Redcar Level Crossing Accident (01/05/2024)

[Clarence Yard]

It isn’t a public vs private thing. In BR days, removing someone from the signalling grade on competence grounds was undertaken on quite a regular basis.

Frankly, the signaller here was very poorly managed. Too much leeway when the individual was clearly a liability and prone to making serious errors.

 

[MadMac]

It isn’t a public vs private thing. In BR days, removing someone from the signalling grade on competence grounds was undertaken on quite a regular basis.

Frankly, the signaller here was very poorly managed. Too much leeway when the individual was clearly a liability and prone to making serious errors.

Which is what led me to wonder if they ended up in Redcar as it was a “difficult to fill” vacancy. Their former area gets rid of an ongoing problem while their new area fills a position. It went on in BR days, let me assure you…..

 

[Sheridan]

Which is what let me to wonder if they ended up in Redcar as it was a “difficult to fill” vacancy. Their former area gets rid of an ongoing problem while their new area fills a position. It went on in BR days, let me assure you…..

Where did the signaller in question transfer from?

 

[Purple Train]

Where did the signaller in question transfer from?

Stonea, Cambridgeshire (paragraph 112 of the report):

The signaller at Redcar had moved to that post in February 2023 after moving from a similar post at Stonea in Cambridgeshire. While at Stonea, the signaller had been under a support plan (see paragraph 114) as a result of not passing routine knowledge reassessments. This plan ended in April 2022. In September 2022, the signaller was placed on another support plan after an incident in which they authorised a train to pass a signal at danger without having confirmed that the line was clear. Because the signaller did not demonstrate the required standard during further rules knowledge tests, this plan continued until just before they left Stonea in January 2023.

 

[JordR]

That is an odd move half way across the country. It's obviously difficult to say with certainty, but seems worrying that so many incidents can occur in a short period of time and he was still being left alone in a signal box.

 

[Dai Corner]

The signaller has been convicted and fined

Signaller fined after forgetting to lower barrier before train smash

Lennon Tambula appeared at Teesside Magistrates' Court charged in connection with the crash between a passenger train and a car in Redcar

www.gazettelive.co.uk

The signaller who forgot to activate a level crossing barrier in Redcar enabling a car to drive onto the tracks into the path of an oncoming train has been fined.

Lennon Tambula was ordered to pay a total of £317 after he admitted, by a wilful omission or neglect, endangering the safety of a person conveyed or being in or upon the railway. This follows an incident which saw a passenger train, which was travelling between Saltburn and Nunthorpe, smash into a car on the Redcar level crossing on May 1, last year.

 

[Camberman]

It is not hard to imagine the public uproar there would be if fatalities occurred, the principal cause of which was down to a signaller who already had numerous safety issues regarding their work. In such circumstances would those responsible for the management of said person face corporate manslaughter charges?

 

[Dave W]

It is not hard to imagine the public uproar there would be if fatalities occurred, the principal cause of which was down to a signaller who already had numerous safety issues regarding their work. In such circumstances would those responsible for the management of said person face corporate manslaughter charges?

It seems as if disciplinary processes were being followed by his management, probably too strictly in truth. If someone is cocking up like that on the regular you'd want a manager to feel empowered to stop them working (I note from the report the individual was actually removed from duties for a while) - if the disciplinary and performance management processes didn't offer the avenue of getting the guy out of the system that's a systematic flaw rather than an individual management one.

I was of the view - perhaps others will put me right - that the threshold for a successful criminal conviction following any railway incident is quite high, so it must have been a pretty clear case against him.

 

[fabs]

It seems as if disciplinary processes were being followed by his management, probably too strictly in truth. If someone is cocking up like that on the regular you'd want a manager to feel empowered to stop them working (I note from the report the individual was actually removed from duties for a while) - if the disciplinary and performance management processes didn't offer the avenue of getting the guy out of the system that's a systematic flaw rather than an individual management one.

I was of the view - perhaps others will put me right - that the threshold for a successful criminal conviction following any railway incident is quite high, so it must have been a pretty clear case against him.

