramway term really - the rail industry calls it “at caution”) but a blanket speed restriction of 40mph, or 20mph where the linespeed is less than 40mph, is imposed on affected sections of line determined by risk assessment. Since the Carmont accident NR Scotland now has its own team of specialist meteorologists embedded within the Integrated Control Centre on a 24/7 shift basis. Support for them is provided by a private contractor called MetDesk and also by a network of weather stations operated by Vaisala. The Met Office has no involvement in it.

 

[InOban]

Thanks for the full explanation. They are certainly more risk averse than before Carmont since these instructions are issued more frequently and often as a precaution, ie as a result of the forecast without waiting for the heavens to open.

 

[AlbertBeale]

Thanks for the full explanation. They are certainly more risk averse than before Carmont since these instructions are issued more frequently and often as a precaution, ie as a result of the forecast without waiting for the heavens to open.

But is this only until all potentially affected lines have been subjected to more detailed checks, to ensure there's nothing undetected that could cause a problem in extreme conditions? Or is there now an assumption that no works on the railways can be relied on as having been done to the right specification, and hence this (slowing down when bad weather is forecast) is going to be an indefinite process?

 

[35B]

But is this only until all potentially affected lines have been subjected to more detailed checks, to ensure there's nothing undetected that could cause a problem in extreme conditions? Or is there now an assumption that no works on the railways can be relied on as having been done to the right specification, and hence this (slowing down when bad weather is forecast) is going to be an indefinite process?

It’s not an assumption about works being done to spec, but that the conditions caused by such weather are inherently risky and need the risk mitigating. So, yes, we can expect more of this - and a current RAIB investigation suggests that the communication and understanding of such blanket restrictions raises issues that haven’t been fixed since reports were issued in 2021

 

[Falcon1200]

Or is there now an assumption that no works on the railways can be relied on as having been done to the right specification, and hence this (slowing down when bad weather is forecast) is going to be an indefinite process?

Without wishing to defend Carillion in any way, it is perhaps worth remembering that the incorrectly-installed drain at Carmont had been in place since 2012, and had therefore coped with the worst of the weather over several years, before it was overwhelmed by very heavy and intense rainfall. There would therefore have to be an acceptance that such conditions, which could occur anywhere and at any time (even in the height of summer, as at Carmont), have to be mitigated against, even where as in almost all cases the railway infrastructure is built and maintained to specification.

 

[The Puddock]

But is this only until all potentially affected lines have been subjected to more detailed checks, to ensure there's nothing undetected that could cause a problem in extreme conditions? Or is there now an assumption that no works on the railways can be relied on as having been done to the right specification, and hence this (slowing down when bad weather is forecast) is going to be an indefinite process?

They are currently doing a lot of work to install remotely monitored movement sensors in at-risk earthworks and also lots of drainage renewal and other improvements to cuttings and embankments to mitigate the risks. So over time the number of locations where these blanket speed restrictions have to be imposed will reduce and/or the severity of convective rainfall to trigger a speed restriction for a particular location will increase. I don’t think they’ll ever go away entirely now the genie is out of the bottle but it should become less disruptive in the future.

 

[Wynd]

Without wishing to defend Carillion in any way, it is perhaps worth remembering that the incorrectly-installed drain at Carmont had been in place since 2012, and had therefore coped with the worst of the weather over several years, before it was overwhelmed by very heavy and intense rainfall. There would therefore have to be an acceptance that such conditions, which could occur anywhere and at any time (even in the height of summer, as at Carmont), have to be mitigated against, even where as in almost all cases the railway infrastructure is built and maintained to specification.

This is the issue, though. The assumptions made for the 2012 design, may well need a tweak.

Weather is becoming more volatile. I have personally witnessed increasing weather volatility here in the shire in the last few years. It appears to be becoming a trend.

Viewing this purely through the lens of increased risk aversion, would be to ignore the increasing volatility of the weather.

When the facts change, we must change with them, etc etc

 

[yoyothehobo]

This is the issue, though. The assumptions made for the 2012 design, may well need a tweak.

Weather is becoming more volatile. I have personally witnessed increasing weather volatility here in the shire in the last few years. It appears to be becoming a trend.

Viewing this purely through the lens of increased risk aversion, would be to ignore the increasing volatility of the weather.

When the facts change, we must change with them, etc etc

However, the original design has been modelled and has shown that it would likely not have failed in the rainfall event, whereas the Carillion (i am not going to say design) installation was inherently flawed.