RAIB: Overspeed at Queen's Park

[ComUtoR]

Sounds like the blind leading the blind. What a terrible indictment of London Midland's management when the people given the task of ensuring standards can't even manage them themselves.

Sounds like a typical Driver Manager

 

[CosherB]

Sounds like a typical Driver Manager

In what sense? :roll:

 

[Zoidberg]

Sounds like the blind leading the blind. What a terrible indictment of London Midland's management when the people given the task of ensuring standards can't even manage them themselves.

I was surprised at the need to stress what I would consider to be best practice for a manager/supervisor of any sort and what should be embedded in day to day working i.e. to be up to date with rules etc.with which the person being managed/supervised is expected to comply.

... the importance of managers fully preparing before driving trains, the need for driving assessors to prepare as if they were driving the train and the use of unambiguous words in safety communications.

 

[bramling]

Sounds like the blind leading the blind. What a terrible indictment of London Midland's management when the people given the task of ensuring standards can't even manage them themselves.

In my view that's rather harsh.

Both were ex-drivers with a good degree of experience, so this is not a case of some newby being on the handle who had no idea about the railway.

A mistake was made, so it's for the industry to implement processes to minimise the chance of that mistake being made again.

 

[notverydeep]

The passenger load of 2000 quoted by the RAIB seems deeply implausible to me. The seating capacity of a 12 car formation of class 350 is only 678. This implies 1322 standing passengers or 110 standees per carriage. This simply isn't credible. Even class 700s cannot be loaded to that level and they would be much better configured for standing space. Dwell times would be lengthened considerably as loading would resemble a 'how many students can fit in a telephone box / mini / whatever' competition!

In normal operation passengers are very reluctant to subject themselves to that level of crowding and it is often difficult for boarders to persuade the passengers already on board to move down to fully occupy the aisles between the seats. Even with a seated and standing total load of say 1200, most passengers would believe the train to be 'very crowded'.

Interesting that the train should contain 350264 (which was damaged in the recent derailment) - is that set London Midland's equivalent of 91023?

 

[Phil.]

In my view that's rather harsh.

Both were ex-drivers with a good degree of experience, so this is not a case of some newby being on the handle who had no idea about the railway.

A mistake was made, so it's for the industry to implement processes to minimise the chance of that mistake being made again.

Not harsh at all. A person in charge in implementing and maintaining standards should be of a high standard themselves. To miss an emergency speed restriction despite e-mails, late notice cases and trackside signed warnings is basic stuff.

 

[edwin_m]

One thing rather skimmed over was that this accident would not have happened if the driver manager driving hadn't confused "crossing" with "crossover". The report says this term is used ambiguously but the definitions section only gives one definition (the correct one in my view, where two rails cross in a set of points). The railway really needs to tighten up on use of jargon, in this case by someone who is supposed to be passing best practice on to others.

 

[GB]

Regardless of the wording of the emails or whether or not drivers see it in the notices cases etc, there should have been absolutely no ambiguity when it came to the lineside signage and ESR setup.

 

[bramling]

Not harsh at all. A person in charge in implementing and maintaining standards should be of a high standard themselves. To miss an emergency speed restriction despite e-mails, late notice cases and trackside signed warnings is basic stuff.

If I'm interpreting the report correctly, he didn't *miss* it, instead he had wrongly formed the opinion it didn't apply to the move he was carrying out.

Yes with the benefit of hindsight it was a silly mistake, as the notices did refer to the Up Slow including giving a location in miles/chains, but we've all at some point in our lives found ourselves in the situation where we've picked up the wrong end of the stick over something. You're entitled to your opinion, however my own is that I don't think there's enough in the RAIB report to point to the individual being careless or sloppy, which is what you seem to be implying.

 

[lightning76]

As an aside...

The email sent to the driver made reference to points 2332.
Note 4 on page 17 says the points were actually numbered 2322.
Fig 8 on page 19 labels the points as 2232.

Very confusing these 3s and 2s. (BTW I'm not suggesting this matters!)

 

[ctyerkes]

The passenger load of 2000 quoted by the RAIB seems deeply implausible to me. The seating capacity of a 12 car formation of class 350 is only 678. This implies 1322 standing passengers or 110 standees per carriage. This simply isn't credible. Even class 700s cannot be loaded to that level and they would be much better configured for standing space. Dwell times would be lengthened considerably as loading would resemble a 'how many students can fit in a telephone box / mini / whatever' competition!

In normal operation passengers are very reluctant to subject themselves to that level of crowding and it is often difficult for boarders to persuade the passengers already on board to move down to fully occupy the aisles between the seats. Even with a seated and standing total load of say 1200, most passengers would believe the train to be 'very crowded'.

