Carmont (near Stonehaven) derailment - 12 August 2020

[NoRoute]

Looking at this from outside the rail industry, it's surprising the direction the report has taken and that there is not more focus on the train speed, the Railway Rule book and the rules surrounding the role and actions of the signallers and train drivers to ensure safety in exceptional conditions.

Given the other landslips and flooding in that area, known to those parties and hence the general uncertainty on the condition and safety of the route in that area, it is difficult to understand why a simple precautionary measure like slowing down is not required under the railway rules. It's surprising there is not more attention directed onto this.

Anyone driving a car is required by the Highway code to reduce their speed when the conditions would make it dangerous, and conditions like heavy rain, flooding and having encountered local landslips would clearly indicate potential for danger and justify reducing your speed given the uncertainty over the condition of the route and what you may encounter around the next bend.

 

[61653 HTAFC]

Having now had a chance to read the report, I'm amazed anyone survived in Coach D. This does seem like the death knell for the HSTs and Mk3 stock in general, possibly even all stock designed prior to 1994.

I predict that the HSTs with Scotrail will end up being withdrawn with slightly greater urgency (AIUI they were expected to last around a decade, when initially deployed) as a result of this tragedy. Not to mention the cumulative list of criticisms from previous incidents. However, this won't happen overnight: think of the Clapham disaster in 1988, which starkly brought attention to how mk1-type vehicles behaved in high(ish) speed collisions. It took well over a decade for the last vehicles of this type to be removed from public service on the national network.

 

[DunsBus]

Agreed. The issue with any construction is it needs far more than one person to check and sign off work has been done to spec and design as anything hidden will generally take years to be found. It also needs someone who can happily tell contractors to rip it up and start again. Sometimes finding it is chance, sometimes its as a result of a tragedy.

Some examples I have come across.

A five story Yorkshire stone facing wall affixed to the original building using door frame fixings and 25mm number 8 screws at half the centres they should have been rather than the specified fixing. movement noticed about 15 years after construction, engineers coukdn't believe the wall hadn't been blown off.

Blocked road gullies, water not draining, washing away road edges. Camera inspection showed at some point a utility company had laid services and in doing so had to disconnect the road drainage to make room and then reroute the road drainage. It never got reconnected.

A building built in the 1970s with a ground anchor system for a complex roof. Building now being demolished. The anchors were grouted in to the concrete, but the anchors were still wrapped in plastic so the grout wasn't doing anything.

Grenfell Tower is probably one of the greatest examples of how badly it can go wrong when somebody asks anybody to do something and what happens is nobody does it.

There was also a case in Edinburgh of a cast iron gas main being laid across a sewer chamber in the city's Cowgate in 1969. Twenty years later, in 1989, the pipe fractured and sent gas into the drains of a nearby tenement.

The resultant explosion resulted in two fatalities and destroyed the tenement; the subsequent inquiry found that it was the aforementioned bad workmanship that was the cause, as the person responsible for laying the main across the sewer chamber had done so against industry advice, and became of where it was no-one could check on the condition. The outcome of this was the phasing-out of the use of cast iron for gas mains and greater care being taken regarding their routing.

 

[GlitterUnicorn]

Agreed. The issue with any construction is it needs far more than one person to check and sign off work has been done to spec and design as anything hidden will generally take years to be found. It also needs someone who can happily tell contractors to rip it up and start again. Sometimes finding it is chance, sometimes its as a result of a tragedy.

Also the case with the coaches - the report mentions that corrosion repairs were undertaken at the discretion and professional judgement of engineers.

