Aviemore incident 29/9/23

[BRX]

It's probably safer to be stood on the balcony and have a second or so warning that the impact is going to happen, than to be stood inside entirely unaware.

 

[Killingworth]

As far as accidents go this one must be much easier to investigate with two very useful videos already available. It could hardly have been more public.

The relationships between the Strathspey Railway, the NRM, Royal Scotsman and Network Rail add complexity. What should have been a very successful weekend for all parties has resulted in a massive expensive embarrassment that could have had more serious consequences.

 

[norbitonflyer]

It's probably safer to be stood on the balcony and have a second or so warning that the impact is going to happen, than to be stood inside entirely unaware.

Indeed - looking at the chaotic view of the catering store after the collision, I wouldn't have liked to be in there when it happened.

 

[172007]

Back to back radios for shunting & the incident would never have happened.

 

[Ken X]

Back to back radios for shunting & the incident would never have happened.

I would take issue with this.

In a past life we would manoeuvre main battle tanks by the driver taking directions via hand signals from a bod standing in front of the vehicle as he reversed. This made judging the gap at the rear difficult and we often used a second bod at the side of the rear of the vehicle to check clearances etc and signal the front bod appropriately. All a bit of a palarva but it worked.

The gods decided this could be improved on and obtained radio headsets. Only one bod required and he could stand at the rear of the tank and chat to the driver. What could possibly go wrong.

Answer, a tiny gap in signal which took out the command "stop" resulting in a flattened wall, and a change of underwear for the marshaller who had got a bit complacent and was very nearly the meat in the sandwich.

We dropped all our shiny new headsets in the bin and went back to hand signals


Apologies I appear to be a victim of "automerge"

As a self confessed non railway bod, I understand that the tender has a corridor on this locomotive. Is it not possible to open the rear door and look at whatever you are reversing up to? Probably a very good reason why not but I just wondered.

 

[35B]

As a self confessed non railway bod, I understand that the tender has a corridor on this locomotive. Is it not possible to open the rear door and look at whatever you are reversing up to? Probably a very good reason why not but I just wondered.

The corridor is actually up one side of the tender, so there is no line of sight.

I would take issue with this.

In a past life we would manoeuvre main battle tanks by the driver taking directions via hand signals from a bod standing in front of the vehicle as he reversed. This made judging the gap at the rear difficult and we often used a second bod at the side of the rear of the vehicle to check clearances etc and signal the front bod appropriately. All a bit of a palarva but it worked.

The gods decided this could be improved on and obtained radio headsets. Only one bod required and he could stand at the rear of the tank and chat to the driver. What could possibly go wrong.

Answer, a tiny gap in signal which took out the command "stop" resulting in a flattened wall, and a change of underwear for the marshaller who had got a bit complacent and was very nearly the meat in the sandwich.

We dropped all our shiny new headsets in the bin and went back to hand signals

I suspect the issue is not technology but people - the videos I've seen don't appear to show anyone acting in that role of shunter/marshal. Why that was, and what that implies about the expectations of those involved in the manoeuvre, may be of more use in understanding events.

 

[357]

I would take issue with this.

In a past life we would manoeuvre main battle tanks by the driver taking directions via hand signals from a bod standing in front of the vehicle as he reversed. This made judging the gap at the rear difficult and we often used a second bod at the side of the rear of the vehicle to check clearances etc and signal the front bod appropriately. All a bit of a palarva but it worked.

The gods decided this could be improved on and obtained radio headsets. Only one bod required and he could stand at the rear of the tank and chat to the driver. What could possibly go wrong.

Answer, a tiny gap in signal which took out the command "stop" resulting in a flattened wall, and a change of underwear for the marshaller who had got a bit complacent and was very nearly the meat in the sandwich.

We dropped all our shiny new headsets in the bin and went back to hand signals


Apologies I appear to be a victim of "automerge"

As a self confessed non railway bod, I understand that the tender has a corridor on this locomotive. Is it not possible to open the rear door and look at whatever you are reversing up to? Probably a very good reason why not but I just wondered.

