Train Setting Back on the WCML- Raib report.

[9K43]

This is a report of a train setting back on the WCML.
Perhaps too many tiring turns , and maybe a bad roster.

http://www.raib.gov.uk/publications/investigation_reports/reports_2011/report152011.cfm

 

[NightatLaira]

Interesting that the driver took 4 minutes to realise he was travelling backwards and had cancelled 2 warnings during that time (presumably because he thought they were going off for no reason(?!)

Very bizarre - but I guess that's tiredness for you..

 

[boing_uk]

To be honest it is quite understandable. What I am surprised at is that, given that fatigue will never be eliminated, is that there is no recommendation for an engineering solution to warn a driver that they are rolling backwards.

What surprised me as well is that the signaller set points at Tebay to essentially derail the train. Now it doesnt say if there was anything behind the train rolling back, in which case I can understand it. However if there wasn't, what would have been the harm in allowing the train to continue rolling?

 

[driver9000]

Runaway trains are diverted away from running lines. You can't just sit there and watch any train runaway in the wrong direction let alone a heavy container train!

If that train had carried on going back downhill picking up speed (it already reached 50mph) it could have been disastrous at the first sharp bend which may have been in a built up area. Given the high freight traffic levels using the WCML I would imagine a following train wasn't far away. If it had been allowed to run and the worst had happened then questions as to why it wasn't diverted would be getting asked instead.

 

[strange6]

and manslaughter charges being made no doubt

 

[boing_uk]

Well, yes, I suppose on the face of it my question does seem very daft. Looking at the line there aren't many opportunities to stop an errant train heading in the wrong direction, so yes it was probably the right decision, particularly if there was something anywhere behind it and the time available in which to take action.

I was looking at it from the perspective of there being nothing behind the train. Looking at the exaggerated gradient profile in the report, there are *some* sections of level and uphill sections of line beyond Tebay, however what the gradients are after Grayrigg southbound, only those with access will know whether an errant vehicle or train would have an opportunity to come to a halt due to natural means.

 

[daikilo]

Well, yes, I suppose on the face of it my question does seem very daft. Looking at the line there aren't many opportunities to stop an errant train heading in the wrong direction, so yes it was probably the right decision, particularly if there was something anywhere behind it and the time available in which to take action.

I was looking at it from the perspective of there being nothing behind the train. Looking at the exaggerated gradient profile in the report, there are *some* sections of level and uphill sections of line beyond Tebay, however what the gradients are after Grayrigg southbound, only those with access will know whether an errant vehicle or train would have an opportunity to come to a halt due to natural means.

Education tells you that if it is going the wrong way along a live line then stop it a.s.a.p. No question. An accident with one train will always be less severe than one with two, and particularly head-on. Prevent, then consider the other options.

That said, the report is very interesting in that it clearly establishes the criticality of the first night shift and also specific sequences of events, but does not appear to suggest a clear solution. In particular, it does not clearly suggest means to enhance vigilence when similar circumstances occur. A communication with control might have helped.

I was not in a safety critical function but I did nap 0215-0225 or thereabouts. Couldn't help it, at that time of day, I only needed to make my last notes then stare at my desk and I fell asleep in seconds, and not always only on the first shift. I was then fully awake for the rest of the shift, returned home and then slept for a few hours.

 

[Caped Crusader]

Interesting article, thanks for sharing it.

 

[Xenophon PCDGS]

The question of the first night of a driver's shift pattern after changes was mentioned on the TV, according to my wife, but she was unable to elucidate what this meant. I was away from home at the time and missed this.

Can any forum members who actually heard about this on TV explain exactly what was said and meant by that statement of "driver's first night".

 

[es373]

To be honest it is quite understandable. What I am surprised at is that, given that fatigue will never be eliminated, is that there is no recommendation for an engineering solution to warn a driver that they are rolling backwards.

What surprised me as well is that the signaller set points at Tebay to essentially derail the train. Now it doesnt say if there was anything behind the train rolling back, in which case I can understand it. However if there wasn't, what would have been the harm in allowing the train to continue rolling?

There is an engineering solution. London Underground has Run back Protection.
Red light flashes and an audible is given.
I'm sure the signaller would have done what's best at the time, does it say anywhere that the driver was doing rest day working or was this the normal shift?

 

[driver9000]

The report says it was the Drivers rostered work. I'm sure it also says he had finished Saturday evening with Sunday off (all rostered). The reference to the Drivers first night means it was his first night turn after a run of daytime turns.

 

[dggar]

There is an engineering solution. London Underground has Run back Protection.
Red light flashes and an audible is given.
I'm sure the signaller would have done what's best at the time, does it say anywhere that the driver was doing rest day working or was this the normal shift?

The report seemed to suggest that it was not cost effective to fit this to existing locos but should be considered in the specification for new locos.

I'm not an engineer but would it be possible to install something like a car satnav which would give an indication of the direction of travel?

 

[es373]

The report seemed to suggest that it was not cost effective to fit this to existing locos but should be considered in the specification for new locos.

I'm not an engineer but would it be possible to install something like a car satnav which would give an indication of the direction of travel?

If it improves safety then I think its worth it. It is possible to fit a 'something like car sat nav" but its a stupid idea. Runback is simple and effective.

No offence by the way

 

[eMeS]

I've not read the report in detail, but with the expected later retirement dates for people in work, and the ease with which I now drop off to sleep, I'd expect more of these incidents in the years to come. I wonder if a "steering wheel" would help detect a driver's alertness?

