Reading 61306 'Mayflower' Incident 13/6/15

[Muzer]

My fault, I suspect, as I phrased that post badly. My reference to fatalities was a secondary point; my argument was that it appears from some comments that the DBS incident was of a more severe and serious nature than the Reading one, yet Lucas' opinion seemed to be that, as he perceived DBS to be better-managed, their incident was of less significance than that of WCR, to the point where he could claim that DBS ought not censured but WCR should be banned permanently. Can I presume that we all agree that those outcomes are rather different?

If we can agree on that point, what justification is there for treating the two companies differently, and what level of importance is placed upon the actual incident (as opposed to management procedures in an office miles from the scene) in determining those differing treatments? From reading his posts, I can only conclude that his responses would be that the actual incident itself is irrelevant, and that his justification for the differential response is solely based upon past performance, management structure and an undefined, nebulous assessment of "professionalism". In any safety-critical organisation, these criteria seem rather weak and unbalanced, given that the severity of the actual incident is swept under the carpet - a state of affairs which I cannot imagine the head of H&S in the University laboratories in which I spent a year researching for a Masters accepting.
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Thanks for putting your case so eloquently - that's the point I was attempting (but failing) to make! If we assume that NR acted correctly when they reversed the WCR ban, we must logically conclude that the Reading incident was unconnected with the previous SPAD in terms of management oversight, procedures etc. Why, then, should these two recent incidents be treated so differently?

I see what you were driving at now, and I do agree — from WHAT WE HAVE HEARD of the incidents, I don't believe there is any grounds for suspending operations from either TOC. What should happen now is WCRC do an internal review of their safety case for train dispatch and from that decide to change their methods to more safe ones, or at the very least improve their radio protocol (if any of this was already specified in their rulebooks, they should look at how well this is known by staff, and how well this is enforced, and look at potential disciplinary action against the people involved if it can be shown to be down entirely to their refusal to follow the rules — and that word there is "IF", not "WHEN" or "BECAUSE", so don't start having a go at me for being anti-staff!). I don't know the details of the DB incident but I suspect the response to that should be somewhat similar.

If, on the other hand, WCRC decide to ignore this incident and not look at revising their dispatch policy, then that's cause for concern.

 

[w0033944]

I see what you were driving at now, and I do agree — from WHAT WE HAVE HEARD of the incidents, I don't believe there is any grounds for suspending operations from either TOC. What should happen now is WCRC do an internal review of their safety case for train dispatch and from that decide to change their methods to more safe ones, or at the very least improve their radio protocol (if any of this was already specified in their rulebooks, they should look at how well this is known by staff, and how well this is enforced, and look at potential disciplinary action against the people involved if it can be shown to be down entirely to their refusal to follow the rules — and that word there is "IF", not "WHEN" or "BECAUSE", so don't start having a go at me for being anti-staff!). I don't know the details of the DB incident but I suspect the response to that should be somewhat similar.

If, on the other hand, WCRC decide to ignore this incident and not look at revising their dispatch policy, then that's cause for concern.

Thanks for your response - I agree entirely with your points. I certainly wasn't trying to underplay the Reading incident - to me, as a moderately-intelligent (I'd like to think!) layman, IF the reports surrounding the premature movement of the train are correct, then it's very concerning indeed, and I can see that procedures must be improved and enforced, or a different means of dispatch used to minimise the chances of a repeat of this incident. What I couldn't understand was the argument that one TOC ought to be treated leniently while the other must be banished entirely, seemingly on the basis that one is highly-respected and viewed as "legit" while the other is seen as "dodgy" due to past failings.

 

[6Gman]

I can but presume from the comments of several professional railwaymen on this forum that the general view is that WCR are "undesirables" who need to be removed forthwith. Dare I suggest that this might be underlain by a more general disdain for/dislike of "kettles" and anything that might be termed "heritage"? Add in the sarcastic comment aimed at a steam enthusiast (essentially implying that all who have an interest in steam are ignorant and shouldn't question their forum betters), and I get a distinct undertone of "RailUK should be a rail industry-only forum - the great unwashed laity are not welcome here".

As a former professional railwayman, now retired, I have some concerns about some minor operators. It is nothing to do with their being small, and certainly nothing to do with steam or other heritage elements.