I've used radios to shunt and would constantly get repeat "keep going" repeated to me. If the radio went silent then I'd put the brake in. Perfectly safe.

 

[172007]

I would take issue with this.

In a past life we would manoeuvre main battle tanks by the driver taking directions via hand signals from a bod standing in front of the vehicle as he reversed. This made judging the gap at the rear difficult and we often used a second bod at the side of the rear of the vehicle to check clearances etc and signal the front bod appropriately. All a bit of a palarva but it worked.

The gods decided this could be improved on and obtained radio headsets. Only one bod required and he could stand at the rear of the tank and chat to the driver. What could possibly go wrong.

Answer, a tiny gap in signal which took out the command "stop" resulting in a flattened wall, and a change of underwear for the marshaller who had got a bit complacent and was very nearly the meat in the sandwich.

We dropped all our shiny new headsets in the bin and went back to hand signals


Apologies I appear to be a victim of "automerge"

As a self confessed non railway bod, I understand that the tender has a corridor on this locomotive. Is it not possible to open the rear door and look at whatever you are reversing up to? Probably a very good reason why not but I just wondered.

The railway rule book is quite specific, back to back radios have to beep ever few seconds and the user also constantly talk as per previous post. If no beep or talk the movement stops immediately.

 

[Ken X]

The railway rule book is quite specific, back to back radios have to beep ever few seconds and the user also constantly talk as per previous post. If no beep or talk the movement stops immediately.

Sounds like a plan. Not versed in the railway rule book as you can tell. Its just when you have seen somebody leap to safety followed by a huge crunch it tends to concentrate the mind somewhat. Try not to do exciting when working. Boring is good.

 

[BRX]

The corridor is actually up one side of the tender, so there is no line of sight.

I suspect the issue is not technology but people - the videos I've seen don't appear to show anyone acting in that role of shunter/marshal. Why that was, and what that implies about the expectations of those involved in the manoeuvre, may be of more use in understanding events.

Maybe because they thought the train was somewhat further up, and the intention was to stop well short, and for someone on board the loco to hop out and carry out that role.

 

[12LDA28C]

I've used radios to shunt and would constantly get repeat "keep going" repeated to me. If the radio went silent then I'd put the brake in. Perfectly safe.

Indeed although back-to-back radios generally rely on a continuous bleep at least for the start of the movement. Verbal messages can then be used when approaching the limit of the movement.

 

[John Bishop]

Maybe because they thought the train was somewhat further up, and the intention was to stop well short, and for someone on board the loco to hop out and carry out that role.

In the absence of any formal hand signals or closed Channel radios controlling the movement, why has nobody got eyes out the cab in the direction of travel? You can’t just set back blind without the movement being controlled by a shunter or suchlike.

 

[chuff chuff]

Or without actually checking the location of the carriages and not just setting off in hope they are in the usual place....

 

[12LDA28C]

In the absence of any formal hand signals or closed Channel radios controlling the movement, why has nobody got eyes out the cab in the direction of travel? You can’t just set back blind without the movement being controlled by a shunter or suchlike.

They have, if you watch the video. A member of traincrew is clearly looking out of the secondman's side of the cab.

 

[John Bishop]

They have, if you watch the video. A member of traincrew is clearly looking out of the secondman's side of the cab.

Was he controlling the movement though? Said person was heard to say “gentle” as they neared the stock. That’s not a recognised call or instruction to a driver in controlling a movement. Why didn’t he stop the movement if he thought they were too fast or nearing contact? So many questions!

To be fair, given the number of people present on the footplate, it’s a wonder the driver was able to see or hear the guy on the second man’s side, but again, that’s his responsibility to ensure a clear line of communication during the move.

 

[Parham Wood]

Mechanical failure can probably be ruled out so clearly human error. It would appear the driver and others on the footplate were unaware of how far up the line the coaches were relative to their position. The line seems to curve on the approach so it appears it would be possible to see where the coaches were from a distance. Perhaps if a preservation crew they were used to shorter trains and habit crept in. Sadly an expensive incident for all concerned.

