Incident at Loversall Carr (Doncaster) involving two freight trains (05/07/22)

[Watershed]

It's concerning that we continue to see FOC incidents (partly) caused by fatigue, due to long, consecutive night shifts. GBRf were clearly paying mere lip service to their obligations to minimise this. It also highlights the importance of monitoring drivers for medical conditions such as sleep apnea, which can have a significant impact on their ability to sleep well.

The lack of an ATP system is also a direct contributing cause to this accident (despite not being mentioned as such by the RAIB). TPWS was always a stopgap measure and should have been replaced with ATP as soon as practicable; it's disappointing that there is no move - even 20 years after TPWS fitment was completed - to roll out an ATP system nationwide. ETCS rollout is piecemeal and will take decades to reach most areas.

There's also mention of the fact that the signalling design doesn't comply with modern standards - as it allows a flashing yellow sequence even where there's a train just after the first signal past the junction. As a minimum, I'd expect the RAIB to make a recommendation that this standard is applied retrospectively, to reduce the likelihood of this sort of error.

If it had been a passenger train in front, we'd almost certainly be looking at fatalities and calls for safety standards to be improved. Unfortunately, as it's 'only' some bent containers and wagons, it seems that little will be learned from this incident.

 

[DerekC]

Why in a couple of instances does the summary refer to the driver of 4E11 as if there were two drivers? "It is also possible that the driver’s awareness was affected by their low workload" and "and by their expectation, based on previous experience," and also "and they had experienced a low quality of rest"?

This does illustrate why the use of "they" as a non-gender-specific singular when it is normally plural, represents a loss of clarity. I can understand and support the need for a non-gender-specific term, but it's a pity that a new one wasn't invented. Too late now, however!

 

[GordonT]

This does illustrate why the use of "they" as a non-gender-specific singular when it is normally plural, represents a loss of clarity. I can understand and support the need for a non-gender-specific term, but it's a pity that a new one wasn't invented. Too late now, however!

Also interesting to reflect upon how far the world has progressed from the days when "railway servants" were actually named in the published accidents reports. Often the retired army Major or Colonel would comment in his report along the lines of "Signalman Tonks was evasive under my questioning and in all respects I found Tonks to be a most unsatisfactory witness." However this is a possible topic for a different thread.

 

[jfowkes]

This does illustrate why the use of "they" as a non-gender-specific singular when it is normally plural, represents a loss of clarity. I can understand and support the need for a non-gender-specific term, but it's a pity that a new one wasn't invented. Too late now, however!

Are there any trains operating today that can be said to have multiple drivers?
I can see that there are instances where there would be multiple crew members in the cab and even other qualified drivers. But at a particular point in time there's only one actual driver of a particular train. Is that a fair statement?

 

[GC class B1]

I am confused by this report. Clause 52 states that the train passed over the AWS magnet for signal D197, which was at red, at 65 MPH. This seems to be excessive as the driver had been braking on the approach to the single yellow. If I have read the report correctly, figure 5 shows the speed at the AWS magnet for Signal D197 to be 53.7 MPH. Can anyone please help me to understand this aspect of this report.
Also could a signalling specialist let me know whether a train that was braking and still travelling at 65 MPH at the AWS magnet for the red signal D197 hadn’t initiated an Emergency Brake application at the OSS loop preceding yellow signal. I understand from the report that D197 didn’t have a TSS loop.

 

[DerekC]

It's concerning that we continue to see FOC incidents (partly) caused by fatigue, due to long, consecutive night shifts. GBRf were clearly paying mere lip service to their obligations to minimise this. It also highlights the importance of monitoring drivers for medical conditions such as sleep apnea, which can have a significant impact on their ability to sleep well.

It's also evident that rest day working is a factor here - and that it allowed the driver to work a progressively varying shift pattern, whereas the intention of the rest days should be to buffer the change between two different patterns.

The lack of an ATP system is also a direct contributing cause to this accident (despite not being mentioned as such by the RAIB). TPWS was always a stopgap measure and should have been replaced with ATP as soon as practicable; it's disappointing that there is no move - even 20 years after TPWS fitment was completed - to roll out an ATP system nationwide. ETCS rollout is piecemeal and will take decades to reach most areas.

