R A I B Report on Waterloo collision

[MotorcycleAlan]

How ironic that on a day of chaos at Waterloo this should appear:
https://assets.publishing.service.g..._data/file/756874/R192018_181119_Waterloo.pdf

Summary
At around 05:42 hrs on Tuesday 15 August 2017, a passenger train was leaving
London Waterloo station when it collided with a stationary engineering train at a speed
of 13 mph (21 km/h). No injuries were reported but both trains were damaged and
there was serious disruption to train services until the middle of the following day.

The passenger train was diverted away from its intended route by a set of points which
were positioned incorrectly as a result of uncontrolled wiring added to the signalling
system. This wiring was added to overcome a problem that was encountered while
testing signalling system modifications which were being made as part of a project
to increase station capacity. The problem arose because the test equipment design
process had not allowed for alterations being made to the signalling system after the
test equipment was designed.

The actions of a functional tester were inconsistent with the competence expected of
testers. As a consequence, the uncontrolled wiring was added without the safeguards
required by Network Rail signalling works testing standards, and remained in place
when the line was returned to service.

A project decision to secure the points in the correct position had not been
implemented.

An underlying factor was that competence management processes operated by
Network Rail and some of its contractors had not addressed the full requirements
of the roles undertaken by the staff responsible for the design, testing and
commissioning of the signalling works.

The RAIB has observed that there are certain similarities between the factors that
caused the Waterloo accident and those which led to the serious accident at Clapham
Junction in 1988. The RAIB has therefore expressed the concern that some of the
lessons identified by the public inquiry, chaired by Anthony Hidden QC following
Clapham, may be fading from the railway industry’s collective memory.

As a result of the investigation, the RAIB has made three recommendations. The
first, addressed to Network Rail, seeks improvements in the depth of knowledge
and the attitudes needed for signal designers, installers and testers to deliver work
safely. Recommendations addressed to OSL Rail Ltd and Mott MacDonald Ltd seek
development and monitoring of non-technical skills among the staff working for them.

The RAIB has also identified four learning points. One highlights the positive
aspects of a plan intended to mitigate an unusually high risk of points being moved
unintentionally. The others reinforce the need to follow established procedures,
prompt staff to clearly allocate duties associated with unusual activities and remind
staff that up-to-date signalling documentation must be available and easily identified in
relay rooms and similar locations.

 

[Antman]

So in short, contractor got it wrong. And systems not good enough. Interesting the RAIB is brave enough to point out that it's similar to Clapham. Hopefully that is enough on its own to wake up the people who do the contracting, and the contractors themselves....

I feel a bit sorry for the actual engineer on the ground, he was presumably trying to get it done as quickly as possible, but it's good luck that this was at a terminus, and good planning to have a blockading train protecting everyone else....

 

[Surreytraveller]

The RAIB has observed that there are certain similarities between the factors that
caused the Waterloo accident and those which led to the serious accident at Clapham
Junction in 1988. The RAIB has therefore expressed the concern that some of the
lessons identified by the public inquiry, chaired by Anthony Hidden QC following
Clapham, may be fading from the railway industry’s collective memory.

I concur with this comment on page seven, and I believe the rail industry is currently operating on borrowed time, and we are well overdue a major incident.

 

[Surreytraveller]

So in short, contractor got it wrong. And systems not good enough. Interesting the RAIB is brave enough to point out that it's similar to Clapham. Hopefully that is enough on its own to wake up the people who do the contracting, and the contractors themselves....

I feel a bit sorry for the actual engineer on the ground, he was presumably trying to get it done as quickly as possible, but it's good luck that this was at a terminus, and good planning to have a blockading train protecting everyone else....

Contractor got it wrong. Systems not good enough. Engineer on the ground trying to get the work done quickly. Exactly the same set of circumstances which led to the Clapham Disaster.
There are a lot of staff in the industry now, including management, who are complacent because they have not been around long enough to remember a major rail disaster.

 

[DarloRich]

thanks - that is a worrying report. It needs to be digested.

