Braking issue on Caledonian Sleeper causes train to "run away" at Edinburgh

[adamello]

The RAIB will go over each element in detail, and will no doubt provide recommendations (if working improvements can be identified) to ensure this doesn't happen again.
Whilst recommendations aren't legally enforceable, should a similar incident happen again and it is more catastrophic - then anyone in a dock would look pretty negligent if they are questioned that they knew of an issue but did nothing to mitigate it.

The recommendations maybe to TOCs on the process of attachment/detachment, or to review how and when brake tests are done - they will decide if these are feasible contributors or not (ie unfeasible to drive the stock 90% of the journey to then do a brake test as this could be higher risk). Could also be to DfT or ORR to instigate devices on all LHCS to include some form of failsafe device (again whether or not if this is feasible for shunting ops etc,.)

now this is a live investigation I personally cannot see how it is useful for any of us to comment on what system or process, may or may not been done correctly, or what they underlying causes maybe as it is purely speculation, I will flag this to a mod and see if the discussion can be put on hold until any updates are provided.

 

[ainsworth74]

The RAIB have now released their report into this incident and so the thread has been re-opened for further discussion.

Sounds like the driver, signaller and guard all acted incredibly in what must have been a very tense and downright scary incident:

Summary
At about 07:25 hrs on Thursday 1 August 2019, the driver of the Edinburgh portion of the Lowlander sleeper service from London Euston was unable to control the train’s speed on the approach to Edinburgh. He was unable to comply with the maximum permitted speed at Haymarket East Junction, and would have been unable to stop the train before the junction if there had been a conflicting train movement. The driver was also unable to stop the train at Edinburgh Waverley station. The train came to a stop approximately 650 metres beyond its intended stopping point at Edinburgh Waverley platform 11, after the train manager operated an emergency button in a coach.

The train crew subsequently identified that an air isolation cock between the locomotive and the coaches was closed when it should have been open. After identifying this and obtaining permission from the signaller, they reversed the train back into the platform where the passengers alighted. There were no injuries and no damage occurred.

The driver was unable to stop the train because the brake pipe isolating cock on the leading end of the leading coach was closed. This prevented the brakes on all the coaches from operating when demanded by the driver, although the driver still had control of the brake systems on the locomotive.

The isolating cock became closed during coupling operations when the Edinburgh train was split from the Glasgow train at Carstairs station; this happened after the mandated brake continuity test had been completed. The closure of the valve was therefore undetected prior to the train’s departure from Carstairs. The effectiveness of the brake systems on the locomotive also masked the absence of the coach brakes until the train was approaching Slateford, on the approach to Edinburgh.

Recommendations
RAIB has made two recommendations. One is addressed to RSSB to change the wording of the railway rule book to make it clear that the brake continuity test should be undertaken after all coupling-related activities have been completed. The second is addressed to Caledonian Sleeper to review the vulnerability of the isolating cocks on its rolling stock, to prevent inadvertent operation by persons or objects.

RAIB has also identified six learning points, relating to procedures for coupling and uncoupling trains, incorporating risk mitigations into operational procedures, risk assessing the running brake test, using the ‘train in distress’ signal, application of standards to rolling stock, and access to recorded train data.

Report 05/2020: Loss of brake control on a sleeper train approaching Edinburgh

Loss of brake control on a sleeper train approaching Edinburgh, 1 August 2019.

www.gov.uk

 

[hexagon789]

The RAIB have now released their report into this incident and so the thread has been re-opened for further discussion.

Sounds like the driver, signaller and guard all acted incredibly in what must have been a very tense and downright scary incident:

Report 05/2020: Loss of brake control on a sleeper train approaching Edinburgh

Loss of brake control on a sleeper train approaching Edinburgh, 1 August 2019.

www.gov.uk

Thanks for the update Ainsworth - the report made for some interesting reading.

 

[jfollows]

In summary, the static brake continuity test that was carried out at Carstairs was performed once the stock had been split, but there were some difficulties with the ETH jumpers which needed connecting, and this was performed after the static brake test had been successfully performed. The brakes were inadvertently isolated during the final procedure. The running brake test showed that the engine's brakes slowed the train down, and didn't show that the brakes on the coaches were isolated.

Wisdom of hindsight, it's all reasonably clear. It could have been a lot worse than it was.

 

[hexagon789]

So if I understand correctly the issue was caused by problems trying to connect an ETS cable which inadvertently knocked the BPIC (Brake Pipe Isolating Cock) closed, thus isolating the coaches brakes from control by the locomotive.

This was likely due to the poor positioning of the BPIC in relation to the ETS receptacle and because the cable was connected up after a brake continuity test had been carried out the closing of the valve was unnoticed until the driver attempted to brake for the more significant speed restrictions coming into Haymarket.