It's surprising that RAIB didn't ask Network Rail to reassess the need for TPWS in these and similar circumstances. As regards ATP, it's the cost per fatality prevented that's the issue - do you spend the public money on ATP or something which would save more lives? There have been rumblings for some time about a low cost ETCS-compatible overlay system, but I am not sure what's happened to that.

 

[Sly Old Fox]

RDW is like a drug. You don’t need it, but you get used to it being there in your pay packet and going without it unexpectedly is hard. So you keep doing it and agreeing to more, no matter the effect on your body.

 

[FrodshamJnct]

I am confused by this report. Clause 52 states that the train passed over the AWS magnet for signal D197, which was at red, at 65 MPH. This seems to be excessive as the driver had been braking on the approach to the single yellow. If I have read the report correctly, figure 5 shows the speed at the AWS magnet for Signal D197 to be 53.7 MPH. Can anyone please help me to understand this aspect of this report.

Hmm, interesting, section 39 does indeed seem to contradict section 52:

39 The driver made two further train brake applications, which had reduced the train’s speed to 54 mph (86 km/h) at the point they acknowledged the AWS warning for signal D197 (in 0.5 seconds). Witness evidence, forward-facing CCTV and OTDR data show that the driver made a full train brake application at a point when both signal D197 and the flashing taillight on the rear of 4E82 were visible

52 Train 4E11 was travelling at 65 mph (104 km/h) when the driver acknowledged the AWS warning for signal D197 (which was displaying a red aspect). The AWS magnet is located at the same position where signal D197 first comes into the driver’s view. GBRf requires drivers to control the speed of trains so that they are travelling at no more than 10 mph (16 km/h) when the train passes over an AWS magnet on the approach to a signal displaying a red aspect.

 

[12LDA28C]

The lack of an ATP system is also a direct contributing cause to this accident (despite not being mentioned as such by the RAIB). TPWS was always a stopgap measure and should have been replaced with ATP as soon as practicable; it's disappointing that there is no move - even 20 years after TPWS fitment was completed - to roll out an ATP system nationwide. ETCS rollout is piecemeal and will take decades to reach most areas.

You'll never see a nationwide ATP system in use, the huge cost and current financial pressures on the railway will see to that. TPWS4 has superseded ATP and even Chiltern no longer use the obsolete system.

 

[Deepgreen]

Are there any trains operating today that can be said to have multiple drivers?
I can see that there are instances where there would be multiple crew members in the cab and even other qualified drivers. But at a particular point in time there's only one actual driver of a particular train. Is that a fair statement?

No, because "multiple" is not the right term here! It has, bizarrely, been adopted by the BBC and so many others to mean 'several' or 'many' when that isn't what it means, which is to operate in tandem or in concert, being connected (as in 'multiple unit'). Sorry - not having a go at you personally but just at yet another term being muddled into parlance by the BBC, who should know better.

 

[12LDA28C]

It doesn't? "Their" is used as a possessive indicating it is about that specific person (the driver) and "They" is used to refer to someone of unspecified gender. Those sentences don't, in context, suggest anything other than one driver to me.

Exactly, and the use of "the driver's awareness" clearly relates to a single driver, unlike "the drivers' awareness" which would relate to more than one driver. Basic knowledge of grammar and punctuation assists in understanding what is meant here.

 

[island]

Going from 0305-1233 (three times) then 0130-1055, 1101-2100, 2009-0759 shifts on consecutive days is a recipe for disaster.

 

[Watershed]

You'll never see a nationwide ATP system in use, the huge cost and current financial pressures on the railway will see to that.

If this accident had resulted in as many fatalities as Ladbroke Grove, then perhaps we would. That's what led to the nationwide rollout of TPWS. Sadly, the impetus for change seems only to come from media pressure.

TPWS4 has superseded ATP and even Chiltern no longer use the obsolete system.

I'm not talking about ATP in the sense of the BR-era systems used on the Great Western, and (scandalously, no longer) on the Chiltern line. I'm talking about a system that provides automatic train protection functionality. In the modern sense that's likely to mean ETCS, but other systems are also available.

The problem with TPWS, regardless of version, is that it doesn't provide continuous speed supervision and doesn't completely prevent signals being passed at danger - it only reduces the likelihood thereof.

