RAIB: Overspeed at Queen's Park

[CharlieSpotted]

RAIB are looking into this:

Investigation into an overspeeding incident at Queen’s Park, 5 January 2016.

At approximately 08:30 hrs on Tuesday 5 January 2016, the 07:39 hrs passenger service from Bletchley to London Euston travelled at a speed of 75 mph (120 km/h) over a section of track near Queen’s Park station, where a 5 mph (8 km/h) emergency speed restriction applied.

The London Midland service, reporting number 2B14, consisted of three class 350 electrical multiple units coupled together; a total of 12 coaches. It was being driven by a driver-manager who was being assessed, as part of a routine competence management process, by a second driver-manager travelling in the driving cab. No injuries or damage resulted from the incident, and the train continued normally to its destination.

The maximum speed generally permitted at this location is 75 mph (120 km/h), but an emergency speed restriction had been imposed during the previous night after a cracked rail was found at a set of points near the east end of Queen’s Park station. The correct line-side signs and warnings had been placed on the approach to the speed restriction, and a notice warning of the speed restriction had been correctly displayed on the late notices board at the drivers’ depot. In addition, emails relating to the speed restriction had been sent to various London Midland managers, including the driver-managers involved in the incident.

https://www.gov.uk/government/news/overspeed-at-queens-park

On the face of it, pretty shocking, especially given that both of the people in the cab are described as "Driver Managers"?

 

[TDK]

RAIB are looking into this:



https://www.gov.uk/government/news/overspeed-at-queens-park

On the face of it, pretty shocking, especially given that both of the people in the cab are described as "Driver Managers"?

including the driver-managers involved in the incident. The key here is more than one in the cab and it is in the plural tense. The report will reveal the root cause.

 

[misterredmist]

Ouch !

 

[Peter Mugridge]

including the driver-managers involved in the incident. The key here is more than one in the cab and it is in the plural tense. The report will reveal the root cause.

Would it not be difficult for one to assess the other if there was only one in the cab? The quote makes it clear that one of them was having their regular routine assessment.

 

[carriageline]

Just proved everyone is fallible really. I imagine there will be a learning point along the lines of "managing distractions when there are other people in the cab"

 

[Islineclear3_1]

So it is probable that the TSR wasn't visible on that morning and the investigation will have to focus on whether it was in place properly, fallen down or there was poor visibility.

Perhaps the DM's hadn't seen the emails considering how late they were sent. Is it normal practice for DM's to log onto PC's when booking on - they may not have had the time to do so? The reason I ask is in my line of work, we are often too busy doing other (important) things before they get time to check (and respond to) our emails. Because of this, anything important/time sensitive is communicated via bleep or mobile phone.

 

[exile]

So it is probable that the TSR wasn't visible on that morning and the investigation will have to focus on whether it was in place properly, fallen down or there was poor visibility.

Perhaps the DM's hadn't seen the emails considering how late they were sent. Is it normal practice for DM's to log onto PC's when booking on - they may not have had the time to do so? The reason I ask is in my line of work, we are often too busy doing other (important) things before they get time to check (and respond to) our emails. Because of this, anything important/time sensitive is communicated via bleep or mobile phone.

We all make mistakes, and errors of omission are probably more common than errors of comission.

Is there a technological solution to this particular issue?

 

[HMS Ark Royal]

They were BOTH DSMs...? Good grief, this is almost too funny

 

[greatkingrat]

So it is probable that the TSR wasn't visible on that morning and the investigation will have to focus on whether it was in place properly, fallen down or there was poor visibility.

Perhaps the DM's hadn't seen the emails considering how late they were sent. Is it normal practice for DM's to log onto PC's when booking on - they may not have had the time to do so? The reason I ask is in my line of work, we are often too busy doing other (important) things before they get time to check (and respond to) our emails. Because of this, anything important/time sensitive is communicated via bleep or mobile phone.

I think the point is they should have checked the notices displayed in the depot at the start of their shift. The fact they happened to get an email about it as well is just a bonus, not the main method of notification.

 

[Islineclear3_1]

As the train passed at full line speed, either the TSR wasn't visible to the DM's or they hadn't read/received the late notification.

Hard to believe that one, let alone TWO experienced drivers would just miss a TSR

 

[HLE]

Pendant here, but it was an ESR, not a TSR.

 

[61653 HTAFC]

As the train passed at full line speed, either the TSR wasn't visible to the DM's or they hadn't read/received the late notification.

Hard to believe that one, let alone TWO experienced drivers would just miss a TSR

Would the unit have forward facing cameras which would record whether the TSR was correctly indicated to drivers at the time?

 

[GB]

Why is it hard to believe?

Hundreads of incidents and accidents across the years have been attributed to experienced people.


All we know is a train exceeded a specified limit. As none of us were there or privy to the investigation who are we to say how it did or did not happen.

 

[Cherry_Picker]

So it is probable that the TSR wasn't visible on that morning and the investigation will have to focus on whether it was in place properly, fallen down or there was poor visibility.

Perhaps the DM's hadn't seen the emails considering how late they were sent. Is it normal practice for DM's to log onto PC's when booking on - they may not have had the time to do so? The reason I ask is in my line of work, we are often too busy doing other (important) things before they get time to check (and respond to) our emails. Because of this, anything important/time sensitive is communicated via bleep or mobile phone.

You are obliged to read the notices before you take a train out on the mainline.

As 5 mph is such a massive (and unusual) speed restriction I'd have thought this would stand out like a sore thumb too. I wonder how they missed the notice, the magnet and the boards. The fact they were doing line speed suggests that they were not running on restrictive aspects but a 5 mph ESR that close to Euston in the morning peak would bunch trains up, surely? Are there reports of any other trains in the area missing it? It's certainly an investigation which will make for interesting reading.