497 Corrosion repairs were undertaken on coach D by Wabtec from June to August 2019 as part of the power door modifications (paragraph 19). During the conversions that occurred before May 2020, which included the Carmont HST set, no formal corrosion allowances were specified for the body-end pillars. Engineering judgements about whether observed levels of corrosion required repair, were based on the expertise of staff. Wabtec reports that subsequently, in May 2020, guidance was introduced to assist staff deciding when repairs due to corrosion were needed. Records for corrosion repairs provided by Wabtec indicate that some localised corrosion had been identified on the two gangway pillars at the leading end of coach D, and repairs were authorised. There are no photographic records of the work actually done, and the pillars were too severely damaged in the accident for a meaningful retrospective assessment of this work.

 

[NoRoute]

Knowing about an event isn't enough because people leave their jobs, new people join, old incidents get forgotten. The challenge is how you get organisations to remember, to stop events repeating and that requires that the learning gets written into Rule books (preferably with an explanation or reference) and codes of practice, which remain even when people leave the organisation.

 

[Bletchleyite]

The cab is getting a lot of attention here, understandably given the dramatic outcome in this crash, but unfortunately I don't think the chances of a driver surviving an impact like that are great in any train.

What I find more concerning are the broken couplers and the lack of anti-climb and bogie retention features. If there had been more passengers on board these factors could have contributed to a much larger number of deaths. The RAIB report references standards on these dating from 1994 - how many trains built prior to that date have the same issues. Do we need an immediate stop of all 15x and Mk-3 derived EMUs?

No, because that would mean more people travelling by road, and road is more dangerous.

It does mean we should be planning better for the replacement of those old, polluting and it seems less safe units, though.

 

[Randomer]

I don't think this has been mentioned yet but my apologies if it has been picked up and I haven't noticed.

I did find the following quote interesting (para 55):

There was no requirement for clamps and scotches to be held at Carmont signal box and the signaller was neither trained, nor expected by Network Rail, to apply them (this differs from some historical practice). Therefore, a Network Rail mobile operations manager (MOM) was tasked (at 07:40 hrs) to travel to Carmont with the equipment for temporarily securing the crossover to allow the passage of train 1T08.

It is very much a Swiss Cheese theory point but one does have to wonder if Signallers had retained the competency to clamp and scotch points close to the box would the accident have happened? The train would have passed before the washout and the line behind and ahead closed to traffic anyway when it did occur. It's not causal to the accident directly but an interesting point to me that seemingly minor changes in practice can lead to very much unexpected changes in outcome.

 

[GB]

“

I don't think this has been mentioned yet but my apologies if it has been picked up and I haven't noticed.

I did find the following quote interesting (para 55):



It is very much a Swiss Cheese theory point but one does have to wonder if Signallers had retained the competency to clamp and scotch points close to the box would the accident have happened? The train would have passed before the washout and the line behind and ahead closed to traffic anyway when it did occur. It's not causal to the accident directly but an interesting point to me that seemingly minor changes in practice can lead to very much unexpected changes in outcome.

No one knows specifically what time the washout occurred. It may have been just a few minutes after the last train. Yes T08 might have got through but equally it might not have.

 

[Killingworth]

Many accidents are seen as relatively minor, and many more possible accidents don't happen due to good luck. On straight level track, in a cutting, that amount of debris would still have derailed the train, but a less serious outcome may have resulted. Almost full line speed, downhill, on outside of curve, and on steep embankment. The only thing that might have made it worse would have been hitting another train or a solid building.

Having slogged through the report I was impressed with the thorough investigation, and the sad coincidence of many little factors that brought about a more tragic result than should have been the case, all previously noted.

I first travelled in an HST in 1976. Given the millions of miles they must have covered since the chances of being in another encounter like this one must be very low. However, I'm alarmed at the number of landslides and tree strikes that are far too frequent and are a real threat to many more services involving rolling stock of all types.

 

[Mcr Warrior]

Had the HST unit that was heading back to Aberdeen (and sadly came to grief at Carmont) made it back, was anything else behind it still scheduled to run Northbound, or had everything been stopped by then, due to the appallingly inclement weather?