It's quite concerning that the train brake system could be defeated so easily after a such a small action accidentally caused the BPIC to be closedm

 

[hexagon789]

In summary, the static brake test that was carried out at Carstairs was performed once the stock had been split, but there were some difficulties with the ETH jumpers which needed connecting, and this was performed after the static brake test had been successfully performed. The brakes were inadvertently isolated during the final procedure. The running brake test showed that the engine's brakes slowed the train down, and didn't show that the brakes on the coaches were isolated.

Wisdom of hindsight, it's all reasonably clear. It could have been a lot worse than it was.

So I did understand it correctly. Presumably now they'll require a brake continuity test to be the last thing performed before moving and for one to be performed again if any alterations are made to the ETS jumpers.

 

[jfollows]

For me, and I'm not any railway expert, I wonder about the process of the running brake test here.

The report states, briefly

1. At 07:04 hrs, the driver used the train brake control to carry out a running brake test, after having travelled two miles (3.2 km). This brought the train’s speed down from 70 mph (113 km/h) to 59 mph (95 km/h).

I wonder what the point of the running brake test is, if it's not able to ascertain that the brakes on the entire consist are working as they should, since clearly all it did here was to ascertain that the locomotive's brakes were working.

The report covers this in more detail in paragraphs 80 to 84, but doesn't really go on to say much more than this. Clearly the running brake test did not enable the driver to be sure that the brakes were operating effectively, to paraphrase the Rule Book slightly (paragraph 81).

Then the report goes on with "learning point 3" which seems important

1. Train and freight operating companies are reminded that any risk assessments undertaken for the operation of trains should recognise that the running brake test mandated by the rule book may not reveal train brake defects, particularly when locomotives with rheostatic braking are being used (paragraph 114b(ii)).

I'm just a little surprised that this point isn't made more significant in the report than it is.

 

[marks87]

So I did understand it correctly. Presumably now they'll require a brake continuity test to be the last thing performed before moving and for one to be performed again if any alterations are made to the ETS jumpers.

That's exactly one of the recommendations made.

 

[43096]

So I did understand it correctly. Presumably now they'll require a brake continuity test to be the last thing performed before moving and for one to be performed again if any alterations are made to the ETS jumpers.

It is also a flawed design to have a below-standard isolating cock in a position that is close to the ETH socket.

I’m also not seeing the advantage of the Dellner coupler given it has to be lifted on the loco before use. The whole point of it is to avoid manual handling. This incident would never have occurred if old fashioned screw couplers (loco), buckeyes (stock) and conventional air pipes/cocks had been in use.

 

[pdeaves]

I am amazed that the driver had the presence of mind NOT to press the emergency GSM-R button, thus giving the signaller a better chance of setting a non-conflicting route.

 

[185143]

I am amazed that the driver had the presence of mind NOT to press the emergency GSM-R button, thus giving the signaller a better chance of setting a non-conflicting route.

Indeed. In doing so he quite probably prevented a collision.

 

[matchmaker]

I'm amazed that the BPIC is so weedy. It looks like something you could pick up in B&Q for £5!

 

[37057]

It is also a flawed design to have a below-standard isolating cock in a position that is close to the ETH socket.

I’m also not seeing the advantage of the Dellner coupler given it has to be lifted on the loco before use. The whole point of it is to avoid manual handling. This incident would never have occurred if old fashioned screw couplers (loco), buckeyes (stock) and conventional air pipes/cocks had been in use.

It does appear to be a half arsed attempt of a coupling system, a better idea would have been to specify dropdown dellners and drawhooks on the stock and retain the traditional loco attachment method.

I can't see anything wrong with the BPIC itself (edit - since read the report in full - and yes, that's shambolic) but it could have been designed with sophistication. Coupler front faces can have inductive switches that detect a 'coupled' coupler and ICs can have microswitches, have a signal discrepancy between those and you can literally design alarm bells to ring! It's a safety critical system on a modern train after all...

 

[Ianno87]

For me, and I'm not any railway expert, I wonder about the process of the running brake test here.

The report states, briefly


I wonder what the point of the running brake test is, if it's not able to ascertain that the brakes on the entire consist are working as they should, since clearly all it did here was to ascertain that the locomotive's brakes were working.

And/or possibly confirming that the train was travelling uphill!

 

[Llama]

For me, and I'm not any railway expert, I wonder about the process of the running brake test here.

The report states, briefly


I wonder what the point of the running brake test is, if it's not able to ascertain that the brakes on the entire consist are working as they should, since clearly all it did here was to ascertain that the locomotive's brakes were working.

The report covers this in more detail in paragraphs 80 to 84, but doesn't really go on to say much more than this. Clearly the running brake test did not enable the driver to be sure that the brakes were operating effectively, to paraphrase the Rule Book slightly (paragraph 81).

