Quintinshill collision 1915.

[beast66606]

Thanks for your comments Stationmaster. The reason I raise this issue is that for me, the distraction caused by copying TRB entries was a major factor in the accident, yet I have never seen any discussion or explanation of why, or indeed if, this was necessary. 

 

If blocking back and the collar had been used the copying of the TRB entries would still have been a distraction - but not a fatal one.

.

[The Stationmaster]

Thanks for your comments Stationmaster. The reason I raise this issue is that for me, the distraction caused by copying TRB entries was a major factor in the accident, yet I have never seen any discussion or explanation of why, or indeed if, this was necessary. 

Have a look at Post 126 - it is also my view that copying the entries would have taken time and have been a distraction  (and it is part of the reason why I am fairly sure it was Meakin who cleared back when the Up coal empties arrived and failed to put on a Block Back)

[flubrush]

Have a look at Post 126 - it is also my view that copying the entries would have taken time and have been a distraction  (and it is part of the reason why I am fairly sure it was Meakin who cleared back when the Up coal empties arrived and failed to put on a Block Back)

 

One thing I did note in the recent programme was that the signalman in the Blea Moor box said that the most critical times in a signal box are the hand-over periods and I would agree with him, having spent a large part of my early working life on a shift system operating a continuing process.  Hand-overs to incoming staff could be tricky if things were very busy and it was fairly common for outgoing staff to stay on for a bit to complete complex operations before handing over.

 

You can put yourself in the position of Tinsley trying to get to grips with a busy situation on the railway,  trying to copy in the movements to the log which might not have been an easy job if he was having to log what was actually happening as he was trying to do this,  and having several other people in the box probably chatting away and engaging him in their conversations.   Meakin really dropped Tinsley in it by not putting a collar on the UP signal lever.  I have noted the remarks that using locking collars was honoured more in the breach probably because signalmen of the time considered it beneath them to remind themselves of operational situations by their use.  But if Meakin had adopted that attitude,  he didn't consider that the locking collar was much more important when it was another person, new to the situation, that needed the reminding and not him.

 

By accepting the troop train,  Tinsley effectively pulled the trigger,  but Meakin supplied the bullets.

 

Jim.

[jjb1970]

The show fell into a classic trap of this sort of revisionism in that it inferred that if the causal factors that contributed to the disaster went way beyond the actions of the two signalmen then it exonerated the signalemen. I think everybody accepts that as with almost all accidents there were many factors at play and that the rolling stock design (which we must recognise was nit unusual nor considered unsafe in 1915) especially contributed to the terrible death toll however that in no way exonerates or reduces the culpability of the signalmen.

[Pacific231G]

The show fell into a classic trap of this sort of revisionism in that it inferred that if the causal factors that contributed to the disaster went way beyond the actions of the two signalmen then it exonerated the signalemen. I think everybody accepts that as with almost all accidents there were many factors at play and that the rolling stock design (which we must recognise was nit unusual nor considered unsafe in 1915) especially contributed to the terrible death toll however that in no way exonerates or reduces the culpability of the signalmen.

I couldn't agree more. There's a phrase I've heard used in respect to aviation safety about "stopping the ducks from lining up". Most accidents in a basically safe system involve a chain of causes. Catastrophic mechanical failures aside, If everyone does their job properly then the various links that could help cause an accident will never join up. Even if someone does make an error the other links will still be broken but if people start working slopplily or bending the rules- themselves the product of generations of hard earned lessons-  then eventually the chain of links will join up and disaster will follow. 

 

I still find Tom Rolt's Red for Danger a brilliant exposition of how Britain's railways went from being a dangerous new form of transport to one of the safest places on earth to be. 

[62613]

I couldn't agree more. There's a phrase I've heard used in respect to aviation safety about "stopping the ducks from lining up". Most accidents in a basically safe system involve a chain of causes. Catastrophic mechanical failures aside, If everyone does their job properly then the various links that could help cause an accident will never join up. Even if someone does make an error the other links will still be broken but if people start working slopplily or bending the rules- themselves the product of generations of hard earned lessons-  then eventually the chain of links will join up and disaster will follow. 

 

I still find Tom Rolt's Red for Danger a brilliant exposition of how Britain's railways went from being a dangerous new form of transport to one of the safest places on earth to be. 

Quoting Tom Rolt, reminds me that he said that self-same thing in connection with the Abermule accident. An analogy might be of an old-fashioned fruit machine; only when you get Tic Tac Toe do you win the jackpot. a terrible analogy I know, but true all the same.

[Edwin_m]

Also known as the Swiss Cheese theory - you get a pile of cheese slices and occasionally the holes will all line up.  Abermule is probably a better example than Quintinshill as it has more links in the chain, each of which would have happened separately on many occasions before that but then they all happened together. 