You really don’t want to see some traincrew SOL records then.

IR issues are preventing some eye watering issues from being dealt with properly.

 

[greatkingrat]

The signaller has been convicted and fined

Signaller fined after forgetting to lower barrier before train smash

Lennon Tambula appeared at Teesside Magistrates' Court charged in connection with the crash between a passenger train and a car in Redcar

www.gazettelive.co.uk

Hardly seems worth the bother. We've seen bigger fines for people whose Railcard is a few days out of date.

 

[Dai Corner]

You really don’t want to see some traincrew SOL records then.

IR issues are preventing some eye watering issues from being dealt with properly.

Are you saying the Unions are content to allow their members and the public to be put in danger when they know of other members' incompetence/carelessness/recklessness/

 

[fabs]

Are you saying the Unions are content to allow their members and the public to be put in danger when they know of other members' incompetence/carelessness/recklessness/

Read into it any way you want.
But there are people out there who you wouldn’t want working a train with your family on it.

 

[endecotp]

It pains me to see quite how easily the correctly-functioning interlocking could be overridden by the humans.

How often would a signaller typically give instructions to a driver to pass a red signal like this? I.e. is it a daily, weekly, yearly, once-per-career event?

I am reminded of the German single-line head-on crash a couple of years ago where the signaller was unable to signal the second train onto the section because the interlocking was functioning correctly, but was able to override it with essentially “one click” that lit a secondary signal lamp that told the driver “ignore the red signal”. Didn’t we say “couldn’t happen here” to that?

One thing that would make the system more “idiot-proof” would be if the signaller got more feedback about why he could not do what he wanted. I.e. in this case, if a lamp lit up saying “cannot set signal to green because level crossing is open”. Do modern panels do anything like that?

 

[Towers]

It pains me to see quite how easily the correctly-functioning interlocking could be overridden by the humans.

How often would a signaller typically give instructions to a driver to pass a red signal like this? I.e. is it a daily, weekly, yearly, once-per-career event?

I am reminded of the German single-line head-on crash a couple of years ago where the signaller was unable to signal the second train onto the section because the interlocking was functioning correctly, but was able to override it with essentially “one click” that lit a secondary signal lamp that told the driver “ignore the red signal”. Didn’t we say “couldn’t happen here” to that?

One thing that would make the system more “idiot-proof” would be if the signaller got more feedback about why he could not do what he wanted. I.e. in this case, if a lamp lit up saying “cannot set signal to green because level crossing is open”. Do modern panels do anything like that?

All signalling systems and their associated interlocking devices will have some means of being ultimately overridden, if they didn’t we’d suffer disruption on a potentially enormous scale. There is only so much that automation can prevent, at the end of the day it’s down to the trained humans to make the final decision, and to follow appropriate protocols when doing so. It’s no different if a driver overrides TPWS and then comes to grief, perhaps due to a misunderstanding or failure of correct communication procedures. The means to defeat the safety net has to exist, but we expect those in charge of doing so to be suitably competent.

 

[Meerkat]

Has the signaller actually been sacked?

 

[AlterEgo]

Has the signaller actually been sacked?

One assumes so as the level of fine levied by the court would be reflective of a very low income.

 

[duffield]

Hardly seems worth the bother. We've seen bigger fines for people whose Railcard is a few days out of date.

It does appear lenient, but the conviction at least serves the purpose of making their dismissal legally watertight and not something their union would take up (in case there was any doubt); the loss of a well paid and secure career is the real punishment though.

 

[Elecman]

As often said to me by a very senior and well respected senior operations manager. The most dangerous words on the railway .. pass it at danger !! You have then p****d every system protection out of the window

 

[PyrahnaRanger]

It pains me to see quite how easily the correctly-functioning interlocking could be overridden by the humans.

As Douglas Adams wrote:

A common mistake that people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools.

One of the things I've learned over the years is that people have their own mental pathways that they follow through life, and the way they approach any given problem is probably going to differ from what you've seen before - what seems perfectly sensible and logical to me may not to you, and vice versa. This makes designing Human/Machine interfaces quite complicated. Here's one example: the person who designed both of my cars thought it was sensible for the gearstick to go forwards to make the car go backwards, and backwards to make it go forward. To me, that's counter-intuitive and poor design, but BMW and Audi no doubt spent a lot of money deciding that's better for some reason!