My concern is whether their staff have the necessary skills and experience to carry out their operations safely. When I read RAIB reports which note that staff are brought in on what is essentially a "casual" basis [by casual I mean 'as required' rather than 'off-hand'], where the same staff may be both drivers and safety managers, and where they are engaged to operate what are effectively 'one-off' movements I worry.

In the days when I planned charter train movements, including steam, the drivers would be men (and a few women) who regularly used the routes and traction involved. On steam they would be accompanied by Traction Inspectors of huge experience - some of the finest men I ever had the privilege of working with.

I saw the start of non-BR founded companies getting involved. It caused problems then - is it still causing problems now?

I don't know. I've retired.

But I worry.

 

[E&W Lucas]

I can but presume from the comments of several professional railwaymen on this forum that the general view is that WCR are "undesirables" who need to be removed forthwith. Dare I suggest that this might be underlain by a more general disdain for/dislike of "kettles" and anything that might be termed "heritage"? Add in the sarcastic comment aimed at a steam enthusiast (essentially implying that all who have an interest in steam are ignorant and shouldn't question their forum betters), and I get a distinct undertone of "RailUK should be a rail industry-only forum - the great unwashed laity are not welcome here".

More specifically, in reply to E&W Lucas; are you claiming that the severity or potential dangers presented by an incident are neither here nor there; the procedures and paperwork being the only determining factor in whether the TOC should be given a pass or hounded from the network? Had the DBS incident occurred in a set of circumstances which caused the death of a passenger, should that persons' family have said "Oh well, at least, after Dave was killed, DBS followed procedure and had their paperwork up to date"? Surely the incident itself must count for at 50% of the assessment?

Please take a couple of minutes to research the railway significance of my forum username. When you've found out what it's usually stamped on, you may pause to reconsider the perspective from which I am posting.

I've posted already that either driver could have found themselves on a manslaughter charge. However, the KX incident seems to be a case of reading the wrong signal - human error. The WCR one may have an underlying cause of using irregular procedures, ie radios, so we could be back in the territory of their original suspension.
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As a former professional railwayman, now retired, I have some concerns about some minor operators. It is nothing to do with their being small, and certainly nothing to do with steam or other heritage elements.

My concern is whether their staff have the necessary skills and experience to carry out their operations safely. When I read RAIB reports which note that staff are brought in on what is essentially a "casual" basis [by casual I mean 'as required' rather than 'off-hand'], where the same staff may be both drivers and safety managers, and where they are engaged to operate what are effectively 'one-off' movements I worry.

In the days when I planned charter train movements, including steam, the drivers would be men (and a few women) who regularly used the routes and traction involved. On steam they would be accompanied by Traction Inspectors of huge experience - some of the finest men I ever had the privilege of working with.

.

You've nailed it.

 

[RPTC]

Thanks for your response - I agree entirely with your points. I certainly wasn't trying to underplay the Reading incident - to me, as a moderately-intelligent (I'd like to think!) layman, IF the reports surrounding the premature movement of the train are correct, then it's very concerning indeed, and I can see that procedures must be improved and enforced, or a different means of dispatch used to minimise the chances of a repeat of this incident. What I couldn't understand was the argument that one TOC ought to be treated leniently while the other must be banished entirely, seemingly on the basis that one is highly-respected and viewed as "legit" while the other is seen as "dodgy" due to past failings.

I'm afraid you do not appear to understand health and safety. There are several levels to it. There is no "leniency", and without getting bogged down in safety management, a key issue is the high level safety culture and processes. As we stand now, whatever the facts of the Reading incident, lets say we have 2 train operators who have identical incidents.

One of those is WCRC. A company who in the last 12 months are on record as having their Chairman state that the company refused to engage with NR over safety matters, couldn't actually confirm if their train crews were properly briefed during investigations into an incident that led to the closure of part of the ECML (IIRC), disengaged from a high level safety review from NR, bangs on about a paranoid conspiracy, and then has one of the worst SPAD's of the year that was seconds from a mass casualty collision, and had to be suspended from the network and investigated by the ORR.

The other is an established operator who has a generally constructive and compliant relationship with NR, is backed with demonstrably effective and appropriate safety processes and culture, and hasn't had a high score SPAD/near miss where their crews interacted inappropriately with safety equipment and failed to follow basic rail procedures.

