Stafford SPAD report

[Pumbaa]

This refers, I'm sure, to main line steam operations in more recent years!

Yes. He is still out and about (on the mainline between Whitby and Grosmont and allegedly whenever he feels like it with other operators.

Anyhow, this is my favourite bit:

54 An extract from the driver’s route card is attached at appendix J; this includes
a number of routes for which the driver had signed to indicate his competence on 1 June 2011. The ‘Supervisor Verification’ on the driver’s route card was signed by the BARS group safety director at the time (a consultant working through Amtrain, see paragraphs 17 and 21). Witness evidence indicates that the safety director believed the driver to have gained route knowledge from his experience as a locomotive fireman, and there was no formal assessment of his training needs as a driver. Colas Rail, which has a broadly similar type of freight operation to DCR, has advised the RAIB that its route learning norms would have required in excess of 148 days’ route learning for all the routes signed by the driver on 1 June 2011. The driver’s experience of these routes had been obtained prior to his involvement as a driver in the operation of DCR’s first train in July 2011 (it had previously run a one-off special to retain its safety certificate, see appendix D). The documents that RAIB has seen in support of the driver’s driving experience identify only seven occasions on which he had driven under supervision on the main line (other than on the Esk Valley line, paragraph 49); none of these had been since October 2005.

55 The driver signed his route card to confirm his competence on additional routes on 1 October 2011, including the route from Washwood Heath to Crewe; further routes were added on 4 January 2012. Colas Rail’s route learning norm for the route from Washwood Heath to Crewe requires a driver to experience a total of sixty trips over the route (thirty days); DB Schenker has assessed the equivalent route learning requirement as fifteen days. These norms are based on the operators’ route risk assessments for the route. Witness evidence suggests that the driver may have driven over the route on only six to eight occasions before the incident on 26 April 2012. The RAIB has seen no record of a formal assessment of his competence for the route.

My emphasis.

And don't worry about this ever happening again... The 'independent' investigator brought in by DCR who then advised (allegedly) to sweep it under the carpet is now in their employ and responsible for driver competencies. The driver involved is still issuing invaluable training and consultancy through Amtrain (of which he is a director), who also provide safety consultancy to DCR and check that their procedures meet the rule book. And of course the ORR still haven't decided how to adequately monitor cowboys like these. Happy days!

 

[SansPareil]

There is a high resolution version of the photo used in the RAIB report on flickr.

http://www.flickr.com/photos/428029...rE-d9Tkge-bGgiXg-bsTbsw-bsTafN-bnb879-cnSVzu/

 

[David Barrett]

Reading the parts of the report concerning the Mechanical & Electrical aspects of the incident four words spring to mind,

"Loco. stopped, job cancelled".

That is speaking as a former Locomotive Fitter.

 

[Aldaniti]

Yes. He is still out and about (on the mainline between Whitby and Grosmont and allegedly whenever he feels like it with other operators.

Jesus Christ, after reading the report on what he did, I really hope that's a joke?

 

[Pumbaa]

Nope..

 

[Monty]

Nope..

Unbelievable! Personally I think ORR need to be looking at if there are any laws that were broken that could be used to prosecute both the driver (if he can even be called that) and DCR. :roll:

 

[185]

Reading that report, it's like a Rodney and Del Boy operation. Just failure after failure... I'm all for smaller operators breaking up the monopoly, but when I say 'breaking up'....

I'm just counting the things broken that were not reported to the box.

Speedo.
DSD.
NRN.

and counting....

 

[Crossover]

That is an absolute shambles from start to finish. Reeks of people playing with trains rather than doing things correctly.

As an outsider, looking in (I don't work in the industry), having read the report I would agree you've hit the nail on the head. As another poster said, Del Boy and Rodney operation does also tie in quite nicely!

According to the report, it was only a few hundred metres behind a 350 stopped in the platform at Stafford. That had the potential to have been pretty nasty.

I was thinking similar - especially had the points not been set for platform 6 at the time it SPADded. I don't think the signals are that far off the platform there, either.

 

[fgwrich]

Reading that report, it's like a Rodney and Del Boy operation. Just failure after failure... I'm all for smaller operators breaking up the monopoly, but when I say 'breaking up'....

I'm just counting the things broken that were not reported to the box.

Speedo.
DSD.
NRN.

and counting....