 

[43096]

Was he controlling the movement though? Said person was heard to say “gentle” as they neared the stock. That’s not a recognised call or instruction to a driver in controlling a movement. Why didn’t he stop the movement if he thought they were too fast or nearing contact? So many questions!

To be fair, given the number of people present on the footplate, it’s a wonder the driver was able to see or hear the guy on the second man’s side, but again, that’s his responsibility to ensure a clear line of communication during the move.

As I said before, the phrase "failed to come to a clear understanding of how the move was to be performed" is a key one.

 

[Julian Atkins]

From my own time on the railways (2002 to 2011) we had quite an intensive service of LHCS (loco hauled coaching stock) on the Rhymney Line for 4 years or so of my time.

We were examined on coupling up and section J of the rule book. Plus practical examination. Regularly re-examined. Indeed section J was ‘drilled’ into us.

I looked at my copy of section J the other evening. I have also watched very closely the now well known video of Flying Scotsman in this incident.

I was challenged on the ‘Nat Pres forum’ for expressing a view that I could see no action by the driver to reduce speed. Indeed my very brief post was deleted by the moderators.

The basic point is that a driver has to know is where the stock is that the driver is going to couple up to. If there is any doubt about that then the driver should not proceed.

A driver should not undertake any shunting movement (and coupling up is a shunting movement) without having a clear line of sight for hand signals from the shunter or guard controlling the movement. (If no line of sight or if hand lamps cannot be seen then the movement must proceed in step stages, or radios used).

I don’t know or understand how a driver can assume stock he is coupling up to might be somewhere else other than where it actually is.

If beforehand and before what must be a controlled movement the driver is not sure where the stock is to be coupled up to, then that must be a most unsatisfactory and potentially dangerous situation requiring at the very least the utmost caution on the part of the driver, and basically according to section J to make sure the clear communication between the shunter or guard controlling the movement is established and the deficit of knowledge corrected.

Anyway, that is my take on this for what it is worth.

 

[43096]

From my own time on the railways (2002 to 2011) we had quite an intensive service of LHCS (loco hauled coaching stock) on the Rhymney Line for 4 years or so of my time.

We were examined on coupling up and section J of the rule book. Plus practical examination. Regularly re-examined. Indeed section J was ‘drilled’ into us.

I looked at my copy of section J the other evening. I have also watched very closely the now well known video of Flying Scotsman in this incident.

I was challenged on the ‘Nat Pres forum’ for expressing a view that I could see no action by the driver to reduce speed. Indeed my very brief post was deleted by the moderators.

The basic point is that a driver has to know is where the stock is that the driver is going to couple up to. If there is any doubt about that then the driver should not proceed.

A driver should not undertake any shunting movement (and coupling up is a shunting movement) without having a clear line of sight for hand signals from the shunter or guard controlling the movement. (If no line of sight or if hand lamps cannot be seen then the movement must proceed in step stages, or radios used).

I don’t know or understand how a driver can assume stock he is coupling up to might be somewhere else other than where it actually is.

If beforehand and before what must be a controlled movement the driver is not sure where the stock is to be coupled up to, then that must be a most unsatisfactory and potentially dangerous situation requiring at the very least the utmost caution on the part of the driver, and basically according to section J to make sure the clear communication between the shunter or guard controlling the movement is established and the deficit of knowledge corrected.

Anyway, that is my take on this for what it is worth.

I'm not sure why people are quoting the mainline/Network Rail rulebook in relation to this as it was on Strathspey Railway infrastructure, which may well/will have a different rulebook.

 

[Julian Atkins]

I'm not sure why people are quoting the mainline/Network Rail rulebook in relation to this as it was on Strathspey Railway infrastructure, which may well/will have a different rulebook.

Because the ‘national’ rule book is subject to considerable thought and input and scrutiny and regular review/amendment that a rule book used by a preserved railway is potentially not subject to.