Anyways, as a result, most "failures" come from unexpected combinations of circumstances. For a great view of how this can play out, I'd suggest watching MentourPilot on YouTube - he does some great videos on how unforseen conditions can come together to have severe consequences.

One thing that would make the system more “idiot-proof” would be if the signaller got more feedback about why he could not do what he wanted. I.e. in this case, if a lamp lit up saying “cannot set signal to green because level crossing is open”. Do modern panels do anything like that?

Again, this shows how people differ - I'd have had a lamp that was lit when you could set it. In your scenario, what happens if the lamp fails? The signaller thinks all the conditions are met because the lamp isn't lit, and might override the system because of that belief...

Sellafield, where there are serious consequences to missed alarms, do positive indication by sound - you get a ticket/tock sound in some buildings - and if it stops, run!

 

[Crossover]

All signalling systems and their associated interlocking devices will have some means of being ultimately overridden, if they didn’t we’d suffer disruption on a potentially enormous scale. There is only so much that automation can prevent, at the end of the day it’s down to the trained humans to make the final decision, and to follow appropriate protocols when doing so. It’s no different if a driver overrides TPWS and then comes to grief, perhaps due to a misunderstanding or failure of correct communication procedures. The means to defeat the safety net has to exist, but we expect those in charge of doing so to be suitably competent.

Not directly railway related, but I am somewhat reminded of The Smiler accident a few years ago at Alton Towers - in that case, the computers had done the right thing, stopping a train entering an occupied section, but had been overridden by engineers who thought the system had gone wrong. I have heard a couple of things that were taken to address the issue (unverified by myself, I would add), one of which was that I believe now, to override the safety system and authorise a movement, it involves an operator/engineer walking to the section concerned (in this case, I think it was the second lift hill) and pressing an override there, not in the control cabin, so extra checks and balances were done to avoid a repeat of that fateful day.

In the case of Redcar, "simply" looking out of the window, a mark 1 eyeball would have given a very big clue as to why the route wouldn't set/clear, but it seems it wasn't taken for reasons better known to the signaller concerned.

 

[ainsworth74]

In the case of Redcar, "simply" looking out of the window, a mark 1 eyeball would have given a very big clue as to why the route wouldn't set/clear, but it seems it wasn't taken for reasons better known to the signaller concerned.

The vibe I got from the report was that this was in part down to the ergonomics issue within the layout of the box. You cannot actually see the crossing when you're sat at the desk so have to stand up walk across to the window to observe the level crossing. Meanwhile you do have a clear view of the other crossing with the CCTV monitor right in front of you which is showing that crossing as being closed and clear. Easy to get into the mindset that both crossings are closed and clear and it must be a fault with the signalling system that's causing the problem...

 

[Crossover]

The vibe I got from the report was that this was in part down to the ergonomics issue within the layout of the box. You cannot actually see the crossing when you're sat at the desk so have to stand up walk across to the window to observe the level crossing. Meanwhile you do have a clear view of the other crossing with the CCTV monitor right in front of you which is showing that crossing as being closed and clear. Easy to get into the mindset that both crossings are closed and clear and it must be a fault with the signalling system that's causing the problem...

And rightly, that has been advised to be looked at. But equally, there is also a point where too many lights and indications may become information overload, so where does it end.

I did also think there maybe there were delay attribution issues (pressure to not unecessarily delay services) - I can't remember off hand whether the report mentioned it and I cn't easily check at the moment.

Ultimately, it does seem this individual was completely unsuited to the work they were doing (as much as it pains me to say it on here) - CYA (Cover Your A**) springs to mind - had things been followed (Route Cards etc) and it had still gone wrong, there maybe isn't so much to do about it, but the person concerned had so many "interventions" in what was a pretty short career, it is maybe little wonder why they didn't just throw caution to the wind and just talk everything passed a signal at red and bu**er the whole system designed to keep things safe

 

[ainsworth74]

And rightly, that has been advised to be looked at. But equally, there is also a point where too many lights and indications may become information overload, so where does it end.

