Carmont (near Stonehaven) derailment - 12 August 2020

[61653 HTAFC]

The 365 bodyshell at Potters Bar was of course the same Networker design as the 165 at Ladbroke Grove, head on into an HST, where, as I described above, the leading passenger car of the 165, almost new at the time, completely disintegrated full length down to the underframe, far worse destruction than any of the HST cars involved. But fortunately, almost empty.

Those two accidents involve very different circumstances in terms of forces exerted upon the vehicles, and more critically where those forces were applied. The same can be said for mk3s: they held up well under a high-speed end-on impact with a much lighter train at Ladbrooke Grove. Less so when subjected to side-on or secondary impacts such as at Ufton Nervet, or Carmont.

 

[bramling]

Those two accidents involve very different circumstances in terms of forces exerted upon the vehicles, and more critically where those forces were applied. The same can be said for mk3s: they held up well under a high-speed end-on impact with a much lighter train at Ladbrooke Grove. Less so when subjected to side-on or secondary impacts such as at Ufton Nervet, or Carmont.

I was ignoring the 165 at Ladbroke Grove, on the basis that the forces and energy there - in particular on the 165 - were in a different league to pretty much any other accident.

There does come a point where we have to accept that crashworthiness will only take us so far, no matter how much is done. I do think we’re at, or at least very near that point, for both the driver and conductor at Carmont, tragically. Likewise for the third fatality who (if I’m interpreting the report correctly) was also located in a vestibule.

 

[AlbertBeale]

Well HS2 is a brand new line, so will be no doubt built to a specification that takes into account climate change and the environment with in-built protections for embankments / cuttings / tunnels etc.

If it took into account the environment it wouldn't be being built - at least not in any way resembling the current plans.

Or do you only mean the effect of the environment on HS2, not HS2's effect on the environment!

 

[rebmcr]

If it took into account the environment it wouldn't be being built - at least not in any way resembling the current plans.

Or do you only mean the effect of the environment on HS2, not HS2's effect on the environment!

Taking freight off the M40 and onto freed-up paths of the WCML is a great effect that HS2 will have on the environment.

 

[Horizon22]

If it took into account the environment it wouldn't be being built - at least not in any way resembling the current plans.

Or do you only mean the effect of the environment on HS2, not HS2's effect on the environment!

Well lets not get into an HS2 debate here, but I more meant the immediate surroundings of the line in terms of trees, escarpments, tunnels, cuttings and the like to conform to very modern standards which is obviously not possible with our classic lines built centuries back.

 

[tomuk]

Is this conclusion the result of expert analysis of numerous incidents? It sounds very like the arguments used against the compulsory wearing of belts in cars. Obviously there will be some incidents which may be made worse, some which will be made survivable, and (probably the vast majority ) where it would make no difference.

For nearly all locomotives, prior to the class 60?, the cab has been at best made of light gauge steel. In an accident where the cab is hit above the buffer beam the cab pretty much crumples to nothing back to the engine room bulkhead. Basically you don't want to be there. Now there is the equally compelling argument that you probably don't want to be thrown round the engine room either and impact against the various moving, hard, hot or high voltage items. I suppose a 'crash' seat with a seatbelt in the engine room would be ideal.

Class 47: 47402 Crewe Works by emdjt42, on Flickr

 

[Taunton]

For those who think that cabs should be some hugely integral part of the front end, here are the spare cabs for the most extensively safety-conscious and highest-speed trains in the country, Eurostar, sat on the gravel at Stratford depot, one for each type of Eurostar train, waiting to be attached should a cab be severely damaged, as above. As can be seen, they are just a bolt-on attachment :

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[tomuk]

For those who think that cabs should be some hugely integral part of the front end, here are the spare cabs for the most extensively safety-conscious and highest-speed trains in the country, Eurostar, sat on the gravel at Stratford depot, one for each type of Eurostar train, waiting to be attached should a cab be severely damaged, as above. As can be seen, they are just a bolt-on attachment :

Google Maps

Find local businesses, view maps and get driving directions in Google Maps.

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They are just the cab 'beauty' covers. The structure is hidden underneath.

 

[Essexal]

I can’t see that this has been stated so far (apologies if it has), but I consider a crucial recommendation has been overlooked.

Proposed Construction vs Actual Construction:

It is clear that Carillion not only failed to construct the drain in accordance with the original specification (Casual Factor s83-b) but also failed to notify Network Rail, and this was not picked up in any audits/trackside inspections.

Whilst recommendation 2 (s94) states that all “New Works” for “As-built information” should be handed over to the maintainer (I imagine Network Rail) to be incorporated into inspection & maintenance regimes, exactly how confident can the rail industry be that sub-contractors didn’t amend design specifications on other projects, and not inform Network Rail (as Maintainer) of the change?

