Derailment in Kent between Ashford and Canterbury (26/07)

[ComUtoR]

Poorly written. Its in reference to the previous crash and the identification that Obstacle deflectors should have, could have been fitted.

Class 375 units are part of a family of units known as Electrostars, and were built between 1999 and 2005. The vehicle standards in force at the time(8) specified requirements for obstacle deflectors in line with the Polmont recommendations (paragraph 45). These stated that obstacle deflectors should be fitted to vehicles with operational speeds of 145 km/h (90 mph) and above, unless their axleload was above 170 kN, or if they operated only on third rail lines. In the latter case, obstacle deflectors should be fitted to vehicles with operational speeds above 160 km/h. The class 375 units were specified with a maximum operating speed of 100 mph which, for the purposes of the standard, was deemed to be equivalent to 160 km/h.

 

[Zoidberg]

Anyone notice a mistake at point 47 or is it me. It's makes out its now a group standard, to me it makes no sence

No, it's not you.

I couldn't see the relevance of the final sentence in para 47 to what went before in that para.

I imagine that inclusion of that sentence in para 47 is a casualty of editting and that it belongs elsewhere.

--- old post above --- --- new post below ---

Poorly written. Its in reference to the previous crash and the identification that Obstacle deflectors should have, could have been fitted.

That makes sense.

 

[theironroad]

With regard to the MCB reset. It takes too long for the radio to reboot for that to have been a reasonable action to take. It would be a more significant risk to reboot the radio, wait till it reloads and tests, then hit the big red button. You would still not be confident for the radio to work.

It would introduce further risk if that became procedure because if that was a 4 car unit and it had tripped in both cabs then it adds too much time to your actions in an emergency. (reset your cab + reset rear cab)

If your MCB's tripped in an accident then it should be reasonable to accept that they had tripped correctly and are doing their job of protecting the electrical supply etc.

As to how Southeastern train their Drivers on emergency procedures. I can assure you its pretty much on every single assessment they do. Scenarios are walked through and your actions talked over at every step. I don't believe that this is a training issue.

I agree that the gsmr mcb reset would take too long, but I think a good learning point from this is if you have a dead gsmr after impact, then rest mcb anyway and then get on with next stage. I've found numerous times when setting up cab that either total gsmr is dead or it refuses to accept registration input. Straight away now I do mcb and every time so far it's sorted it, but does take a couple minutes.

I did put Sig box phone numbers in my phone many years ago, but aside from local box have never used any and never in a emergency, but will update from pon soon.

One raib suggestion to put these numbers on a cab notice is a good one I think and hope TOCs adopt it, because even if in your phone, might have dead battery etc.

I feel for the driver and there would have been thousands of things going through his head, but a little surprised to read he put the scb down but not TC clips on opposite line, but good effort for running up line to warn trains.

Also interesting that signaller felt pressure not to delay more trains. Whenever I report back after cautioning I always stress that it's what I've seen , or more often than not there is nothing to see. We are all human and could miss something, and as the report highlights, corridor units arent great for seeing offside at best of times. Should really be a minimum of two or three cautions before normal running resumed.

Hopefully TOCs will take notice that emergency scenarios should be practiced more. The good safety record of the railways in the last decade may have made some TOCs complacent.

Finally, seeing how this train demolished the parapet of the bridge, this incident could have been a lot worse had the any carriages toppled off the track.

 

[SPADTrap]

With regard to the MCB reset. It takes too long for the radio to reboot for that to have been a reasonable action to take. It would be a more significant risk to reboot the radio, wait till it reloads and tests, then hit the big red button. You would still not be confident for the radio to work.

It would introduce further risk if that became procedure because if that was a 4 car unit and it had tripped in both cabs then it adds too much time to your actions in an emergency. (reset your cab + reset rear cab)

If your MCB's tripped in an accident then it should be reasonable to accept that they had tripped correctly and are doing their job of protecting the electrical supply etc.

As to how Southeastern train their Drivers on emergency procedures. I can assure you its pretty much on every single assessment they do. Scenarios are walked through and your actions talked over at every step. I don't believe that this is a training issue.

I totally agree, can you imagine being in court to explain why, post collision instead of carrying out emergency protection as demanded by the rule book you went into a cupboard to investigate if the MCB was tripped or not or started messing with the MCBs on the back cab wall, during which time the train you'd have flagged to a stand piles into your train which is derailed and foul of another line?! And when the GSM-R finally boots up and you mash the red button you get a panel in Norwich.

