RAIB Report 03/2020: Class investigation into human performance in signalling operation

John Webb

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The Rail Accident Investigation Board (RAIB) has published the above report on the 12th May 2020 - available through this link. Some 55 pages long it is rather complex to try and make a summary of it here. I quote part of the RAIB's own Summary:
The investigation examined five categories of incident:
  • user worked crossing irregularities
  • line blockage irregularities
  • users trapped at CCTV level crossings
  • irregularities involving level crossings on local control
  • other operational irregularities.
The investigation identified several common factors influencing the actions of
signallers across these scenarios, associated with:
  • signaller workload
  • user-centred design
  • competence management
  • experiential knowledge
  • organisational structure.
The report also observes that Network Rail’s incident investigations do not always fully
exploit the opportunities to learn from these incidents.
As a result, RAIB has made six recommendations to Network Rail, addressing each
of the five areas listed above as well as the observation on learning from incident
investigations. There is also a learning point for incident investigators relating to the
identification of systemic causal factors.
 
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SamYeager

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The link above does not work. Try this one.

Summary of conclusions;
Causal factors
The common causal factors identified in this class investigation were:
a. Network Rail’s management of signaller workload does not fully reflect the complex cognitive demands of modern signalling centres (paragraph 75, see paragraph 141 and Recommendation 1).
b. Network Rail’s management of change does not consistently involve signallers in decisions about equipment or processes that affect their work (paragraph 81, Recommendation 2).
c. There are shortcomings in Network Rail’s competence management arrangements for signallers (paragraph 87, see paragraphs 129 and 139, and Recommendations 3 and 5).
d. Network Rail’s procedures and training for operating railway signalling do not sufficiently account for the information, strategies and knowledge used by experienced signallers (paragraph 95, Recommendation 4).
e. Local management structures within Network Rail adversely affect the competence management and professional development of signallers (paragraph 100, see paragraph 139 and Recommendation 5).
 

markymark2000

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To help with the user worked crossing issues, can then not introduce a QR code and web portal so that when a user scans the QR code, they go through to a portal which asks for a level crossing number (which is specific to the crossing) and asks what is crossing. User then waits for a signaller to approve or decline the request via the computers, they then cross and upon getting to the other side, they click on their phone when the crossing is clear and off they go on their way.
For a signaller, it could then show up active crossings with the crossing number, crossing name and what is crossing. If the signaller has any enquiries, they could ring the crossing phone or the web portal could request phone numbers to call.

While this isn't entirely fault proof, it has to be an improvement on the current system where signallers can get confused about which crossing the person is at.

This system would help give the signaller more time as they aren't taking phone calls from crossing users and can instead just read the information in plain text. The note remains there until the crossing has finished and possibly a signaller approving a crossing could link then to the signalling system computers so it shows up the crossing as occupied somehow.
 

Tom Quinne

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To help with the user worked crossing issues, can then not introduce a QR code and web portal so that when a user scans the QR code, they go through to a portal which asks for a level crossing number (which is specific to the crossing) and asks what is crossing. User then waits for a signaller to approve or decline the request via the computers, they then cross and upon getting to the other side, they click on their phone when the crossing is clear and off they go on their way.
For a signaller, it could then show up active crossings with the crossing number, crossing name and what is crossing. If the signaller has any enquiries, they could ring the crossing phone or the web portal could request phone numbers to call.

While this isn't entirely fault proof, it has to be an improvement on the current system where signallers can get confused about which crossing the person is at.

This system would help give the signaller more time as they aren't taking phone calls from crossing users and can instead just read the information in plain text. The note remains there until the crossing has finished and possibly a signaller approving a crossing could link then to the signalling system computers so it shows up the crossing as occupied somehow.
Good idea, but the UWC are usually in the back of beyond with poor or no mobile signal. I’d suggest a significant number of users wouldn’t have the technology to use the QR codes on their phones, or have the confidence to do it.

You can beat a simple phone call to the signaller from a clearly labelled crossing, with a competent crossing user and sustainable workloaded signaller.

Three critical elements which often have one missing unfortunately.
 

edwin_m

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Good idea, but the UWC are usually in the back of beyond with poor or no mobile signal. I’d suggest a significant number of users wouldn’t have the technology to use the QR codes on their phones, or have the confidence to do it.

You can beat a simple phone call to the signaller from a clearly labelled crossing, with a competent crossing user and sustainable workloaded signaller.

Three critical elements which often have one missing unfortunately.
There would also be a safety integrity issue - risk of a glitch in a system that isn't designed for safety-vital purposes resulting in an accident.
 

MotCO

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Good idea, but the UWC are usually in the back of beyond with poor or no mobile signal.
Maybe one for Speculative Ideas, but could train tracks be used as a horizontal mobile phone aerial, which would then give a useable mobile phone signal at Unmanned Crossings? Taking it further, would it improve mobile signals on trains?
 