Interesting that the train should contain 350264 (which was damaged in the recent derailment) - is that set London Midland's equivalent of 91023?

Indeed. And the report describes this as 'the average loading for this service as reported by London Midland' (my emphasis).

Sent from my SM-T520 using Tapatalk

 

[edwin_m]

If I'm interpreting the report correctly, he didn't *miss* it, instead he had wrongly formed the opinion it didn't apply to the move he was carrying out.

Yes, because he'd decided it was applicable to the "crossover" (actually just a turnout) to the goods loop. I think it's one of those typical human errors when the first impression sticks despite subsequent evidence that it was wrong.

 

[Trackman]

The RAIB has published its report linked to from:

https://www.gov.uk/raib-reports/overspeed-incident-at-queen-s-park

Summary:

Answered the questions I was going to ask.

Just one, how do they detect over-speeds on an ESR, Is it something TC signalling wise? do they treat it is a SPAD?

 

[PermitToTravel]

One thing rather skimmed over was that this accident would not have happened if the driver manager driving hadn't confused "crossing" with "crossover". The report says this term is used ambiguously but the definitions section only gives one definition (the correct one in my view, where two rails cross in a set of points). The railway really needs to tighten up on use of jargon, in this case by someone who is supposed to be passing best practice on to others.

Is there any benefit in telling the driver that it's a problem with a crossing, rather than with the points or even with the track?

 

[Zoidberg]

Answered the questions I was going to ask.

Just one, how do they detect over-speeds on an ESR, Is it something TC signalling wise? do they treat it is a SPAD?

Just in case your question was posed to me, sorry, I'm not competent to answer, but, hopefully another member will furnish a reply.

 

[Paul180]

Answered the questions I was going to ask.

Just one, how do they detect over-speeds on an ESR, Is it something TC signalling wise? do they treat it is a SPAD?

I think when the train was reported at excessive speed they do a download of the event recorded (black box).

 

[bramling]

Is there any benefit in telling the driver that it's a problem with a crossing, rather than with the points or even with the track?

Personally, I'd prefer to know what the issue is.

But is there a *need*? - probably not. Too much information can lead to someone over-analysing a piece of information, which seems to be what has happened here.

 

[MichaelAMW]

Answered the questions I was going to ask.

Just one, how do they detect over-speeds on an ESR, Is it something TC signalling wise? do they treat it is a SPAD?

The report explains this for this case:

29 In the early hours of 5 January 2016, a Network Rail permanent way team, inspecting the plain line in the Queen’s Park area, noticed a crack in the crossing of 2322B points. This was reported to Network Rail control at 03:10 hrs. The track maintenance staff arranged for a dye penetrant inspection to be carried out and for an emergency speed restriction to be applied in accordance with Network Rail standards. They also appointed a watchman who was required to monitor the crossing’s condition until the fault was repaired.

39 The watchman telephoned the signaller at 08:30 hrs to report that a London Midland train had just passed him at line speed. The watchman asked the signaller to caution (ie instruct drivers to reduce speed) trains on approach to the emergency speed restriction. The signaller confirmed that he would do this.

 

[ComUtoR]

In what sense? :roll:

In the sense that it is a well known issue that Driver Managers have rules fade just like the rest of us and that their competencies are not as micro managed as regular Drivers. It often leads to issues like this as well as the number of times it happens when a Manager steps in to do an employees role on a temp basis to cover something.

This is typically an industry wide problem and as the RAIB rightly states.

The RAIB has also identified three learning points concerning the importance of managers fully preparing before driving trains

Anybody, not just Managers, who doesn't perform a task on a regular basis will be at a higher risk of something going wrong and have a larger degree of knowledge fade.

There have been more than a few cases where a Manager has stepped in to drive a train and it has gone wrong and they have had an incident. So yes, this is very typical.

I could list a number of incidents that have happened on my patch where a Driver Manager was driving / or undertaking an assessment. However; they are not public domain and therefore cannot be proven either way.

 

[LNW-GW Joint]

Wouldn't you expect the protecting signal on the Up Slow to be held at single yellow for such a severe speed restriction?

 

[GB]

Wouldn't you expect the protecting signal on the Up Slow to be held at single yellow for such a severe speed restriction?

No, that is what the lineside warning boards are for.

 

[Elecman]

What action/inaction did the booked driver take before or on arrival at Euston to report the overspeed incident himself ? He must surely have noticed that the train was not doing 5 mph when passing Queens Park, as he will have read the Late Notice case so should,have been aware of the emergency speed restriction before starting the journey given that he was relieved by the DM en route. One wonders what would have happened if NR had not appointed the watchman who appears from the RAIB report to be the only person reporting this very serious incident.