It is entirely right that one of these is put under the a microscope for our hypothetical situation, and one is allowed to resolve it in other methods, since one of the outfits have proven incapable of managing safely competently and the other has proven satisfactory. NR has legal duties to protect the public and other operators, and most focus on those who pose the greatest risk overall. I have little doubt NR also had a big scare after Wotton, as ambulance chasing lawyers as well as the ORR and Coroners would have wanted NR to explain, given WCRC's recent safety record, why they had not been suspended prior to this. It would have been hellish for NR, as they would be blamed (and probably sued) for allowing steam trains on a modern network.

The other unrelated point, is that NR are late into the public sector cost cutting/austerity process. I work in the non-railway public sector and the cuts are so severe in many areas that anything "non-essential" is cut. Steam trains are entirely non-essential to the operation of a costly and heavily indebted NR. The utter stupidity of WCRC's management is that if austerity bites NR hard, it will be nigh on impossible to convince a minister or the Treasury that steam services are not a huge burden on NR running costs. If someone totals up what WCRC have cost NR in avoidabel and unnecessary management time and money from closures and incidents etc, it will be game over. WCRC even tried to claim compensation from NR following a temporary steam ban on one stretch of line, despite the fact that the ban arose from a safety incident and fire caused by WCRC!

 

[w0033944]

As a former professional railwayman, now retired, I have some concerns about some minor operators. It is nothing to do with their being small, and certainly nothing to do with steam or other heritage elements.

My concern is whether their staff have the necessary skills and experience to carry out their operations safely. When I read RAIB reports which note that staff are brought in on what is essentially a "casual" basis [by casual I mean 'as required' rather than 'off-hand'], where the same staff may be both drivers and safety managers, and where they are engaged to operate what are effectively 'one-off' movements I worry.

In the days when I planned charter train movements, including steam, the drivers would be men (and a few women) who regularly used the routes and traction involved. On steam they would be accompanied by Traction Inspectors of huge experience - some of the finest men I ever had the privilege of working with.

I saw the start of non-BR founded companies getting involved. It caused problems then - is it still causing problems now?

I don't know. I've retired.

But I worry.

I can appreciate such concerns, and your experience reinforces my conviction that (whisper it quietly) the nationalised railway may have been superior to the modern, fragmented network as regards standards for steam railtours.
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Please take a couple of minutes to research the railway significance of my forum username. When you've found out what it's usually stamped on, you may pause to reconsider the perspective from which I am posting.

I've posted already that either driver could have found themselves on a manslaughter charge. However, the KX incident seems to be a case of reading the wrong signal - human error. The WCR one may have an underlying cause of using irregular procedures, ie radios, so we could be back in the territory of their original suspension.

I'm well aware of the significance of your username, and, in fact, I didn't include you in my "anti-kettle" comment, as your posts didn't show an anti-steam bias, merely a strong opinion towards WCR. I understand your point regarding the initial mistakes - a procedural radio error may well be indictive of a greater structural problem than a mistake by a single person - my understanding, though, was that, after the initial mistake, the WCR Reading incident was dealt with in a more professional manner by staff on the ground than the KX incident, where (IIRC) the train left anyway, and the driver wasn't replaced until later in the trip. Surely, the actions of those present in the immediate aftermath count for something (they seem to in RAIB reports)? It just seems to me that some members are focusing on the worst parts of the Reading incident, and the least worst aspects of the KX one, in order to reinforce existing prejudices or opinions. I'm trying (though maybe not succeeding) to take all of the factors into account, within the limitations I experience of not being a railwayman.

I'm also confused by the differing opinions of professionals such as yourself in this thread on whether the Reading situation is related to, or counts as evidence of failings similar to, the infamous SPAD from earlier this year. You feel that it might, from what you've said - others within the industry have already stated in this thread that it doesn't. This is apt to confuse someone in my position! I suppose my layman's instinct would be to wait until the RAIB reports into each incident are published, or until NR decides what to do with WCR.

 

[E&W Lucas]

I'm well aware of the significance of your username, and, in fact, I didn't include you in my "anti-kettle" comment, as your posts didn't show an anti-steam bias, merely a strong opinion towards WCR. I understand your point regarding the initial mistakes - a procedural radio error may well be indictive of a greater structural problem than a mistake by a single person - my understanding, though, was that, after the initial mistake, the WCR Reading incident was dealt with in a more professional manner by staff on the ground than the KX incident, where (IIRC) the train left anyway, and the driver wasn't replaced until later in the trip. Surely, the actions of those present in the immediate aftermath count for something (they seem to in RAIB reports)? It just seems to me that some members are focusing on the worst parts of the Reading incident, and the least worst aspects of the KX one, in order to reinforce existing prejudices or opinions. I'm trying (though maybe not succeeding) to take all of the factors into account, within the limitations I experience of not being a railwayman.

