RAIB - Serious operational irregularity at Balham

[zuriblue]

Quite a close call. The PICOPs were working from home.

https://www.gov.uk/raib-reports/report-01-2020-serious-operational-irregularity-at-balham

At around 19:05 hrs on Saturday 20 April 2019, a tamper, a self-propelled piece of on- track machinery, made an unsignalled and unauthorised move of about 600 metres, passing over Balham Junction, and entering platform 3 at Balham station, south London. The tamper could potentially have collided with a passenger train, which had travelled over the same junction in the opposite direction around 75 seconds earlier. The tamper stopped in the station, when the on-board crew realised that it was in the wrong place. There was no damage or personal injury.

The incident happened at the boundary of an engineering possession, where lines were closed for maintenance purposes. The plans for train movements out of the possession required the tamper, which had been working on the down line, to be crossed over to the adjacent up line while it was still inside the area under possession, and leave the possession on the up line. The crossing over move did not take place, and the tamper left the possession on the wrong line.

This happened because the person in charge of the possession (PICOP) provided incomplete information about the position of the tamper; the tamper driver and conductor driver did not query the instructions provided by the PICOP; and two signallers did not query the instructions provided by another PICOP. The standard of safety critical communications was poor throughout, resulting in no party having a clear understanding of the location of the tamper or the actions to be taken, and Network Rail’s management of the PICOP role has been ineffective. Underlying factors were that the labour supplier which employed the PICOPs had not effectively managed its own policy on monitoring safety critical communications, and that Network Rail’s strategy for improving and maintaining the standard of safety critical communications within the rail industry has been ineffective, and has not changed the work force culture or secured the adoption of good practice in respect of communications with and between signallers and other operations staff.

 

[ArchieWoodbine]

I've heard a few clangers over the GSM-R before, but that communication is shockingly bad (from all parties). The driver/conductor not having any means of contacting the PICOP or posession staff should have been picked up by the signaller as a red-flag, suggesting that the people on the ground didn't have a good grasp of the situation.

Edit: It's worth noting that Vital also supplied the posession staff involved with the Stoats Nest Jnc. fatality in 2018. Their poor management of staff was highlighted as a contributory factor in that incident too.

 

[alxndr]

The comms there was absolutely appalling, and the fact that the PICOPs didn't know where their tamper was is even more so.

What I can't understand is that the conductor driver knew that they were supposed to be on the Up Fast ("We're on the down fast but we're making, um, we're going to go across onto the fast up obviously and then we're changing..." - first transcript, pg. 21) but then never questions the fact that they're never actually put onto the Up Fast.

 

[6Gman]

The whole point of a route conductor (and I've arranged loads of them in the past) is that he/she should be intimately familiar with the route. I am bemused by the idea of a conductor not being very, very suspicious of a wrong line movement out of a possession unprotected by signalling.

The background of the conductor isn't entirely clear from the Report but how familiar would he have been with that area? Wouldn't a conductor from the TOC which works that line on a daily basis have made more sense?

 

[30907]

The comms there was absolutely appalling, and the fact that the PICOPs didn't know where their tamper was is even more so.

What I can't understand is that the conductor driver knew that they were supposed to be on the Up Fast ("We're on the down fast but we're making, um, we're going to go across onto the fast up obviously and then we're changing..." - first transcript, pg. 21) but then never questions the fact that they're never actually put onto the Up Fast.

I think the answer lies in their very next sentence:

But I mean we can do it Balham actually, and, um, shoot up towards Streatham Hill that way, so instead of going all the way into town, you know what I mean?

I read that as hinting to the signaller that they authorise a wrong-line movement up the DF into P3, to save time. None of the later conversations take this up, but the mental move from "This is a good idea" via "Bobby said they'll talk to PICOP" to "We've agreed I'm OK to do it" isn't IMO far fetched. In non-railway contexts (non-safety-critical, I hasten to add) I've known similar.
(Which is why of cours protocols should be followed - I'm merely saying what might have gone through the conductor driver's mind.)

 

[ComUtoR]

but then never questions the fact that they're never actually put onto the Up Fast.

I am bemused by the idea of a conductor not being very, very suspicious of a wrong line movement out of a possession unprotected by signalling.

