In delivering the RAIB report into the Stonehaven rail tragedy, Chief Inspector of Rail Accidents Simon French, said ‘we owe it to everybody who was affected by it to strive to learn safety
lessons for the future.’ Yet, reflects Greg Morse, corporate memory can soon fade
Imagine being in the cab of a train. Maybe it’s a job, maybe it’s a dream come true. Either way, you’re at a station. Waiting. On the Ilkley branch. Waiting. At Burley-in-Wharfedale. Waiting. At last, you get the tip and you power away. Except you don’t. There’s a problem. It’s an elderly lady, whose coat has caught between the closing doors, who’s dragged along for several yards, who will die
three weeks later from an infection to the wounds she suffered.
This actually happened – back in 1989. The problem was that the coat was thin enough to fool the train’s door interlocking system, allowing the blue ‘traction interlock light’ to illuminate. This meant that the train’s control systems allowed it to be moved. The guard also took it as proof that the train was safe to do so. He gave the appropriate signal to the driver without performing a final check of the platform. This was back in the days of British Rail.
As a result of the accident, the company made a couple of safety films to highlight the dangers, and saw to it that the instructions relating to power-operated doors were reissued, with an emphasis put on the need for that final check and the unacceptability of relying on the interlock light.
If the above sounds familiar, that’s because the assumption that getting the traction interlock light means it’s safe to go was a factor not only in a similar incident at West Wickham on 10 April 2015, but also one at Hayes & Harlington the following July.
That’s the trouble with corporate memory: it only exists while we remember it – ‘we’, the people there at the time, not the company as it existed then. So, while ‘we’ learned in 1989 – and did something with that lesson, the fluid nature of our industry – in which people retire, move on, or move in from elsewhere – cannot possibly guarantee that a lesson learned over 30 years ago will remain more than 30 years on.
Yesterday is important. Yesterday is the bedrock of all that comes after. Learning, indeed, has its origins in experience, and experience quickly becomes part of history. The Clapham accident of 1988 is a case in point – a wiring error, and one which rang bells in the minds of Rail Accident Investigation Branch (RAIB) inspectors when they investigated more recent incidents at Cardiff East Junction (2016) and Waterloo (2017). Simon French, RAIB’s Chief Inspector, drew a clear line from Cardiff back to Clapham, pointing out ‘how easy it is to forget the lessons of Clapham and slip back into those habits under the time pressures of a big commissioning’.
Since 1955, the role of helping safety practitioners to remember has been fulfilled by L. T. C. Rolt’s Red for Danger, which is not only the grand narrative of death by rail, but also the grand narrative of safety’s evolution. At the time, The Listener called it an ‘intensely human story’ and it is this link to the human condition that makes it such an important work: when we care, we’re more apt to remember. Not that Rolt resorted to ‘gruesome descriptions of charred or mangled corpses’; nor did he put words into the mouths of those involved – in the story of the collision at Norton Fitzwarren in 1890, for example, the fireman – Albert Dowling – warns his driver that there’s ‘a train a-coming on our line and he is never going to stop’. This is Rolt using a phrase from the original inquiry report. His skill is in adding more human colour, his use of language managing to convey fear, terror, appalling weather conditions.
At the opening of his description of the double collision at Abbots Ripton in January 1876, for instance, the reader is asked to ‘imagine a heavy coal train of thirty-seven wagons rumbling slowly southwards from Peterborough’. In its cab, driver and firemen peer for signals ‘through puckered eyes round the cab side sheets for the spectacle glasses were blinded with snow’. You can hear the rhythm of the wagons on the track joints, feel the white-cold of the whiteout as the engine’s fire roars in the firebox.
As The Times wrote in its own review, ‘[m]any who repeat glibly the claim that British railways are the safest in the world have no real idea on what basis this claim is made’. Red for Danger helped explain that claim, Rolt noting that Abbots Ripton had been caused in part by a signal freezing in the ‘clear’ position, despite the signalman setting it to danger to protect a train on the line ahead. A couple of pages later, he explains how the accident therefore led to changes and improvements in signalling such that henceforth signals were held at ‘danger’ until cleared for a specific train to pass.
Storytelling, though part of the history of the human race, is now vaunted anew as a means of managing knowledge, generating emotional connections, keeping the corporate memory alive. Stories stick, their lessons stick and they are more easily remembered when they need to be. This is why Red for Danger remains vital, but a recommendation to read it is no guarantee that anyone will. So what else can be done?
In Japan, a possible solution came in the form of JR East’s Accident History Exhibition Hall. Opened at the company’s General Education Centre in 2002, it features video footage of past accidents, reports and documents, but also full-size replicas of trains. In Britain, RSSB produces a number of learning presentations and documents relating to the relevance of corporate memory to railway safety. RSSB also joined with Network Rail to produce Learning from History, a document dealing with corporate memory and published by Rail magazine.
Aware that film can be more evocative than print, RAIB itself is helping preserve the corporate memory visually by commissioning an animated reconstruction of the fatal tram derailment that occurred at Sandilands on 9 November 2016, while RSSB produced an episode in its ‘RED’ staff briefing series (49, Past at Danger), which strove to chart the history of SPAD events and their mitigations. Similarly, Network Rail uses its Safety Central website as a platform for accident reconstruction and analysis shorts made by its own film unit.
These are very much the macro-scale, full industry versions of a solution, although all rely on collaboration, on people ‘being bothered’ to read or watch or listen. On the micro scale, talking (and listening) to those with a longer history in the industry is absolutely vital, although it is not a case of getting the retiring railway person to ‘download their brains’, as some have suggested. As Michael Woods, former BR Dartford Area Manager and later Principal Operational Specialist at RSSB, explains: ‘sometimes I don’t know what I can remember until I remember it; it’s the conversations about safety that help bring this detail or that back to the front of my mind.’ Sometimes, though, the pride of youth means that youth won’t ask questions of the old; and sometimes the old are too cynical about the willingness and ability of youth to understand.
If any of the lessons we learned in the past are to survive, we’re going to have to keep telling the stories. Whether this be embodied in training, in procedures, in formalised briefings or less formal
discussion, the human element will remain. Technology will doubtless help in a big way. Technology will doubtless improve our various databases, digital resources and risk analysis tools. But none of it will be much good if we don’t talk about the lessons and keep on sharing them.
Dr Morse, a Member of the Chartered Institution of Railway Operators, is the RSSB’s Operational Feedback Lead. He is also a co-opted member of the IOSH Railway Group. The views expressed in this article are his own. His book on Clapham, its context and lessons, should be published later this year