After all if NR didn’t have the infrastructure in place to pick up the issue at Carmont (processes to ensure design spec was correct, audits & inspections) who is to say this hasn’t happened elsewhere on the network, which could be an incident waiting to happen?

To this effect I would have expected the RAIB to have at least asked the question to relevant authorities and/or included this within their recommendations?

Carmont was a tragedy that according to this report could, and should have been prevented, and it’s only right for the families of the deceased & injured that this should never be allowed to happen again.

 

[tomuk]

After all if NR didn’t have the infrastructure in place to pick up the issue at Carmont (processes to ensure design spec was correct, audits & inspections) who is to say this hasn’t happened elsewhere on the network, which could be an incident waiting to happen?

To this effect I would have expected the RAIB to have at least asked the question to relevant authorities and/or included this within their recommendations?

RAIB Report says:
https://assets.publishing.service.g...67/R022022_220310_Carmont_High_resolution.pdf

295 RAIB asked Network Rail for information concerning other H&S files which, as the
client, it should have retained for other projects completed by Carillion in 2012.
Network Rail used its purchase order system to determine that H&S files should
be available for between 48 and 64 projects. Network Rail stated that it held H&S
files for only 16 of these.

296 RAIB also sought to quantify the extent to which new works had not been
transferred into maintenance. In response to a request from RAIB, Network
Rail identified 11 drainage schemes completed in Scotland from 2014 to 2019
and which should have resulted in new drains being transferred into Ellipse,
the Network Rail maintenance system. Network Rail stated that 5 of these 11
schemes had not been transferred (these schemes did not involve Carillion).

297 The above evidence shows that the transfer of information from infrastructure
projects to the infrastructure managers was deficient in Scotland. Witness
evidence also indicates that the inefficient transfer of asset knowledge from
constructors to maintainers was a known problem across other Network Rail
routes.

 

[43096]

This is exactly what happened to the driver of the Grayrigg Pendolino. He was seriously injured but not fatally.

But at Grayrigg, the leading vehicle didn't go cab first into the ground, the vehicle turned round and ended up backwards. That is rather different from the power car at Carmont which went from moving at speed to a stop instantaneously.

It should also be noted the the couplers between vehicles one and two at Grayrigg also failed, just as happened at Carmont, despite them being of modern design. There comes a point with any design where the amount of energy involved overwhelms the coupler.

 

[swt_passenger]

None of those designs have the front car given over to staff or storage areas. If you look at a Class 180 and IET in particular, it's not even half the leading car.

As discussed at length in the past, group standards were in a state of flux during the Voyager/Pendolino design. A few amendments to the standard later and the rules, (as Virgin‘s rolling stock builders had interpreted them), had gone. Later stock including IET, as you said, certainly doesn’t have excess non passenger space at both ends, and I think it’s been regularly noted that the Javelins don’t.

 

[O L Leigh]

None of those designs have the front car given over to staff or storage areas. If you look at a Class 180 and IET in particular, it's not even half the leading car.

To be entirely fair, you’re picking me up on a typo that I’ve only just realised I made. Thank you.

 

[InOban]

It seems as if NR was allowing contractors to self certify their work. Rather like housebuilders certifying that their new houses are built properly and to current regulations. Or the FAA believing what Boeing told them.

And of course if you are being squeezed for money it's cheaper to dispense with inspectors and trust your contractors. But only in the short run. Pigeons/roost..

 

[Grumpy Git]

It seems as if NR was allowing contractors to self certify their work. Rather like housebuilders certifying that their new houses are built properly and to current regulations. Or the FAA believing what Boeing told them.

........ and all to save a few quid.

 

[DelW]

It seems as if NR was allowing contractors to self certify their work. Rather like housebuilders certifying that their new houses are built properly and to current regulations. Or the FAA believing what Boeing told them.

And of course if you are being squeezed for money it's cheaper to dispense with inspectors and trust your contractors. But only in the short run. Pigeons/roost..

It's the way the whole construction industry has gone (and indeed others, as per your Boeing example).

When I started working for a civil engineering contractor in the 1970s, everything we did was inspected and approved by Resident Engineers and Clerks of Works, representing the client, designer, or both (often the same organisation in those days).

Since then, clients have largely dispensed with in-house engineering expertise, having outsourced the design as well as construction. They've been unwilling to pay designers to carry out an inspection role, and indeed few of the engineers in design consultancies have the necessary construction experience to do that effectively.

So the whole responsibility rests with the contractor's QA system, and the ability and honesty of the staff applying it. I have to say that the colleagues I worked with until retirement were (almost!) without exception rigorous in applying it correctly, but there is always a temptation not to do so.

