Stafford SPAD report

[Pumbaa]

Yes, THAT one. Report finally out in full. Fill ya boots.

http://www.raib.gov.uk/publications/investigation_reports/reports_2013/report162013.cfm

Summary:
The Rail Accident Investigation Branch (RAIB) has released its report into a signal passed at danger at Stafford, 26 April 2012. The RAIB has made five recommendations.

 

[GB]

A failure from top to bottom. I wonder if any of the people concerend are still employed at DCR.

 

[The Planner]

By the sounds of the state of the 47 in question, I am surprised it didn't shake itself to bits at 103mph!

 

[Zoidberg]

Yes, THAT one. Report finally out in full. Fill ya boots.

http://www.raib.gov.uk/publications/investigation_reports/reports_2013/report162013.cfm

An extract from the Summary for link challenged members:

At about 13:35 hrs on 26 April 2012, a locomotive operated by Devon & Cornwall Railways passed signal SD4-81 at Stafford, which was displaying a red aspect, by about 94 metres.

The investigation found that the locomotive had been travelling at excessive speed as it approached the Stafford area. The driver was probably aware that he had been exceeding the maximum permitted speed for a locomotive running on its own, but he did not make a full brake application as soon as he saw the signal displaying a double yellow aspect, which was his preliminary warning of the red signal ahead. The driver probably did not have sufficient experience or competence for the task he was performing and Devon & Cornwall Railways had not followed its own process for managing the competence of drivers. The company also had insufficient management
controls to ensure compliance with its safety management system.

The Office of Rail Regulation had not examined the implementation of Devon & Cornwall Railways’ safety management system following the issue of the company’s safety certificate nearly two years before this incident.

 

[ainsworth74]

By the sounds of the state of the 47 in question, I am surprised it didn't shake itself to bits at 103mph!

I was thinking that. They cancelled the exam it was undergoing because it was in such a state the costs of rectifying it would have been significant. Then they allowed it to travel under it's own power to Crewe...

And then the driver drove it at 103mph (or probably what he thought was 90mph due to the under-read of the speedo)...

What on earth was going through peoples heads!?

 

[Eng274]

If it wasn't deemed 'broken' before, then it certainly would be after the run to Crewe! By the sounds of it there are non-mainline certified diesel locos in better nick at heritage railways.

I'm very surprised that the vehicle maintenance instruction did not have an annual speedometer check, especially if the loco potentially hasn't turned a wheel for months and months.

Personally I'd implement a days/miles maintenance regime, where if a vehicle is sat idle for months it needs to have a basic return to service or A exam after a certain number of calendar days or x thousand miles, whichever came first. Pretty standard to most TOCs AFAIK!

 

[455driver]

If it wasn't deemed 'broken' before, then it certainly would be after the run to Crewe! By the sounds of it there are non-mainline certified diesel locos in better nick at heritage railways.

I'm very surprised that the vehicle maintenance instruction did not have an annual speedometer check, especially if the loco potentially hasn't turned a wheel for months and months.

Personally I'd implement a days/miles maintenance regime, where if a vehicle is sat idle for months it needs to have a basic return to service or A exam after a certain number of calendar days or x thousand miles, whichever came first. Pretty standard to most TOCs AFAIK!

yeah sounds good, who pays?

 

[Eng274]

yeah sounds good, who pays?

The owner/lessee the exact number of days/miles could be based on an RCM (Reliability Centred Maintenance) study based on the vehicle records for component renewal and deterioration rates, along with risk assessments to determine the likelihood and impact of component failure with extended mileage/days between exams.

If a person/organisation wants to have a mainline-worthy loco, then there are minimum maintenance standards expected of them, coupled with (no pun intended) robust operational standards so that locos don't enter traffic from a maintenance location with safety systems isolated, as happened in this case.

 

[Cherry_Picker]

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

 

[KA4C]

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

Nail right on head

 

[swt_passenger]

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

Just look at all the posts in these forums suggesting that all it really needs for their favourite local branch to be reopened is a startup OA operator, using some old loco and stock or other saved from the scrap line. As the report shows you need a certain critical mass to run trains on the network properly.

Personally I'd rather wait until one of the usual TOCs was given the job by DfT...

 

[daikilo]

Just look at all the posts in these forums suggesting that all it really needs for their favourite local branch to be reopened is a startup OA operator, using some old loco and stock or other saved from the scrap line. As the report shows you need a certain critical mass to run trains on the network properly.

Personally I'd rather wait until one of the usual TOCs was given the job by DfT...

The question I would like to see answered, and I can't find it in the report, is how was this private owner cl47 and zero-time driver ever authorised to make the planned move? And if they weren't, how did they get onto mainline track?