Then the report goes on with "learning point 3" which seems important

I'm just a little surprised that this point isn't made more significant in the report than it is.

It's significant when read from the point of view of an experienced driver. The (as it turns out *only* the) rheostatic brake which was applied on the rising gradient gave the (very experienced) driver the impression that the brake was performing satisfactorily, albeit at what he considered at the lower end of the normal expected performance range. If the running brake test had been carried out shortly afterwards on the level or falling gradient I'm sure the performance would have been immediately obvious as unsatisfactory and the driver would have taken the necessary action.

The fact that the loco's vacuum circuit breaker never reclosed after the overhead neutral section is significant too, as that would have meant the rheostatic brake was inoperable and the loco was braking using its friction brake instead - the report notes that as friction brakes of this type get hotter their retardation is reduced. The friction brake wouldn't be as effective as the rheostatic brake even if it was functioning perfectly (and assuming brake blocks weren't new) before the temperature significantly increased.

I'm amazed that the BPIC is so weedy. It looks like something you could pick up in B&Q for £5!

I'm going to hazard a guess that you haven't done much poking around CAF rolling stock.

 

[43096]

I'm going to hazard a guess that you haven't done much poking around CAF rolling stock.

There’s a reason why they are known round Europe as “Cheap As....”; well I think you can guess the rest.

 

[nag67]

And/or possibly confirming that the train was travelling uphill!

Figure 3 and paragraph 82 show the running brake test was done on a relatively level stretch of line.

 

[Bletchleyite]

I'm amazed that the BPIC is so weedy. It looks like something you could pick up in B&Q for £5!

And why is the ETS connector such that you have to lie in the turds on the track to connect it? Surely it would make more sense for it to be higher up.

But yes, it looks like a home mains water isolating cock.

Cheap as...

 

[O L Leigh]

The fact that the loco's vacuum circuit breaker never reclosed after the overhead neutral section is significant too, as that would have meant the rheostatic brake was inoperable and the loco was braking using its friction brake instead - the report notes that as friction brakes of this type get hotter their retardation is reduced. The friction brake wouldn't be as effective as the rheostatic brake even if it was functioning perfectly (and assuming brake blocks weren't new) before the temperature significantly increased.

To be entirely fair, every braking system is limited by it's abilities to lose heat to atmosphere, and overheating due to overuse will inevitably result in a reduction in brake performance. The problem here is that the loco friction brake was attempting to slow the weight of the entire train. Adding the rheo brake may have helped reduce the distance of the overrun, but that would have depended on the whether or not the loco had already reached the limit of adhesion. Adding more and more brakeforce risks exceeding this limit, after which the loco is sliding and no longer decelerating.

 

[Dave W]

Very interesting report.

It seems a lot of this can be traced back to substandard equipment, setting up a pretty much unavoidable trap for three incredibly experienced railwaymen (118 years experience between them was it?) If it was caused by, e.g., degradation of 40 year old equipment, it might be forgivable. But these coaches are brand new.

The handle and its latch appear to be less robust than the latched type handles normally used on UK rolling stock

I found this line to be quite telling. RAIB inspectors usually go out of their way to avoid comparisons like this (with good reason), so they clearly aren't impressed with it.

The fortitude and foresight of the driver to not hit the emergency call button to keep other trains moving is quite something, too.

 

[Taunton]

It was 70 years ago that the EP brake first appeared on BR. Electric application, with jumpers between vehicles, with an air brake pipe for power. The jumpers on the new stock apparently have 61 connections, way more than previously, but it seems no pair of wires could be made available to operate the brakes in this manner. If the electric application failed, venting the straight air brake pipe was the emergency second system. Now with brand new stock there is no EP application, and thus apparently no emergency second system.

 

[ainsworth74]

(118 years experience between them was it?)

That stood out to me as well. There was hell of a lot of experience on that train that day!

 

[O L Leigh]

Very interesting report.

It seems a lot of this can be traced back to substandard equipment, setting up a pretty much unavoidable trap for three incredibly experienced railwaymen (118 years experience between them was it?) If it was caused by, e.g., degradation of 40 year old equipment, it might be forgivable. But these coaches are brand new.

I'm not so sure about sub-standard, but rather that the usual standards were believed by all involved in the commissioning, designing, building, testing and acceptance of these coaches not to be the appropriate ones. Hence the use of a BPIC design that was less robust than preceding designs.

However, there is a line in the report that suggests an element of incorrect use. These BPICs are designed to latch either fully open or fully closed. If the BPIC was closed in error it suggests that it hadn't been opened fully so that the latch engaged.