 

[12LDA28C]

The problem with TPWS, regardless of version, is that it doesn't provide continuous speed supervision and doesn't completely prevent signals being passed at danger - it only reduces the likelihood thereof.

And neither did ATP although whether that can be said of ETCS I couldn't say.

 

[zwk500]

And neither did ATP although whether that can be said of ETCS I couldn't say.

The Chiltern ATP was discontinuous but ETCS L2 is continuous speed supervision. Level 1 is normally continuous but there is a Limited Supervision mode that would do effectively what Chiltern ATP did (AIUI). AFAIK nowhere in the UK is proposed for Level 1 of either kind, and there is no suggestion from NR of exploring Limited supervision for L2.

 

[edwin_m]

It's surprising that RAIB didn't ask Network Rail to reassess the need for TPWS in these and similar circumstances. As regards ATP, it's the cost per fatality prevented that's the issue - do you spend the public money on ATP or something which would save more lives? There have been rumblings for some time about a low cost ETCS-compatible overlay system, but I am not sure what's happened to that.

The report points out that very few trains approach this signal at red, which suggests that TPWS wouldn't bring much benefit. However, the very fact that it doesn't happen more often may make it a higher risk when it does. It's somewhat reminiscent of the Lumo incident in Peterborough in this respect, and also in the misinterpretation of an approach controlled signal.

 

[Towers]

RDW is like a drug. You don’t need it, but you get used to it being there in your pay packet and going without it unexpectedly is hard. So you keep doing it and agreeing to more, no matter the effect on your body.

Of course, some folk get themselves into a situation where RDW very much is needed!

 

[mwmbwls]

It's concerning that we continue to see FOC incidents (partly) caused by fatigue, due to long, consecutive night shifts. GBRf were clearly paying mere lip service to their obligations to minimise this. It also highlights the importance of monitoring drivers for medical conditions such as sleep apnea, which can have a significant impact on their ability to sleep well.

The lack of an ATP system is also a direct contributing cause to this accident (despite not being mentioned as such by the RAIB). TPWS was always a stopgap measure and should have been replaced with ATP as soon as practicable; it's disappointing that there is no move - even 20 years after TPWS fitment was completed - to roll out an ATP system nationwide. ETCS rollout is piecemeal and will take decades to reach most areas.

There's also mention of the fact that the signalling design doesn't comply with modern standards - as it allows a flashing yellow sequence even where there's a train just after the first signal past the junction. As a minimum, I'd expect the RAIB to make a recommendation that this standard is applied retrospectively, to reduce the likelihood of this sort of error.

If it had been a passenger train in front, we'd almost certainly be looking at fatalities and calls for safety standards to be improved. Unfortunately, as it's 'only' some bent containers and wagons, it seems that little will be learned from this incident.

My late and sadly missed friend, Dr Jim Ford of Southport and Portmadog was the Occupational Health Specialist for Northern. This meant that he had a cab pass which he would use to travel in the cab from time to time. The Drivers knew him and he would chat to them when the train was stationery. He would ask an innocent question "What neck size shirt do you wear?". If the driver's answer was greater than 16 inches he would recommend that they consulted their doctor. I drove a desk not a train but he asked me the same question and that is how I came to be diagnosed with sleep apnea.

 

[Signal_Box]

Of course, some folk get themselves into a situation where RDW very much is needed!

There is another problem especially on the freight side, if jobs aren’t covered there is a potentially for contracts to be lost which can equal job losses.

There’s a unspoken fear that unless you bend over backwards to cover jobs then it could look bad when the grim reaper is looking for savings.

But certain companies have overstretched themselves without the resources to cover the work, which leads to the resources that are available being used to the maximum.

 

[GordonT]

There is another problem especially on the freight side, if jobs aren’t covered there is a potentially for contracts to be lost which can equal job losses.

There’s a unspoken fear that unless you bend over backwards to cover jobs then it could look bad when the grim reaper is looking for savings.

But certain companies have overstretched themselves without the resources to cover the work, which leads to the resources that are available being used to the maximum.

Literally a wake-up call to freight operators. Is there still a confidential means of employees with concerns about fatigue contacting an independent body to investigate, in effect whistleblowing, without any fear of recrimination?

 

[Towers]

Literally a wake-up call to freight operators. Is there still a confidential means of employees with concerns about fatigue contacting an independent body to investigate, in effect whistleblowing, without any fear of recrimination?