And Siemens didn't test the integrity of the GSM-R in the event of a train colliding with something on the railway...

REALLY!!?! :roll::-x

 

[NSEFAN]

Would it be so difficult to have a small backup battery as part of the GSM-R kit? That way if the power is tripped it will continue to function for a while.

 

[SPADTrap]

Would it be so difficult to have a small backup battery as part of the GSM-R kit? That way if the power is tripped it will continue to function for a while.

It does have a that already, it wasn't just the power that was tripped upon current isolation but the GSM-R MCB tripped, perhaps a safety feature could be that this doesn't isolate the battery from the radio? Unless it already does and I have misunderstood.

 

[NSEFAN]

Yes a battery that cannot be isolated in that manner might be a good idea. I'm a little surprised that an MCB for the backup battery is fitted in the first place, to be honest. I know the GSM-R kit is safety critical and needs to be robust, but in terms of complexity is it really much more advanced than a standard mobile phone?

 

[SPADTrap]

Yes a battery that cannot be isolated in that manner might be a good idea. I'm a little surprised that an MCB for the backup battery is fitted in the first place, to be honest. I know the GSM-R kit is safety critical and needs to be robust, but in terms of complexity is it really much more advanced than a standard mobile phone?

To my knowledge there isn't an MCB for the backup battery but my stock does have a seperate button for the 'UPS' to the GSM-R which I've used when I was stuck and the OLE was isolated and my batteries died. I'm not sure if the tripping of the main GSM-R MCB will prevent this 'UPS' from functioning though although I'd hope not, but if Siemens didn't think testing the GSM-Rs robustness if the event of a collision then...

 

[ainsworth74]

I wonder if another learning point might be to, before going for another train or signal post telephone, check if the GSMR is operational in any other units that might happen to be in the formation?

 

[ComUtoR]

ironroad makes a good point in that it could form part or the procedure as long as it is more a reset and continue rather than reset and wait. I'm also not sure if ALL GSMR MCB's are in the cab either so you need to ensure that the GSMR MCB is readily accessible.

I wonder if another learning point might be to, before going for another train or signal post telephone, check if the GSMR is operational in any other units that might happen to be in the formation?

It already is. (rule book as well I think) The problem is time. In an emergency we are taught all possibilities through scenario based training, using the simulator and the simkits. As well as many many briefings on the subject.

I've never been convinced that you should walk past your train to another cab, enter that cab, then try the radio. There are too many what if's to consider. No communication is certainly a priority but do you potentially walk 200yrds on ballast past a derailment just to check a radio when you have already seen the radio failed ? Those questions are boiling in the Drivers head at lightning speed.

Ultimately in an emergency we are taught that you must use what you believe to be the best methods at the time. In this instance the Driver believed that protecting the passengers with the bar was a priority and then communication and stopping oncoming trains were his next priority. Even if he used TCOC's and reverted the signals to red he still would have to seek communication just in case. His priority was to get communication.

He used local knowledge and headed towards an oncoming train whilst seeking communication. There was another Driver and a Guard mentioned in the report and potentially he may have believed or may have asked for them to protect the line. The Driver made a judgement call and that is his job. There is no right or wrong in an emergency as long as you are making decisions.

The rule book doesn't specify what order to do things and what to do if it was a multiple layout etc. We have tools and guidance at our disposal and are expected to make the best decision. Its why we are taught just to do our absolute best. Your never going to be 100% in an emergency.

The GSMR is certainly a concern and no TOC should have been allowed to choose if battery backup was "optional"

Handheld terminals may be a decent step forward but an expensive one. When I first saw them I wondered why we were not issued them as our company mobiles. Operationally my mobile only has one use; emergencies.

 

[TEW]

I wonder if another learning point might be to, before going for another train or signal post telephone, check if the GSMR is operational in any other units that might happen to be in the formation?

The problem of course is time. You could waste a lot of it going to check if the GSMR is working in any other cab. And if you don't yet have any assurance that any obstructed lines are blocked to trains you don't want to be wasting time. If the train has a guard then checking the train for working GSMR could be something the guard does whilst the driver goes to find an alternative means of contacting the signaller.