I'm also confused by the differing opinions of professionals such as yourself in this thread on whether the Reading situation is related to, or counts as evidence of failings similar to, the infamous SPAD from earlier this year. You feel that it might, from what you've said - others within the industry have already stated in this thread that it doesn't. This is apt to confuse someone in my position! I suppose my layman's instinct would be to wait until the RAIB reports into each incident are published, or until NR decides what to do with WCR.

These incidents did not take place in a vacuum, and the wider safety performance of the companies involved must also be considered. I acknowledge that WCR acted promptly in caping their charter, but I still have concerns that lax/ inappropriate methods of working may have caused the issue in the first place. Eastern loco footplates are particularly noisy; radios have too much chance of being miss - heard, as seems to have happened.

Looking at it as a driver, WCR does not seem to operate on a level playing field with the rest of us. If I'd been involved in either incident, I would be thinking "Bye bye job, bye bye house, bye bye pension."
That WCR driver can just walk away. The fireman will have a regular job somewhere else, that will be totally unaffected. They are not under the same cosh as the rest of us. That is what frightens me.

 

[w0033944]

I'm afraid you do not appear to understand health and safety. There are several levels to it. There is no "leniency", and without getting bogged down in safety management, a key issue is the high level safety culture and processes. As we stand now, whatever the facts of the Reading incident, lets say we have 2 train operators who have identical incidents.

One of those is WCRC. A company who in the last 12 months are on record as having their Chairman state that the company refused to engage with NR over safety matters, couldn't actually confirm if their train crews were properly briefed during investigations into an incident that led to the closure of part of the ECML (IIRC), disengaged from a high level safety review from NR, bangs on about a paranoid conspiracy, and then has one of the worst SPAD's of the year that was seconds from a mass casualty collision, and had to be suspended from the network and investigated by the ORR.

The other is an established operator who has a generally constructive and compliant relationship with NR, is backed with demonstrably effective and appropriate safety processes and culture, and hasn't had a high score SPAD/near miss where their crews interacted inappropriately with safety equipment and failed to follow basic rail procedures.

It is entirely right that one of these is put under the a microscope for our hypothetical situation, and one is allowed to resolve it in other methods, since one of the outfits have proven incapable of managing safely competently and the other has proven satisfactory. NR has legal duties to protect the public and other operators, and most focus on those who pose the greatest risk overall. I have little doubt NR also had a big scare after Wotton, as ambulance chasing lawyers as well as the ORR and Coroners would have wanted NR to explain, given WCRC's recent safety record, why they had not been suspended prior to this. It would have been hellish for NR, as they would be blamed (and probably sued) for allowing steam trains on a modern network.

The other unrelated point, is that NR are late into the public sector cost cutting/austerity process. I work in the non-railway public sector and the cuts are so severe in many areas that anything "non-essential" is cut. Steam trains are entirely non-essential to the operation of a costly and heavily indebted NR. The utter stupidity of WCRC's management is that if austerity bites NR hard, it will be nigh on impossible to convince a minister or the Treasury that steam services are not a huge burden on NR running costs. If someone totals up what WCRC have cost NR in avoidabel and unnecessary management time and money from closures and incidents etc, it will be game over. WCRC even tried to claim compensation from NR following a temporary steam ban on one stretch of line, despite the fact that the ban arose from a safety incident and fire caused by WCRC!

Thanks for your response - might I reply point-by-point?

- I'm baffled by the idea that different TOCs are held to different standards depending on the quality of their management response to regulators and their recent (lack of) incidents. Imagine a situation in which DBS gains new senior management in their British TOC business, and that these managers erode the good practice and trustworthy systems that NR uses as a reason to adopt a "soft-touch" policy towards them. At some stage, this new, lax culture leads to a potentially serious incident occurring, but, as DBS are seen as 'model pupils', NR fails to apply the same scrutiny to the circumstances of the incident as they did to the WCR SPAD; after a cursory internal investigation, DBS changes nothing. Subsequently, this lax attitude leads to a major accident involving DBS including significant loss of life. How does NR then explain to the families of those killed that they failed to prevent the newly-careless TOC from causing the accident as they'd previously been of no concern, by ceasing to regulate them as stringently as other operators?