 

[Taunton]

It is very much a Swiss Cheese theory point but one does have to wonder if Signallers had retained the competency to clamp and scotch points close to the box would the accident have happened? The train would have passed before the washout and the line behind and ahead closed to traffic anyway when it did occur. It's not causal to the accident directly but an interesting point to me that seemingly minor changes in practice can lead to very much unexpected changes in outcome.

Given this is a predominantly passenger route, which are going to be the trains crossed over in various scenarios, one also wonders with all the hoo-hah necessary for a train to use the crossover why the points were not fitted with facing point locks in the first place. It's not as if they are some gold-plated component, on a single line minor route all the passing loops need to have them.

But yes, others have commented above that the use of clamps held in the box was traditionally just a part of the job, not particularly rocket science, with simple training. I wonder who decided to stop competency for it. It would be a Network Rail small cost saving, but now a confounded nuisance for the TOC should the crossover be required.

 

[IanXC]

It is very much a Swiss Cheese theory point but one does have to wonder if Signallers had retained the competency to clamp and scotch points close to the box would the accident have happened? The train would have passed before the washout and the line behind and ahead closed to traffic anyway when it did occur. It's not causal to the accident directly but an interesting point to me that seemingly minor changes in practice can lead to very much unexpected changes in outcome.

It's an interesting one as there are examples where in recent years where signallers have clamped points (and other similar activates). Whether there is a different view of this question in different parts of the network, or whether the signallers concerned also have MOM competence I'm not sure.

 

[tomuk]

“


No one knows specifically what time the washout occurred. It may have been just a few minutes after the last train. Yes T08 might have got through but equally it might not have.

In the report the RAIB suggest that based on modelling, by AECOM?, the washout occurred relatively near to the time of the accident. Therefore if the turnback had happened sooner the accident may not of occurred.

 

[GlitterUnicorn]

In the report the RAIB suggest that based on modelling, by AECOM?, the washout occurred relatively near to the time of the accident. Therefore if the turnback had happened sooner the accident may not of occurred.

It's not contributory though, it's just fate really.

 

[simonw]

There was also a case in Edinburgh of a cast iron gas main being laid across a sewer chamber in the city's Cowgate in 1969. Twenty years later, in 1989, the pipe fractured and sent gas into the drains of a nearby tenement.

The resultant explosion resulted in two fatalities and destroyed the tenement; the subsequent inquiry found that it was the aforementioned bad workmanship that was the cause, as the person responsible for laying the main across the sewer chamber had done so against industry advice, and became of where it was no-one could check on the condition. The outcome of this was the phasing-out of the use of cast iron for gas mains and greater care being taken regarding their routing.

A tangent, but the phasing out of cast iron gas pipes had started well before 1989.

 

[Falcon1200]

It is very much a Swiss Cheese theory point but one does have to wonder if Signallers had retained the competency to clamp and scotch points close to the box would the accident have happened? The train would have passed before the washout and the line behind and ahead closed to traffic anyway when it did occur.

That is certainly a valid point.

one also wonders with all the hoo-hah necessary for a train to use the crossover why the points were not fitted with facing point locks in the first place.

Because in normal circumstances the crossover would never need to be used for passenger train movements, however the cost of training Signallers and providing clamps and scotches would not be great so I would hope and expect that issue is being addressed by Network Rail.

I first travelled in an HST in 1976. Given the millions of miles they must have covered since the chances of being in another encounter like this one must be very low.

Same here, and given that their demise looks likely to be a lot sooner now, given the political and Trade Union reaction, I intend to travel on as many as possible, as soon as possible !

 

[scotraildriver]

It's an interesting one as there are examples where in recent years where signallers have clamped points (and other similar activates). Whether there is a different view of this question in different parts of the network, or whether the signallers concerned also have MOM competence I'm not sure.

I did find it surprising signallers cannot clamp and scotch points. Scotrail drivers are trained and permitted to clamp and scotch any points in RETB areas, it's not a difficult task and not much training is required.