 

[pompeyfan]

I'm clearly talking without experience, but could a 999 call with specific instructions to relay a message to X signal box be a viable alternative? I know you have to factor in the fact that modern mobile phones can take an eternity to boot up, but with no experience that would seem like a sensible idea.

 

[notlob.divad]

I am not a train driver, or really involved in the industry, just an interested passenger and an Electrical Engineer in another industy. Please don't bite my head off if anything I say is obvious or comes across as crass.

My first question is, If there is a radio in the rear unit, and the member of staff in the rear unit has been made aware of the incident, could they try the radio there?

Secondly the talk about restarting the radio. I hope I am not offending any wonderful drivers on here, but I would not expect them to be qualified electricians. Resetting an MCB is fine in normal circumstances, but having just experienced an emergency I would never expect a driver to go looking in switchboards for a switch which may bring the radio back to life, but may equally make the situation worse. Primarily because you have no idea what damage may have been caused out of view. It is certainly not something I would write into a procedure in our industry.

I would have thought Mobile phones are risky to reliance and should be kept as a last resort, coverage is still not 100% particularly on rural routes. However a list of signal box numbers in the area would surely be sensible even for non-emergency situations.

Obviously you guys have a lot more experience on the priorities of safety on the railway so I divest to you the order of any action to be taken. From what I have read this driver seems to have acted upon instinct and made some good decisions, protecting the passengers of his train and then of the on coming train. One thing that I don't know about is these clips. What are they? I am assuming it is something to trigger the track circuits, but if someone could clarify that would be greatly appreciated.

As people are saying communication is critical in the aftermath of any incident, and if he felt the quickest way to ensure everyone is safe and establish communication was to run down the isolated line to flag down an oncoming train then I don't think anyone could fault him.

Finally, I read in the report prior to the incident, one train was sent through under caution in the opposite direction and reported nothing. Is this normal practice? I would feel that was too few and would expect at least a train in each direction to go through observing. A cow, or anything for that matter, in a dip on the other side of the line must surely be miss-able to even the most beady eye of observer.

 

[the sniper]

I've got to be honest, I find the report's disinterest in what the Guard was doing to be a bit bizarre. For a start, they're not even mentioned in the 'Staff involved' section. Other than acknowledging that there was a Guard, their involvement is only briefly mentioned once:

Events during the accident

26 The driver applied the brakes and once the train had stopped, he contacted the guard, who was in the third carriage of the train, using the train’s internal communications system. The travelling driver, realising that an accident had occurred, entered the rearmost cab of the train and overheard this conversation. He then started making his way forward through the train to assist the driver and passengers.

No more detail than that. What was the Guard up to? The report gives no detail. Had they been in the back, and were walking through the train to contact the Driver? If they had been in the back cab, did they believe the opposite line wasn't obstructed by whatever had happened, so didn't put down the track circuit clips? Were they in the third carriage doing tickets and just happened to get to the phone when the driver called? Were they on their way to check the line? What was agreed and understood between them and the Driver? Did the Driver know the GSM-R wasn't working in the leading cab when he called the Guard? The time line of the report doesn't make this clear.

Going by their omission from the report, you have to presume that the report deems them to have acted entirely correctly, which is great. Personally for me as a Guard though this incident highlighted major learning points to use should I be involved in a major incident like this. Maybe RAIB wouldn't acknowledge these as it would make the industry pig sick to accept that a Guard has a role to play, and that putting all you eggs in the basket of one Driver and GSM-R in an emergency might not be ideal...

 

[ComUtoR]

My first question is, If there is a radio in the rear unit, and the member of staff in the rear unit has been made aware of the incident, could they try the radio there?

Potentially yes. They would need to be trained on the equipment though or at least know the minimum needed in an emergency.

Secondly the talk about restarting the radio. I hope I am not offending any wonderful drivers on here, but I would not expect them to be qualified electricians. Resetting an MCB is fine in normal circumstances, but having just experienced an emergency I would never expect a driver to go looking in switchboards for a switch which may bring the radio back to life, but may equally make the situation worse. Primarily because you have no idea what damage may have been caused out of view. It is certainly not something I would write into a procedure in our industry.

Hence my earlier posting.

I would have thought Mobile phones are risky to reliance and should be kept as a last resort, coverage is still not 100% particularly on rural routes.

Mobiles can be used if no other method of communication is available. No mobile then means you go the emergency distance and seek the quickest form of commnication. Hence the Drivers actions.

However a list of signal box numbers in the area would surely be sensible even for non-emergency situations.

