Wootton Bassett junction SPAD (07/03/15) RAIB Update released

[ainsworth74]

The RAIB have released an update regarding the above incident which can be found here. I've included a couple of extracts below:

13 The RAIB has found no evidence of any malfunction of the traction and rolling stock, signalling, AWS or TPWS equipment involved in the incident.

18 The driver indicated to the fireman that an AWS brake demand had occurred. His expectation was that the fireman would open the AWS isolating cock in order to by-pass the AWS brake demand and release the brakes. The fireman has stated that he believed that he was following the driver’s instructions when he subsequently crossed the cab and opened the AWS isolating cock. Witness evidence suggests that the AWS isolating cock was not sealed before the fireman opened it.

19 The railway rule book permits the drivers of trains that are in service to isolate the AWS system only if it has become defective or if it is inoperable due to the configuration of the infrastructure. In these circumstances, the railway rule book requires drivers to immediately bring their trains to a stand and then contact the signaller. Certain conditions must then be met before the train can proceed any further.

20 However, in this case, the train was not brought to a stand and instead continued on its journey. OTDR data shows that the brake demand made by the AWS system ceased to be effective around 12 seconds after it was initiated. The brief brake application which resulted from the AWS brake demand before it was by- passed reduced the train’s speed by a total of 8 mph (13 km/h). Witness evidence and OTDR data show that the AWS isolating cock remained open during the remainder of the incident; this had the effect of making any subsequent AWS or TPWS brake demands ineffective.

21 During this 12 second period, a second AWS warning occurred. This was created by the fixed AWS magnet located around 275 metres on approach to signal SN43, which was displaying a single yellow caution aspect. This warning occurred around 2.5 seconds after the AWS warning from the TSR had been acknowledged; OTDR data shows that it was acknowledged by the driver within 0.5 seconds. Witness evidence suggests that the driver was unaware that he had received two separate AWS warnings and that he instead believed that he had received a single warning. Because he had seen the TSR warning board, he also believed that the warning he had acknowledged was associated with a TSR. The driver did not see signal SN43 and, therefore, was not aware that it was displaying a caution aspect.

22 Just over a minute after the AWS brake demand had been triggered, train 1Z67 approached signal SN45, which was displaying a red danger aspect, at a speed of around 52 mph (84 km/h). As it did so, it passed over the first TPWS OSS for this signal, located approximately 750 metres on the approach. This OSS is configured so that the TPWS system fitted on any train passing it at a speed greater than 65 mph (105 km/h) will demand a brake application. Because the train was travelling more slowly than this set speed, the TPWS system on Tangmere did not generate a brake demand.

23 Train 1Z67 then passed over the second OSS at a speed of around 53 mph (85 km/h). This OSS is located approximately 360 metres on the approach to the signal and has a set speed of 45 mph (74 km/h). The TPWS system correctly identified that the train was travelling over the set speed and demanded a full brake application. However, because the AWS isolating cock was still open, this demand had no effect on the train’s braking systems.

24 At some point on the approach to SN45, the driver of 1Z67 saw that the signal was at danger and fully applied the train’s brakes. Analysis of the OTDR data available suggests that the earliest point which the driver could have applied the brakes would probably have been around 220 to 230 metres on approach to the signal. By the point where the driver applied the brakes, there remained insufficient distance to bring the train to a stand at signal SN45. The train subsequently came to a stand around 550 metres beyond the signal, standing on both the crossovers and the up and down Badminton lines, at just after 17:26 hrs.

26 The evidence available to the RAIB indicates that the SPAD at SN45 was not the only occasion on which the AWS isolating cock was used by a train crew operating Tangmere in order to by-pass an AWS brake demand. The extent of this practice continues to be the subject of further investigation.

 

[Iskra]

Wow. Shockingly reckless behaviour and very dangerous.

 

[najaB]

At risk of sounding like a member of the baying masses, the behaviour of this 'train operator' means he isn't worthy of the title train driver.

 

[NSEFAN]

It's like reading something out of Red for Danger.

 

[ComUtoR]

At risk of sounding like a member of the baying masses, the behaviour of this 'train operator' means he isn't worthy of the title train driver.