 

[es373]

I've not read the report in detail, but with the expected later retirement dates for people in work, and the ease with which I now drop off to sleep, I'd expect more of these incidents in the years to come. I wonder if a "steering wheel" would help detect a driver's alertness?

Vigilance does that fella. I haven't read the report yet as I'm at work but surely you're supposed to leave the train in a service brake notch while at a stand still.
You have have all the safety systems on stock that you want but it will never get rid of driver error.

 

[HugePilchard]

In the report, it mentions an "emergency stop call" - could someone elaborate on exactly what that is? Is that a radio call which will apply the brakes remotely, or just something to try and get the driver's attentions so that they'll do it?

 

[talltim]

Vigilance does that fella. I haven't read the report yet as I'm at work but surely you're supposed to leave the train in a service brake notch while at a stand still.
You have have all the safety systems on stock that you want but it will never get rid of driver error.

I have scanned through the report. The driver did cancel the vigilance alerts, even after passing (I think) two signals the wrong way. From what I gather he was in the process of stopping whilst going uphill, so had reduced power but not applied the brakes. He thought he was still in the process of slowing, when in fact he had slowed, stopped and started rolling back.
Presumably any automatic rollback prevention device has to know which way you are supposed to be going.

The thing that struck me from the report was the way that the shifts all started at different times, which I can't help feeling would make it harder to adjust to. They also got earlier each day, which again would make it harder to cope with and the report does mention that this is not as good as getting later thought the pattern.

 

[driver9000]

In the report, it mentions an "emergency stop call" - could someone elaborate on exactly what that is? Is that a radio call which will apply the brakes remotely, or just something to try and get the driver's attentions so that they'll do it?

Emergency broadcast over the NRN radio from Network Rail control. Very loud they are too as they automatically come through at a high volume regardless of the Drivers setting.

 

[es373]

The run back protection knows which was its going when the cab is opened up. It can be isolated and should be sealed.
--- old post above --- --- new post below ---
I think it works off of the gearbox. Not sure though.

 

[driver9000]

Any run back system could be tied into the direction selector to dump the brakes if movement over a certain speed was detected in the opposite direction. The trains I drive have system that dumps the brakes if movement over 3mph is detected with no direction selected, most if not all locomotives have a similar sytem known as SSF (Speed sensing fitted) which also works in Neutral/EO.

 

[es373]

So what stocks are you on then driver9000?

 

[jopsuk]

As I understand it, the ERTMS system on trial in Wales CAN issue a command that will stop a train without the driver doing anything?

 

[dggar]

If it improves safety then I think its worth it. It is possible to fit a 'something like car sat nav" but its a stupid idea. Runback is simple and effective.

No offence by the way

No offence taken, like I said I'm just a layman in these matters.

 

[pablo]

All the gimmicks in the world won't work if the driver is too fatigued to notice them.
The analysis and recommendations are all in section 20 onwards.
Railway industry far behind Aviation in setting less fatiguing shift patterns.

 

[driver9000]

So what stocks are you on then driver9000?

Sprinters and Pacers.

 

[rmt-driver]

Yes some years ago after a LU train rolling a long way back on Network Rail (can't find the exact details), RPS (runback-protection system) was retro-fitted to ALL rolling stock on LUL.

Basically if the train is in 'forward' mode, and the train moves backwards more than two complete wheel revolutions the emergency brake will apply, complete with a alarm and warning light operated in the cab. There is a cut out switch (for example, if the system develops a fault) which is a sealed switch. If the cut out is operated, the train must be withdrawn from service.

If the train is working in 'reverse' (for example if the train can not be driver from the front due to a fault, and is being propelled by a driver in the rear cab in communication with the driver at the front) then the system will operate if the train rolls forward (if that makes sense).

 

[es373]

Good explanation rmt-driver. I guess an advanced system has been fitted to the S and 09 stocks?
Also is it the case with LU that if any seal has been broken, the train must be taken out of passenger service?

Driver9000 - NXEA?

 

[rmt-driver]

Good explanation rmt-driver. I guess an advanced system has been fitted to the S and 09 stocks?
Also is it the case with LU that if any seal has been broken, the train must be taken out of passenger service?

Driver9000 - NXEA?

I don't think so, the fitter would probably be called to re-seal.. depending on the reason

 

[es373]

Ah, only asked because when a friend of mine took over a set with a missing SCAT isolator seal (I think it was SCAT... Could have been CSDE), the train was taken empty to Neasden!
--- old post above --- --- new post below ---
Well having read the report it certainly seems that RAIB are insinuating that the driver fell into a sub conscious sleep! For obvious reasons they won't actually say that!

 

[Old Timer]

Railway industry far behind Aviation in setting less fatiguing shift patterns.

Sadly you are wrong on this point.

There are increasing concerns about flight deck fatigue and there have been a number of reported instances where the whole flight deck crew has fallen asleep on long haul for short periods of time.

A case recently occurred in the US when an internal flight flew on beyond the destination when the crew fell alseep. Fighters were scrambled and reported they could not rouse the crew. The crew eventually came round and the iunitial story was that they were deeply involved in a debate over Company Procedures !

The requirement to make the cockpit inaccessible prevented the cabin crew from being able to take any action, because there was no way they could gain access.