They are programmed into the GSMR :/

One thing that I don't know about is these clips. What are they? I am assuming it is something to trigger the track circuits, but if someone could clarify that would be greatly appreciated.

That is exactly what they are.

Finally, I read in the report prior to the incident, one train was sent through under caution in the opposite direction and reported nothing. Is this normal practice?

Stop and caution was done and is standard practice. In this case nothing was found. Its more commonplace for the unit in front to see an animal etc but the unit behind see nothing.

A cow, or anything for that matter, in a dip on the other side of the line must surely be miss-able to even the most beady eye of observer.

Probably exactly what happened

but could a 999 call with specific instructions to relay a message to X signal box be a viable alternative?

Not really. I don't believe the police have direct communication with the signal boxes and you are introducing a variable. Also if you had communication you could just as quickly call the box directly. I think the RAIB were correct when they said that numbers should be programmed into company mobiles
--- old post above --- --- new post below ---

No more detail than that. What was the Guard up to? The report gives no detail. Had they been in the back, and were walking through the train to contact the Driver? If they had been in the back cab, did they believe the opposite line wasn't obstructed by whatever had happened, so didn't put down the track circuit clips? Were they in the third carriage doing tickets and just happened to get to the phone when the driver called? Were they on their way to check the line? What was agreed and understood between them and the Driver? Did the Driver know the GSM-R wasn't working in the leading cab when he called the Guard? The time line of the report doesn't make this clear.

You make some good points.

The RAIB report facts and pretty much nothing else. If the Guard was carrying out their duties on-board then its not really relevant to the derailment. Their investigation was solely about the derailment. I don't know if the Guard was trained in the use of the GSMR. The second Driver would have been and should have been involved in the safety of the line. Again, the report is about the derailment rather than anything else. If the was a collision then I think they would be investigating it as a crash and then all actions would be relevant.

 

[TEW]

I'm interested as to why the report did not touch more on the guard's actions too. The rulebook requires the guard of a train involved in an accident to check if other lines are obstructed, and then apply track circuit operating clips to any lines obstructed, and then contact the driver to agree what will be done regarding emergency protection. This incident highlights the importance of doing this as the driver had not applied track circuit operating clips. The guard could also have attempted to contact the signaller by other means, either their mobile phone or the GSMR in another cab. I'm pretty sure the guard would have been trained in the use of the GSMR, the RAIB have noted the importance of train crew being trained in its use previously, in to the investigation in to the electroctuion of a driver at Sutton Weaver: https://assets.digital.cabinet-offi...b615b600001a/R072015_150624_Sutton_Weaver.pdf
--- old post above --- --- new post below ---

I'm clearly talking without experience, but could a 999 call with specific instructions to relay a message to X signal box be a viable alternative? I know you have to factor in the fact that modern mobile phones can take an eternity to boot up, but with no experience that would seem like a sensible idea.

There was another RAIB report out recently in to the collision between a train and a fallen bridge parapet at Foxfield which highlighted how a 999 call is not effective at protecting the lines:
https://assets.digital.cabinet-offi...ed915d468c00002f/R022016_160120_Froxfield.pdf

A member of public made a 999 call about the obstruction around 8 minutes before the collision, but provisions were not made to stop the train in time.

 

[notlob.divad]

Thanks to ComUtoR for answering my questions

They are programmed into the GSMR :/

To this day I have still not found anything better than a laminated piece of paper.

There was another RAIB report out recently in to the collision between a train and a fallen bridge parapet at Foxfield which highlighted how a 999 call is not effective at protecting the lines:
https://assets.digital.cabinet-offi...ed915d468c00002f/R022016_160120_Froxfield.pdf

A member of public made a 999 call about the obstruction around 8 minutes before the collision, but provisions were not made to stop the train in time.

This being why all railway bridges have a phone number on them to ring before 999 in case of a bridge strike. But I have to admit, I think I would instinctively think to call 999, as I am sure many members of the public would. Chances are you already have a number of passengers thinking or calling 999. (or the local newspaper depending on how serious it is) so I don't see the driver doing it to is going to help when there are other people more specifically trained in these issues who could be contacted.

 

[Llanigraham]

I'm clearly talking without experience, but could a 999 call with specific instructions to relay a message to X signal box be a viable alternative? I know you have to factor in the fact that modern mobile phones can take an eternity to boot up, but with no experience that would seem like a sensible idea.

