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Signal Passed at Danger (SPAD) and near miss at Sileby Junction 05/05/2021

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DerekC

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RAIB is investigating a SPAD and near miss at Sileby Junction:

https://www.gov.uk/government/news/...ae71-4ea8-9a8f-8a0cd3b01f3a&utm_content=daily

At around 05:29 hrs on 5 May 2021, a train made up of machines used for reprofiling (grinding) rails, travelling on the down slow line near Sileby, passed signal LR477 at danger by about 350 metres. The signal was at danger because a train of empty coaches, travelling in the opposite direction, was crossing the down slow line ahead to move from the up fast to the up slow line.


The rail grinding train came to a stop fouling the junction over which the train of empty coaches had passed, less than ten seconds earlier.


RAIB’s preliminary examination has found that there were no technical faults in the trains or the signalling equipment. The brakes of the rail grinding train were applied by its driver and by intervention of the train protection and warning system (TPWS), but this intervention did not stop the train within the safe overrun distance, and allowed it to reach the conflict point at the junction.


Our investigation will seek to identify the sequence of events which led to the incident. It will also consider:


  • The management of the grinding train driver’s competence and fitness
  • The design of the signalling on the Leicester to Loughborough section of line
  • The effectiveness of TPWS in circumstances where train braking rates are lower than those used in calculations relating to the design of the system
  • Any relevant underlying factors, including the rail industry’s response to RAIB’s recommendations made in previous reports involving train driver fatigue management

Our investigation is independent of any investigation by the railway industry or by the industry’s regulator, the Office of Rail and Road.


We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on our website
 
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Trackman

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I read about this, certainly a very close call.
I wonder if the driver saw the ECS train?
 

MarkyT

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This part of the initial statement from the RAIB is interesting:
Our investigation will seek to identify the sequence of events which led to the incident. It will also consider:
...
The effectiveness of TPWS in circumstances where train braking rates are lower than those used in calculations relating to the design of the system
Suggests they are already aware of a problem with the braking rate of some train types and formations.
 

Efini92

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The signal protecting the movement left very little margin for error. Even the best braked trains would’ve ended up in the conflict point if they’d passed the signal.
 

edwin_m

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This part of the initial statement from the RAIB is interesting:

Suggests they are already aware of a problem with the braking rate of some train types and formations.
The report into the nearby near-miss at Barrow-on-Soar cited excessive speed by a train with less than normal braking.
 

HSTEd

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Is there any particular reason a train like this can't achieve the normal braking performance?

Or is just longstanding practice that they don't need to?
 

4F89

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Is there any particular reason a train like this can't achieve the normal braking performance?

Or is just longstanding practice that they don't need to?
Because they have high weight and **** brake force
 

LAX54

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Reduce the maximum permitted speed from 60 mph to 45.
Back in the day they were always 7Z02 or 7Z09 if not guaranteed to occupy track circuits, there were very few class 6's, but they were a pain to get from A to B in general traffic.
 

Nottingham59

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You'd have thought that a rail grinding train would be a perfect candidate for friction track brakes, wouldn't you?

For emergency use only, of course.
 

trainmania100

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350m is quite an overrun, I'm assuming there would have been at least one caution aspect beforehand giving enough time to slow down? Very unusual if the driver signed the route and knew where the signals were. Even if the driver didn't know where the red signal was, the caution aspects should have given more than enough warning - will be interesting to see the outcome
 

GB

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350m is quite an overrun, I'm assuming there would have been at least one caution aspect beforehand giving enough time to slow down? Very unusual if the driver signed the route and knew where the signals were. Even if the driver didn't know where the red signal was, the caution aspects should have given more than enough warning - will be interesting to see the outcome

Trains are driven by humans and its entirely possible to see the cautionary aspect and not react to it or the red....it does happen. Add the less then optimum braking characteristics, potential issues with TPWS calculations and the fact the fouling point is apparently not that far away then it all adds up to potential problems.
 

24Grange

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Do you get disciplined for a SPAD ( if it proves to be your fault) or fired or some other sanction - retraining?
 

GB

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Do you get disciplined for a SPAD ( if it proves to be your fault) or fired or some other sanction - retraining?