 

[Scotrail314209]

Seeing some of the pictures on the report of the passenger carriages, i’m so glad that the train wasn’t fully loaded as some of the images are absolutely jarring.

 

[GB]

I did find it surprising signallers cannot clamp and scotch points. Scotrail drivers are trained and permitted to clamp and scotch any points in RETB areas, it's not a difficult task and not much training is required.

Like most things comes down to money saving. I imagine removal of said competence coincided with the removal of PTS for signallers.

 

[DunsBus]

A tangent, but the phasing out of cast iron gas pipes had started well before 1989.

Thanks for that. I've just been doing a check online as to when the phasing out of cast-iron mains started and came across a mention of a gas explosion in Putney in 1985 that killed eight people, in similar circumstances to the Edinburgh explosion, with British Gas starting to replace these mains soon afterwards.

 

[simonw]

Thanks for that. I've just been doing a check online as to when the phasing out of cast-iron mains started and came across a mention of a gas explosion in Putney in 1985 that killed eight people, in similar circumstances to the Edinburgh explosion, with British Gas starting to replace these mains soon afterwards.

Putney certainly accelerated the replacement programme although it had been underway before then. The Putney explosion was caused by a gas line being paid across the foundations of the house that had stood where the flats were built. It fractured due to the land moving and recoup breaking where it crossed the old fondations. But we are well off course now.

 

[Bikeman78]

I predict that the HSTs with Scotrail will end up being withdrawn with slightly greater urgency (AIUI they were expected to last around a decade, when initially deployed) as a result of this tragedy. Not to mention the cumulative list of criticisms from previous incidents. However, this won't happen overnight: think of the Clapham disaster in 1988, which starkly brought attention to how mk1-type vehicles behaved in high(ish) speed collisions. It took well over a decade for the last vehicles of this type to be removed from public service on the national network.

17 years in fact, although I don't think there were any serious accidents in their last 11 years in service.

== Doublepost prevention - post automatically merged: 11 Mar 2022 ==

Seeing some of the pictures on the report of the passenger carriages, i’m so glad that the train wasn’t fully loaded as some of the images are absolutely jarring.

Totally agree. The image of coach D is horrific. How anyone survived in there I don't know. Won't put me off though.

 

[matchmaker]

There was also a case in Edinburgh of a cast iron gas main being laid across a sewer chamber in the city's Cowgate in 1969. Twenty years later, in 1989, the pipe fractured and sent gas into the drains of a nearby tenement.

The resultant explosion resulted in two fatalities and destroyed the tenement; the subsequent inquiry found that it was the aforementioned bad workmanship that was the cause, as the person responsible for laying the main across the sewer chamber had done so against industry advice, and became of where it was no-one could check on the condition. The outcome of this was the phasing-out of the use of cast iron for gas mains and greater care being taken regarding their routing.

And of course the Clarkston gas explosion in 1971. 21 (or 22) killed.

From Wikipedia (my bolding):

An inquiry was held, and a jury on 11 February 1972 returned a verdict that no fault for the explosion lay with any organisation or individual. No cause was identified for the ignition of the leaked gas, and the leak itself was deemed the result of an accidental gas main fracture caused by "stress and corrosion". The main had been insufficiently supported to withstand vibrations from traffic, and a large crack was found in it during the investigation.

Before retiring a couple of years ago I worked in the construction industry. One of my main tasks was the production of Health & Safety Files as required by the
Construction Design and Management (CDM) Regulations 2015. This is a legal requirement and I find it incredible that no such a file was produced in the case of the drainage works. There is a lot of work involved in making up a H&S File, but no CDM Coordinator should sign off on a job without such a file. From the RAIB report it seems that Carmont was not unique in this respect, which does not say much for NR management

 

[yoyothehobo]

I think luckily we are at the stage that no one is (or a minor %) avoiding taking train travel because of the risk of a crash.