Oh yeah for sure, though this one feels like an eminently fixable problem! Even if it was just a CCTV monitor next to the existing one but showing the second level crossing!

I did also think there maybe there were delay attribution issues (pressure to not unecessarily delay services) - I can't remember off hand whether the report mentioned it and I cn't easily check at the moment.

Paragraph 22:

On 8 April 2024, just over 3 weeks before the accident, the signaller received an email from one of the signaller managers asking for an explanation for a 2-minute delay that a train had experienced at Redcar station. This was part of the delay attribution process that allocates the costs of delays between the train operators and Network Rail. The signaller replied, saying that the delay was related to passengers boarding and not due to signalling. This was the first and only time that the signaller had received such an email, and they stated that it drew their attention to the requirement not to unduly delay trains while undertaking signalling duties.

Though perhaps I'm just being uncharitable but that felt like trying to find a post incident explanation for part of their behaviour to me...

Ultimately, it does seem this individual was completely unsuited to the work they were doing (as much as it pains me to say it on here) - CYA (Cover Your A**) springs to mind - had things been followed (Route Cards etc) and it had still gone wrong, there maybe isn't so much to do about it, but the person concerned had so many "interventions" in what was a pretty short career, it is maybe little wonder why they didn't just throw caution to the wind and just talk everything passed a signal at red and bu**er the whole system designed to keep things safe

Agreed.

 

[Crossover]

Though perhaps I'm just being uncharitable but that felt like trying to find a post incident explanation for part of their behaviour to me...

I do remember that comment, but couldn't quite remember if it was a learning point. The fact it only happened once, suggests it was probably not a significant stressor for the individual (though on a wider scale, could be, and could lead to hasty decisions being made for the wrong reason)

 

[MadMac]

I took a look at Stonea box online. It’s a Portacabin dating from the 1980s which replaced an older box before it collapsed. It has a similar panel to Redcar: it also has a set of manual gates (had to leave the box to swing them) with their “keys” incorporated into the panel.

I also Googled the signaller: assuming it’s the same fellow, he was a director of a company (with other family members) in Peterborough which listed its businesses as construction and used vehicle sales. He also appears to have been trying to carve out a career as an actor/model.

 

[Meerkat]

I do remember that comment, but couldn't quite remember if it was a learning point. The fact it only happened once, suggests it was probably not a significant stressor for the individual (though on a wider scale, could be, and could lead to hasty decisions being made for the wrong reason)

Seems a push to me as he had a fault to blame for any delay.

 

[66701GBRF]

interesting that no one here has mentioned the train drivers action.

 

[Lockwood]

They didn't do what they were told to do properly.
But they shouldn't have been told to do it in the first place.

I guess that they had the complacency of the first crossing being down, and the signaller not mentioning a problem with the one right next to the box. Therefore, if one is working and nobody mentioned the other, then the other is working. It is a false statement, but there is logic behind it.

The driver would not reasonably expect the signalling to be in the state it was in.


It's telling that the report mentions consequences for the signaller, but not the driver. While it does not and cannot apportion blame, that does seem to imply the fault lies more on the side of the signaller.

 

[edwin_m]

I guess that they had the complacency of the first crossing being down, and the signaller not mentioning a problem with the one right next to the box. Therefore, if one is working and nobody mentioned the other, then the other is working. It is a false statement, but there is logic behind it.

The driver would not reasonably expect the signalling to be in the state it was in.

Also, with the box blocking the sightline between the train and a road vehicle, it would have to have been almost literally inching forward to be able to stop in time to avoid a collision.

 

[66701GBRF]

Also, with the box blocking the sightline between the train and a road vehicle, it would have to have been almost literally inching forward to be able to stop in time to avoid a collision.

This was mentioned in the report. It acknowledges the train would have had to travel unreasonably slow to completely avoid a collision but recognises that a more suitable speed would have lessened the impact.