On 26 February 2012, three men were in the cab of a locomotive heading through the Canadian countryside. Their train – a regular passenger service – made a scheduled stop and powered up for the journey ahead. As the speed climbed, the crew saw a group of technicians working on the line. The driver sounded the horn but – unbeknown to him or his colleagues – the signaller had routed the train round the worksite…via a 15-mph crossover.
The locomotive hit the pointwork at 67 mph and derailed. It slid down an embankment, where it collided with
a building abutment, killing the crew outright. The subsequent investigation revealed issues around train protection, train crashworthiness, human factors and a lack of in-cab video recording equipment.
Some have called the accident ‘Canada’s Ladbroke Grove’. Yet no sooner was the report out than a cut of crude oil-carrying tankers ran away before derailing, catching fire and killing 47 people in Quebec. These two events led GB rail professionals back to those dark days at the turn of the century, when Hatfield followed Ladbroke Grove followed Southall – all in the space of three years.
We know that accidents can bring safety improvements in the longer term, but though Hatfield, Ladbroke Grove and Southall led (variously) to improvements in track maintenance, track renewal and train protection, the fact is that we have been learning from accidents since railways began more than 200 years ago. By 1900, we – and our various regulatory bodies – had ensured the adoption of interlocking, block signalling and continuous brakes, while more recently we’ve seen increasing mechanisation and safer rolling stock contribute to the impressive drop in train accident fatalities recorded over the last 50 years.
That doesn’t mean learning is easy – how many times have you hit your hand hanging a picture, told yourself you’ll never do that again, only to put on a repeat performance the very next day? In a company, it’s even harder: companies comprise a number of different and disparate memories, which don’t always interface perfectly, and which can change as staff retire, move on, or move in from elsewhere. When you expand the idea to a complete industry like rail, it becomes even more complicated. One thing I’m always saying in my job is that ‘we combat complacency with continued vigilance’. But we do – and in a fluid industry like ours, it’s the only way. Through RSSB, I’ve been able to remind the railway of lessons it learnt in the past – and those learnt by other industries, including episodes as diverse as the Nimrod air crash of 2006, the Deepwater Horizon oil rig explosion of 2010, the inquiry into care at the Mid- Staffordshire NHS Foundation Trust and the Fukushima nuclear accident of 2011.
Biggest safety story still the PTI
Another way we help the learning process is by producing a Learning from Operational Experience Annual Report (LOEAR) to capture some of the lessons learnt during a given fiscal year.
The latest issue, covering 2012-13, shows that the biggest safety story is still the platform-train interface (PTI), where major injuries have risen, despite a 10 per cent drop in overall harm.
Behind every statistic, however, is a face. In November, we were reminded of Georgia Varley, when RAIB published its report on the James Street fatality. Georgia died on the night of 22 October 2011, after falling between the platform and the train she had left 30 seconds earlier as it pulled out. The manslaughter case was widely reported, but less well known to the national media is the fact that the Toc involved – Merseyrail –
later added an alternative process to its dispatch procedure, which allows guards to give the ‘right away’ before their door has fully closed. This allows them to view the dispatch corridor for longer than the previous official process, which was to get on, shut the door and look out of a small window.
ORR and RSSB hosted a joint workshop in March to discuss the issues highlighted by the accident. The day was attended by train operators, Network Rail, the unions and reps from the ORR, RAIB and RSSB – all agreeing a need for consistency and new guidance.
This work builds on the Station Safety Improvement Project, established by RSSB in 2011 after safety performance analysis highlighted PTI risk. The aim now is to develop a holistic approach
to the assessment of all types of station risk, along with specialist research into potential human factors, engineering and asset solutions.
Cattle issue replaced by a deer one
Another incident type on the rise – perhaps surprisingly – involves animals on the line. Statistics show that, while the total reported number of animal on the line incidents has fallen by 43 per cent since 2002/03, reported cases of animals being struck by trains have risen by 77 per cent.
Many of the risks posed by cattle (and, by implication, other large-boned animals) were addressed by British Rail after the Polmont accident of 1984, when fence management processes, cab-to-shore communications, the rules for reporting incidents and the robustness of trains to collision were all improved. Despite this, however, RSSB’s analysis shows that the cattle question posed by Polmont has largely been replaced by a deer one.
At two million, the deer population is reportedly higher now than at any time in the last 1000 years, thanks to milder winters, more winter crops, increased woodland cover and greater connectivity between green spaces in urban areas.
The good news is that, although deer have an innate ability to jump fences of varying heights, the derailment risk is considered to be less than with a cow or horse, although the withdrawal of lightweight driving trailers, the fitment of obstacle deflectors and the general improvement in train crashworthiness exemplified by Classes 220, 221 and 390 means that it is now low for all animal types.
Just as important as collating the learning is feeding that learning back into the rail system. RSSB supports this process with periodic safety reports as well as briefing tools like the RED DVD and Right Track magazine. We also help the Rail Accident Investigation Branch (RAIB) set incidents into context, by offering statistical data, expert knowledge from staff with extensive industry experience, and by bringing cross-industry groups together to tackle industry-wide issues.
The source material for learning opportunities like these often comes from the coal face, whether it’s part of routine incident logging, confidential reporting via CIRAS, or simply having a management-level understanding of what’s actually happening ‘out there’. The key for us office dwellers is to make sure we’re reaching out to get this source material and to brief the learning back into the rail system. After all, the 2012 Olympics showed how good we can be as an industry when we share. If we keep sharing, we’ll win.