Condition of the loco / brake blocks. God knows how the poor thing faired being driven overspeed and with poor brake blocks.

Appendix H - The condition of the locomotive’s brake blocks
H1 In the immediate aftermath of the incident of the SPAD incident at Stafford on
26 April 2012, arrangements were made for an independent engineer from
URS to examine the brakes on the locomotive. The URS report concluded that
second hand brake blocks had been fitted to the locomotive, with the result that
only 57% of the friction surface was in contact with the wheels (paragraph 66).
The principal evidence cited in support of this hypothesis was that the internal
diameter of the blocks’ friction surfaces appeared to be smaller than the external
diameter of the wheels. Figure H1a shows the gap between the centre of one
of the brake blocks and the wheel tread, which was observed before locomotive
47843 was moved from Stafford. Figure H1b is typical of photographs taken
by RTL at Crewe on 14 May 2012, and shows a brake block after removal from
the locomotive; the centre of the block is ‘blued’ (defined at Appendix B) due to
overheating. This is the part of the block that was not in contact with the wheel in
Figure H1a. The URS hypothesis does not account for the recent bluing, scoring
and burring which is evident in the centre part of the brake block.

H2 Advice given to the RAIB by Interfleet Technology, Railway Brake Services and a
train operator with relevant experience suggests that the condition of the blocks
is probably attributable to a sustained high-speed application of the locomotive’s
brakes; this is consistent with the opinion of the locomotive’s owners, RTL. A
possible mechanism for the damage to the inside face (the friction surface)
of the brake block is that, during such a brake application, the friction surface
experiences an extreme temperature, whereas the mounting point on the outside
of the block acts as a heat sink. The temperature gradient through the brake
block causes the inside face to expand more than the outside, and therefore
tends to flatten its curved shape; on cooling, the block contracts again. The
energy needed to stop a vehicle from 103 mph (166 km/h) is 189% of that needed
to stop it from 75 mph (121 km/h); this energy must be dissipated by the brakes.
The light wear at the ends of the block is likely to have been caused by the
subsequent use of the locomotive’s brakes when it was moved from Stafford to
Crewe after the incident.

I'd say this report gets more shocking the further you read into it. How DCR are allowed to run when things like this goes on behind the scenes amazes me. What i'd also put up for question are DCRs Route Learning policies. Colas, despite being of a similar small company put a heck of a lot of work into their drivers - as the report shows in various parts, So how DCR got away with so few days again is questionable. And then there's the drivers NVQ...

 

[David Barrett]

............
Inomplete Examinations
Siezed Slack Adjuster
Second Hand Brake Blocks, a practice which for good reason was, and still is as far as I'm aware, forbidden.

Given this inattention to fundementals it's a good job that we are no longer operating Class 9 Unfitted Freights.

 

[Murph]

Second Hand Brake Blocks, a practice which for good reason was, and still is as far as I'm aware, forbidden.

While the overall situation is pretty much a dreadful catalogue of failures and negligence, the way I read the report is that it's not a certainty that they were second-hand blocks. The alternative explanation of the blocks expanding under sustained high speed braking does seem to be quite credible. Also, it seemed to be saying that the actual brake performance was well within expected and accepted limits (possibly even "good", but I'm not qualified to say that).

As far as I can see, the brakes were only really an issue in as much as being attempted to be used as a frankly pathetic attempt to deflect blame away from the way the loco was being operated.

68 The RAIB has concluded that the braking performance of the locomotive was
broadly as effective as that of the class 47 locomotive tested by British Rail in
1983, and that it would have complied with the relevant standard (curve A1 in
GM/RT2042). It was therefore not causal to signal SD4-81 being passed at
danger on 26 April 2012. The condition of the brake blocks is discussed at
appendix H.

 

[David Barrett]

While the overall situation is pretty much a dreadful catalogue of failures and negligence, the way I read the report is that it's not a certainty that they were second-hand blocks. The alternative explanation of the blocks expanding under sustained high speed braking does seem to be quite credible. Also, it seemed to be saying that the actual brake performance was well within expected and accepted limits (possibly even "good", but I'm not qualified to say that).

As far as I can see, the brakes were only really an issue in as much as being attempted to be used as a frankly pathetic attempt to deflect blame away from the way the loco was being operated.

