Low speed buffer collision at London Kings Cross 15/08/17

[AM9]

This has to get an award for being one of the silliest posts I've ever read.

Well bitten.

 

[Adlington]

RAIB is investigating:

At 06:23 hrs on Tuesday 15 August 2017 a train arriving from Royston collided with the buffer stops in platform 9 at Kings Cross station, while travelling at about 4 mph (6 km/h). Three passengers were slightly hurt, and there was minor damage to the train and the buffer stop equipment.

We have undertaken a preliminary examination of the circumstances surrounding this accident. Having assessed the evidence which has been gathered to date, we have decided to publish a safety digest.

The safety digest will shortly be made available on our website.

 

[Adlington]

A safety digest has been published: html & pdf.
The main point:

The accident occurred because the driver was suffering from fatigue and apparently experienced a microsleep in the last few seconds of the approach to the buffer stops. The driver reported being aware of passing the TPWS sensor but then briefly closed her eyes because they felt tired and were stinging. When she opened them, she was close to the buffer stops and, although she made an emergency brake application, it was too late to avoid a collision.

The driver was fatigued because this journey was at the end of a relatively demanding night shift, which was her first night shift after a period of rest days, and because she was not sufficiently well rested.

 

[Joe Paxton]

A safety digest has been published: html & pdf.

On a more general note, as a question for drivers and indeed other railway staff on this forum, how do you manage and indeed avoid fatigue, and ensure you are well rested before your shift (particularly night shifts)? In other words, what are the tricks of your trade?

 

[dk1]

On a more general note, as a question for drivers and indeed other railway staff on this forum, how do you manage and indeed avoid fatigue, and ensure you are well rested before your shift (particularly night shifts)? In other words, what are the tricks of your trade?

There are none. If you can't sleep you can't sleep. I have known some drivers (often the same few) who have said they are too tired to drive & nobody is going to allow them to after stating that. Most of us just wing it, open a window if possible or drink strong coffee. I'd be worried if I dozed off between the TPWS & buffer stops in a platform.

 

[Adlington]

how do you manage and indeed avoid fatigue, and ensure you are well rested before your shift

The RAIB safety digest quotes two documents on this subject:
https://www.rssb.co.uk/Pages/research-catalogue/T1084.aspx
https://www.rssb.co.uk/rgs/standards/RS504 Iss 1.pdf

I'm sure there are many unpublished tricks of the trade.

 

[Bletchleyite]

A thought on this that occurred to me...if you're a bit tired driving your car you are recommended to have a caffeinated drink, a brief kip and once going again after said kip to open the window and play the radio.

Obviously a train driver can do 3 of those 4 (provided the kip is during their break) - but should it actually be considered to allow fitting of a radio in train cabs in order to break the monotony?

 

[Bromley boy]

On a more general note, as a question for drivers and indeed other railway staff on this forum, how do you manage and indeed avoid fatigue, and ensure you are well rested before your shift (particularly night shifts)? In other words, what are the tricks of your trade?

I hate early starts and tend to swap my early shifts away so I end up doing a week of "office hours" earlies starting at 0800 or 0900 and a week of lates. Early-early shifts are far more popular than late-early shifts (if that makes sense) so it's quite easy to swap.

Generally I try and eat at the correct meal times irrespective of shift, and avoid lying in too long after a late shift to maintain my body clock at something approaching normality.

The very early starts are a killer - if your alarm is set for 0300 you won't sleep properly and won't be able to get to sleep any earlier. Three or four days of that on the trot and it's easy to become dangerously fatigued. I'm actually surprised there aren't more incidents as a result of fatigue.

 

[ChiefPlanner]

I hate early starts and tend to swap my early shifts away so I end up doing a week of "office hours" earlies starting at 0800 or 0900 and a week of lates. Early-early shifts are far more popular than late-early shifts (if that makes sense) so it's quite easy to swap.

Generally I try and eat at the correct meal times irrespective of shift, and avoid lying in too long after a late shift to maintain my body clock at something approaching normality.

The very early starts are a killer - if your alarm is set for 0300 you won't sleep properly and won't be able to get to sleep any earlier. Three or four days of that on the trot and it's easy to become dangerously fatigued. I'm actually surprised there aren't more incidents as a result of fatigue.

With you on all this - always swopped for lates if possible (and never too late in my opinion) , on a night shift never ate much after midnight , though the shift hardened shunters would often cook up elaborate meals in the trough period in the very small hours. I made myself scarce , as could not face it , though they were very generous in their offers to share ! - and trying to sleep daytime in hot summer weather was hard.

 

[Bromley boy]

With you on all this - always swopped for lates if possible (and never too late in my opinion) , on a night shift never ate much after midnight , though the shift hardened shunters would often cook up elaborate meals in the trough period in the very small hours. I made myself scarce , as could not face it , though they were very generous in their offers to share ! - and trying to sleep daytime in hot summer weather was hard.