 

[Surreytraveller]

http://www.railwaysarchive.co.uk/documents/DoT_Hidden001.pdf

I encourage everyone in the industry to read the Inquiry into the Clapham crash. It is very thorough, and mirrors how changes in the industry today, such as constant reorganisation, can kill people.

 

[Signal Head]

Too much pressure to do to much work in too little possession.
This was a huge signalling changeover, which unfortunately was badly planned from the outset, and designed as one big commissioning, rather than being split into stages.
By the time it was realised that there was a problem, it was too late to redesign it to carve up into separate stages and still meet the programmed dates.
I understand that in the run up to the blockade, NR commissioned internal and 3rd party reviews into the feasibility of the commissioning strategy, every one of which came out with a recommendation to reprogramme with a longer possession, and/or redesign and split the work.
The politics of delaying the work (for at least a year) meant that all these recommendations were overruled at progressively higher and higher levels in NR.
This is the result.

 

[Dieseldriver]

The only lucky factor is that this occurred in an area with low line speeds. If this same scenario had occurred somewhere like Woking for example, the potential consequences of a 100mph train encountering a set of points in this state doesn't bear thinking about.

 

[Bayum]

http://www.railwaysarchive.co.uk/documents/DoT_Hidden001.pdf

I encourage everyone in the industry to read the Inquiry into the Clapham crash. It is very thorough, and mirrors how changes in the industry today, such as constant reorganisation, can kill people.

Unfortunately there was a very similar incident in Cardiff in 2016.

 

[Mag_seven]

Unfortunately there was a very similar incident in Cardiff in 2016.

Link please.

 

[jfowkes]

https://www.gov.uk/government/news/report-152017-serious-irregularity-at-cardiff-east-junction

It's mentioned in the Waterloo report on page 27, para. 189:

Fading collective memory of Clapham Junction was also apparent in the RAIB’s investigation into a serious irregularity at Cardiff East Junction on 29 December 2016...

 

[ComUtoR]

https://assets.publishing.service.g...5896/R152017_171030_Cardiff_East_Junction.pdf

Link for the Cardiff report.

 

[Mag_seven]

https://www.gov.uk/government/news/report-152017-serious-irregularity-at-cardiff-east-junction

It's mentioned in the Waterloo report on page 27, para. 189:

Fading collective memory of Clapham Junction was also apparent in the RAIB’s investigation into a serious irregularity at Cardiff East Junction on 29 December 2016...

https://assets.publishing.service.g...5896/R152017_171030_Cardiff_East_Junction.pdf

Link for the Cardiff report.

Cheers, that's tonight's bedtime reading sorted!

 

[theageofthetra]

Too much pressure to do to much work in too little possession.
This was a huge signalling changeover, which unfortunately was badly planned from the outset, and designed as one big commissioning, rather than being split into stages.
By the time it was realised that there was a problem, it was too late to redesign it to carve up into separate stages and still meet the programmed dates.
I understand that in the run up to the blockade, NR commissioned internal and 3rd party reviews into the feasibility of the commissioning strategy, every one of which came out with a recommendation to reprogramme with a longer possession, and/or redesign and split the work.
The politics of delaying the work (for at least a year) meant that all these recommendations were overruled at progressively higher and higher levels in NR.
This is the result.

Will anyone who did the overruling be sacked?

 

[Dieseldriver]

Will anyone who did the overruling be sacked?

I doubt it. Even if sacked, I'm sure they'll find themselves a similarly well paid position elsewhere...

 

[Tio Terry]

One thing I find odd is that this report, along with the vast majority of RAIB reports, never mention the Common Safety Method Risk Assessments that are required by law and their effectiveness. Network Rail owns Network Certification Body (NCB) and most projects employ them to undertake a review of the project risk assessments in accordance with the EU requirements. But there is never any reference to these assessments and their effectiveness, they are not cheap and add to project costs, but are they really required if the RAIB totally ignore them?