I think you would be shocked of the practices of "Train Drivers" back in the day. Whilst I do concur with your thoughts I find it hard to judge past practices of Drivers based on current standards.

For me this highlights that Heritage stock and the running of it needs to be brought under stricter controls and standards with rigorously maintained competencies.

 

[Bayum]

I think you would be shocked of the practices of "Train Drivers" back in the day. Whilst I do concur with your thoughts I find it hard to judge past practices of Drivers based on current standards.

For me this highlights that Heritage stock and the running of it needs to be brought under stricter controls and standards with rigorously maintained competencies.

That's the same as saying a doctor trained in the 30s would be more than justified in treating a patient as they would in the 30s, as opposed to looking at recent, rigorous treatment methods and changes. It just wouldn't happen.

Whether the driver was trained 'in the past' or not, you have to, I assume, be upto date with current standards and training so these exact scenarios don't occur?

 

[Dave1987]

It makes for truly shocking reading, and the fact this may not be an isolated case of crews isolating the AWS to stop a brake demand on this loco makes it even worse.

 

[CharlieSpotted]

Hopefully this will be exactly the type of incident to galvanise the industry into taking action. The level of recklessness involved here is just staggering. The RAIB's clear writing style makes it clear even to a layperson.

 

[ainsworth74]

It makes for truly shocking reading, and the fact this may not be an isolated case of crews isolating the AWS to stop a brake demand on this loco makes it even worse.

That to me was the biggest thing. This incident itself is bad enough but to then find out that this wasn't an isolated incident and has happened before was shocking in the extreme.

 

[ComUtoR]

That's the same as saying a doctor trained in the 30s would be more than justified in treating a patient as they would in the 30s, as opposed to looking at recent, rigorous treatment methods and changes. It just wouldn't happen.

I'm highlighting that making a judgement on how that Dr. would have treated their patient based on current standards doesn't make that Dr any less of a Dr.

Working practices of past Drivers frankly frighten and horrify me but they were still Drivers.

Whether the driver was trained 'in the past' or not, you have to, I assume, be upto date with current standards and training so these exact scenarios don't occur?

I would certainly hope so but I am finding that it is not quite the case. It does appear that some of the Heritage Drivers are somewhat lacking.

 

[Iskra]

Out of interest, why are the crew(s?) feeling the need to isolate the AWS on this loco? Surely its not necessary?

Is it time to say only professional drivers who drive modern types as well should be allowed to run mainline specials?

 

[Zoidberg]

That to me was the biggest thing. This incident itself is bad enough but to then find out that this wasn't an isolated incident and has happened before was shocking in the extreme.

... and that those involved seemed not to be aware that they were doing anything wrong!

 

[MrPIC]

wow, scary stuff!

 

[ComUtoR]

Is it time to say only professional drivers who drive modern types as well should be allowed to run mainline specials?

Euro license
Traction certified
Route competent
Fully tracked SOL record
Regular FDA's

And all the bells, whistles, assessments etc us modern professional go through.

 

[61653 HTAFC]

I think you would be shocked of the practices of "Train Drivers" back in the day. Whilst I do concur with your thoughts I find it hard to judge past practices of Drivers based on current standards.

For me this highlights that Heritage stock and the running of it needs to be brought under stricter controls and standards with rigorously maintained competencies.

As I understand it as a layperson, overspeeds were more common prior to OTMR being introduced, particularly overspeeds for the traction rather than linespeed - tales of 95mph in pacers on the ECML and so on. It's worrying that isolation of the AWS/TPWS seems to have been commonplace on steam specials and clearly there needs to be better training and refreshment of said training (as presumably the crews on steam specials do not work as regularly) along with closer supervision and monitoring.
I do hope that if this is a case of a few "bad eggs" it doesn't threaten the future of mainline steam though.

 

[Dave1987]

Euro license
Traction certified
Route competent
Fully tracked SOL record
Regular FDA's

And all the bells, whistles, assessments etc us modern professional go through.

Do these heritage drivers go through the same type of sim assessments that we do?

