Issues at Stafford - 2023/08/22

[train_lover]

Being as we've got a few sensitive individuals in here, I've been asked to clarify where my information has come from by the moderators.

I worked a train from the North of Crewe into Crewe where the signaller contacted me and said there had been a fatality at Stafford and an operational incident south of Crewe I'd be stuck at Crewe for a while before continuing south.

I then replied to someone on this thread giving a very vague but what I knew to be correct at the time account of what I had been told.

This information later turned out to be incorrect in part and for that if like to offer my sincere apologies to all that my original post has gone and upset. I know it was out of order and I'll be sure to raise a complaint with the signaller in question for the duff information.

 

[Cowley]

Being as we've got a few sensitive individuals in here, I've been asked to clarify where my information has come from by the moderators.

I worked a train from the North of Crewe into Crewe where the signaller contacted me and said there had been a fatality at Stafford and an operational incident south of Crewe I'd be stuck at Crewe for a while before continuing south.

I then replied to someone on this thread giving a very vague but what I knew to be correct at the time account of what I had been told.

This information later turned out to be incorrect in part and for that if like to offer my sincere apologies to all that my original post has gone and upset. I know it was out of order and I'll be sure to raise a complaint with the signaller in question for the duff information.

Thanks for the clarification @train_lover.
I think we’ll call it a day here now.

 

[ainsworth74]

The RAIB have announced that they will be carrying out an investigation into this incident:

At about 16:42 hrs on 22 August 2023, an electric locomotive operated by Freightliner, which was travelling on a test run between Nuneaton and Crewe, passed a signal at red (danger) on the approach to Stafford Trent Valley No.1 Junction.

The locomotive then ran through points as it came to a stand at the junction. The position where the locomotive stopped conflicted with a route that had been set for another train, although neither that train nor any other trains were in the immediate vicinity at the time. No one was injured and the locomotive did not derail, although some damage was sustained to the points which were run through.

Our investigation will seek to identify the sequence of events which led to the incident. It will also consider:

• the actions of those involved and anything that may have influenced them
• the management of drivers working for Freightliner, including their training and competence
• the configuration and performance of the signalling equipment and locomotive involved
• any underlying management factors.

Our investigation is independent of any investigation by the railway industry or by the industry’s regulator, the Office of Rail and Road.

We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on our website.

Signal passed at danger at Stafford Trent Valley No.1 Junction

Signal passed at danger at Stafford Trent Valley No.1 Junction, Staffordshire, 22 August 2023.

www.gov.uk

When the report is published the thread will be re-opened.

 

[John Webb]

The RAIB have released their report on the above incident - seehttps://assets.publishing.service.gov.uk/media/667044d688f6f369b8363f39/R052024_240617_Stafford.pdf

The Summary reads:

At about 16:41 hrs on 22 August 2023, an electric locomotive operated by Freightliner passed a signal at danger (red) on the approach to Stafford Trent Valley Junction No. 1. The locomotive was on a test run, after repair work, and continued for 740 metres beyond the signal, before running through points as it came to a stand at the junction.
The position where the locomotive stopped conflicted with a route that had been set for a southbound train, although that train was not in the immediate vicinity at the time that the locomotive stopped. A second, northbound, train had passed the junction a few seconds before the locomotive reached the points, but the locomotive did not foul the line that the northbound train had been travelling on.
No one was injured in the incident and the locomotive did not derail, although some damage was sustained to the points which were run through.
The investigation found that the locomotive had been travelling too quickly as it approached the red signal before the junction, meaning it was unable to stop before passing it. This was because the driver’s focus was diverted from the aspects showing at previous signals which warned that a red signal should be expected ahead. This took place while the driver was dealing with a fault that had occurred on the locomotive and which had caused the driver to bring the locomotive to a stand at a previous signal. It is possible that this previous signal was not clearly visible to the driver when they restarted the train after resetting the fault, and that the presence of the fault, and the need to rectify it, distracted the driver, who had not experienced that scenario before.
RAIB found that Freightliner had no formal process for managing the risks associated with the operation of test runs and light locomotives, and that its competence management system had not equipped the driver to deal with an unexpected and potentially distracting situation in an effective and safe manner. RAIB also found that the consequences of the incident were exacerbated by the high level of acceleration applied after the driver cleared the fault, the configuration of the locomotive and by the locomotive being driven at speeds above those permitted by relevant operating rules. RAIB also found that no engineered safety system intervened to apply the locomotive’s brakes before they were applied by the driver.
RAIB has made two recommendations to Freightliner. The first deals with reviewing risk assessments and processes for the operation of light locomotives and test runs, to better manage the operational risk. The second relates to how train drivers are trained and assessed in the skills required to manage out-of-course, abnormal and potentially stressful events.
Three learning points have also been identified. These relate to the need to comply with rules relating to locomotive speeds, the requirements for the development and maintenance of route knowledge, and settings for train protection systems.

