RAIB - Serious operational irregularity at Balham

[alxndr]

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

But it is our job to get them swung on power, so we're at an impasse. It's like the old question of who reads out the signal number when testing an SPT. That said, I've never found someone who won't, as long as there's permission from the ES and no technical reason why they can't.

I fear I've started a digression though, so I'll leave it here.

 

[GB]

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.

.

Yes you are right, however I still find it strange that the conductor driver was dealing with ALL communications despite having no (or very little) T3 knowledge. Entry and exit in possessions is extremely hazardous and degraded after all.

 

[ComUtoR]

Do you always exit a possession via a main signal or shunt or is going wrong road commonplace ? Cheers in advance.

 

[Sunset route]

Do you always exit a possession via a main signal or shunt or is going wrong road commonplace ? Cheers in advance.

All three, although travelling in the right direction with a main aspect is desirable, but it can’t always be done.

 

[ZL exile]

The above highlights why whenever I was booked on a possession job as a driver, I always did a sketch map of the possession showing possession limits worksite limits, crossings, signals and access points, with notes as applicable, if asked to do anything that wasn’t in the plan then I just just don’t do it. Too many times as a driver you get asked to do things that are not authorised, just to save time. The biggest issue always was communications, like them PICOP and their teams wanting to rely on mobile phones, even when moving, they get quite upset when told it is an absolute no-no, all for the cost savings of not buying / leasing back to back radios and the correct number of staff to do the job properly.

 

[Chris M]

One thing that I didn't see mentioned in the report is who was (meant to be) responsible for moving the points to allow the shunt move from fast to slow? Nobody seems to have been surprised at something they were meant to be doing not being done?

I'm also unclear if there is anybody whose job it is to know where every train in a possession actually is? If it is someone (PICOP?) not on site, is there anybody who is on the ground who is specifically responsible for giving them that information?

 

[lineclear]

One thing that I didn't see mentioned in the report is who was (meant to be) responsible for moving the points to allow the shunt move from fast to slow? Nobody seems to have been surprised at something they were meant to be doing not being done?

Whoever was responsible for the train movement within the possession, see below.

I'm also unclear if there is anybody whose job it is to know where every train in a possession actually is? If it is someone (PICOP?) not on site, is there anybody who is on the ground who is specifically responsible for giving them that information?

The Engineering Supervisor within a worksite, the PICOP everywhere else (PICOP land).

 

[Chris M]

So if the PICOP is not on site, they will have needed to (a) delegate the task of actually moving the points to someone else, who? and (b) be informed of the actual location of trains by someone who is, who?

 

[Put Kettle On]

So if the PICOP is not on site, they will have needed to (a) delegate the task of actually moving the points to someone else, who? and (b) be informed of the actual location of trains by someone who is, who?

The crossover the Tamper was supposed to use was within the Engineering Worksite, so would have been the responsibility of the Engineering Supervisor, either using Signaller to set the crossover for this movement, although as has been mentioned up thread, some Signallers will not do this, so a Points Operator would be used to do the setting of crossover.

 

[lineclear]

So if the PICOP is not on site, they will have needed to (a) delegate the task of actually moving the points to someone else, who? and (b) be informed of the actual location of trains by someone who is, who?

(a) Either somebody working within the possession, or ask the signaller to move individual sets of points
(b) It's their job to keep track of trains. They authorise train movements from detonator protection to worksite marker boards, between worksites, and from worksite marker boards to detonator protection. The latter is done before a train leaves a possession. When a train arrives at the end of its movement its driver or a member of possession staff will inform the PICOP.

It's also worth noting that, for train movements from detonator protection out of the possession, the driver must be personally authorised by the signaller. This was not done in this incident.

 

[Robertj21a]

Sounds like a massive c*ck up by all concerned, and quite a few comments that suggest some people are still unsure of the correct procedures.

 

[LAX54]

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.

That is a bit of a statement ! Just for the record at the place I work at that is NOT the case at all !

 

[LAX54]

But it is our job to get them swung on power, so we're at an impasse. It's like the old question of who reads out the signal number when testing an SPT. That said, I've never found someone who won't, as long as there's permission from the ES and no technical reason why they can't.

I fear I've started a digression though, so I'll leave it here.

That is why they are supposed to have points operators, but they rarely do, (cheaper not to) they rely on the Signaller to assist.

Don't forget the signaller may have no idea where an OTM or similar is, the only info will be the Driver saying I am at such and such signal.

 

[bramling]

That is a bit of a statement ! Just for the record at the place I work at that is NOT the case at all !