 

[WestCountry]

You omitted some other quotes that are important:

6. The portable AWS magnet was positioned so that there was less than four
seconds running time (for trains travelling at the maximum permitted line speed
of 125 mph) between it and the fixed AWS magnet for signal SN43. In addition,
the TSR warning board was placed between the fixed AWS magnet for SN43 and
the signal itself. The position of the portable AWS magnet and the TSR warning
board did not meet the requirements relating to TSRs contained within the railway
rule book and other Railway Group Standards.

21. During this 12 second period, a second AWS warning occurred. This was
created by the fixed AWS magnet located around 275 metres on approach to
signal SN43, which was displaying a single yellow caution aspect. This warning
occurred around 2.5 seconds after the AWS warning from the TSR had been
acknowledged; OTDR data shows that it was acknowledged by the driver within
0.5 seconds. Witness evidence suggests that the driver was unaware that he
had received two separate AWS warnings and that he instead believed that he
had received a single warning. Because he had seen the TSR warning board, he
also believed that the warning he had acknowledged was associated with a TSR.
The driver did not see signal SN43 and, therefore, was not aware that it was
displaying a caution aspect.

The TSR board was located between the AWS magnet for SN43 and the signal itself, so the driver looking out of his window would have seen the TSR board right in front of him when the signal's AWS triggered. Given the limited visibility from a steam loco cab, it's not surprising that he missed the signal after assuming he'd seen the cause of the warning.

Disabling the AWS was certainly wrong, but not the only cause.

 

[ainsworth74]

You omitted some other quotes that are important

I think you'll find I did include twenty one

Fair enough regarding six but I was skim reading and trying to pull out the most interesting bits of the report so that's probably how I missed it.

 

[ComUtoR]

Its not uncommon for a TSR board to be placed like that and not uncommon for magnets to be placed so close together.

Its our job and part of our skillset to be able to determine what the AWS magnet is for. Part of our duties is to check what TSR's are in place on the route we are booked to work.

I can certainly attest that the visibility from Tangmere is limited.

 

[Bayum]

I'm highlighting that making a judgement on how that Dr. would have treated their patient based on current standards doesn't make that Dr any less of a Dr.

Working practices of past Drivers frankly frighten and horrify me but they were still Drivers.



I would certainly hope so but I am finding that it is not quite the case. It does appear that some of the Heritage Drivers are somewhat lacking.

I think you'd find that if there were particular practices that had been stopped due to lack of research or lack of improvement post treatment, that a Doctor who still uses such treatments is, less of a doctor. The first and foremost teaching should be 'do no harm'.

A train driver who was trained in the 30s and is driving trains based on past practises is no more a driver in the sense that I drive a car. You'll find that in job role descriptions there are a number of skills and attributes that modern drivers have to abide by and work to - this driver wasn't.

 

[CharlieSpotted]

I can certainly attest that the visibility from Tangmere is limited.

I'm wondering if it would be appropriate to fit steam locos in mainline use with a forward-facing camera and a monitor in the cab, so that it can be used instead of the window if the visibility is poor. It could be done at the same time as fitting the other safety systems, I suppose.

Clearly the nature of a steam loco causes its own unique problems in terms of visibility of signals etc. Perhaps this could be a relatively inexpensive solution?

 

[Dave1987]

You omitted some other quotes that are important:


The TSR board was located between the AWS magnet for SN43 and the signal itself, so the driver looking out of his window would have seen the TSR board right in front of him when the signal's AWS triggered. Given the limited visibility from a steam loco cab, it's not surprising that he missed the signal after assuming he'd seen the cause of the warning.

Disabling the AWS was certainly wrong, but not the only cause.

You don't get an AWS warning horn without an associated board or signal. If there were two AWS magnets then he should immediately of been thinking there are two things I need to be paying attention to and acknowledging. This is where the modern "press, call & react" comes in. He missed the most important thing he was getting the AWS warnings for.

I could show you hundreds of examples of TSR warning boards that are not laid out according to the rule book but because we read our WONs we know where the published TSRs are. This driver didn't even know about this TSR.

 

[SPADTrap]

You omitted some other quotes that are important:


The TSR board was located between the AWS magnet for SN43 and the signal itself, so the driver looking out of his window would have seen the TSR board right in front of him when the signal's AWS triggered.Given the limited visibility from a steam loco cab, it's not surprising that he missed the signal after assuming he'd seen the cause of the warning.