Doubtful.
Most 999 Control Centres wouldn't know where you were talking about, especially as they could be hundreds of miles away, and they would have to have the number of every Box in the country.

 

[nom de guerre]

Finally, I read in the report prior to the incident, one train was sent through under caution in the opposite direction and reported nothing. Is this normal practice? I would feel that was too few and would expect at least a train in each direction to go through observing. A cow, or anything for that matter, in a dip on the other side of the line must surely be miss-able to even the most beady eye of observer.

No, it's not normal practice. The standard procedure in this type of situation is to caution a minimum of one train in each direction. If neither driver reports anything amiss, the signaller would then typically resume normal working.

 

[bramling]

I agree that the gsmr mcb reset would take too long, but I think a good learning point from this is if you have a dead gsmr after impact, then rest mcb anyway and then get on with next stage. I've found numerous times when setting up cab that either total gsmr is dead or it refuses to accept registration input. Straight away now I do mcb and every time so far it's sorted it, but does take a couple minutes.

I did put Sig box phone numbers in my phone many years ago, but aside from local box have never used any and never in a emergency, but will update from pon soon.

One raib suggestion to put these numbers on a cab notice is a good one I think and hope TOCs adopt it, because even if in your phone, might have dead battery etc.

I feel for the driver and there would have been thousands of things going through his head, but a little surprised to read he put the scb down but not TC clips on opposite line, but good effort for running up line to warn trains.

Also interesting that signaller felt pressure not to delay more trains. Whenever I report back after cautioning I always stress that it's what I've seen , or more often than not there is nothing to see. We are all human and could miss something, and as the report highlights, corridor units arent great for seeing offside at best of times. Should really be a minimum of two or three cautions before normal running resumed.

Hopefully TOCs will take notice that emergency scenarios should be practiced more. The good safety record of the railways in the last decade may have made some TOCs complacent.

Finally, seeing how this train demolished the parapet of the bridge, this incident could have been a lot worse had the any carriages toppled off the track.

I think the RAIB's semi-criticism of the driver's response is unjustified. Having just walked out of a 70mph derailment he's bound to be in a degree of shock, so the fact that he applied the SCD and ran along the tracks is commendable in itself. Indeed, had the oncoming train already passed its last applicable signal then this would have been the only effective response.

Expecting the driver to fiddle with MCBs is bordering on farcical IMO, I definitely wouldn't entertain it after such an incident - especially in a train which is at risk of being hit by another.

As others have noted, it's strange how RAIB don't say much about what role the guard did or didn't play. Had the driver been incapacitated in the derailment then the guard would have been a vital resource.

 

[ComUtoR]

I think the RAIB's semi-criticism of the driver's response is unjustified.

RAIB reports are hard to read. They are not critical or judgemental. They are very impassioned and stick to facts only. The fact is that the Driver did not fully adhere to the rule book and other actions could have been taken that may have had a significant impact on the situation. Learning points are raised and recommendations are made to mitigate against future incidents.

They are cold and clinical. I do understand and respect that we have an independent accident investigation branch but I really wish they had more powers of enforcement.

Another body could be responsible to ensure that actions and recommendations from previous accidents. I hate reading RAIB reports and seeing the list of recommendations from previous accidents that had not been implements that could have prevented or at least mitigated against another accident.

 

[nom de guerre]

Also interesting that signaller felt pressure not to delay more trains.

Not sure why (the signaller, that is - not your comment). I've never heard of a signaller being censured for causing delays due to cautioning.

 

[SpacePhoenix]

Are all staff who work the trains (no matter what their job) trained how to operate the GSM-R or is it strictly drivers and guards only?

 

[theironroad]

... I hate reading RAIB reports and seeing the list of recommendations from previous accidents that had not been implements that could have prevented or at least mitigated against another accident.

It was very interesting that in this report, the raib have also said that had some of their recommendations from previous reports been implemented it would have mitigated or prevented the issues in this report.

 

[nom de guerre]

I think the RAIB's semi-criticism of the driver's response is unjustified. Having just walked out of a 70mph derailment he's bound to be in a degree of shock, so the fact that he applied the SCD and ran along the tracks is commendable in itself. Indeed, had the oncoming train already passed its last applicable signal then this would have been the only effective response.