- Despite what I've said above, I'm not arguing against holding WCR to an unusually-high level of oversight until they satisfy regulators with management and procedural improvements, though there may be a fine line between that and finding any excuse to banish them from the network. My argument is that it shouldn't be a zero-sum game; extra oversight for one operator shouldn't be paired with a laissez-faire approach to others on the basis that they are seen as being a safer pair of hands. I'd like, if I may, to clarify whether or not this is indeed the case - would any other operator with a good safety record be treated similarly to DBS, or would a middle-ground approach be used?

- Glad to see that we appear to be in agreement on the excesses of the current austerity fetish. If NR budget is cut to the point of losing main line steam, could the heritage operators, and the groups constructing new-build locos from extinct classes for main line use not sue for restriction of trade? It would be a terrible pity, but austerity has had many more wide-ranging and damaging effects IMO than the loss of main line steam, so, if it happens, we shall just have to accept that the "anti-heritage" mindset will have won the day.
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These incidents did not take place in a vacuum, and the wider safety performance of the companies involved must also be considered. I acknowledge that WCR acted promptly in caping their charter, but I still have concerns that lax/ inappropriate methods of working may have caused the issue in the first place. Eastern loco footplates are particularly noisy; radios have too much chance of being miss - heard, as seems to have happened.

Looking at it as a driver, WCR does not seem to operate on a level playing field with the rest of us. If I'd been involved in either incident, I would be thinking "Bye bye job, bye bye house, bye bye pension."
That WCR driver can just walk away. The fireman will have a regular job somewhere else, that will be totally unaffected. They are not under the same cosh as the rest of us. That is what frightens me.

I get what you're saying about incidents not taking-place in a vacuum, but, on the other hand, our legal system, IIRC, does not allow disclosure of previous convictions of the accused to the jury lest it sway their judgement in the case at hand, implying that judging new cases on the basis of past behaviour isn't universally accepted as correct. I'm not concerned by WCR being placed under greater scrutiny than other operators; what concerns me is the implication that I've picked-up from this thread that operators such as DBS who are seen as scrupulous are effectively being permitted to self-regulate, or at least are being given greater leeway than normal on the basis of their "good behaviour". I find that as concerning as WCR's recent past - possibly more so in the light of how many of each TOC's trains are running on the network during the average week.

Also, just one final thought - I appreciate it's unlikely, but is there not a chance that the DBS incident was underlain by inappropriate working methods as well, just not as obviously as the WCR case? Is the jump to the conclusion that the DBS driver made a simple mistake that was not influenced by any procedural failing a touch premature, or at least unfair to WCR, in whose case many are gleefully pointing the finger?

 

[alastair]

The other unrelated point, is that NR are late into the public sector cost cutting/austerity process. I work in the non-railway public sector and the cuts are so severe in many areas that anything "non-essential" is cut. Steam trains are entirely non-essential to the operation of a costly and heavily indebted NR. The utter stupidity of WCRC's management is that if austerity bites NR hard, it will be nigh on impossible to convince a minister or the Treasury that steam services are not a huge burden on NR running costs. If someone totals up what WCRC have cost NR in avoidabel and unnecessary management time and money from closures and incidents etc, it will be game over. WCRC even tried to claim compensation from NR following a temporary steam ban on one stretch of line, despite the fact that the ban arose from a safety incident and fire caused by WCRC!

But isnt NR payed a vast subsidy by the taxpayer to operate the network for the benefit of all TOC's including Open Access TOC's,of which WCRC is one? Are you suggesting that all charter trains come into the "too difficult" category,or just steam ones?

I struggle with the notion that steam operations are a "huge burden" on NR running costs. WCRC presumably pay the normal track access charges?

Whilst not trying to defend WCRC's recent debacles,is it actually the case that,in relation to the number of trains they run(just a few hundred a year),they are any more prone to causing line closures and incidents than any other TOC? Surely NR must be much more concerned with the massive disruption caused by very regular dewirements,freight train failures,and (sadly)suicides. Compared with those,any delays due to WCRC must be vanishingly small.

 

[ExRes]

Also, just one final thought - I appreciate it's unlikely, but is there not a chance that the DBS incident was underlain by inappropriate working methods as well, just not as obviously as the WCR case? Is the jump to the conclusion that the DBS driver made a simple mistake that was not influenced by any procedural failing a touch premature, or at least unfair to WCR, in whose case many are gleefully pointing the finger?