I should qualify that when I said full of people like that I meant that there’s a smattering of them all over the place, not that *everyone* is cut from that cloth. As with most things it only take a handful to toxify things, or one to pressurise someone into making a mistake...

 

[6Gman]

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.

This is a rather blunter version of what I alluded to earlier.

The obvious place to find a route conductor would be the TOC which works the route on a daily basis, not a company which only goes there on an ad hoc basis.

EDIT: The conductor driver had worked since 2007 as an "Infrastructure monitoring and testing train driver". In such a role how often would he have worked the Streatham Common to Balham route?

 

[Tom Quinne]

I’m sure he worked over the route or refreshed it within the required time scales to retain “knowledge”.

it really does make me wonder how anyone can retain the in-depth knowledge required to sign a route with literally huge route cards, often at far flung places.

Especially highly complex areas like South London.

unfortunately there will always be drivers who see glory in signing rare routes, or clapped out locos - but don’t think about the Stafford incident and it’s potentially lethal outcome.

A huge route card and signing 31s, 37s, 55s isn’t much good when you’ve in prison, or on the dole after a serious cock up.

 

[Tom Quinne]

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...

Agreed, it’s our job to keep trains running - happy signaller and happy train is one running on green signals with white lights on the front, and red on the back.

BUT.....

All to often we as signallers are the catch bet for the contractors and planning sides ills.

How many crap GZACs have you rejected because their plain wrong, how many down the pub PTS card contractors have you stopping taking blocks because their bloody dangerous?

We’ve got enough to do, let alone ensuring other do their jobs - the jobs their paid to do correctly?

 

[Tom Quinne]

Do you always exit a possession via a main signal or shunt or is going wrong road commonplace ? Cheers in advance.

Usually it’s via a right direction exit signal, but it’s not unknown leave the possession wrong road to cross back on the live railway.

Usually machines cross inside the job to exit at the exit signal, like this one should. We do it with full on High output trains as well of their top and tail usually.

All the comms I’ve had with OTM drivers have been with the conductor driver, he’s the one with the knowledge - the driver is there to just drive.

Outside the big 2 (DB & Freightliner) especially GB have a dedicated grade of driver who are authorised fo drive inside possessions only with zero actual knowledge of the line, only a briefing pack.

 

[Tom Quinne]

That is why they are supposed to have points operators, but they rarely do, (cheaper not to) they rely on the Signaller to assist.

Don't forget the signaller may have no idea where an OTM or similar is, the only info will be the Driver saying I am at such and such signal.

Indeed, you could have half a dozen track sections showing occupied inside the job so you’ve literally no idea where anything is - nor do you have any requirement to.

The problem is when a Point Op calls fo get 12345A and B PtS swung for a move of a OTM from the DN to UP, and those track sections are occupied (axle counters) you can’t swing the points so have to rely on the varying quality of points op to tell you the machine is clear of the points. They also need the ES or PICOP permission, I’ve been lied to on many occasions on this regard.

The moment we touch points, and start setting routes for moves we have then been dragging into the potential cock up. Hence why I don’t touch them, it’s the PICOPs Railway he/she can deal with it.

 

[Tom Quinne]

Possessions are a very black aspect for signallers, all the rules and principles we work to are off once the PLB + Dets have been placed, we don’t get a whole load of training on the inner workings of them either.

 

[Dai Corner]

Question for Tom or any other signallers.

Should there be a conversation along these lines when a train leaves a possession?

Driver: This is the driver of 6A44 and I am stood at xxxx on the Up Fast. May I have permission to exit the possession in the Up direction?

Signaller: Yes driver. You may proceed from xxxx in the up direction on the Up fast line as far as signal yyyy .

 

[Tom Quinne]

Yes in sort.

The PICOP will call you prior to the move being authorised to seek permission to allow the train to move to stop short of the PLB + Dets.

Signaller confirms with the PICOP that is in order, and seek permission to authorise the train beyond the protection to exit signal.

A basic possession limits list goes:

UP Main Beyond Sig AB1 to App AB3
DN Main App AB2 to Beyond AB4

The train will then proceed to the Det protection + PLB.
Protection assistant will having had permission from the PICOP lift the protection.

Driver of the exiting train will then seek permission from the signaller to leave the possession into the live railway beyond.

Signaller will then tell the driver to drop down to the exit Signal and tell the driver to obey the aspect.

At each call the line name will be called our, and signal number checked - well should be anyway.