Both of these points were raised in the report. The Conductor Driver was used to having movements changed at the last minute so accepted the instruction. Non Technical skills would make people 'suspect' something wrong and that is also addressed in the report. Having 'situational awareness' is a bit of a double edged sword. Sometimes you suspect a movement could be wrong but also based on previous knowledge and/or experience you are so used to things always being different, you simply accept it.

One minute they were going to East Croydon and then the next they were going to Clapham and shunting back instead. Looking at the map and seeing the path of the passenger service, it gives me the impression that either movement could be accepted depending on which direction you were going. The confusing information, the poor communication, the lack of clear instruction, as well as the lack of any real clarity between all parties has led to this incident.

 

[alxndr]

I think the answer lies in their very next sentence:

But I mean we can do it Balham actually, and, um, shoot up towards Streatham Hill that way, so instead of going all the way into town, you know what I mean?

I read that as hinting to the signaller that they authorise a wrong-line movement up the DF into P3, to save time. None of the later conversations take this up, but the mental move from "This is a good idea" via "Bobby said they'll talk to PICOP" to "We've agreed I'm OK to do it" isn't IMO far fetched. In non-railway contexts (non-safety-critical, I hasten to add) I've known similar.
(Which is why of cours protocols should be followed - I'm merely saying what might have gone through the conductor driver's mind.)

I can see how that thought process might have happened. The comment about Balham might have been seen as a passing comment by the signaller in the context that the phonecall was primarily to obtain the PICOP's number, but the conductor driver might have seen it as confirmation as a change of plan.

Still doesn't explain how the conductor driver knew that they would need to move onto the Up Fast to exit onto signal VC632, but then, while still on the Down Fast, told the next signaller that they were going to exit at VC632.

I also wonder if they might have questioned or explained a little better if the conductor driver realised that they were talking to a different signaller (e.g. "Earlier I suggested to the other signaller about changing ends at Balham instead, is this going to be the case?" "That's not possible. Can you confirm again which line you're currently on?"...) I can see how not giving names helps to prevent over familiarity, but it also leads to situations where assumptions are made about the information that they hold based on previous phonecalls where the signaller has switched without the caller's knowledge. Some people can have very similar sounding voices, so it's not immediately apparent if you're talking to the same person or not. It shouldn't make a difference if there's good comms and everything is repeated back properly, but as this shows, lapses happen.

 

[bramling]

I think the answer lies in their very next sentence:

I read that as hinting to the signaller that they authorise a wrong-line movement up the DF into P3, to save time. None of the later conversations take this up, but the mental move from "This is a good idea" via "Bobby said they'll talk to PICOP" to "We've agreed I'm OK to do it" isn't IMO far fetched. In non-railway contexts (non-safety-critical, I hasten to add) I've known similar.
(Which is why of cours protocols should be followed - I'm merely saying what might have gone through the conductor driver's mind.)

I wonder if page 21 also provides a clue, where it states that the conductor driver expressed frustration about the time it was taking to get the tamper out of the possession, and wished to meet their booked arrival time back at East Croydon.

To me this hints at the possibility they’d been sitting there for a while getting increasingly irritated at not having moved, and once things did start to happen there was a subconscious focus on getting things done as quickly as possible, and not taking a few moments to think through what they were actually doing. One wonders if the conductor driver was due to finish after arrival at East Croydon.

 

[ComUtoR]

Still doesn't explain how the conductor driver knew that they would need to move onto the Up Fast to exit onto signal VC632, but then, while still on the Down Fast, told the next signaller that they were going to exit at VC632.

You are also falling into the trap of mis-communication and assumptions.

SIGNALLER 1 : Six nine one sorry, uh, whereabouts, are you?
Conductor driver : Just south of Balham Junction. We’re uh, I think it’s Victor Charlie six three six we can see.
We’re in a worksite anyway at the moment, at the stop boards.
SIGNALLER 1 : What line are you on, sir?
Conductor driver : We’re actually...wrong direction. We’re on the uh, on the down fast in... travelling in the up direction.
SIGNALLER 1 : On the down fast going in the up direction?
Conductor driver : Yeah, well we’re not moving obviously. Yeah, we’re...yeah. I was just wondering if you’ve got a number for the PICOP please because they’re meant to be up here and we’ve got nobody to come and remove the detonators and stop boards yet.