 

[edwin_m]

One thing I find odd is that this report, along with the vast majority of RAIB reports, never mention the Common Safety Method Risk Assessments that are required by law and their effectiveness. Network Rail owns Network Certification Body (NCB) and most projects employ them to undertake a review of the project risk assessments in accordance with the EU requirements. But there is never any reference to these assessments and their effectiveness, they are not cheap and add to project costs, but are they really required if the RAIB totally ignore them?

Signalling design is very heavily controlled by standards. Risk assessment would come in at the stage of examining the risks of the track layout and any issues outside the core design process, but isn't really relevant to the causes of this accident. It does mention that clipping the points in question (planned to be done but not actually done) wasn't required by standards but identified as a sensible precaution in a risk assessment.

 

[GreatAuk]

I'm not really familiar with signalling projects, but I'd imagine that the risk of errors resulting in a train collision will have been in the hazard record. To control that hazard, I'd imagine that applying standards and using competent personnel (and apparently clipping these points) will have been identified as key safety requirements. I daresay there will even have been considerable evidence demonstrating that these requirements were being fulfilled but obviously there were in fact certain lapses - risk assessments of that sort can't really prevent that.

I think it's an interesting point about csm never being mentioned in these reports. Also interesting that as far as I know there has been no measurable improvement in safety following introduction of csm (perhaps because it replaces previous risk assessment / safety processes that might have been applied? Or maybe its just difficult to measure thing like this when we don't know what would have happened if csm wasn't applied). I think a lot of it is about identitying sensible things that should be done, but then it's up to the project /organisation to actually do them properly.

CSM was also not necessarily intended to improve safety - its main purpose was to work towards harmonising safety approvals across the EU to stimulate trade with improving or maintaining current safety levels as a secondary purpose. There is surely also an element of legal arse-covering ('we did did all the proper assessments and did all these things so please don't sue us!') to these assessments.

 

[Tio Terry]

Signalling design is very heavily controlled by standards. Risk assessment would come in at the stage of examining the risks of the track layout and any issues outside the core design process, but isn't really relevant to the causes of this accident. It does mention that clipping the points in question (planned to be done but not actually done) wasn't required by standards but identified as a sensible precaution in a risk assessment.

Never believe that the existence of, in particular, a NetworkRail standard means that a risk is adequately mitigated. NR are very bad at updating their standards in a timely manner and many do not comply with changes in the law - the electrical clearances issues show this very clearly but that's by no means the only area that is affected. Clearly, in this case, there is an argument that the existence of a standard did not prevent what happened, so is the standard adequate? Yes, the standard was not followed fully, but that's the same with Clapham Junction where a Southern Region instruction existed for insulating bare wire ends but was not fully complied with.

But my point was that a lot of work was done in terms of identifying risks and their mitigations that wasn't even looked at by the RAIB, which I find strange.

 

[Taunton]

I find the report rather minimizes the failure to clip the points. Yes it gets mentioned in passing, but that is a key safety feature, long in place to guard against all sorts of errors that can arise elsewhere, yet was not done. No comment I can see on who was principally responsible for this, and who failed to ensure it was done.

It's not a hard job, is it?

 

[2HAP]

From my understanding of the report, nobody was assigned the responsibility to either clip the points, or check that the points had been clipped.

 

[Wilts Wanderer]

I find it interesting that early in the report, it states that OSL was determined to be best placed to design the Test Desk installation, despite the primary interlocking design responsibility lying with MML. This decision created the need to coordinate and manage a complicated relationship between the two signalling contractors, a choice which, given the complexity of the Waterloo works, surely imported significant risk into the overall scheme. Yet the report doesn't explain or quantify why this decision was taken. Does anyone know?

 

[Tio Terry]

From my understanding of the report, nobody was assigned the responsibility to either clip the points, or check that the points had been clipped.

True. But then the points were supposed to be detected within the interlocking. But the unauthorised wiring alteration carried out by the functional tester effectively bypassed the detection by directly energising the detection relay, so that what ever position those points were in they would by seen as normal by the interlocking.