We also had to produce and deliver to the client, comprehensive Operation and Maintenance Manuals (O&Ms), detailing everything from design inputs and records, through construction and as-built drawings, to equipment specifications, maintenance schedules and methods, H&S information, and even guidance for eventual decommissioning and demolition. These were very time consuming and expensive to produce, sometimes after a contract had made a loss as well, so again there can be a temptation to cut corners. That shouldn't ever happen, but it's human nature.

Unfortunately, when these corners have been cut, something like Carmont can suddenly expose them many years later, with possibly disastrous consequences.

 

[edwin_m]

It's the way the whole construction industry has gone (and indeed others, as per your Boeing example).

When I started working for a civil engineering contractor in the 1970s, everything we did was inspected and approved by Resident Engineers and Clerks of Works, representing the client, designer, or both (often the same organisation in those days).

Since then, clients have largely dispensed with in-house engineering expertise, having outsourced the design as well as construction. They've been unwilling to pay designers to carry out an inspection role, and indeed few of the engineers in design consultancies have the necessary construction experience to do that effectively.

So the whole responsibility rests with the contractor's QA system, and the ability and honesty of the staff applying it. I have to say that the colleagues I worked with until retirement were (almost!) without exception rigorous in applying it correctly, but there is always a temptation not to do so.

We also had to produce and deliver to the client, comprehensive Operation and Maintenance Manuals (O&Ms), detailing everything from design inputs and records, through construction and as-built drawings, to equipment specifications, maintenance schedules and methods, H&S information, and even guidance for eventual decommissioning and demolition. These were very time consuming and expensive to produce, sometimes after a contract had made a loss as well, so again there can be a temptation to cut corners. That shouldn't ever happen, but it's human nature.

Unfortunately, when these corners have been cut, something like Carmont can suddenly expose them many years later, with possibly disastrous consequences.

The logical conclusion of this would be to go back to a system of "man marking" where everything has to be signed off by the client.

But how far do you go? Someone inspecting the completed work at Carmont wouldn't have been able to see, for example, that the geotextile membrane hadn't been installed (which the report commented on but it had no effect on the accident). So you'd be sending inspectors in while work was in progress too. This is not only expensive but requires extra resource within Network Rail's maintenance teams, where time after time RAIB reports have shown that there aren't enough people to do the work itself and all the paperwork that comes with it.

Perhaps the answer is random inspections at random stages of random projects. This would also need stiff penalties for any contractor found to be deficient, otherwise some would just continue doing the shoddy work and just fix the problem when they were caught by an inspection. Potentially any significant fault found would lead to that contractor having increased levels of inspection for a certain period, and having to pay the costs of same.

Another part of the solution might be to pick up on what was done for the report - cross-checking that for every purchase order raised, there are as-builts and a health and safety file supplied. Withholding a chunk of the payment until this is done ought to be a good incentive.

 

[Peter Mugridge]

........ and all to save a few quid.

A point I raised concerns about in reply #1161, but the thread was very busy at the time and it got buried...

As I understand things, NR has basically contracted out quite a large chunk of their back office admin functions and I cannot say that this is a good idea as it does result in a loss of oversight on even the most basic paperwork.

I'm not completely sure, but a bit of online digging suggests that Carillion used the exact same back office subcontractor and it is one which I have no confidence at all in.

 

[Grumpy Git]

The problem as I see it, (as someone with 40 years of engineering experience in a non-rail related industry) is that the client does not have the relevant expertise.

I get asked to produce qualification documents for kit I've both designed and installed, then also get asked to execute the actual tests! All the client does is witness the results! All in all it's a very lucrative business, so happy days.

 

[Hellzapoppin]

NR have/had Construction managers with relevant expertise who check on the works as it progresses, certain critical stages are checked and signed off before the works recommences. On my old area the CMs were/are top notch and have stopped jobs because of concerns, I've personally done that even after the designs have been done and signed off as correct, telling the designers it wouldn't work.

 

[DelW]

The logical conclusion of this would be to go back to a system of "man marking" where everything has to be signed off by the client.

But how far do you go? Someone inspecting the completed work at Carmont wouldn't have been able to see, for example, that the geotextile membrane hadn't been installed (which the report commented on but it had no effect on the accident). So you'd be sending inspectors in while work was in progress too. This is not only expensive but requires extra resource within Network Rail's maintenance teams, where time after time RAIB reports have shown that there aren't enough people to do the work itself and all the paperwork that comes with it.

Perhaps the answer is random inspections at random stages of random projects. This would also need stiff penalties for any contractor found to be deficient, otherwise some would just continue doing the shoddy work and just fix the problem when they were caught by an inspection. Potentially any significant fault found would lead to that contractor having increased levels of inspection for a certain period, and having to pay the costs of same.