You are probably still more likely to catch Covid on a train and get severely ill from that at the moment.

It is interesting to see what will happen with the HSTs. Yes they are past their best, are old tech and will need to be replaced sooner rather than later. How soon is a complex question.

Another point is that the network is suffering from similar weather induced failures, particularly in Scotland, however they are network wide and although this one was a result of poor workmanship and supervision etc... there are several incidents caused by failures on slopes, embankments, cuttings and the like that are the results of increased rainfall periods and Network Rail clearly doesnt have the resources to undertake remedial measures on all potential failures immediately, which is why we are seeing such drastic measures with weather warnings at the moment.

So although this incident was caused by build problems and should rightly be criticised for the results from its poor execution and paperwork records, i fear that this could have happened elsewhere on the network very easily.

 

[island]

A couple of thoughts I had looking through the report, which came out of it, but didn't seem to be commented on:
1) The 'conductor travelling as passenger' was able to contact the (civil) emergency services (para 582) by dialling 999 (from their mobile phone) immediately after the accident; was not able to use the train GSM-R phone; and was only able to contact the Carmont signalman (and hence the railway) after walking (or hobbling) to a lineside telephone. Wondering why she could not contact the railway control (Scotrail or Network Rail) from her mobile? (Directly or via the emergency services). Similarly, the contractors for the scouring works at the bridge (who would perhaps seem to be the first to able to say 'train crash HERE') were not seemingly not able to relay that (however).

No signal from the relevant network at the location? 999 calls use any available network.

Yes, that's what I was also thinking. She also might not have had the relevant number(s) to hand.

 

[Wynd]

Carmont is a signal blackspot. I'm amazed any mobile was able to dial out.

I too have wondered if the delay in turnback had been avoided, if things may have been different.

As a side point, Carmont roughly marks the beginning of what has been (to my experience at least, 25 years of living here) a period of exceptional and unusual weather for Aberdeenshire. That summer was unusually warm, the rain that day of the crash was extremely heavy and the following winters (2019/20, then 2021/22) have been exceptionally snowy and then windy respectively. Short version, its feeling like a very hostile climate here nowadays, more hostile than I have been used to. Its anecdotal I accept and id love to see some data.

It seems this report will hasten the demise of the HST. However, getting one in the first place in daily service is unlikely as it is. Most are still at Clayhills, Haymarket or parked up in other places. The introduction has not been good.

The image I have see of the power car minus cab suggests a steel structure could be retrofitted to meet impact requirements, but with single figure years left in service, the Capex would need some justification.

Carmont is a tragedy, no doubt about it. I have every faith that the lessons outlined in the report will be learned and applied in future.

 

[bramling]

Looking at this from outside the rail industry, it's surprising the direction the report has taken and that there is not more focus on the train speed, the Railway Rule book and the rules surrounding the role and actions of the signallers and train drivers to ensure safety in exceptional conditions.

Given the other landslips and flooding in that area, known to those parties and hence the general uncertainty on the condition and safety of the route in that area, it is difficult to understand why a simple precautionary measure like slowing down is not required under the railway rules. It's surprising there is not more attention directed onto this.

Anyone driving a car is required by the Highway code to reduce their speed when the conditions would make it dangerous, and conditions like heavy rain, flooding and having encountered local landslips would clearly indicate potential for danger and justify reducing your speed given the uncertainty over the condition of the route and what you may encounter around the next bend.

I think more would perhaps have been made of this had the accident not been caused by the incorrectly installed drain. Generally there is - and has to be - an expectation that the infrastructure is sound.

As regards HST crashworthiness. I’m in two minds over this. The circumstances of the derailment were such that this was always going to result in a bad outcome. Had it been a more recent train I’m not convinced the driver would have fared any better, simply because of the decelerations involved and the fact that he would have been thrown around the cab at considerable force.