 

[whoosh]

What a bizarre incident.
No-one gave permission for a wrong direction move out of the possession. Conductor Driver didn't say, "On the Down Fast adjacent to Victor Charlie six three two."

It seems the Conductor Driver wanted them to turn in the platform at Balham for them then to be on their way to East Croydon more quickly, but exiting the possession on the Down Fast in the Up direction was unsignalled with no signal or limit of shunt to go to.
If a signal doesn't operate or exist to give you permission, then you need to be very clear about the (unsignalled and in this case wrong direction) movement you about to make.

 

[Horizon22]

I should qualify that when I said full of people like that I meant that there’s a smattering of them all over the place, not that *everyone* is cut from that cloth. As with most things it only take a handful to toxify things, or one to pressurise someone into making a mistake...

Whilst I agree with you to a point, all the signallers involved had <5 years experience at Victoria ASC.

 

[TheEdge]

That is a bit of a statement ! Just for the record at the place I work at that is NOT the case at all !

I'd say its a fair statement honestly. In the driving grade we have Press and Call which is a good equivalent. Often you'll have the older "better" drivers poo-pooing things like that which can make it embarrassing for newer drivers in the face of experience.

Meanwhile I don't mind people thinking I look like an idiot if it helps me keep my job!

 

[bramling]

Agreed, it’s our job to keep trains running - happy signaller and happy train is one running on green signals with white lights on the front, and red on the back.

BUT.....

All to often we as signallers are the catch bet for the contractors and planning sides ills.

How many crap GZACs have you rejected because their plain wrong, how many down the pub PTS card contractors have you stopping taking blocks because their bloody dangerous?

We’ve got enough to do, let alone ensuring other do their jobs - the jobs their paid to do correctly?

Fair enough. It comes over as a little bloody-minded, but equally I can see there’s good reasons why that might be done. Like you say it’s someone else’s job so I guess they should do it.

 

[Nicholas Lewis]

The crossover the Tamper was supposed to use was within the Engineering Worksite, so would have been the responsibility of the Engineering Supervisor, either using Signaller to set the crossover for this movement, although as has been mentioned up thread, some Signallers will not do this, so a Points Operator would be used to do the setting of crossover.

Correct the crossover specified was within w/s A so that ES would have had to manage the crossing move however w/s A was given up at 1550 so it now became the PICOPs responsibility. What the report doesn't discuss is whether the planned crossing move was to be done within w/s A or whether it was planned to be cleared before the tamper was finished with in w/s B so would have been always been the PICOPs responsibility. Its no defence to subsequent issues but it may have been a change to the plan that initiates confusion with the PICOP. Ultimately these are Senior PICOPs responsible for the possession, with specific emphasis on multiple train/otp movements, so should be professional in everything they do but what we see here is rather cack handed approach not befitting of role equivalent to a signaller operating the railway in degraded mode. The report eludes to competence management being a probable underlying cause but doesn't make recommendations as Vital and NR have taken action which is the usual "rebriefing" approach. If people are competent why do they need rebriefing!! Given the incidents that RAIB have investigated over the years in relation to contractors its time ORR upped its surveillance and enforcement action on both NR and its contractors.

 

[Dai Corner]

Possibly silly question from an outsider.

If the PICOP isn't going to be on site, wouldn't the best place from which to work be the signal box covering the area of the possession?

Face to face communication with the signaller when handing over responsibility for the trains would seem the safest way to do it.

 

[Tom Quinne]

Possibly silly question from an outsider.

If the PICOP isn't going to be on site, wouldn't the best place from which to work be the signal box covering the area of the possession?

Face to face communication with the signaller when handing over responsibility for the trains would seem the safest way to do it.

occasionally you’ll have the picop come in prior to the job taking place to go over the limits with you, but their pretty much always on the phone to one person or another you really don’t need that in the SB.

It’s also against the national operations rules to use a mobile in the signalling floor.

 

[alxndr]

Possibly silly question from an outsider.

If the PICOP isn't going to be on site, wouldn't the best place from which to work be the signal box covering the area of the possession?

Face to face communication with the signaller when handing over responsibility for the trains would seem the safest way to do it.

Face to face can be a blessing or a curse. It can help as you can enhance explanations with diagrams etc, but also tends to end in over familiarity and subsequent poor comms. You'd also be less likely to have voice recordings for monitoring and as a record of what was said and happened.

You also don't generally want lots of people in a signal box. There might not be space in small boxes, and ROCs will have plenty of other signallers busy with open railway that won't want randomers getting in their way.