Depends on the circumstances and drivers previous record but none of the above is off the table.
 

Mag_seven

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RAIB report now published:

RAIB has today released its report into a near miss between a rail grinding train and an empty passenger train at Sileby Junction, Leicestershire, 5 May 2021.

At about 05:29 hrs on Wednesday 5 May 2021, a train made up of machines used for reprofiling (grinding) rails passed a signal at danger (red) at Sileby Junction, between Leicester and Loughborough, resulting in a near miss with an empty passenger train travelling in the opposite direction. The passenger train had cleared the junction less than 10 seconds before the rail grinding train reached it. There were no injuries or damage as a consequence, but the incident resulted in delays to several trains in the area.

The incident was caused by two factors. Firstly, the driver did not control the train’s speed to be able to stop at the signal at danger, probably due to fatigue. Secondly, although the train’s systems made an automatic emergency brake intervention, this did not stop the train before it reached a point at which it could collide with another train. A probable underlying factor was associated with the fatigue risk management processes used by the train operator.

RAIB has also made four observations which, although not linked to the cause of the incident, nevertheless had safety implications. The first observation identified that there was no system-wide risk assessment to control the risk of overruns arising from the operation of non-standard vehicles on the national rail network. The second observation noted that the train operator did not obtain safety-critical information about the driver when he joined the company. The remaining observations relate to industry processes for managing the operational and technical response to such incidents.

Recommendations
There are two recommendations arising from this investigation. These cover fatigue risk management and managing the risks of trains with lower braking rates passing signals at danger. RAIB has also identified three learning points, addressing the use of napping as a fatigue mitigation, the importance of organisations sharing safety-critical information when employees move between companies, and railway procedures for post-incident management.

 
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RAIB report now published:



The report mentions percent g / metres per second squared. If drivers are criticised by such units of deceleration / performance; surely driver training should include explanation.
 

TheEdge

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The report mentions percent g / metres per second squared. If drivers are criticised by such units of deceleration / performance; surely driver training should include explanation.

Oh no, here we go again.

As has been gone over on this point with you countless times, there is a difference between the forensic reconstruction of an incident or the application of theoretical physics and the day to day judgements a driver makes when braking.

Another report into an incident where fatigue has played its role yet again. Yet NR, TOCs and FOCs are constantly after "productivity" which invariably translates as longer shift, shorter breaks and tighter rostering.

Also, impressive record of the driver managing to get his own old incident investigation referenced as a "similar occurrence" in his new RAIB report
 
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66701GBRF

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Another report into an incident where fatigue has played its role yet again. Yet NR, TOCs and FOCs are constantly after "productivity" which invariably translates as longer shift, shorter breaks and tighter rostering.
Wait 'till the report comes out for the recent Doncaster collision. I'm sure that will be an interesting read fatigue/shift wise.
 

Efini92

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Wait 'till the report comes out for the recent Doncaster collision. I'm sure that will be an interesting read fatigue/shift wise.
From what I’m hearing it’s going to read like a disaster movie.
 

304033

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Question... Do any passenger services currently use Sileby Jnc to go from UF to US.
Not mentioned in RAIB report (or I missed it...)
 

TheEdge

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Indeed, I wont spoil the movie for anyone but hopefully fatigue and rostering will finally start to be taken seriously.

Hopefully because at the moment it really seems to be "the spreadsheet says you're not tired so you can't be tired" regardless of all other factors.
 

Watershed

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Some pretty shocking failures there; it's only through sheer luck that an actual collision was avoided.

Whilst having a SPAD on your record shouldn't automatically mean instant dismissal or disqualification from applying for a driver role, clearly this driver did not have the required skills, or perhaps qualities, to be operating trains safely. As proven by the fact they now have two RAIB reports to their name!

There's also a worrying accountability gap here because, as with many RAIB reports, we are again reminded that decade-old recommendations have still not been fully implemented. It's no good having the RAIB simply make recommendations if they don't have the power to force companies to comply.

It's frankly astonishing that the rail network doesn't have more incidents, with so many holes in the Swiss cheese just waiting to line up...
 
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