LAX54

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To help with the user worked crossing issues, can then not introduce a QR code and web portal so that when a user scans the QR code, they go through to a portal which asks for a level crossing number (which is specific to the crossing) and asks what is crossing. User then waits for a signaller to approve or decline the request via the computers, they then cross and upon getting to the other side, they click on their phone when the crossing is clear and off they go on their way.
For a signaller, it could then show up active crossings with the crossing number, crossing name and what is crossing. If the signaller has any enquiries, they could ring the crossing phone or the web portal could request phone numbers to call.

While this isn't entirely fault proof, it has to be an improvement on the current system where signallers can get confused about which crossing the person is at.

This system would help give the signaller more time as they aren't taking phone calls from crossing users and can instead just read the information in plain text. The note remains there until the crossing has finished and possibly a signaller approving a crossing could link then to the signalling system computers so it shows up the crossing as occupied somehow.
Far too 'iffy' to be adopted, Mobile phones are fickle at the best of times, and as for a QR code, many would not know what you are talking about. A direct line is much preferable, crossings in the box are clearly marked, it is the user, who may use a local name, or even one he calls it himself, this is where errors can be made,
 

SECR263

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Why not take a another approach. Rebuild all user worked gates so that they remain electromagnetically locked. A user would press a button which shows the crossing in the box. Signaller advises user to wait and unlocks gates when safe to do so. User crosses and shuts gates which allows signaller to clear route. If gate not shut box cannot clear route. Expensive but a lot of problems eliminated possibly?
 

LAX54

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Why not take a another approach. Rebuild all user worked gates so that they remain electromagnetically locked. A user would press a button which shows the crossing in the box. Signaller advises user to wait and unlocks gates when safe to do so. User crosses and shuts gates which allows signaller to clear route. If gate not shut box cannot clear route. Expensive but a lot of problems eliminated possibly?
Is it a person on their own, walking with a pack of dogs, or is it a car, maybe a tractor, or an artic with trailer, there are different rules for different requirements, pressing a button which lights up will not cut the mustard, and if you are going to talk to them, then picking up the phone, and just talking to Signaller works well. IF the MOP does what he/she is told, many do not
Interlocking every crossing would cost millions, and quite complicated inertlockign too, then when there are two boxes involved, even more complicated !
 

ainsworth74

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Authorise driver to Pass signal at Danger and procede with Caution?
That'll work well on somewhere like the ECML where line speeds are 125mph and would cause rather a lot of delays until someone was able to get out there to close it again...
 

Llanigraham

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To help with the user worked crossing issues, can then not introduce a QR code and web portal so that when a user scans the QR code, they go through to a portal which asks for a level crossing number (which is specific to the crossing) and asks what is crossing. User then waits for a signaller to approve or decline the request via the computers, they then cross and upon getting to the other side, they click on their phone when the crossing is clear and off they go on their way.
For a signaller, it could then show up active crossings with the crossing number, crossing name and what is crossing. If the signaller has any enquiries, they could ring the crossing phone or the web portal could request phone numbers to call.

While this isn't entirely fault proof, it has to be an improvement on the current system where signallers can get confused about which crossing the person is at.

This system would help give the signaller more time as they aren't taking phone calls from crossing users and can instead just read the information in plain text. The note remains there until the crossing has finished and possibly a signaller approving a crossing could link then to the signalling system computers so it shows up the crossing as occupied somehow.
1/ Not every crossing will have a dependable mobile signal.
2/ Not every user will have a mobile phone capable of reading a QR code.
3/ Which signaller is going to answering this "portal"?
4/ Many signallers aren't using computers for signalling in their Boxes.
5/ People on the phone lie!! All signallers dealing with UWC's will tell you that!
6/ As far as I can see that "system" would actually take longer than simply picking up the phone.
and finally, you seem to have forgotten that we still have manual signal boxes.
 

Tomnick

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Authorise driver to proceed at caution, stop, get down and close the gate? [THIS IS A JOKE!]
It’s not a joke - it’s probably the most sensible suggestion in the thread as it’s what actually happens, reasonably frequently, when gates at a user worked crossing are reported as left open!

Everything else in the last few posts seems to involve an extravagant and incredibly expensive solution looking for a problem...
 

HSTEd

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Authorise driver to proceed at caution, stop, get down and close the gate? [THIS IS A JOKE!]
As opposed to having the train wait for hours whilst a signaller is sent out to the same job?