Indeed I would go as far to suggest that a preserved railway rule book, where it differs to the ‘national’ rule book, would need to risk assess carefully anything departing from same.

Indeed it may well be that a preserved railway rule book, dealing not exclusively with employees, but those who do not necessarily carry out safety critical roles on a daily basis and may be of an amateur status etc should be more rigorous.

 

[172007]

I'm not sure why people are quoting the mainline/Network Rail rulebook in relation to this as it was on Strathspey Railway infrastructure, which may well/will have a different rulebook.

It would be difficult for any railway to argue if a health and safety prosecution was made that best practice / a requirement on the big railway does not have any baring on them. Precedence has been set would be the argument.

 

[Lost property]

Mechanical failure can probably be ruled out so clearly human error. It would appear the driver and others on the footplate were unaware of how far up the line the coaches were relative to their position. The line seems to curve on the approach so it appears it would be possible to see where the coaches were from a distance. Perhaps if a preservation crew they were used to shorter trains and habit crept in. Sadly an expensive incident for all concerned.

I am sure the ORR / RAIB will be indebted to you for not having to investigate the incident as you've clearly done such a thorough one yourself.

I make no apologies for being critical of your statement because you are clearly oblivious to the many potential causal factors, including, as I've said, Human Factors which certainly includes cultures, such as operational / management / organisational / personnel / quality control and training and decided the crew were to blame..." case closed ! "....

Instant blame was common in aviation for many years, and it still exists, sadly, but thankfully there are people who don't take everything at face value, who are prepared to investigate a lot deeper, and it's far from surprising what can emerge, because there are always cumulative precursors to incidents / accidents which may have gone unheeded, or, conveniently ignored, until one day when you find swiss cheese is being served. Very few are intentional and even those that are demand investigation as to why.

 

[35B]

Because the ‘national’ rule book is subject to considerable thought and input and scrutiny and regular review/amendment that a rule book used by a preserved railway is potentially not subject to.

Indeed I would go as far to suggest that a preserved railway rule book, where it differs to the ‘national’ rule book, would need to risk assess carefully anything departing from same.

Indeed it may well be that a preserved railway rule book, dealing not exclusively with employees, but those who do not necessarily carry out safety critical roles on a daily basis and may be of an amateur status etc should be more rigorous.

On the contrary, railway regulators have been highly critical of preserved railway rule books that have cut & pasted mainline rule books (whether BR 1952 or more recent) without carefully considering where and how they will be used.

Mainline rule books have to cater for a much wider range of circumstances than short heritage railways, which brings significant complexity. For those amateurs, that increases the learning burden for whole chunks of material that they’ll never need. Not just obvious stuff like electrification, but also signalling - if a line is single track worked with track circuits only in the station areas, all the material about working on multiple track railways and train protection on track circuited lines will be irrelevant, and potentially confusing.

Taking just one example, I’ve seen experienced steam crews express real discomfort about the mainline rule book requirement to stop then buffer up, due to the characteristics of steam locomotives.

We have very partial evidence from what happened last week, that gives some insight into “what” but none whatsoever into “why”. That lack of knowledge includes whatever was agreed before FS started moving.

 

[paul1609]

Because the ‘national’ rule book is subject to considerable thought and input and scrutiny and regular review/amendment that a rule book used by a preserved railway is potentially not subject to.

Indeed I would go as far to suggest that a preserved railway rule book, where it differs to the ‘national’ rule book, would need to risk assess carefully anything departing from same.

Indeed it may well be that a preserved railway rule book, dealing not exclusively with employees, but those who do not necessarily carry out safety critical roles on a daily basis and may be of an amateur status etc should be more rigorous.

There is a guidance note issued by the Heritage Railway Association and endorsed by ORR: A0052- Shunting: Including Coupling & Uncoupling. This is the standard that heritage railways rulebooks have to adhere to. The Safety Management System which will be audited by the ORR will ensure this is so.
I don't have experience of the network rulebook but I would be surprised if the two diverge all that much.
Obviously I'm not going to quote on the standards in this incident.