The Conductor gives their location incorrectly. He says he can see VC632 but not that his train is standing at it. The Signaller confirms this by saying he is on the down fast, in the up direction. This should have highlighted that they were not at the signal.

Signaller 1 and the PICOP then have a convo and the PICOP states they will exit at VC632.

They were all discussing a new move instead of the booked one. This adds to the confusion and potentially why assumptions start being made. The Conductor Driver assumes that there is a new movement, that has been authorized, the Signaller assumes that the PICOP has spoken with the Conductor and the PICOP assumes that the Conductor has spoken with the Signaller. It's a huge mess and slowly getting worse.

Signaller 2 : Hello, Victoria signaller panel two B signaller
Conductor driver : Hello signaller, yeah driver, I’m the conductor driver on six Juliet nine one, you wanted to speak to me about a route we’re going back?
Signaller 2 : Yeah hello there driver of six Juliet Nine One, um, where are you at the moment?
Conductor Driver : Uh...we’re just south of Balham Junction at the moment.
Signaller 2 : Okay, you’re still there. What signal are you actually... going to start coming out from? Do you know?
Conductor driver : Um, I can tell you if you bear with me a moment...just bear with me a moment ...yeah... I’ve got a... Balham junction at Victor Charlie Six Three Two..............
Signaller 2 : Okay yeah, that’s what I thought it would be, alright. Um, you have to go to East Croydon now I hear. Is that correct?
Conductor driver : Yes, that’s correct. East Croydon into the siding there yeah.
Signaller 2 :Do you sign platform sixteen in Clapham Junction? (...)

Irrespective of the Signaller change. The location is given incorrectly again. There is the assumption that the Signaller knew they were on the Down Fast in the Up Direction because that was confirmed earlier.

Then you get another mis-communication. The Signaller asks if they knew what signal they were coming out from. The confirmation of VC632 here is taken from the booked workings (which is my assumption...) Neither party confirmed that that was the previous working and there was a new move to take place. Or that the Tamper was sitting on a completely different line and was not actually sitting at VC632.

The PICOP spoke with Signaller 2 and stated the Tamper was going to move towards VC632. The PICOP didn't then confirm with the Conductor.

Lots of communication and assumption issues. :?

My questions(s) for the experts.

Would the track circuit show as occupied up to VC632 ? Would the Tamper show as occupying the Down Fast ? (Yes I've read paragraph 79/80)
At no point is the shunt back via 334 crossover mentioned. Who's responsible for that movement to be carried out ? Should that have been confirmed by the PICOP ?
PICOPs don't attend site ? I thought they would be on site at all times. (No I don't work in T3s)
I suspect that the Conductor Drivers route knowledge may have contributed to this too. Anyone else get that weird feeling ?

 

[GB]

Why was the conductor driver *driving in a possession without having any T3 training or experience?

*including communicating with relevant parties.

 

[Horizon22]

This incident has mis-communication layered upon mis-communication in what needs to be a fairly exacting set of instructions. Some of the signaller / tamper conductor driver transcripts are terrible for safety critical communications. These always stick out as causing significant issues in many incidents.

 

[alxndr]

Would the track circuit show as occupied up to VC632 ? Would the Tamper show as occupying the Down Fast ? (Yes I've read paragraph 79/80) Yes, although as stated in the report, indications within possessions aren’t to be trusted.
At no point is the shunt back via 334 crossover mentioned. Who's responsible for that movement to be carried out ? Should that have been confirmed by the PICOP ?
PICOPs don't attend site ? I thought they would be on site at all times. (No I don't work in T3s) They don’t have to be. Even if they did have to be, possessions could be many, many miles long and one person can only be in one place at any one time.
I suspect that the Conductor Drivers route knowledge may have contributed to this too. Anyone else get that weird feeling ? Either the driver did not know, or had forgotten, that VC632 was not on the Down Fast and that there was not a route from the Down Fast to platform 16 at Clapham Junction. If he had known either of these things he would surely have not agreed to the plan with the signaller.

I typed a response the rest of your post, but I’m having major issues getting the forum to post it. Essentially the salient points were:

The conductor driver confused things by first mentioning VC636, but then correctly stated that he was on the Down Fast. The conductor driver was the first to mention the Down Fast, and thus knew which line he was on without prompting.

The only conversation which references the “new move” was the initial one between the conductor driver and the signaller. None of the other conversations hint towards this and the conductor driver agrees to go up to Clapham Junction as booked.