It was 70 years ago that the EP brake first appeared on BR. Electric application, with jumpers between vehicles, with an air brake pipe for power. The jumpers on the new stock apparently have 61 connections, way more than previously, but it seems no pair of wires could be made available to operate the brakes in this manner. If the electric application failed, venting the straight air brake pipe was the emergency second system. Now with brand new stock there is no EP application, and thus apparently no emergency second system.

I thought this too, but I can understand why it wasn't selected. The report says that the 61 way connector had to be engaged only after the portions were split to avoid damage to the loco equipment from having more than one loco coupled to the train at a time. You also have to provide an additional braking system for the loco to work both conventionally using the two-pipe system and effectively as an MU with an EP brake.

Venting the brake pipe in an emergency is not necessary for an EP brake, though. Brake continuity is electrically proved and de-energising the wires would be enough to initiate an emergency brake application.

 

[37057]

It was 70 years ago that the EP brake first appeared on BR. Electric application, with jumpers between vehicles, with an air brake pipe for power. The jumpers on the new stock apparently have 61 connections, way more than previously, but it seems no pair of wires could be made available to operate the brakes in this manner. If the electric application failed, venting the straight air brake pipe was the emergency second system. Now with brand new stock there is no EP application, and thus apparently no emergency second system.

I think (so could be totally wrong) 92s already have a form of EP control (solenoids acting on the brake pipe within the loco) but I'm not sure if it would be possible to mirror the system into the fail safe energise-to-release system often found on MUs. For starters the auto brake controller on the loco is sprung loaded and is operated to adjust the brake pipe pressure whereas on MUs the brake controller isn't sprung loaded and 'holds off' the relevant mode wire contacts.

To summarise - I don't think train wire control of the train brakes from a 92 would be possible without a complex modification.

 

[Taunton]

You also have to provide an additional braking system for the loco to work both conventionally using the two-pipe system and effectively as an MU with an EP brake.

Isn't having the EP brake and air brake combinations all on one locomotive just what Class 73 (a 1960s design) long had, locos which handle other sectors of the Scottish sleeper operation.

 

[JohnMcL7]

If I'm reading the report correctly when the locomotive went through the neutral section, the pan dropped and the rheostatic brake was longer functional. What should happen normally in this situation?

 

[Bald Rick]

It’s a super report, and a classic example of the ‘Swiss cheese’ model:

* late changes to design and function of coupling / connection systems
* BPIC not designed to correct standard (as a result of above)
* BPIC positioned in a place where it could be operated inadvertently
* Procedure for timing of brake continuity test had the potential for a different interpretation to the intention of the procedure relating to the coupling / connection procedure for this stock
* VCB opened and did not close, preventing use of Rheo brake
* Train manager didn’t have a functioning radio with him for communication with driver

It is likely that if any of these had been different, the incident would not have happened (or the train would have been brought to a stand at Waverley)

Fortunately, a couple of the swiss cheese holes were not aligned:

* the train had a route set through Slateford / Haymarket to Waverley, ie no conflicting movements set against it
* the driver had the presence of mind not to press the GSMR REC button
* the driver was able to contact the signaller, and the signaller was able to action the setting of a route through Waverley in short order
* the train manager was sufficiently aware of a problem, and pressed the passenger alarm button in the train (albeit it took two attempts).

Had one or more of these been ‘aligned’, then the consequences could have been rather worse.

A lucky escape, but a very unlucky chain of events.

 

[O L Leigh]

Isn't having the EP brake and air brake combinations all on one locomotive just what Class 73 (a 1960s design) long had, locos which handle other sectors of the Scottish sleeper operation.

Correct. But it's a system that is not replicated on the Cl92. To be clear, I'm not suggesting that a loco cannot have an EP brake, but rather that to have an EP brake the loco would require a fairly extensive electrical refit.

 

[37057]

Isn't having the EP brake and air brake combinations all on one locomotive just what Class 73 (a 1960s design) long had, locos which handle other sectors of the Scottish sleeper operation.

I can't speak for the original brakes on a 73 but a while back I had a nosey inside a Caledonian 73/9 in Craigentinny and what I saw was a joystick type brake controller, similar to that of a 92! (though it could have been the straight air).

 

[hexagon789]

That's exactly one of the recommendations made.

Thanks I missed that bit but I did look for the recommendations in the report but couldn't seem to find that section.

It is also a flawed design to have a below-standard isolating cock in a position that is close to the ETH socket.

I’m also not seeing the advantage of the Dellner coupler given it has to be lifted on the loco before use. The whole point of it is to avoid manual handling. This incident would never have occurred if old fashioned screw couplers (loco), buckeyes (stock) and conventional air pipes/cocks had been in use.

Very flawed, I'm surprised that it wasn't required to be resited before the coaches entered traffic.