Expecting the driver to fiddle with MCBs is bordering on farcical IMO, I definitely wouldn't entertain it after such an incident - especially in a train which is at risk of being hit by another.

I think the "semi-criticism" is entirely justified (and not just of the driver).

The driver, guard, travelling driver and signaller all made errors which, had circumstances been slightly different, might have resulted in the oncoming train ploughing into the stricken 2R66.

Why did the signaller only caution one train before returning to normal working (and why were control satisfied with this)? Why did neither the driver, guard or travelling driver use the most efficient methods of protecting their train - making a GSM-R REC (using a different handset/by tripping MCBs), applying a TCOC to the opposite line, contacting the signaller directly? Did the driver, guard or travelling driver have the signal box phone number stored in their mobiles - if not, why not? Why did it take ten minutes to alert the signaller that a train was heading towards the scene of a derailment? Why did the signaller not use the highest priority of GSM-R call to stop the oncoming train? All valid questions, IMO...

 

[GB]

Where does it say in the rule book the signaller MUST caution at least one train in each direction?

What happens when there is only one train available anyway?

 

[BestWestern]

Are all staff who work the trains (no matter what their job) trained how to operate the GSM-R or is it strictly drivers and guards only?

It is only Drivers and Guards who work trains....?!

Revenue and catering bods wouldn't generally be trained in anything to do with train working, although supposedly Virgin do train their buffet crews in some safety procedures, so I believe? I wouldn't have thought that would extend to entering cabs and making emergency calls, but don't quote me on it!

The equipment is very user friendly, the emergency call function in particular.

 

[ainsworth74]

It is only Drivers and Guards who work trains....?!

I figure they meant 'work on' trains

 

[BestWestern]

I'm interested as to why the report did not touch more on the guard's actions too. The rulebook requires the guard of a train involved in an accident to check if other lines are obstructed, and then apply track circuit operating clips to any lines obstructed, and then contact the driver to agree what will be done regarding emergency protection. This incident highlights the importance of doing this as the driver had not applied track circuit operating clips. The guard could also have attempted to contact the signaller by other means, either their mobile phone or the GSMR in another cab. I'm pretty sure the guard would have been trained in the use of the GSMR, the RAIB have noted the importance of train crew being trained in its use previously, in to the investigation in to the electroctuion of a driver at Sutton Weaver.

Regretfully, from what I hear it seems that at some TOCs those who appreciate the importance of Guards being properly trained and instilled with the confidence to carry out their roles properly and fully, are up against management who wish to undermine the relevance of the job at every opportunity. This has lead to a sliding decline in the confidence and expertise of the Guard grade, and in particular a culture of "the Driver will do it" when anything happens out of course, even when it should be well within a Guard's capabilities to act themselves. I have absolutely no idea if that has any bearing here, but it is something which may play an unfortunate part in such incidents.

Of course, in this case the Guard may have been injured, shocked or simply told by the Driver that the protection was being taken care of. As RAIB also seems to have disregarded this second fully trained crew member, I suspect we shall never know.

I figure they meant 'work on' trains

I expect so!

 

[bramling]

I think the "semi-criticism" is entirely justified (and not just of the driver).

The driver, guard, travelling driver and signaller all made errors which, had circumstances been slightly different, might have resulted in the oncoming train ploughing into the stricken 2R66.

Why did the signaller only caution one train before returning to normal working (and why were control satisfied with this)? Why did neither the driver, guard or travelling driver use the most efficient methods of protecting their train - making a GSM-R REC (using a different handset/by tripping MCBs), applying a TCOC to the opposite line, contacting the signaller directly? Did the driver, guard or travelling driver have the signal box phone number stored in their mobiles - if not, why not? Why did it take ten minutes to alert the signaller that a train was heading towards the scene of a derailment? Why did the signaller not use the highest priority of GSM-R call to stop the oncoming train? All valid questions, IMO...

I agree to a point.

The issue of how many trains should have been cautioned is definitely something which needs further thought.

Likewise we don't know what the guard did or didn't do, as this element is conspicuously missing from the report.

However I don't think we should be overly critical of the driver. No one is going to be thinking at their best having just walked out of a 70 mph derailment. To be honest, in such a situation you are lucky with whatever happens -- in this case the driver did take useful actions, but also made an omission (the clips). However the clips would have been useless had the train already entered the section, bearing in mind this area has some longish signal sections. Easy to criticise with hindsight. I agree that *someone* should have done it, however.