During the years that I had been involved in Locomotive Maintenance I had never come across the stark difference between Wheel Diameter and Block Face Diameter as shown here from braking alone. Whilst it is credible that there will be different rates of expansion in different areas of the block I find it hard to accept that the sort of distortion mentioned here would manifest itself in anything much other than the disintegration of the block. I'm firmly in the second hand camp on this one.

Whether the braking efficiency was a contributory factor in this case is not my concern, the fact that a Locomotive was allowed to enter traffic with these, and other, defects leads me to beleive that there are multi-disciplinary and compliance issues within D.C.R.

As I said in an earlier post the words which come to mind on this one are "Loco. Stopped job cancelled". Had a more appropriate course of action of action been taken by the "Shed Staff" then there could have been no attempts at all to muddy the waters in the wake of the incident.

 

[TDK]

How did that Driver even get a job with DCR ?

Look at reality Bev - he is one of those enthusiasts so will do anything to get his fix
--- old post above --- --- new post below ---

Unbelievable! Personally I think ORR need to be looking at if there are any laws that were broken that could be used to prosecute both the driver (if he can even be called that) and DCR. :roll:

The worrying thing is how many more are there out there? At a guess I would say quite a few.

 

[Geargrinder]

So is the report the end of the matter? It seems to me that some of what's gone on in this incident goes beyond a spad report and is criminal. Do btp get involved?

 

[tbtc]

I think that this thread should be linked to every time we see a post along the lines of "all drivers do is push a button"...

 

[Pumbaa]

So is the report the end of the matter? It seems to me that some of what's gone on in this incident goes beyond a spad report and is criminal. Do btp get involved?

No. Nothing to do with them. The ORR could push for a prosecution, but they won't as it's their fault for not having adequate regulatory framework in place from the off. The RAIB makes that clear in the recommendations.

The best we can wait for is the electronic database of driver identity and qualifications in (2018?).

 

[D1009]

I doubt that it will be the end of the matter, the more established freight operators, and even other newcomers like Colas have been involved in giving evidence, and they are DCR's competitors.

 

[Eccles]

ASLEF have got hold of it:
http://www.aslef.org.uk/information/139068/stafford_red_light/

17 Sep 2013

Mick Whelan, incensed by the ‘institutional negligence’ of Devon & Cornwall Railways, has demanded a public inquiry into all the circumstances of a red signal passed at danger at Stafford.

A damning report by the Rail Accident Investigation Branch of the Department for Transport, just published, reveals that on 26 April 2012 a Class 47 diesel-electric locomotive, owned by Riviera Trains, and operated by Devon & Cornwall Railways, part of the British American Rail Services group, was ‘travelling at excessive speed’, according to accident investigators, when it ran a red signal at Stafford. The report concludes: ‘The driver was probably aware that he had been exceeding the maximum permitted speed but did not make a full brake application.’


‘We are calling for a proper public inquiry into all the circumstances,’ said Mick, speaking after publication of the rail accident report. ‘And we will be writing to demand answers from all the stakeholders involved.


‘I am absolutely appalled at the institutional negligence of Devon & Cornwall Railways. Their attitude to what happened is completely at odds with what happens when one of our members is involved in a SPAD (signal passed at danger).’


The driver was a senior manager of Amtrain, a company which provides part-time consultancy to the British American Rail Services group, and working on a controversial zero hours contract with Devon & Cornwall Railways.


On the Bushbury to Stafford line he accelerated continuously to 100mph, made a ‘partial brake application’ and passed a double yellow (preliminary caution) signal, passed another single yellow (caution) signal at 70mph and then ran a red (danger) signal.


The driver subsequently claimed the speedometer was stuck, but failed at the time to report a defective speedometer as required by the rule book.


Devon & Cornwall Railways tried to hush up the incident, claiming it was ‘low risk’.


But the RAIB’s damning rail accident report says the locomotive ‘was travelling at excessive speed’; the driver ‘did not make a full brake application as soon as he saw the double yellow signal’; ‘the driver may have deliberately exceeded the speed permitted for light locomotives’; ‘had limited experience of high speed operation’ and ‘insufficient route knowledge’; and that ‘the locomotive had not been maintained in accordance with vehicle maintenance instructions’. The RAIB condemns the ‘non-compliance’ of Devon & Cornwall Railways with its own safety management system and the ‘underlying deficiency’ in its safety culture.

A public enquiry might help bring the database forward a bit?