Another part of the solution might be to pick up on what was done for the report - cross-checking that for every purchase order raised, there are as-builts and a health and safety file supplied. Withholding a chunk of the payment until this is done ought to be a good incentive.

I agree there's an economic balance to be struck between the ongoing costs of an inspection regime, and the infrequent but possibly very high cost of a failure resulting from its absence. Unfortunately when lives are lost, the economic trade-off becomes rather moot.

As for potential punishment for errant contractors, as well as the enhanced inspections you've suggested, the threat of removal from tender lists is one way to concentrate minds - it certainly used to get senior management's attention at my previous employer.

 

[Nicholas Lewis]

NR have/had Construction managers with relevant expertise who check on the works as it progresses, certain critical stages are checked and signed off before the works recommences. On my old area the CMs were/are top notch and have stopped jobs because of concerns, I've personally done that even after the designs have been done and signed off as correct, telling the designers it wouldn't work.

Absolutely but I never had enough of them to cover the whole portfolio effectively on routine renewals works but the bigger projects were better equipped with resources and dedicated project engineers who would also take a keen interest in certain stages of the works especially hidden elements. You could say this cost money but there is so much pointless effort in projects in producing safety paperwork by the contractor (method statements etc) that it could easily be neutralised by changes in working practices so NR has more oversight resources.

 

[Deltic1961]

According to the article below, ASLEF members may boycott working on HSTs from August next year unless "meaningful discussions" take place.

Link to Daily Record article on Pressreader: https://www.pressreader.com/uk/daily-record/20220312/281840057141165

Some 25 HSTs remain in operation in Scotland. Lindsay said: “We want them phased out as quickly as possible. We understand the practicalities and will participate in the steering group. If the group just pays lip service to safety concerns, our members will boycott these trains from August 12 next year – the third anniversary of the crash.”

ScotRail chief operating officer Ian McConnell said: “The RAIB report is clear that the high-speed trains were not the cause of the accident and there is insufficient evidence to show that a more modern train would have prevented the derailment.”

 

[Nicholas Lewis]

According to the article below, ASLEF members may boycott working on HSTs from August next year unless "meaningful discussions" take place.

Link to Daily Record article on Pressreader: https://www.pressreader.com/uk/daily-record/20220312/281840057141165

I suggest they are being pretty reasonable currently just escalating concerns in respect of their members safety and Scottish Transport Secretary wants to discuss report with Shapps so lets hope they take ASLEF with them.

 

[tomuk]

I suggest they are being pretty reasonable currently just escalating concerns in respect of their members safety and Scottish Transport Secretary wants to discuss report with Shapps so lets hope they take ASLEF with them.

Will they be blacking other locos like the 57s on the Night Rivera or 47s on charters/stock moves their cabs are equally if not more dangerous than HSTs. Will they be blacking all other stock until seatbelts and airbags are fitted, the RAIB report seems quite convinced that the driver died due to secondary impact with the cab desk\windscreen and goes on at length about secondary safety equipment such as airbags, seat belts etc.

 

[Nicholas Lewis]

Will they be blacking other locos like the 57s on the Night Rivera or 47s on charters/stock moves their cabs are equally if not more dangerous than HSTs. Will they be blacking all other stock until seatbelts and airbags are fitted, the RAIB report seems quite convinced that the driver died due to secondary impact with the cab desk\windscreen and goes on at length about secondary safety equipment such as airbags, seat belts etc.

Currently there not blacking anything but they represent their members so its not unreasonable they raise the issue and the industry needs to engage with them.

 

[scotraildriver]

ASLEF fully realise that the HSTs won't be replaced by August 2023. What they are looking for is an agreed plan/new train order and a timescale for the HST withdrawal. Given that HSTs were always meant to be a 10 year stop gap, and we are 4 years in already I don't think it's unreasonable. Unfortunately with the imminent transfer to Scotgov nothing is happening or even being discussed right now.

 

[Hagbard Celine]

One thing I don't recall noticing when I skimmed the report is why the train had to return to Stonehaven on the down line. Shortly after it had been brought to a stand by the GSMR call the whole network was FUBAR and nothing was moving south of Carmont or north of Stonehaven. Rather than wait for two hours for a MOM to fit facing point locks why didn't it just return to Stonehaven under caution on the up line?

 

[AlbertBeale]

One thing I don't recall noticing when I skimmed the report is why the train had to return to Stonehaven on the down line. Shortly after it had been brought to a stand by the GSMR call the whole network was FUBAR and nothing was moving south of Carmont or north of Stonehaven. Rather than wait for two hours for a MOM to fit facing point locks why didn't it just return to Stonehaven under caution on the up line?

Sorry - but what's FUBAR?

 

[Watershed]

Sorry - but what's FUBAR?

The latter three letters stand for "beyond all recognition". I'll let you guess for the remainder!