 

[Bigfoot]

Reading about the "finger test" the signaller was trained in but was not comfortable performing it infront of other staff says a lot about the attitude of the other signallers in the box.

 

[ComUtoR]

Reading about the "finger test" the signaller was trained in but was not comfortable performing it infront of other staff says a lot about the attitude of the other signallers in the box.

In what way ?

When I have someone in my cab, I get uncomfortable about some things. This isn't about the person in my cab, it's about me and how I feel about myself or the way that I drive.

 

[Put Kettle On]

Why was the conductor driver *driving in a possession without having any T3 training or experience?

*including communicating with relevant parties.

The Conductor Driver was not driving, he was conducting, as he had route knowledge. As the Conductor Driver with route knowledge he is the one who does the communication.
The Driver of the Tamper did not have route knowledge of this area.



52 At 19:02 hrs, the night PICOP called signaller 2. The PICOP reported that
the conductor driver had now contacted him and his understanding was that signaller 2 was happy for the tamper to proceed to signal VC 632 and take further instructions from signaller 2 when it had arrived at the signal. Signaller 2 agreed that was what he had instructed the conductor driver to do, and requested the PICOP to tell the conductor driver to call signaller 2 when he was at the signal, and signaller 2 would ‘sort it out from there’. The night PICOP stated he would speak to the conductor driver, and would get the protection lifted. However, no further communication between the PICOP and the conductor driver took place.

The PICOP never called the Conductor Driver back & it also states the Tamper proceeded once the Detonator Protection had been removed .

As such, the movement was unauthorised, as they had no permission or instruction from Signaller, who must give direct authority to proceed from detonator protection towards protecting Signal .

Alarm bells should have been ringing at this, but the whole thing is amateur in the extreme, & was easily avoidable if at least one of them had been more professional in their communication.

 

[Bigfoot]

In what way ?

When I have someone in my cab, I get uncomfortable about some things. This isn't about the person in my cab, it's about me and how I feel about myself or the way that I drive.

If something you are trained to do could prevent an incident by double checking something and you're not comfortable doing it due to others perception of you and the process then there are serious issues within the environment you work in.

 

[bramling]

If something you are trained to do could prevent an incident by double checking something and you're not comfortable doing it due to others perception of you and the process then there are serious issues within the environment you work in.

Have to agree with this. The railway is full of people who think they know it all, in particular older people with years behind them, who take every opportunity to rubbish others - presumably because it either overshadows their own inadequacies, or is their only opportunity in life to assert their own importance.

Unfortunately, experience shows these old hands often don't know quite as much as they think they do, especially when confronted with an unfamiliar situation.

 

[edwin_m]

I wonder if page 21 also provides a clue, where it states that the conductor driver expressed frustration about the time it was taking to get the tamper out of the possession, and wished to meet their booked arrival time back at East Croydon.

To me this hints at the possibility they’d been sitting there for a while getting increasingly irritated at not having moved, and once things did start to happen there was a subconscious focus on getting things done as quickly as possible, and not taking a few moments to think through what they were actually doing. One wonders if the conductor driver was due to finish after arrival at East Croydon.

It said earlier in the report that the conductor driver's shift finished at 2000 and they were due to arrive at East Croydon at 1939. Possibly it was in someone's mind to go "bang road" to Balham and reverse there which would put them directly onto the Down line towards Crystal Palace and East Croydon, instead of going to Clapham Junction and back as originally planned.

 

[ComUtoR]

due to others perception of you

From the report

Witness evidence indicates that signallers 1 and 2 had both been trained to use this method, but they did not feel comfortable about using it in front of their colleagues.

There is no mention of other peoples perception. Neither of the technique itself or how the colleagues treat individuals for using it. Some people are not as confident as others. People often worry about themselves and what they do. You can have a very positive environment and very supportive colleagues and yet, people still feel uncomfortable.

I was on a course a few years ago. Everyone was very supportive, I was one of the most senior members of staff in the room, Everyone was sharing experiences, my colleagues were really great. And yet, I was still pulled aside for being the quiet one during certain parts. Nothing to do with anyone else in the room. Just that I didn't want to step up for a change and I was taking a step back for personal reasons.