 

[Eng274]

Just surmising here, but it was probably a planned move with NR requested for a path well in advance etc. what NR shouldn't need to ask is proof that the loco is fit for traffic and the driver is fully competent. That's what the operator's safety management system, staff competence management system and the duty holder are for - its entirely the operator/owner's responsibility.

In this case the ORR's licence scrutinisers were noted to be passing the company inspection buck between the FOC and heritage people due to the unusual nature of the organisation, which would have picked up on the poor route knowledge and experience of the driver(s).

 

[LWB]

......... which would have picked up on the poor route knowledge and experience of the driver(s).

hock:



'Poor' just doesn't begin to describe it!! A previous poster described it as "playing at trains" and that does just about begin to touch on it.

 

[anthony263]

Certainly this inccident could have led to something a lot more serious (Imagine this on the front pages of national newspapers, certainly wouldnt be good for the railfreight industry)

BARS/DCR acted like a buch of cowboys at the time this inccident happened and although DCR have said this kind of inccident will not happen again, It should have never happened in the 1st place.

If I was the owner of that 47 and the insurers etc I wouldnt be pleased with DCR etc after reading this report.

Good on those who alerted the RAIB although from reading what has been posted on other forums such as Wnxx the ORR havent come off to well in this either.

 

[Eagle]

Certainly this inccident could have led to something a lot more serious (Imagine this on the front pages of national newspapers, certainly wouldnt be good for the railfreight industry)

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.

 

[Flying Snail]

Just look at all the posts in these forums suggesting that all it really needs for their favourite local branch to be reopened is a startup OA operator, using some old loco and stock or other saved from the scrap line. As the report shows you need a certain critical mass to run trains on the network properly.

Personally I'd rather wait until one of the usual TOCs was given the job by DfT...

It is hardly fair to tarnish all small/startup/non multinational transport group just because this lot acted recklessly.

As previously said most heritage railways would not consider running their volunteer railways in this manner never mind other small mainline operators.

It is worth pointing out that some of the usual TOCs (current and past) copybooks are not pristine either, just because an organisation is big and wealthy and in receipt of large sackfulls of public money does not ensure they will do everything properly either.

Is SWT unsafe because Souter started out as a lowly bus driver ferrying passengers up and down the M6 while his sister made the tea? Everyone has to start somewhere and what is needed is strong oversight to make sure the cowboys stay in the fields and only the competent organisations, big and small get to play trains.

 

[swt_passenger]

Is SWT unsafe because Souter started out as a lowly bus driver ferrying passengers up and down the M6 while his sister made the tea? Everyone has to start somewhere and what is needed is strong oversight to make sure the cowboys stay in the fields and only the competent organisations, big and small get to play trains.

Stagecoach is a completely irrelevant comparison as far as I can see. They didn't commence railway operations like BARS/DCR, with a few dubiously qualified drivers and a few hired in locos - they took over the complete Southwestern division of the former Southern Region of BR, lock stock and barrel...

 

[edwin_m]

As previously said most heritage railways would not consider running their volunteer railways in this manner never mind other small mainline operators.

The driver in question was accustomed to driving heritage trains at low speeds but the report comments that this isn't good enough experience to handle a loco on the main line at 75mph (officially - actually 100mph plus - which says something about the standard of driving involved here). And several heritage railways have come in for stick from RAIB on the adequacy of their safety management systems, which is essentially the same issue as with DCR. So I don't think we can assume that all heritage railways would do any better, especially if they were tasked with running an operation of this sort.

 

[CyrusWuff]

Hrm...Clicking through to the report page is giving me a "Page not found." message, but this appears to be being generated by their Content Management System rather than by the server itself.

 

[IanXC]

Just look at all the posts in these forums suggesting that all it really needs for their favourite local branch to be reopened is a startup OA operator, using some old loco and stock or other saved from the scrap line. As the report shows you need a certain critical mass to run trains on the network properly.

Personally I'd rather wait until one of the usual TOCs was given the job by DfT...

Or contract an established TOC a la Devon County Council, FGW and Okehampton.

 

[TDK]

Although the depot manager had repaired the DSD, it failed again and was
isolated by the technician on board the locomotive, in the vicinity of the gates
just before the locomotive crossed the boundary between Washwood Heath
depot and Network Rail’s main line infrastructure

Rule breaking

The locomotive’s national radio network (NRN) radio also failed at Duddeston
Junction, after the driver and technician changed ends to reverse the locomotive
immediately following departure from the depot. The driver did not stop and
report the failure of either of these safety systems to the signaller as required by
Module TW5 of the Rule Book.