Absolutely, eating in the middle of the night at odd times is terrible for you. I'm convinced the shift patterns and irregular meals explain why so many drivers are very out of condition.

 

[SPADTrap]

I had to get air con fitted to my bedroom when I joined the railways. Couple that with a blackout blind and curtains and an understanding partner and I just about manage. Expensive but worth it.

 

[ModernRailways]

A thought on this that occurred to me...if you're a bit tired driving your car you are recommended to have a caffeinated drink, a brief kip and once going again after said kip to open the window and play the radio.

Obviously a train driver can do 3 of those 4 (provided the kip is during their break) - but should it actually be considered to allow fitting of a radio in train cabs in order to break the monotony?

A driver could probably even get away with a radio - I was on a Thameslink service where the driver had a radio playing with commentary of a football match. A little further up the line there was an issue and he turned the radio off - I'm guessing so he could focus on driving and paying attention moreso.

I've also seen a lot of drivers with a headphone in one ear so there's that as well.

 

[SPADTrap]

A driver could probably even get away with a radio - I was on a Thameslink service where the driver had a radio playing with commentary of a football match. A little further up the line there was an issue and he turned the radio off - I'm guessing so he could focus on driving and paying attention moreso.

I've also seen a lot of drivers with a headphone in one ear so there's that as well.

In the current set up you'd be sacked and potentially prosecuted, that is quite a risk they were taking! Quite a level of stupid..Thameslink for you

 

[Taunton]

The report doesn't seem to say where the driver was based, but does state that they signed on at Cambridge at 2155, and signed off at 0630 the next morning at Kings Cross. So what was their actual shift duration from base back to base.

 

[Chrisgr31]

A safety digest has been published: html & pdf.
The main point:

If I have read the Digest properly it states that the shift did not comply with the latest guidance on dealing with fatigue. In that case why is it a Digest and why doesn’t it oblige the TOC to implement the latest guidance?

 

[Adlington]

why doesn’t it oblige the TOC to implement the latest guidance?

See https://www.gov.uk/government/uploa...data/file/456936/guidance_to_rair_regs_v4.pdf (Introduction)

RAIB [...] makes recommendations on what could be done by government, the industry or others to improve railway safety in future.

(my emphasis)

 

[WeGoAgain]

The report doesn't seem to say where the driver was based, but does state that they signed on at Cambridge at 2155, and signed off at 0630 the next morning at Kings Cross. So what was their actual shift duration from base back to base.

I'd imagine the sign on time was actually at King Cross.

 

[Taunton]

Signing on at Kings Cross and then travelling on the cushions to Cambridge? I wonder why the report does not say that. It's a significant addition to the duty.

In passing, I wonder just how many other morning commuter services are driven by crews who signed on before 10pm the previous evening.

 

[tsr]

In passing, I wonder just how many other morning commuter services are driven by crews who signed on before 10pm the previous evening.

It seems it varies enormously, even between depots within companies.

In the case of GTR, for example, it's something which is quite rare at Southern (which is "compensated" for by having ridiculously early shift start times at most depots) but, it seems, much more likely at Thameslink or GN. Gatwick Express used to have more of this, but less so now - partly helped by a distinct lack of early morning services which could otherwise fill up a night shift.

As for other companies, a number of the very early morning services on various "intercity" mainlines towards London do get driven by drivers approaching the end of a night turn. Sometimes these drivers (alongside other crew who work the train with them) may have spent all night away from their home depot, with their shift perhaps having started with the penultimate or last outbound train to a particular location, and will be heading back to base at the start of the morning peak.

But all of what I've just typed is relevant to your question about passenger services - there are other issues at play, too, such as repetitive train prep work, attachments, detachments etc., all being carried out by potentially very fatigued individuals. Some of these sorts of activities are very common even for mainline drivers at certain TOCs.

 

[vikingdriver]

I've found job has become much harder since having a child. Often I'll be up at 0530 - 0600, deal with / entertain a toddler all day and start work 10 - 12 hours later for another 9 hours ish. Having a nap during the day before work is easier said than done as I'm sure many of you know all too well!

 

[philthetube]

One thing which was got fight with the design of S stock for the underground is that it is possible to drive standing up, a bitg help when fatigued, I think this should be a design requirement for all trains.

 

[Taunton]

I really am a bit disappointed at RAIB reports nowadays at their inability to ask penetrating questions. For example, there was established guidance that such night shifts should not exceed 8 hours. Yet this incident happened 8hr35min into the shift, even with the train on time. But where is the question to the TOC asking WHY they had scheduled a regular shift which exceeded the guidance.

 

[theageofthetra]

I really am a bit disappointed at RAIB reports nowadays at their inability to ask penetrating questions. For example, there was established guidance that such night shifts should not exceed 8 hours. Yet this incident happened 8hr35min into the shift, even with the train on time. But where is the question to the TOC asking WHY they had scheduled a regular shift which exceeded the guidance.

Because they are guidelines not law. That's the issue.