If the gate is interlocked having the signaller block the lines for the driver is unlikely to make the situation worse.
And we do have reliable comms between driver and signaller these days.
 

carriageline

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The best system I’ve seen is the MSL (miniature stop light) crossings which do not require any signaller involvement at all (whilst all working ok)

System uses treadles/axle counters to detect trains. When a train strikes in, it displays a red light, when no trains are in section it shows green. Simple, effective! They normally have power lifting barriers too
 

edwin_m

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The best system I’ve seen is the MSL (miniature stop light) crossings which do not require any signaller involvement at all (whilst all working ok)

System uses treadles/axle counters to detect trains. When a train strikes in, it displays a red light, when no trains are in section it shows green. Simple, effective! They normally have power lifting barriers too
However some or all of these systems had (and may still have) a major safety defect, that the gate controls are not interlocked with the lights. While there are reasons why this is so, I suspect 99% of casual users would expect that if the button works to open the gates, there can't be a train coming.
 

Llanigraham

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The best system I’ve seen is the MSL (miniature stop light) crossings which do not require any signaller involvement at all (whilst all working ok)

System uses treadles/axle counters to detect trains. When a train strikes in, it displays a red light, when no trains are in section it shows green. Simple, effective! They normally have power lifting barriers too
And how will that cope with a siganlling section some 20+ miles long with no continuos track circuiting?
 

PG

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However some or all of these systems had (and may still have) a major safety defect, that the gate controls are not interlocked with the lights. While there are reasons why this is so, I suspect 99% of casual users would expect that if the button works to open the gates, there can't be a train coming.
Yes I'm almost certain I've read an RAIB report at some time which raised that very point. It may even have been an incident or near-miss occurring in those exact circumstances of the button allowing the gate to open so the user crossed.

From my hazy memory was it a delivery driver crossing to deliver to a farm on a single track line somewhere?
 

Pumbaa

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I always thought the combination of MSL with a double gate arrangement that locks the outer gate, but leaves the inner gate unlocked so you can reach a place of safety, was the optimum solution.

Not sure a road equivalent was ever attempted?
 

james_the_xv

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The best system I’ve seen is the MSL (miniature stop light) crossings which do not require any signaller involvement at all (whilst all working ok)

System uses treadles/axle counters to detect trains. When a train strikes in, it displays a red light, when no trains are in section it shows green. Simple, effective! They normally have power lifting barriers too
Does this not take into account the length/mobility of vehicle wanting to cross? If a slow vehicle gets a green light (such as a HGV moving on a soft surface round a tight corner after the crossing). If a vehicle takes more than 5 min to be safely clear then that could be a line block of up to 10 miles in each direction
 

alxndr

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And how will that cope with a siganlling section some 20+ miles long with no continuos track circuiting?
The EBIgate system can be set up with it's own treadles and works completely independently of the signalling system. It's not a perfect system and has its flaws, but is well suited for scenarios like that, and even in track circuitted areas its considerably cheaper as installation doesn't require alterations to the existing signalling system.

Does this not take into account the length/mobility of vehicle wanting to cross? If a slow vehicle gets a green light (such as a HGV moving on a soft surface round a tight corner after the crossing). If a vehicle takes more than 5 min to be safely clear then that could be a line block of up to 10 miles in each direction
It wouldn't be possible to set up for all scenarios, or suitable for situations where signals need to be kept at danger to protect the crossing, but if you can provide MSLs for some scenarios and have prominent and clear signage instructing other users to contact the signaller that will still have an impact on signaller workload.
 

carriageline

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Does this not take into account the length/mobility of vehicle wanting to cross? If a slow vehicle gets a green light (such as a HGV moving on a soft surface round a tight corner after the crossing). If a vehicle takes more than 5 min to be safely clear then that could be a line block of up to 10 miles in each direction
I would guess that would come under the“long, low or slow” category and require a call to the signaller.

I haven’t seen what is signposted on the crossing, as the only ones I deal with are locked by key. Only authorised users are allowed
And how will that cope with a siganlling section some 20+ miles long with no continuos track circuiting?
it’s an “overlay” system, so it’s put on top of whatever signalling system is already there. It also operates completely independently of the signalling system, and just requires outside power. IE the treadles/axle counters are purely to operate the R/G lights, and nothing else.

the signaller has no oversight or indications of the crossing, and will only get phone calls if it breaks. Like I say, the only ones I “work with” have authorised users only, with keys. That alone make the situation many times easier and safer.
 

Islineclear3_1

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The best system I’ve seen is the MSL (miniature stop light) crossings which do not require any signaller involvement at all (whilst all working ok)

System uses treadles/axle counters to detect trains. When a train strikes in, it displays a red light, when no trains are in section it shows green. Simple, effective! They normally have power lifting barriers too
These are a great invention but are still open to abuse
 

Islineclear3_1

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Where UWC's can't be removed (and replaced by a bridge or underpass), could they not be reconfigured with automatic closing gates? For example, a simple spring-loaded gate found on many National Trust trails would suffice

Still have an emergency telephone with a clear sign donating the name of the crossing
 

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