As a former mainline driver who worked many charter trains with many different types of traction and rolling stock, I am growing increasingly worried about the attitude towards this type of incident

We are told that the DBS driver started to move away after accepting an RA indication from a signal which was not his/hers, this is not 'a simple mistake' by any stretch of the imagination, it is an appallingly dangerous mistake and shouldn't be mistaken for anything else

 

[w0033944]

As a former mainline driver who worked many charter trains with many different types of traction and rolling stock, I am growing increasingly worried about the attitude towards this type of incident

We are told that the DBS driver started to move away after accepting an RA indication from a signal which was not his/hers, this is not 'a simple mistake' by any stretch of the imagination, it is an appallingly dangerous mistake and shouldn't be mistaken for anything else

As a member f the great unwashed, I thought it seemed pretty dodgy, but the response seemed to be that it was "just one of those things".

 

[Clarence Yard]

Can we clear something up here about NR potentially banning steam if it becomes too expensive to cater for?

It isn't NR's call, nor the DfT's. Economic regulation is carried out by the ORR and they determine who gets onto the network for economic reasons. The charges that operators pay are determined by the ORR, not NR. NR cannot refuse traffic on economic grounds.

The only ways NR can withhold access are on safety or capacity grounds. Even then they can be challenged via the ORR, who also hold the ultimate card on safety and who are the body responsible for periodically monitoring operators safety procedures.

Although some at NR would love to have no freight hours and ban steam to a few lines, they cannot do it. BR could've and did but, under european law, NR are effectively just an infrastructure provider and systems controller, not the guiding and controlling mind for the industry.

 

[cjmillsnun]

They were never banned due to an incident!

I agree they didn't get suspended over one incident, however the Wooton Bassett SPAD was the straw that broke the camel's back. Just because they got the suspension lifted, does not mean that WCRC go back to a clean slate. There are still concerns that need to be looked at, and it will take many years for WCRC to fully show themselves to the entire satisfaction of the industry and NR. Once you have a bad reputation, it is very hard to lose it!.

Safety wise DBS are obviously a company with established safety procedures and management systems, and it is known that this kind of incident will be dealt with. However any incident they have will be noted, and investigated externally if it is felt necessary. No one is undermining how serious it was, and it is likely that the crew involved will have been dealt with appropriately.

 

[TorqueOfTheDevil]

Safety wise DBS are obviously a company with established safety procedures and management systems, and it is known that this kind of incident will be dealt with. However any incident they have will be noted, and investigated externally if it is felt necessary. No one is undermining how serious it was, and it is likely that the crew involved will have been dealt with appropriately.

Exactly. Until the RAIB report on the DBS incident is released, we can't say if any leeway is being applied to them.

I appreciate it's unlikely, but is there not a chance that the DBS incident was underlain by inappropriate working methods as well,

Of course there is - and this is what the investigation will be look into.

What I couldn't understand was the argument that one TOC ought to be treated leniently while the other must be banished entirely, seemingly on the basis that one is highly-respected and viewed as "legit" while the other is seen as "dodgy" due to past failings.

I don't think the RAIB will give much credence to that argument!

this is not 'a simple mistake' by any stretch of the imagination, it is an appallingly dangerous mistake and shouldn't be mistaken for anything else

It is both. It is a simple mistake which could have been appallingly dangerous. And this is why the management will be under the microscope: was it just one individual making a classic human error, or had they been insufficiently trained/checked by the management? Or were they too ill/fatigued to carry out their duty due to poor rostering, but felt unable to say so due to fear of punishment? I work in aviation, where human error can be equally disastrous, but is a fact of life - if a human being is involved, there is the possibility of a smart, keen, well-trained human making a simple mistake which could cost hundreds of lives. The only guaranteed way to avoid this is to stop flying (or running trains), but the risk can be mitigated to an acceptable level by careful training and checking of those involved in safety-critical tasks. The management also needs to be seen to be fair, and to create a culture where lessons are learned from near-misses without undue censure of an individual who made a mistake while trying to carry out their duties to the best of their ability.

To me this is the crux of the matter: is the incident due to one slightly weak/careless (possibly rogue) individual, or was the individual set up to fail by his/her organisation due to poor safety management/training etc? In the former case, the individual can be re-trained/disciplined/dismissed as appropriate, but in the latter, the whole organisation may face being banned...as quite rightly happened to WCRC after the SPAD.