Rail Accident Investigations

[BrianW]

It has been suggested that a thread be started on this.

I have been interested for some time in the reports published by thew Rail Accident Investigation Branch, as most recently exemplified in the current thread: Derailment near Grange Over Sands (22/03/24)

Other that come to mind include for instance in regard of the bridge over the Thames near Culham, at the Fisherton Tunnel near Salisbury, at Carmont near Stonehaven, and several 'near misses' with track workers.

Each time, the excellent forensic analysis points up 'learning points' and refers back to similar points made in previous reports; observations are also made on the action taken (or inaction) as a result of previous recommendations.

IIUC, RAIB has no powers to REQUIRE any action; I think they should and would welcome comments from Forumites.

 

[skyhigh]

I think they should and would welcome comments from Forumites.

I think it's reasonable for the regulating and licencing authority (Office of Rail and Road) rather than RAIB to have the power to require action.

 

[Dr Hoo]

What sort of ‘requirements’ are being considered?
E.g. You must immediately withdraw X class of rolling stock until it’s been modified; you must immediately close Y line until it has been rebuilt with a landslide shelter; you must immediately close Z signalling centre until it’s been replaced with a more modern version; you must immediately take member of staff Q off any duties relating to safety critical activities…

 

[BrianW]

The RAIB report related to the derailment near Grange Over Sands makes four references to the ORR (Office of Rail and Road- no reference to Regulation now)- in paragraphs 168-171, in relations to obligations to report. Para 171 shows dissatisfaction (delicately put) in the inadequacy of response in relation to GSM-R 'issues' at a previous incident:

'171 ORR has reported that the rail industry took sufficient action in response to this
recommendation for it to be considered as ‘Implemented’.'

The UK has a poor record of response to recommendations made at Inquiries, for instance in relation to child protection.

When I was involved in Quality Assurance and Review processes (in Higher Education) there was an expectation that responses to Recommendations and Requirements would be received by a due date.

 

[Indigo Soup]

I think it's reasonable for the regulating and licencing authority (Office of Rail and Road) rather than RAIB to have the power to require action.

Indeed, I believe the inability of the AIBs to impose binding requirements to act is deliberate. If they could do so, it would undermine their status as independent investigators.

 

[skyhigh]

The RAIB report related to the derailment near Grange Over Sands makes four references to the ORR (Office of Rail and Road- no reference to Regulation now)- in paragraphs 168-171, in relations to obligations to report. Para 171 shows dissatisfaction (delicately put) in the inadequacy of response in relation to GSM-R 'issues' at a previous incident:

'171 ORR has reported that the rail industry took sufficient action in response to this
recommendation for it to be considered as ‘Implemented’.'

I don't read it that way, at all?

 

[DanNCL]

Do I think the RAIB should enforce it themselves? No. But I do think that adhering to RAIB recommendations should be mandatory and I think that the ORR should be required to ensure that they are implemented, in full, without undue delay, and impose fines in cases of non-compliance.

 

[ainsworth74]

I tend to agree the function of ensuring recommendations are implemented and learning points taken onboard rests properly with the regulator. The investigating organisation needs to be kept out of such matters so their sole focus can be on working what happened, why and how to avoid it again. I think it's also important they those they are cooperating with the investigation know that their cooperation only enables the achievement of those objectives. Giving enforcement powers to the investigators I think distorts that role.

For my money the the fact that the RAIB find similar occurrences cropping up speaks to a failure of the existing regulator.

Personally I've thought for a while that the ORR isn't actually fit for purpose multiple different ways.

 

[BrianW]

I don't read it that way, at all?

But can it be read that way? Maybe I've developed a 'way with words'- what is said and what is not being said. The RAIB will be rightly careful to stick to facts. 'ORR reported that ...'. Does the incident at Grange suggest that perhaps insufficient action had been taken?

RAIB Reports helpfully include in all their accident reports IIUC definition of terms such as 'possible', 'probable' and 'observation'.

I tend to agree the function of ensuring recommendations are implemented and learning points taken onboard rests properly with the regulator. The investigating organisation needs to be kept out of such matters so their sole focus can be on working what happened, why and how to avoid it again. I think it's also important they those they are cooperating with the investigation know that their cooperation only enables the achievement of those objectives. Giving enforcement powers to the investigators I think distorts that role.

For my money the the fact that the RAIB find similar occurrences cropping up speaks to a failure of the existing regulator.

Personally I've thought for a while that the ORR isn't actually fit for purpose multiple different ways.

I note from the ORR website that it made just one response to RAIB in 2024, in relation to the striking of debris at Yarnton (which also featured in a thread on RailUKforum). I am wondering whether and when we shall see an ORR response to the management of the drains beneath the tamper at Grange Over Sands.

I also note the wider context of yet another government seeking to release industry from the iron grip of 'red tape' (regulation!) in the quest for 'growth', reduction of standards, and the growth of corner-cutting and turning of blind eyes while cutting costs, including staff.

 

[renegademaster]

impose fines in cases of non-compliance.

So the government just taking the money from their left pocket and placing it in their right one?

 

[DanNCL]

So the government just taking the money from their left pocket and placing it in their right one?

If that’s what it takes to get compliance then yes. But of course even after nationalisation there’ll still be open access and freight.

 

[BayPaul]

Do I think the RAIB should enforce it themselves? No. But I do think that adhering to RAIB recommendations should be mandatory and I think that the ORR should be required to ensure that they are implemented, in full, without undue delay, and impose fines in cases of non-compliance.

That would effectively mean that the RAIB were making the rules still, which would damage their prime responsibility of independent investigation. It would, for example, mean that they might avoid making a recommendation that they knew was very expensive, or would take years to implement.

A subtle change to your suggestion would be for the ORR to be required to make an action plan for each recommendation. This could include the option of 'we've considered it but do not believe it is appropriate and have done this instead' but at least it would mean that all recommendations had a full close out.