 

[Hadders]

What action/inaction did the booked driver take before or on arrival at Euston to report the overspeed incident himself ? He must surely have noticed that the train was not doing 5 mph when passing Queens Park, as he will have read the Late Notice case so should,have been aware of the emergency speed restriction before starting the journey given that he was relieved by the DM en route. One wonders what would have happened if NR had not appointed the watchman who appears from the RAIB report to be the only person reporting this very serious incident.

At the time the driver didn't believe he had done anything wrong. The report states the driver believed that the speed restriction didn't apply to the line he was on but only for trains entering the loop.

 

[GB]

What action/inaction did the booked driver take before or on arrival at Euston to report the overspeed incident himself ? He must surely have noticed that the train was not doing 5 mph when passing Queens Park, as he will have read the Late Notice case so should,have been aware of the emergency speed restriction before starting the journey given that he was relieved by the DM en route. One wonders what would have happened if NR had not appointed the watchman who appears from the RAIB report to be the only person reporting this very serious incident.

Why should the "rostered" driver have done anything? He was travelling in the passenger compartment and could have been concentrating on other things or taking rest.

The ESR could have also been changed or withdrawn for all he or she knew.

 

[bramling]

What action/inaction did the booked driver take before or on arrival at Euston to report the overspeed incident himself ? He must surely have noticed that the train was not doing 5 mph when passing Queens Park, as he will have read the Late Notice case so should,have been aware of the emergency speed restriction before starting the journey given that he was relieved by the DM en route. One wonders what would have happened if NR had not appointed the watchman who appears from the RAIB report to be the only person reporting this very serious incident.

The rostered driver wouldn't be required nor expected to take any action. He'd been relieved from being in charge of the train, so would have been travelling "pass", in the passenger area. There would be no need for him to be paying any attention to the running of the train.

 

[edwin_m]

The rostered driver wouldn't be required nor expected to take any action. He'd been relieved from being in charge of the train, so would have been travelling "pass", in the passenger area. There would be no need for him to be paying any attention to the running of the train.

If there were 2000 people on the train as alleged, then he was probably wedged up in a corner somewhere with no chance to see where he was.

 

[SouthStand]

No, that is what the lineside warning boards are for.

If you have a signal conveniently located near the ESR then why not use it?

 

[Tetchytyke]

The passenger load of 2000 quoted by the RAIB seems deeply implausible to me. The seating capacity of a 12 car formation of class 350 is only 678.

That train is normally 2x350/2 and 1x350/1 on the back, so the seating capacity would be a bit higher. But yeah, 167 people in each carriage of a 350, including the three first class compartments, really isn't credible. I'd have said a really busy London Midland train at that time would have 1500 people on it, mind.

Quite frightening that London Midland gave the figure, really.

 

[swt_passenger]

That train is normally 2x350/2 and 1x350/1 on the back, so the seating capacity would be a bit higher. But yeah, 167 people in each carriage of a 350, including the three first class compartments, really isn't credible. I'd have said a really busy London Midland train at that time would have 1500 people on it, mind.

Quite frightening that London Midland gave the figure, really.

Other evidence for the figure being plucked out of thin air, is that the spring 2015 top 10 overcrowding statistics only had two 12 car trains in the table, both on SWT Waterloo services, carrying about 1200 passengers each.

A hypothetical LM 12 car train with 2000 on board would have been off the scale...

 

[tsr]

Other evidence for the figure being plucked out of thin air, is that the spring 2015 top 10 overcrowding statistics only had two 12 car trains in the table, both on SWT Waterloo services, carrying about 1200 passengers each.

A hypothetical LM 12 car train with 2000 on board would have been off the scale...

1200 is actually a conservative estimate for how many people a 12 coach train can carry. Suggesting the busiest 12 coach services only carry that many people is, if anything, an underestimate. I'm always puzzled by this when the statistics hit the headlines about the most overcrowded trains.

On a 12 coach train with 3+2 seating in the high peak, a figure of around 1200 per train would suggest all seats taken, around 10 people per vestibule and about 10 more in each coach's aisles.

Given that many trains leave (for example) East Croydon every morning with people not just standing in each other's armpits in the aisles, but also in the corridors adjacent to the intermediate cabs, and crammed into areas such as wheelchair spaces, you're probably looking at a reasonable figure of at least 1300 or so. This story is also repeated on other flows in and out of London, of course, including within my experiences of overcrowding on routes served by LM via stations such as Milton Keynes Ctl and Watford Jn.

2000 is way too high, though.