 

[bramling]

No. Nothing to do with them. The ORR could push for a prosecution, but they won't as it's their fault for not having adequate regulatory framework in place from the off. The RAIB makes that clear in the recommendations.

The best we can wait for is the electronic database of driver identity and qualifications in (2018?).

It would look ridiculous, given ORR's willingness to prosecute for other incidents, if no prosecution occurred for this incident -- especially as ORR were flagged up by the RAIB as having been a contributory factor in the incident.

One can understand one or two failings flagging up in any investigation, however this whole incident is a disgrace from start to finish. The driver was clearly not competent to be driving. The loco was clearly not in a fit state to run as shown by the multiple defects which appeared within minutes of the start of the journey. Multiple failures to follow the Rule Book (was this lack of knowledge or deliberate violation?). Excess speed for a light loco movement. Poor judgements by the driver regarding the speed the loco was driven at. And finally the poor driving technique and route knowledge leading to the SPAD.

If any incident merits a prosecution it is this one, but could open up a massive can of worms given ORR's involvement and also that by all accounts Network Rail's house isn't totally in order since the signal's sighting was not as good as it could have been, as well as it being a multi-SPAD signal.

 

[talltim]

If only the driver had had an invalid ticket, then he could be prosecuted!

 

[Lockwood]

The awkward part here is whether ORR can prosecute ORR for their part in this.

If they don't, then ORR are "letting themselves off the hook whilst prosecuting other parties"
If they do they are "pushing the taxpayers' money around in a big circle in a red tape exercise"

 

[Murph]

The awkward part here is whether ORR can prosecute ORR for their part in this.

If they don't, then ORR are "letting themselves off the hook whilst prosecuting other parties"
If they do they are "pushing the taxpayers' money around in a big circle in a red tape exercise"

They seem to do ok with that when it comes to Network Rail. ORR impose a penalty for something, returning some of NR's money back to the treasury. NR don't have enough money, so the treasury gives them some more. The civil service rejoices at several jobs well done (in triplicate, supervised by Sir Humphrey)!

 

[W230]

Surely the HSE would prosecute in these sort of situations? They've just prosecuted FCC for their failings with the incident at Kentish Town?

I especially like the bit in the report too:

The driver and technician state that DCR management initially instructed them to continue their journey to Crewe.

"What you've had a SPAD? Loco's got no radio, speedo, DSD and crap brakes? Yeah carry on. We'll have a chat 30 miles down the line..."

 

[Lockwood]

I think that this thread should be linked to every time we see a post along the lines of "all drivers do is push a button"...

"All drivers do is push a button, and know when to stop pushing it."

That better? :P

 

[Cherry_Picker]

That's not fair. Sometimes we pull a lever too.

 

[D1009]

ASLEF have got hold of it:
http://www.aslef.org.uk/information/139068/stafford_red_light/



A public enquiry might help bring the database forward a bit?

I thought ASLEF might get involved in this, though I find it difficult to understand what a (very expensive) public inquiry might establish beyond what is painfully obvious from the RAIB report. I'm surprised ASLEF haven't called for DCR's operating licence to be revoked on the evidence in the report.

 

[34D]

Okay.... am I the only one reading this wondering just what the minimum standard is to drive under these conditions?

I've driven locos on preserved railways, and would love to have a go on the main line too. I have no wish to become a 'career' driver with a TOC.

So how do I do it? What is the minimum requirement?

 

[pjnathanail]

Okay.... am I the only one reading this wondering just what the minimum standard is to drive under these conditions?

I've driven locos on preserved railways, and would love to have a go on the main line too. I have no wish to become a 'career' driver with a TOC.

So how do I do it? What is the minimum requirement?

Send a CV to DCR by the look of things.
Driven something vaguely trainlike before? Can you start tomorrow.

 

[talltim]

Set up a consultancy company, advising on safety requirements, pass yourself to drive and find a sucker TOC/FOC

 

[Whistler40145]

I don't work on the Railway network, but even I would have had the intelligence that neither the locomotive or driver were fit for the job.

This company sounds like the "Ryanair" of the railway industry, operating on the cheap & cutting corners!

How the heck did the locomotive manage to venture onto the Network Rail system?

Is there a railway equivalent of a Factory Inspector?

If yes, said person should visit outfits e.g. DCR & ground their mainline fleet until necessary repairs & exams take place to bring locomotives up to a higher standard of maintenance & if they don't, their mainline operating license should be revoked.