 

[Islineclear3_1]

Then surely one must consider what signal aspect(s) were visible to the drivers on the approach. I hardly imagine that they would have been given green or double yellows on the approach to a 5mph speed limit !?

 

[najaB]

It's instructive to note how many airline accidents have had either a pilot under instruction or a senior instructor involved. KLM at Tenerife was the worst, but in recent history there was Turkish Airlines at Schiphol and Asiana at San Francisco among others.

 

[snowball]

There were a load of people in the cab in the recent TGV test train crash.

 

[MrPIC]

Then surely one must consider what signal aspect(s) were visible to the drivers on the approach. I hardly imagine that they would have been given green or double yellows on the approach to a 5mph speed limit !?

Why not? For an ESR laid out correctly you would have two AWS warnings for it and service braking distance which is the braking distance for the longest heaviest type train, a distance which a modern EMU would not need in order to be at the correct speed.
These things happen, and can happen to anyone as this clearly shows. Its impossible to know what happened in the cab at this time as none of us were there. There by the grace of god...

 

[HMS Ark Royal]

It's instructive to note how many airline accidents have had either a pilot under instruction or a senior instructor involved. KLM at Tenerife was the worst, but in recent history there was Turkish Airlines at Schiphol and Asiana at San Francisco among others.

The problem with 214 was that the pilot in the left seat only had 43 hours on type over 9 flights and was, in line with company policy, flying the route automated from start to almost finish. Another factor to 214's accident was the fact he did not know what he was doing, but didn't want to bother the senior pilot due to a cultural thing. Long and short of the matter is that he was a dangerous and unsafe pilot to be working that flight

 

[GB]

Then surely one must consider what signal aspect(s) were visible to the drivers on the approach. I hardly imagine that they would have been given green or double yellows on the approach to a 5mph speed limit !?

Of course you can get greens and yellows upto and over 5mph ESRs.

With an ESR that has been boarded there is no requirement to stop and caution trains as that is what the boards and magnets are for.

 

[misterredmist]

The problem with 214 was that the pilot in the left seat only had 43 hours on type over 9 flights and was, in line with company policy, flying the route automated from start to almost finish. Another factor to 214's accident was the fact he did not know what he was doing, but didn't want to bother the senior pilot due to a cultural thing. Long and short of the matter is that he was a dangerous and unsafe pilot to be working that flight

Wouldn't the Senior Pilot be in the LH Seat ? - any way, don't let my intervention distract from the validity of your post.....

 

[najaB]

The problem with 214 was that the pilot in the left seat only had 43 hours on type over 9 flights and was, in line with company policy, flying the route automated from start to almost finish. Another factor to 214's accident was the fact he did not know what he was doing, but didn't want to bother the senior pilot due to a cultural thing. Long and short of the matter is that he was a dangerous and unsafe pilot to be working that flight

Agreed. But it was exactly that 'don't want to look a fool in front of the senior pilot' attitude that made things ten times worse than they could've been. I'm not saying that incompetence was a factor in the incident under discussion, just that the stress of having two seniors in the cab could be a factor.

 

[Dave1987]

Of course you can get greens and yellows upto and over 5mph ESRs.

With an ESR that has been boarded there is no requirement to stop and caution trains as that is what the boards and magnets are for.

+Like x1000

As long as the ESR emergency indicator was in place with both lights flashing with the appropriate AWS magnets, speed boards in place and a suitable service braking distance there is no excuse for them to have missed the speed order. As with all these things the RAIB will get to the root cause.

 

[HMS Ark Royal]

Wouldn't the Senior Pilot be in the LH Seat ? - any way, don't let my intervention distract from the validity of your post.....

Normally,yes, but the left seater was essentially a student with the PIC sitting in the right seat with the FO in the jump.

To get back on topic, when Blame is issued, who will be at fault? From the first look at things,they must have seen the notice about the speed restriction but if the one of them was being assessed, would the assessing DSM be at fault for not asking if he'd seen the notice?

 

[DarloRich]

RAIB do not seek to apportion blame. The preamble to their reports state:

Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose.

and i don't think we should comment on the particulars until such time as a report is issued.

 

[Dave1987]

Normally,yes, but the left seater was essentially a student with the PIC sitting in the right seat with the FO in the jump.

To get back on topic, when Blame is issued, who will be at fault? From the first look at things,they must have seen the notice about the speed restriction but if the one of them was being assessed, would the assessing DSM be at fault for not asking if he'd seen the notice?

Sorry but you are not understanding how this works. It does not matter if you have seen the notice or not. As you are going along there are two very very bright strobe lights flashing that you can't miss along with two AWS magnets on the track that you need to acknowledge so unless you are not paying any attention to what you are doing it doesn't matter if you have not seen the notice you cannot fail to know about the ESR if it is boarded correctly.

 

[380101]

If the line side warning equipment was not in place at the time the signaller should have cautioned and stopped all trains before reaching the 5mph restriction. The signaller should then inform of the location and speed before giving a proceed signal.

If the Line side equipment was there, then either the AWS on the train was defective or the driver manager driving and the driver manager carrying out the assessment have failed to react to the AWS and not followed the relevant requirements of the rule book.

 

[hello]

so does anyone know how that it was discovered that the train did not adhere to the speed restriction?

 

[Islineclear3_1]

Surely it is also the duty of the signaller to caution trains in that area on the approach.as an extra layer of safety?

 

[GB]

Surely it is also the duty of the signaller to caution trains in that area on the approach.as an extra layer of safety?

It is not the signallers duty to caution trains unless the ESR has not been boarded, has been placed incorrectly or is in someway not correctly visable.

It is the drivers responsibility to adhere to lineside signs and indications.