 

[TheEdge]

As current rail staff I am terrified the industry has got complacent due to a lack of any truly multiple fatality serious incidents in recent years. To now see two reports from RIAB in quick succession say memories and lessons of Clapham are being forgotten scares me.

I hope I'm not driving the next train break that complacency!

 

[krus_aragon]

From my understanding of the report, nobody was assigned the responsibility to either clip the points, or check that the points had been clipped.

True. But then the points were supposed to be detected within the interlocking. But the unauthorised wiring alteration carried out by the functional tester effectively bypassed the detection by directly energising the detection relay, so that what ever position those points were in they would by seen as normal by the interlocking.

My understanding from the report was that the normal indication from points C (under the freight train) was not only correctly energising the detection relay for point C, but also points A and B (on the passenger train's route) due to the wiring alteration.

 

[ComUtoR]

As current rail staff I am terrified the industry has got complacent due to a lack of any truly multiple fatality serious incidents in recent years.

Do you think its complacency or other factors ?

I've been around for +10yrs now and I've seen a few things creep in over time. I'm not convinced that the comments about complacency are entirely accurate and may be slightly disingenuous.

 

[TheEdge]

Do you think its complacency or other factors ?

I've been around for +10yrs now and I've seen a few things creep in over time. I'm not convinced that the comments about complacency are entirely accurate and may be slightly disingenuous.

I think it's a complacency caused by a loss of memory and change of staffing.

We run a safe railway, I think Grayrigg was the last fatal accident caused solely by railway faults and the last multi fatality was Potters Bar. That is almost 20 years ago. That's a long time to go without incident and I think we just assume now we are safe all the time. In the 6 years I've been about I've seen rules that were solid be bent and loosened to get round certain issues. I honestly believe the complacency of almost two decades without a serious crash is allowing that to happen.

I think that complacency is creeping in becuase, as the RAIB report says, the people who remember those incidents and lessons first hand are gone or going. That knowledge is fading. I'd love to know how many current rail staff know how much more the Hidden Report covered than just how many hours can be worked. As management, especially the higher ups, be they in TOCs or NR, are gradually formed of more and more people who have lots of management experience but have never sat in a cab, or in a box, or a pway van, the knowledge and lessons learnt in those environments are not passing into the offices who make the safety rules for the rest of us.

And I honestly think that sooner or later that complacency will lead to a serious incident.

 

[edwin_m]

I'm not really familiar with signalling projects, but I'd imagine that the risk of errors resulting in a train collision will have been in the hazard record. To control that hazard, I'd imagine that applying standards and using competent personnel (and apparently clipping these points) will have been identified as key safety requirements. I daresay there will even have been considerable evidence demonstrating that these requirements were being fulfilled but obviously there were in fact certain lapses - risk assessments of that sort can't really prevent that.

I think it's an interesting point about csm never being mentioned in these reports. Also interesting that as far as I know there has been no measurable improvement in safety following introduction of csm (perhaps because it replaces previous risk assessment / safety processes that might have been applied? Or maybe its just difficult to measure thing like this when we don't know what would have happened if csm wasn't applied). I think a lot of it is about identitying sensible things that should be done, but then it's up to the project /organisation to actually do them properly.

CSM was also not necessarily intended to improve safety - its main purpose was to work towards harmonising safety approvals across the EU to stimulate trade with improving or maintaining current safety levels as a secondary purpose. There is surely also an element of legal arse-covering ('we did did all the proper assessments and did all these things so please don't sue us!') to these assessments.

Trains colliding due to signal wiring errors is a generic hazard on any signalling scheme and has a generic mitigation of applying the standards and competencies discussed in the report - many of which were stated to be for the exact purpose of mitigating that hazard after it arose at Clapham. It may appear on the register simply because it's obviously a hazard, but putting it there won't improve safety in any way unless the project is so thoroughly slapdash that it doesn't even know of the existence of fundamental signalling standards and practices. That is not so here - the standards were known about but not followed.