 

[Wilts Wanderer]

Extract from the report (page 19, from the link previously provided):

47 At 16:41:41 hrs, the rear end of a passenger train with reporting number 2K58, the 15:52 hrs service from Birmingham to Crewe, had just cleared the points
at Stafford Trent Valley Junction No. 1, having approached them from the Wolverhampton direction on its way towards Stafford station. At the same time, the front of the locomotive forming 0Z90 was passing the switch diamond at the junction (paragraph 8), which was set for the passage of the next southbound train towards the Up Penkridge line. As it passed the switch diamond it deviated violently to the right towards the Up Penkridge line (figure 8) while travelling at about 13 mph (21 km/h).

48 At 16:41:48 hrs, the locomotive came to a stop on the Up Penkridge line, between the switch diamond and the switch tips at Stafford Trent Valley Junction No. 1. The locomotive did not derail as it passed through the switch diamond.

That’s quite astonishing. I’ve sometimes wondered how a switch diamond would behave when run-through but this was not what I expected would actually happen!

 

[Watershed]

Extract from the report (page 19, from the link previously provided):





That’s quite astonishing. I’ve sometimes wondered how a switch diamond would behave when run-through but this was not what I expected would actually happen!

Indeed. If the switch diamond had been run through completely, we'd potentially have been looking at a serious collision and injuries or worse.

Yet more findings in there which make clear the lip service that a lot of FOCs pay to training requirements, e.g. just giving drivers a slideshow on non-technical skills, and letting a fairly new driver loose on a mainline test run despite having only driven light loco at shunting speeds around the yard.

 

[Boodiggy]

Extract from the report (page 19, from the link previously provided):





That’s quite astonishing. I’ve sometimes wondered how a switch diamond would behave when run-through but this was not what I expected would actually happen!

First time I have known of a set be run through like that and the train not derail.

 

[Carlisle]

Did TPWS work as intended as it doesn’t sound like it .

 

[james_the_xv]

Did TPWS work as intended as it doesn’t sound like it .

Driver had already applied emergency brake, so TPWS had no effect. See para 46 (relevant sentence in bold):

46 By 16:40:58 hrs, the locomotive’s speed had been reduced further to 63 mph (101 km/h) as the locomotive passed LS5575 signal at danger. Passing the TSS loop at the signal resulted in a further demand for an emergency brake application from the TPWS system, but this again had no effect as it was already applied. The locomotive passing LS5575 at danger caused the signal in Stafford station that had previously been cleared for a train that was due to pass south towards Wolverhampton to revert to red. This occurred before that train had stopped in the platform at Stafford to pick up and set down passengers.

 

[Carlisle]

Ok thanks for the information as I hadn’t read the full report.

 

[james_the_xv]

That’s quite astonishing. I’ve sometimes wondered how a switch diamond would behave when run-through but this was not what I expected would actually happen!

I believe (and please someone correct me if I'm wrong) this is an example of flank protection.

 

[4COR]

I believe (and please someone correct me if I'm wrong) this is an example of flank protection.

I don't suspect switch diamonds are designed with that behaviour in mind at all - it's not like a single slip! (and I'm amazed it managed to "jump" routes and stay out of the dirt!)

 

[Bald Rick]

I believe (and please someone correct me if I'm wrong) this is an example of flank protection.

No, this is not flank protection.

It is quite remarkable that the loco diverted through the switch diamonds in the way that it did. I have seen 1 or 2 similar cases before, and all occur at low speeds, as was the case here.

 

[Boodiggy]

I don't suspect switch diamonds are designed with that behaviour in mind at all - it's not like a single slip! (and I'm amazed it managed to "jump" routes and stay out of the dirt!)

Exactly this.

== Doublepost prevention - post automatically merged: 18 Jun 2024 ==

No, this is not flank protection.

It is quite remarkable that the loco diverted through the switch diamonds in the way that it did. I have seen 1 or 2 similar cases before, and all occur at low speeds, as was the case here.

I have only seen it end in derailment.
In possessions when a route setting agent or engineering supervisor thought they could use the switch diamond as a crossover with the two opposite toes set in different directions...

 

[AY1975]

Does anyone know which loco was involved? The front cover of the report has a photo of 90008 although the loco number doesn't appear to be mentioned anywhere in the text of the report.

 

[jfollows]

Does anyone know which loco was involved? The front cover of the report has a photo of 90008 although the loco number doesn't appear to be mentioned anywhere in the text of the report.

90006
Item 15 in the report.

 

[nag67]

Does anyone know which loco was involved? The front cover of the report has a photo of 90008 although the loco number doesn't appear to be mentioned anywhere in the text of the report.

90006
Item 15 in the report.

Thanks jfollows. The photo is of 90006 (not 90008) and was taken during the test run, and is credited inside and at Figure 5.