[The Stationmaster]

Quoting Tom Rolt, reminds me that he said that self-same thing in connection with the Abermule accident. An analogy might be of an old-fashioned fruit machine; only when you get Tic Tac Toe do you win the jackpot. a terrible analogy I know, but true all the same.

But some of these things tend to keep happening 

 

In the 1960s at a crossing station on a single line several people were involved in handling tokens - they did it like that all the time, nothing ever went wrong, except for the day a Driver received back for the section in advance the very same token he had surrendered a minute or two earlier for the token in rear.  Fortunately in that case, unlike Abermule, there was no train coming the other way and the correct token had been drawn from the machine, it was just that the two tokens were somehow mixed up.

 

In 1974 I caught out two Signalmen changing over sometime after the booked time, when I arrived in the signalbox the newly arrived one was busily copying entries into the TRB off a piece of paper.  No real safety risk, it was a quiet time of day (night. I turned up around 22.30) and there were no trains about plus the 'box had fairly comprehensive block controls and a reasonable number of track circuits (but it was one where at least one train a day was frequently shunted across the road for regulating purposes.

 

The all too simple fact is that it is possible for human beings to make mistakes (wrong token) and it is also possible for them to attempt to circumvent the system (copying entries into TRB after unauthorised changeover time).  The fortunate thing is that as far as Britian's railways are concerned a large amount has been done to minimise the impact of people doing human things such as forgetting or ignoring Instructions.  The only problem I see nowadays is the increasing (and in my view often pointless) added complexity of many Rules and Instructions and the very poor format of presentation of many of them to those who have the responsibility of knowing and implementing them.

[John_Hughes]

... and, as I've commented before, there were certainly incidents when drivers were given the Right Away and headed off without any staff at all - I personally know one driver who did just that, and over the years there must have been others.

[jjb1970]

Nowadays there is much greater awareness of human factors and ergonomics and the necessity to build in a resilience to human error into safety critical systems as well as an emphasis on engineering risks out of systems rather than relying on procedures. Although in some ways, attempts to engineer risk out don't so much eliminate human failings as potentially move them to another part of the chain and into design offices and design verification areas and away from front line staff. I've seen control systems laid out in a way which is an open invitation to error and where designing them well would not have cost anymore simply because operator needs do not seem to have been really considered at the design stage. Equally, operational procedures have to be comprehensible and usable, if an official procedure has 110 complex steps to do a job that can be done with 5 easy steps then it is entirely precictable what is likely to happen. That is not to condone ignoring official procedures but it is an argument that those who write procedures should give due attention to human behaviours and consider whether they are fit for purpose. Unfortunately I think things have actually gone into reverse with procedures proliferating and becoming more verbose. A procedure in my view should be kept short and sweet and give the operator the instructions needed to do a job and essential guidance, not a slightly slimmed down encyclopeadia. I had one employer whose SMS was very short, consultant SMS writers came in and assured them it was inadequate, too short etc and the result was it went from a series of documents that were eminently usable and provided operators with what they actually needed to about two full shelves of documents that were never used and were just nonsense and were full of info that was of zero relevance. I'm sure they were paid by weight, after about six months the company binned it and reverted to their original SMS which was contained in a single box file. I think a big part of it is that whereas in older times operations managers, maintenance managers and safety managers had served their time at the coal face and had a very good understanding of behaviours within their organisation and the processes they were managing that is now often no longer the case and I often see safety procedures written in a way which makes it obvious that whoever wrote it has zero understanding of the task.

[Arthur]

 

Absolutely. I used the phrase earlier 'that working men all over the world will seek ways to ease their burden'. Nothing to do with being lazy or devious, it's just human nature, that with repetition of a task, men will soon boil it down to it's essential components.

 

Ignore that basic human desire in the development your procedure and you run the risk of the proceedure being seen as irrelevant. Within the context of achieving overall safety, KISS.

[s_ellinson]

On the "why wasn't the fire brigade called" front, it might be worth remembering that carlisle is on the other side of the border in England. I suspect that in 1915, such things mattered. The nearest "local" fire brigade to Quintinshill might have been Annan (if it had one) or Dumfries.

 

Equally, it was the role of the railway company servants to intervene - hence questions in the B-o-T report about the provision of tools etc in the trains.

 

In the 21stC we are very used to calling an expert. in 1915, the experts were there, on the ground.

[kevinlms]

On the "why wasn't the fire brigade called" front, it might be worth remembering that carlisle is on the other side of the border in England. I suspect that in 1915, such things mattered. The nearest "local" fire brigade to Quintinshill might have been Annan (if it had one) or Dumfries.