The whole safety issue is one of diminishing returns. There is a clear statistical trend of reductions in accidents in recent decades but it gets more and more difficult to chase down the remaining amount of risk. Most accidents are down to a failure of someone to observe a standard or procedure, so introducing more standards and procedures isn't the answer and may actually make things worse because with more things to be done there is more likelihood that something will be missed either due to error or because of time pressure and because the person involved doesn't see the need to carry out that activity (the safety culture issue highlighted in the report).

Never believe that the existence of, in particular, a NetworkRail standard means that a risk is adequately mitigated. NR are very bad at updating their standards in a timely manner and many do not comply with changes in the law - the electrical clearances issues show this very clearly but that's by no means the only area that is affected. Clearly, in this case, there is an argument that the existence of a standard did not prevent what happened, so is the standard adequate? Yes, the standard was not followed fully, but that's the same with Clapham Junction where a Southern Region instruction existed for insulating bare wire ends but was not fully complied with.

But my point was that a lot of work was done in terms of identifying risks and their mitigations that wasn't even looked at by the RAIB, which I find strange.

The standards are intended specifically to mitigate this exact hazard, and it appears to me that the temporary works were clearly covered by the standard and in breach of it in several respects. As above, I'm not sure of the point of providing extra lines of defence if people just ignore them or the whole thing just gets too difficult to understand. As I posted above, the relevant part of the risk mitigation was discussed in the report, and again the problem was failure to implement the mitigation not failure to identify the risk. No shortcomings were found in the CSM process that either contributed to the accident or were worthy of observations, so it wasn't discussed in the report just as there was no detailed discussion of the driver's handling of the train or of the weather.

My understanding from the report was that the normal indication from points C (under the freight train) was not only correctly energising the detection relay for point C, but also points A and B (on the passenger train's route) due to the wiring alteration.

This is true, but you also have to consider that points C were clipped normal as they were under the engineering train. This meant that the detection of A and B was false-fed regardless of their actual position. If the safety precaution of clipping points C handn't been followed then the accident might not have happened (though some other accident might).

 

[bramling]

Do you think its complacency or other factors ?

I've been around for +10yrs now and I've seen a few things creep in over time. I'm not convinced that the comments about complacency are entirely accurate and may be slightly disingenuous.

There’s always a risk of complacency. The causes behind accidents are rarely quite as simple as first meets the eye.

In my part of the world I certainly see things happen which could well be the first link in a chain ultimately leading towards something bad happening. I’d suggest money, internal brownie points and wanting to finish on time are the things most likely to encourage people to do something unsafe.

Then there’s poor training or competence. There’s certainly some management complacency at times, but there’s also a syndrome of fading corporate memory - when the organisation’s corporate memory isn’t senior enough to know or remember *why* a specific rule or procedure exists. Again that in itself isn’t a problem so long as decision-makers are prepared to listen to those who do know.

 

[theageofthetra]

I think it's a complacency caused by a loss of memory and change of staffing.

We run a safe railway, I think Grayrigg was the last fatal accident caused solely by railway faults and the last multi fatality was Potters Bar. That is almost 20 years ago. That's a long time to go without incident and I think we just assume now we are safe all the time. In the 6 years I've been about I've seen rules that were solid be bent and loosened to get round certain issues. I honestly believe the complacency of almost two decades without a serious crash is allowing that to happen.

I think that complacency is creeping in becuase, as the RAIB report says, the people who remember those incidents and lessons first hand are gone or going. That knowledge is fading. I'd love to know how many current rail staff know how much more the Hidden Report covered than just how many hours can be worked. As management, especially the higher ups, be they in TOCs or NR, are gradually formed of more and more people who have lots of management experience but have never sat in a cab, or in a box, or a pway van, the knowledge and lessons learnt in those environments are not passing into the offices who make the safety rules for the rest of us.

And I honestly think that sooner or later that complacency will lead to a serious incident.

Sadly I fear you are correct.