 

[Chris M]

It is not the RAIB's job to ask questions like that, it is not a regulator. That is the job of bodies like the ORR.
The job of the RAIB is to establish the facts and make recommendations, based on those established facts, to reduce the likelihood of a re-occurrence. In this case they didn't make any new recommendations because if the existing recommendations had been followed then the incident probably wouldn't have happened. It is now up to the ORR to follow up with the TOC.

 

[Bromley boy]

In the current set up you'd be sacked and potentially prosecuted, that is quite a risk they were taking! Quite a level of stupid..Thameslink for you

Yep the regime is petty draconian when it comes to stuff like this.

I'm not sure if this is based on any evidence that radios are distracting, I suspect it's just the railway's usual heavy-handed, knee-jerk approach. I'm not sure that having a radio on in the background would be any more distracting than making announcements, speaking to the signaller etc. which are all things drivers are expected to do. Especially as the same railway that bans radios is apparently quite happy for drivers to drive trains in a highly fatigued state!

God forbid train drivers be treated as professionals who can exercise their own judgement over what works for them in the cab environment.

 

[Clip]

It is not the RAIB's job to ask questions like that, it is not a regulator. That is the job of bodies like the ORR.
The job of the RAIB is to establish the facts and make recommendations, based on those established facts, to reduce the likelihood of a re-occurrence. In this case they didn't make any new recommendations because if the existing recommendations had been followed then the incident probably wouldn't have happened. It is now up to the ORR to follow up with the TOC.

its worth pointing out this part of their report also

which was her first night shift after a period of rest days, and because she was not sufficiently well rested.

And this is important as much as it was being at the end of her shift.

so can you tell me Chris M - how would this not have happened if they had followed the recommendations that you talk about? I'm sure its in the other thread but cant find it now.

 

[Taunton]

It seems from what we are discussing here, then, that the RAIB are therefore allowed to write negative comments about the individuals, but not about the TOC scheduling their shift beyond industry standard guidelines. That is surely inconsistent.

I also think that the insufficient rest comment quoted above is taken out of context, and refers not to any inappropriate approach but more to the issue of somebody starting nights after a period, whether on rest days or work, of normal day-night sleep pattern, a known issue discussed at length in the report.

 

[Clip]

It seems from what we are discussing here, then, that the RAIB are therefore allowed to write negative comments about the individuals, but not about the TOC scheduling their shift beyond industry standard guidelines. That is surely inconsistent.

I also think that the insufficient rest comment quoted above is taken out of context, and refers not to any inappropriate approach but more to the issue of somebody starting nights after a period, whether on rest days or work, of normal day-night sleep pattern, a known issue discussed at length in the report.

so when do you think would be a suitable time to start a night shift then? Surely after a couple of rest days is better because you should be well rested by then? If nbot when?

 

[Taunton]

so when do you think would be a suitable time to start a night shift then? Surely after a couple of rest days is better because you should be well rested by then? If not when?

It is not for me to comment on that; the RAIB pointed to professional research into this. One aspect of which states that the first such shift is the one most liable to incidents, as borne out by past examples and here, and therefore such shifts should not exceed 8 hours, which this one was scheduled by the TOC to do, and this duty was well known to staff as the most challenging night shift of all.

 

[ComUtoR]

so when do you think would be a suitable time to start a night shift then?

I don't think there is a sensible time.

Surely after a couple of rest days is better because you should be well rested by then?

'Well rested' is misleading in terms of fatigue. The issue more specifically here is that having days off before a night shift means that your body clock will regulate itself back to a day/night pattern based on the current amount of darkness. Nights shift is then more difficult because, on that first night at least, you tend to have to stretch out your evening. You would have normally woken up in the morning and then you take an early evening nap because you want to force yourself into sleep credit and then wake up and then push through 15 or so hours until the morning. Knowing you can nap at work tends to convince people they can use short naps to push themselves through any fatigue issues. The problem is that your body clock is still on a normal day/night pattern. Thus the fatigue creeps in.

Adjusting your body clock is the most important factor and that is harder to do from a few days off.

Its the same when you exit the nights. Your tired when you get in so typically you sleep when you get home. Then your still on the reversed sleep pattern and you then wake late afternoon and are still awake deep into the evening. If you are unlucky you are then heading towards an early shift as your next start.

I believe the railway suffers so badly because our shift patterns are erratic. Our start times are inconsistent and even within the same week you can have an 0345 start and then have a 0953 start the next day (or vice versa)

One of our depots managed to remove the night shift all together. The effect that had is what tsr described. You have more early early and more late late finishes. I'm not sure if that's better or worse.

The only real way to eliminate fatigue is to increase staffing levels and reduce turn lengths and increase the number of turns to mitigate against late lates and early earlies. I very much doubt that any TOC would be inclined to increase staffing to reduce the minimal % of fatigue based incident. Fatigue is very much an acceptable risk to the TOCs. Especially when the blame is passed directly to the Drivers.