The Railways and "Just Culture"

[70014IronDuke]

Not an operational "incident" - but this anecdote I presume put me well to the left (?) of the blame culture.

41 years ago, at the depot I was at, we had a Cl 47 which was regularly stopped for "need to replace Motak". It was my job to find out why, and solve it.

Motak is (was?) the thick black gunge put into the gear box which houses the traction motor drive to the axle. When running, of course, the higher temperature means it's a more runny oil lubricant. That's its job.

Well, we could not fathom what was wrong, so after a few weeks of trying, and all the motak tanks were still obviously leaking. we reluctantly sent the loco to be lifted (obviously an expense, so wanted to avoid this). A day or two later the answer came back:the seals which should have been inserted around the axle gear wheel casing (I think it was) were missing on all axles.

the only way this could have happened was for a failure to fit them at a major exam (and E, I think) or when in the shops for overhaul. But as it hadn't had the relevant exam, all the evidence pointed to a failure to fit after overhaul- which happened to be at Crewe. Well, i went up to Crewe to speak to the examiners, and wrote the report - which concluded that Crewe was at fault.

But rather than just send this to the regional CMEE and let Crewe know indirectly that way, I phoned them up beforehand. I said I was not trying to have a blame game, I wanted to warn them what was coming because the whole point was to avoid any repeats, not nail someone or some team to the cross.

Although I was pretty sure i would never go to Crewe again, I also thought this way, should it ever happen, or even should another guy have some kind of similar job to do, he would be received well and get cooperation for any future enquiry.

AFAIR Crewe said thanks for the notice, and some form of extra checking was created to ensure that problem did not happen again.

My view was simply we were all one team that needed best to pull together and get the best job done.

 

[Bromley boy]

I see your point and raise you another.

What if there was a way to prevent a specific incident. And I mean pretty much eliminate it altogether. Would you still mitigate and reduce the incident or eliminate it ?

At what cost ? Because, there is and always will be a cost. (not always financially either)

Keeping it within the realm of being on topic. At what point does it becomes the TOC's responsibility ?

Not to specifically blame the TOC but surely a portion of the responsibility must be down to the TOC policies, procedures, practices, training etc.

I suspect it all comes down to cost in the end. An example is the adoption of TPWS in place of ATP. ATP was more effective at preventing SPADs, but the vastly increased cost meant that TPWS was implemented despite being not (quite) as good.

There probably isn't much of an incentive to invest in completely eliminating incidents given how safe the current system is. Even if a SPAD occurs TPWS will usually mitigate its consequences. How many lives have been lost to accidents caused by SPADs since TPWS was implemented? None as far as I'm aware?

Eventually when ETCS is implemented entirely across the network SPADs will be a thing of the past. It's telling that the investment bringing about this change is being justified more by the increased capacity than the small increase in safety.

Ultimately TOCs can only train their drivers to drive within the infrastructure provided to them by network rail.

 

[bahnause]

Eventually when ETCS is implemented entirely across the network SPADs will be a thing of the past.

We had several SPADs with ETCS L2 so far...

 

[D1009]

Why 'minimise'. Why not eliminate ?

I often find it odd that we have a target for SPADS. Surely that target should be zero. Its the same with incidents. We have targets and acceptable risks. Why can't we build systems and put procedures in place that serve to eliminate incidents instead ?

The circumstances leading to the collision at Plymouth could have been eliminated by banning permissive working for passenger trains there. A balance has to be struck somewhere.

 

[dviner]

We had several SPADs with ETCS L2 so far...

Hmmm... If the signalling aspects are displayed within the cab, then can you actually pass them?

Exceeding Limit of Movement Authority isn't catchy enough, though.

 

[Bromley boy]

We had several SPADs with ETCS L2 so far...

My understanding was that ETCS monitored speed continuously and would put the emergency brake in if the appropriate braking curve wasn't adhered to. Thereby almost eliminating SPADs and dispensing with TPWS completely (and dispensing with signals depending on level).

 

[signallerscot]

As always the devil is in the detail. It's technically correct to say there have been SPADs on the Cambrian since ETCS came in but what was not mentioned by bahnause was that these have taken place during degraded working where the trains involved have not been in "Full Supervision" mode. That is to say the driver rather than the equipment on the train has been responsible for stopping it before passing the block marker.

 

[Moonshot]

I see your point and raise you another.

What if there was a way to prevent a specific incident. And I mean pretty much eliminate it altogether. Would you still mitigate and reduce the incident or eliminate it ?

At what cost ? Because, there is and always will be a cost. (not always financially either)

Keeping it within the realm of being on topic. At what point does it becomes the TOC's responsibility ?

Not to specifically blame the TOC but surely a portion of the responsibility must be down to the TOC policies, procedures, practices, training etc.

This brings us nicely on to a point occupying a thread with over 11000 posts..................How do you prevent or eliminate " trap and drag " incidents on trains operated in DOO mode.......and how do you you prevent or eliminate " trap and drag " incidents on a train operated with a guard. The answer for both is to employ methods of working which " as low as is reasonably practical " will do this. I ve absolutely no doubt that both guards and drivers are trained to a very high standard, but there is no absolute guarentee that either method will not result in one.

 

[bahnause]

My understanding was that ETCS monitored speed continuously and would put the emergency brake in if the appropriate braking curve wasn't adhered to. Thereby almost eliminating SPADs and dispensing with TPWS completely (and dispensing with signals depending on level).

ETCS in a very complex system that works quite fine in normal circumstances. However when it comes to non normal operations, things can get really complicated and differ depending of the installed lineside equipment and cab equipment. Processes are often complicated, and once in "staff responsible" mode there is no more safety net. You think today's signalling equipment

Even under "full supervision" you still can exceed the movement authority due to the release speed. Because the calculated braking curve and the odometry isn't exact enough, you need the release speed to be able to approach a "signal" at a reasonable speed without the system interfering.

But that is all a bit OT here.

 

[30907]

As always the devil is in the detail. It's technically correct to say there have been SPADs on the Cambrian since ETCS came in but what was not mentioned by bahnause was that these have taken place during degraded working where the trains involved have not been in "Full Supervision" mode. That is to say the driver rather than the equipment on the train has been responsible for stopping it before passing the block marker.

Given that bahnause Is posting from Switzerland, I wonder if s/he is referring to ECTS incidents there?

 

[bahnause]

Given that bahnause Is posting from Switzerland, I wonder if s/he is referring to ECTS incidents there?

Yes, I'm referring to incidents on the swiss network.