I get where your coming from, and I agree with Bramlings post too, but sometimes it's too easy to blame the culture of a place or situation and we often forget that there are many human factors involved.

 

[alxndr]

It can be difficult to be the first person to do something. If all the longer standing signallers don't do it, then odds are the newer ones are likely to feel a bit silly being the first ones to do it.

People do this all the time, although thankfully not with such serious consequences. Go into an office and get told to wear an ID badge, but see no one else wearing one so feel silly doing so. See everyone else taking a shortcut across a road or through a fire door so feel silly being the only one to walk further to the proper place. Kids at school knowing they should have ties done up and shirts tucked in, but no one else does.

Humans like to fit in.

 

[30907]

. One minute they were going to East Croydon and then the next they were going to Clapham and shunting back instead.

Small point, but the move to ECR was always going to be via Streatham Hill not direct.

 

[Tom Quinne]

The only interaction a signaller should have inside a T3 with anyone is to get trains in or out at the blocking limits after the PICOP has given permission.

Points operator, Crossing attendents etc are there to carry out the signallers role.

PICOPS being 100s of miles away managing multiple T3s is standard, in fact If a picop is on the ground it’s a surprise.

Route conductors are often hired in from spot hire FOCs like the infamous WCR, we all know how good they’ve been in the past - not to mention the bingo drivers or the ££££ men who’ll put their name to any route for the RDW, we all know their out there.

 

[Tom Quinne]

I think the answer lies in their very next sentence:

I read that as hinting to the signaller that they authorise a wrong-line movement up the DF into P3, to save time. None of the later conversations take this up, but the mental move from "This is a good idea" via "Bobby said they'll talk to PICOP" to "We've agreed I'm OK to do it" isn't IMO far fetched. In non-railway contexts (non-safety-critical, I hasten to add) I've known similar.
(Which is why of cours protocols should be followed - I'm merely saying what might have gone through the conductor driver's mind.)

My take is that conductor driver wanted to take the shorter route to the stabling point, rather than the booked longer route.

I do not believe, nor would the signaller allow a wrong direction move.

 

[Tom Quinne]

I wonder if page 21 also provides a clue, where it states that the conductor driver expressed frustration about the time it was taking to get the tamper out of the possession, and wished to meet their booked arrival time back at East Croydon.

To me this hints at the possibility they’d been sitting there for a while getting increasingly irritated at not having moved, and once things did start to happen there was a subconscious focus on getting things done as quickly as possible, and not taking a few moments to think through what they were actually doing. One wonders if the conductor driver was due to finish after arrival at East Croydon.

The report says his turn was 1200-2000,leaving the possession around 1930.

 

[Tom Quinne]

Why was the conductor driver *driving in a possession without having any T3 training or experience?

*including communicating with relevant parties.

he wasn’t, the tamper driver was - the conductor was however conducting all comms it appears.

 

[alxndr]

The only interaction a signaller should have inside a T3 with anyone is to get trains in or out at the blocking limits after the PICOP has given permission.

Points operator, Crossing attendents etc are there to carry out the signallers role.

Or testing points under power after any work has been done to prevent some nitwit leaving them on manual.

 

[Tom Quinne]

Or testing points under power after any work has been done to prevent some nitwit leaving them on manual.

Some (signallers) won’t swing test points during a T3 fo check they’ve been put back on power - it isn’t our job....

 

[carriageline]

Some (signallers) won’t swing test points during a T3 fo check they’ve been put back on power - it isn’t our job....

No it’s not, but it stops embarrassing issues when trains start running and we’ve got a points failure.

They shouldn’t be left on manual agreed, but if it’s caught before it causes delay then brilliant. Plus you then avoid issues with trapped trains etc

 

[bramling]

Some (signallers) won’t swing test points during a T3 fo check they’ve been put back on power - it isn’t our job....

Is that not a little cut nose to spite face? In that if something doesn’t come to light until traffic starts then it will be the signaller who has the disruption to manage...

 

[edwin_m]

PICOPS being 100s of miles away managing multiple T3s is standard, in fact If a picop is on the ground it’s a surprise.

Unless it's a very small possession they're not going to be able to observe every movement personally, so need to rely on information from others. Particularly for a complex possession (nine other trains involved in this one) I'm sure it's better to be in an office free from other distractions and with space to spread out the paperwork and a magnetic board to keep track of where everything is.