Rule breaking

He and the
technician subsequently both stated that the speedometer had been stuck, and
that it had indicated a maximum speed of 55 mph (89 km/h).

Anyone knows the difference between 55mph and 100mph especially a qualified train driver

The permissible speed on the Down Main line is 90 mph (145 km/h)10, and the
light locomotive should have been driven at no more than 75 mph (121 km/h), as
required by Module TW3 of the Rule Book.

Rule breaking

A driver with sufficient route knowledge would anticipate
the possible need to brake at certain locations before a signal came into view.

This a qualified driver with route knowledge does every day but in this admittance by NR I feel that if the braking distance is not sufficient and they expect a driver to anticipate a signal the infrastructure is at fault, at the minimum a "green banner" should be installed at the said location.

In my opinion I feel the same as other people in that this whole incident is a total breach of rules and regulations across the board. How was this allowed to happen? It is playing trains and I can associate this in the same context as if someone has bough a new car and taken it out on the motorway and then been caught speeding at 100mph? The drivers route knowledge must come into questions as I signed that route and the signal that would have been showing 2 yellow aspects is known and yes, I anticipated this signal, and yes I have driven a light loco over this route. The signal displaying the 2 yellow aspects if you are aware of your route risks is one of the main risks of the route due to it's distance from the red aspect, the line speed and the signals sighting. If a driver has a competent route knowledge over this section they must know these risks. This signal is displaying 2 yellows very frequently as Stafford is a busy station and on many occasions especially if you are freight, light engine or ECS will almost certainly be displaying 2 yellows.

The whole report is condemning all concerned and it seems that actions have been taken however the main concern is how did it come to the stage where a company can think they can operate totally ignoring the fundamental rules of railway operation.

If this had been a qualified driver for a TOC the said driver would have most likely been dismissed, if it had been a TOC the most likely scenario would have been for the TOC to be stripped of it's franchise.

Keep the relics off the main line I think unless the companies running these trains adhere to the same working conditions as the commercial railway companies.

 

[Peter Mugridge]

It's not the relics that are the problem; it's some of the people maintaining and driving them.

 

[Monty]

How the individual at the controls of the locomotive when the incident happened was even allowed to enter the cab is astonishing.

 

[anthony263]

How the individual at the controls of the locomotive when the incident happened was even allowed to enter the cab is astonishing.

I agree and questions certainly need to be asked of those who allowed this driver to drive this loco out onto the mainline.

I wouldnt blame the drivers who do a good job day in day out for being pretty angered at this since it does effectively seem liek DCR were happy to just throw anyone into the cab of a train when they have had to work extrmely hard to qualify as a train driver.

 

[Beveridges]

How did that Driver even get a job with DCR ?

From what I can understand t, his previous experience was driving on the NYMR and the branch line to Whitby, and that was it?

Did he even sign the Stafford route, or was he just driving a route that he didnt sign?

 

[W230]

I agree and questions certainly need to be asked of those who allowed this driver to drive this loco out onto the mainline.

Including the driver themselves! How exactly did he consider himself competent to drive this train over this route with such a small number of trips made so rarely?!

Like others have said it screams of playing trains on the mainline from start to finish, with:

a blurring of responsibilities and potential for a conflict of interest
which enabled the consultants from Amtrain, who had been taken on to
provide safety direction to the BARS group, also to act as drivers for DCR
(paragraphs 17, 21 and 64).
f. There was a lack of independence in the arrangements for managing driver
competence (paragraph 64).

How does that work exactly then? Authorise each others routes and then just crack on?!

So basically:

47 On Britain’s main line railway, the principal elements of competence on which train drivers are assessed are:

• relevant parts of the Rule Book (‘rules knowledge’);

• the types of train that the driver will operate (‘traction knowledge’)

• the routes over which the driver will drive (‘route knowledge’).

But it seems the driver didn't have the route knowledge, or the traction knowledge. And he didn't have the rulebook knowledge (or if he did he deliberately breached the rules).

More worryingly is that the whole incident looks to have been heading for the 'brushed under the carpet' treatment by DCR until someone made the RAIB aware. I wonder whether this Cat A SPAD appears on the driver's record. Hmmmm....

 

[455driver]

I wonder whether this Cat A SPAD appears on the driver's record. Hmmmm....

What record?

 

[Zoidberg]

What record?

In keeping with his apparent age *, it'll probably be a 78.

* I inferred from "... he had worked as a fireman on steam locomotives operating on the main line." a reference to working on the railway when steam was in vogue.

 

[Tomnick]

In keeping with his apparent age *, it'll probably be a 78.

* I inferred from "... he had worked as a fireman on steam locomotives operating on the main line." a reference to working on the railway when steam was in vogue.

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