Yes, there is ‘CIRAS’ - an independent industry body who will take forward legitimate safety concerns and investigate on behalf of the informer. However, they will only become involved if all other safety avenues within the organisation have already been exhausted, which still requires a whistleblower to go down those avenues first.

 

[The Puddock]

Yes, there is ‘CIRAS’ - an independent industry body who will take forward legitimate safety concerns and investigate on behalf of the informer.

CIRAS is totally toothless. Their response to just about every issue is “We spoke to [company name] and they told us that it isn’t a problem. Thanks for your report.”

 

[12LDA28C]

The Chiltern ATP was discontinuous but ETCS L2 is continuous speed supervision. Level 1 is normally continuous but there is a Limited Supervision mode that would do effectively what Chiltern ATP did (AIUI). AFAIK nowhere in the UK is proposed for Level 1 of either kind, and there is no suggestion from NR of exploring Limited supervision for L2.

Chiltern ATP was continuous for speed supervision, but not for signalling aspects.

 

[Signal_Box]

Literally a wake-up call to freight operators. Is there still a confidential means of employees with concerns about fatigue contacting an independent body to investigate, in effect whistleblowing, without any fear of recrimination?

There are, but you might as well wee in the wind for all the good it does.

 

[Towers]

CIRAS is totally toothless. Their response to just about every issue is “We spoke to [company name] and they told us that it isn’t a problem. Thanks for your report.”

That’s depressingly predictable! Do they still publish their periodical with assorted success stories in it?

 

[edwin_m]

There is another problem especially on the freight side, if jobs aren’t covered there is a potentially for contracts to be lost which can equal job losses.

There’s a unspoken fear that unless you bend over backwards to cover jobs then it could look bad when the grim reaper is looking for savings.

But certain companies have overstretched themselves without the resources to cover the work, which leads to the resources that are available being used to the maximum.

The report noted that the accident driver was previously based at and lived near Immingham, but after the company lost a contract they were transferred to Doncaster with an hour of road driving before and after each shift.

Road accidents caused by over-tired employees are another source of danger to the public.

 

[newtownmgr]

I am confused by this report. Clause 52 states that the train passed over the AWS magnet for signal D197, which was at red, at 65 MPH. This seems to be excessive as the driver had been braking on the approach to the single yellow. If I have read the report correctly, figure 5 shows the speed at the AWS magnet for Signal D197 to be 53.7 MPH. Can anyone please help me to understand this aspect of this report.
Also could a signalling specialist let me know whether a train that was braking and still travelling at 65 MPH at the AWS magnet for the red signal D197 hadn’t initiated an Emergency Brake application at the OSS loop preceding yellow signal. I understand from the report that D197 didn’t have a TSS loop.

If you are referring to the over speed grids at the one yellow, they would not activate. The only ones that would be live are the over speed & train stop grids at the red. The only over speed grids that are live at all times are those for permanent speed restrictions/approaching stop blocks.

The spacing of signals should allow a train to pass a yellow signal at linespeed & allow sufficient braking distance to stop at the red. Obviously every company has a driving policy in place that dictates that you respond Positively at 2 yellows. For instance shut off power & coast etc

 

[Signal_Box]

The report noted that the accident driver was previously based at and lived near Immingham, but after the company lost a contract they were transferred to Doncaster with an hour of road driving before and after each shift.

Road accidents caused by over-tired employees are another source of danger to the public.

This is why Network Rail introduced the 14hr maximum day after a contractor died in a road accident after a long shift.

 

[12LDA28C]

If you are referring to the over speed grids at the one yellow, they would not activate. The only ones that would be live are the over speed & train stop grids at the red. The only over speed grids that are live at all times are those for permanent speed restrictions/approaching stop blocks.

The spacing of signals should allow a train to pass a yellow signal at linespeed & allow sufficient braking distance to stop at the red. Obviously every company has a driving policy in place that dictates that you respond Positively at 2 yellows. For instance shut off power & coast etc

This is not correct. I'm aware of many trains being brought to a stand by TPWS due to approaching a single yellow signal too fast.

 

[357]

This is not correct. I'm aware of many trains being brought to a stand by TPWS due to approaching a single yellow signal too fast.

Is it grids for the single yellow or TPWS+ grids for the red?