 

[Townsend Hook]

There is a guidance note issued by the Heritage Railway Association and endorsed by ORR: A0052- Shunting: Including Coupling & Uncoupling. This is the standard that heritage railways rulebooks have to adhere to. The Safety Management System which will be audited by the ORR will ensure this is so.
I don't have experience of the network rulebook but I would be surprised if the two diverge all that much.
Obviously I'm not going to quote on the standards in this incident.

I wasn’t aware that HRA guidance such as this was mandatory for their members, I understood it to be simply ‘best practice’ that their member organisations may incorporate into their own procedures?

 

[Parham Wood]

I am sure the ORR / RAIB will be indebted to you for not having to investigate the incident as you've clearly done such a thorough one yourself.

I make no apologies for being critical of your statement because you are clearly oblivious to the many potential causal factors, including, as I've said, Human Factors which certainly includes cultures, such as operational / management / organisational / personnel / quality control and training and decided the crew were to blame..." case closed ! "....

Instant blame was common in aviation for many years, and it still exists, sadly, but thankfully there are people who don't take everything at face value, who are prepared to investigate a lot deeper, and it's far from surprising what can emerge, because there are always cumulative precursors to incidents / accidents which may have gone unheeded, or, conveniently ignored, until one day when you find swiss cheese is being served. Very few are intentional and even those that are demand investigation as to why.

I agree that there may be many factors as you have stated that could be casual factors in why it happened and I have hinted at under usual operating conditions the stock may be further down the platform.

 

[Julian Atkins]

I am grateful for @paul1609 referencing this HRA guidance that I will look at.

@35B I don’t think that I suggested that the whole of the ‘national’ rule book as I knew it should be relevant to a preserved railway. If I didn’t make this clear then I apologise. But section J as I was taught and had to carry out and supervise for shunting and coupling up was what I referenced in my post 198.

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Here are some of the relevant section J provisions

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Section J 6.5.1 is crucial, then we have (not necessarily in order of the pics as I’m not very good at doing this) 6.1.3.2, 6.1.1.1 and 6.1.1.2

Also 6.4.1.6

In my time, section J 6.1 was not amended since 1996. Section J 6.5.1 is December 2002 had not been amended when I left in 2011.

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Section J 6.4.1.1

“You must control movements in order to prevent heavy impact with other vehicles”

 

[35B]

I am grateful for @paul1609 referencing this HRA guidance that I will look at.

@35B I don’t think that I suggested that the whole of the ‘national’ rule book as I knew it should be relevant to a preserved railway. If I didn’t make this clear then I apologise. But section J as I was taught and had to carry out and supervise for shunting and coupling up was what I referenced in my post 198.

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Here are some of the relevant section J provisions

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Section J 6.5.1 is crucial, then we have (not necessarily in order of the pics as I’m not very good at doing this) 6.1.3.2, 6.1.1.1 and 6.1.1.2

Also 6.4.1.6

In my time, section J 6.1 was not amended since 1996. Section J 6.5.1 is December 2002 had not been amended when I left in 2011.

== Doublepost prevention - post automatically merged: 4 Oct 2023 ==

Section J 6.4.1.1

“You must control movements in order to prevent heavy impact with other vehicles”

Noted re intent - I picked up on the generalisation and missed the specifics.

It seems self evident that clear understandings were not reached. As previously, the question that matters is why that was, and how that arose.

The answer to that question may identify issues with the rules in force, or with how they were followed, or something else entirely. We simply can’t know based on those two videos.

 

[Mcr Warrior]

That video gives a very good aspect of the speed of the loco, it made no effort to slow down at all prior to the collision.

What is the general consensus as to the actual speed of the loco immediately before the incident at Aviemore?

 

[12LDA28C]

What is the general consensus as to the actual speed of the loco immediately before the incident at Aviemore?

I estimate around 10-12mph.