Likewise in terms of crashworthiness, there can’t really be too much criticism of the vestibule (where the conductor was unfortunately located) disintegrating, when on a modern train this would have been designed as a crumple zone. Note how the cab and lead vestibule all but disappeared on the Salisbury 159. Previous accident reports have identified that Mk3 vestibules act as de-facto crumple zones. And of course on a modern walk-through train there would be little to stop people being being ejected to their deaths through the vehicle ends.

So from a personal perspective I will quite happily travel on Mk3s without a second thought - indeed the chances of an accident happening is minimal, and HSTs have carried millions of people safely in their 40+ years.

I’m less relaxed about driver safety however. Again the odds of a serious incident are fairly minimal, and of the 3 HST collisions where the driver has been killed I’d say at least two weren’t down to cab crashworthiness, though at Ufton the driver might have fared better in something else. But there’s the possibility of minor incidents having a disproportionately bad outcome, and on that basis I’d say it’s probably time to move on from HSTs now, though if the power cars could be replaced by something else and the Mk3s continue then in my view that would be fine. It’s perhaps rather remiss that the industry has been busy replacing EMUs it didn’t need to replace, whilst allowing some rather older traction to continue past its sell-by date.

 

[Nicholas Lewis]

Southall 1997 gave a forewarning of the fragility of the cab and that was from a sideswipe of the stone train but given the underlying issues it wasn't investigated although if you were an owner or operator of class 43 power cars you should have had more than a passing interest.



Or after Ladbroke grove 1999 when the enquiry noted


and the enquiry recommended


Again what happened after this and surpised RAIB haven't delved further.

As an aside looking back at these reports and comparing them to the RAIB reports there is a lot more background information, diagrams and pictures to aid understanding.

 

[bramling]

Southall 1997 gave a forewarning of the fragility of the cab and that was from a sideswipe of the stone train but given the underlying issues it wasn't investigated although if you were an owner or operator of class 43 power cars you should have had more than a passing interest.

View attachment 111286

Or after Ladbroke grove 1999 when the enquiry noted

View attachment 111287
and the enquiry recommended
View attachment 111288

Again what happened after this and surpised RAIB haven't delved further.

As an aside looking back at these reports and comparing them to the RAIB reports there is a lot more background information, diagrams and pictures to aid understanding.

It is curious that a considerable amount of work seems to have gone into developing crashworthiness for the HST passenger vehicles, yet little if any for the cab. One can only presume that the view was taken that in any serious collision the front of the train would likely be worst affected and there was simply little point in attempting to overcome that - in the same way that crumple zones offer little protection to people standing in them.

There’s no easy answers to all this, and in all fairness we can’t expect there to be as running metal objects at high speeds is never going to produce good outcomes when things go wrong. And there is almost certainly a case to say that expenditure is better aimed at preventing accidents happening in the first place, which to be fair the industry has done rather well this century.

I suspect the cabs issue is going to gather salience, and I wouldn’t be surprised if at some point in the not too distant future we reach a position where one or more of the unions take the position that drivers are told to refuse to drive HSTs. That would be extremely unfortunate, but one could understand why.

 

[Taunton]

Southall 1997 gave a forewarning of the fragility of the cab and that was from a sideswipe of the stone train

View attachment 111286

That's a considerable misrepresentation. At Southall, as the HST progressively struck the stone train at a combined closing speed of near 100mph, each wagon as pushed over progressively presented the next one more and more head on. Look at your picture. The drivers' windscreen is not even broken.

And if you want to comment on Ladbroke Grove as well and the HST driver's cab being "severely compromised", maybe we can carry on to the, new and modern at the time, front car of the colliding Class 165, which was completely shredded for its whole length down to the underframe. In such an incident, I think "severely compromised" would be pretty good.

I do feel that, for Carmont, issues in the report about the train have given Network Rail a "Get Out Of Jail" card, to (once again, unfortunately) stick it as much as possible on the train operator. For their own complete failings. There, that's been said. But it needed saying.