Disabling the AWS was certainly wrong, but not the only cause.

It is all about route knowledge, especially approaching a junction, that alone should tell the train crew where the signals are located and alarm bells should be ringing if you're approaching that junction and you are unable to recall your last signal. Were they just driving signal to signal?

Secondly, if a locomotive is running about which can shroud signals leaving the train passing it without action being taken based on that signal's aspect for any reason, poor visibility through the window, steam blowing about, whatever, then it shouldn't be on the mainline until rectified, that's just trying to trip the train crew up.

As a driver, never assume, not because it 'makes an ass of u and me', because it can lose you your job and it can kill!

The mispositioned boards were one thing and the train crew would have had a right to 'complain' about that error but how can you complain when you intentionally remove the safety system that is there to cover your back from such 'traps'?

 

[ComUtoR]

Would they have "booked on" as per the current standards ?

Do they have access to or required to check the Late Notice case before taking a loco out ?

 

[ASharpe]

What training would the fireman have had? Would he know that the AWS should not have been isolated?

 

[Arglwydd Golau]

It is all about route knowledge, especially approaching a junction, that alone should tell the train crew where the signals are located and alarm bells should be ringing if you're approaching that junction and you are unable to recall your last signal. Were they just driving signal to signal then?!..

Isn't it the role of the Inspector on the footplate to ensure that issues such as these are known to the driver?

 

[bnm]

My reading is there were multiple failings. All laid at the door of WCRC and those on the footplate.

The incorrectly placed temporary AWS associated with the TSR is but a sideshow, neither causal or contributory to the incident.

A passenger train was in service with safety systems isolated. Unacceptable.

 

[Chris M]

You don't get an AWS warning horn without an associated board or signal. If there were two AWS magnets then he should immediately of been thinking there are two things I need to be paying attention to and acknowledging.

It seems that he was unaware that he received two warnings, and hadn't seen that the signal was displaying a restrictive aspect (for whatever reason) so he would not have been expecting two warnings - only the one for the TSR. As the TSR was greater than the maximum permitted speed for the train he was driving, he would not be expecting to do anything for the restriction other than acknowledge it. It seems very likely to me that the second acknowledgement was subconcious - either he didn't think the first acknowledgement had been successful and was trying again or he wasn't even aware that he had acknowledged more than once*.

Don't get me wrong, disabling the safety system was absolutely the wrong thing to do, but it seems likely he had in his mind that there was no restrictive aspect and so he only needed to make one acknowledgement. It is a well known human factor that in certain situations it is entirely possible to react to the situation you expect and think you are in, rather than the actual situation. With the exception of disabling the safety system, he seems to have reacted exactly how he would have been expected to react IF the first signal had been green.
This is a problem, but it's a different problem to the one your comment seems to indicate you think it is.

*I have no idea how much physical effort is required to acknowledge an AWS warning - the less effort that is required the more likely it is to be possible for someone to be unaware that they've made two actions rather than one. I also have no idea whether it is possible to incompletely acknowledge on a first attempt (e.g. if a button requires depressing 1cm to acknowledge, it would be possible to depress it only 0.5 or even 0.8 cm on a first attempt and thus require a second press).

 

[Dave1987]

Chris M - two things, firstly from your route knowledge you should know where signals are located (or at least the rough location), in an AWS area you always get a 'Bing' for green lights which require no action from the driver. Yellow or red signals give a warning horn which you have to acknowledge. The driver should have known about the speed restriction already and known it didn't apply to him as it was faster than the max speed he could do. So at that point his concentration should have been on the signals. As a driver if you ever get into a position where you are cancelling the AWS without acknowledging in your mind the reason you have got that warning you are at risk of having an incident.

 

[TDK]

There is another thing that needs to be considered is that modern signalling systems have a signal sighting review before being operational, the thing is these signals were not sighted for steam traction. Therefore if the case is poor visibility of signals from the cab of a steam train it should not be permitted on the line. Is there a risk assessment for steam on mainline? Maybe, maybe not!