 

I agree, I raised the Scotland/England thing back in post 93. Borders have a significant role to play.

 

In Victoria Australia, there are 2 main fire services. In the Melbourne area, we have the Metropolitan Fire Board, which is a 100% paid firemen. Outside of the MFB, there is the Country Fire Authority, which is largely a volunteer service, with some paid firemen in larger regional areas.

Now the two systems use different incompatible fittings on their fire hoses/trucks. In boundary areas, both services have adaptors on their trucks, so that they can assist each other.

 

One wonders what disaster occurred to make a decision to carry such adaptors & to be able to cross boundaries. Where I lived previously was right on the boundary, one side of the road being MFB, the other CFA. A fire call from such areas, brings out the nearest 2 appliances.

[PhilJ W]

I agree, I raised the Scotland/England thing back in post 93. Borders have a significant role to play.

 

In Victoria Australia, there are 2 main fire services. In the Melbourne area, we have the Metropolitan Fire Board, which is a 100% paid firemen. Outside of the MFB, there is the Country Fire Authority, which is largely a volunteer service, with some paid firemen in larger regional areas.

Now the two systems use different incompatible fittings on their fire hoses/trucks. In boundary areas, both services have adaptors on their trucks, so that they can assist each other.

 

One wonders what disaster occurred to make a decision to carry such adaptors & to be able to cross boundaries. Where I lived previously was right on the boundary, one side of the road being MFB, the other CFA. A fire call from such areas, brings out the nearest 2 appliances.

On the question of incompatible fire brigade equipment this turned out to be a major problem at the start of WW2 in the UK especially with the formation of the National Fire Service in about 1940. The government then laid down standards that although they have changed from time to time all fire brigades have to adhere to.

[beast66606]

The box in question (video was originally pointed out by a member of The Signal Box forum, so thanks to him)

 

https://www.youtube.com/watch?v=YcgX3cyE5vc

 

 1:55 - 6:06

[jjb1970]

In terms of the two signalmen ignoring procedures/rules I'm guessing the situation today is what it was then. On day one of my safety rules training in electricity generation the instructor was brutally blunt in telling us that these are the safety rules, these are local management instructions and these are operating procedures. Collectively they are the company safe system of work. If you work within this safe system of work and somebody ends up dead or you blow the plant up then it will be the company in the dock as their safe system of work has failed. If you work outside this safe system of work then the company legal position is that you worked outside their safe system of work, ignored your training and they will hang you out to dry to take whatever legal consequences are headed in your direction (which, btw, was the best reason for being in a union). By ignoring safety rules and procedures the two signalmen didn't have a leg to stand on. Yes there were other causal factors, particularly with regards reasons for the high death toll, but ultimately it does not alter the guilt of the signalmen.

[LMS2968]

If you work outside this safe system of work then the company legal position is that you worked outside their safe system of work, ignored your training and they will hang you out to dry to take whatever legal consequences are headed in your direction (which, btw, was the best reason for being in a union).

As the NUR shop steward put it to me, "The Rule Book is there so they have someone to blame if things go wrong!"

[s_ellinson]

I agree, I raised the Scotland/England thing back in post 93. Borders have a significant role to play.

 

My apologies - I'd read my way through the thread but not noticed that.

[kevinlms]

My apologies - I'd read my way through the thread but not noticed that.

No probs, it was a long way back, but no one had commented about it until you.

[david.hill64]

As the NUR shop steward put it to me, "The Rule Book is there so they have someone to blame if things go wrong!"

Wow! What an unfortunate view. Rule books are there to try to prevent things going wrong in the first place. 

[LMS2968]

Yes, it struck me as an odd thing to say at the time, but I know what he was saying. The Rule Book is very prescriptive and few men stuck absolutely to what it said. For example, a bobby admitting a train into a section under Regulation Five (Section clear but quarter mile blocked) usually did so by holding up his hand with five fingers extended, instead of a steady green hand signal. Slight variation made the job run more smoothly or eased out a few wrinkles. Many of the short cuts were known to management, although the wise ones made sure thay didn't actually see them. But if you did take the short cut and something went wrong, then they would throw the (Rule) Book at you.

[jjb1970]

Management have a responsibility to manage and if Quintinshill happened today the courts would certainly examine training regimes, safety procedures/rules, corporate cultures and management supervision. The courts tend to take a rather dim view these days of management saying "we didn't know", as they should. Clearly management cannot be everywhere all of the time but they do have a responsibility to have mechanisms in place to ensure staff are acting in accordance with company rules and procedures. The courts do also pay attention to accepted practices. Where a deviation from rules is identified as necessary then it should be codified, I don't know what mechanisms the railways have but in electricity we have a clause in the rules called General Provision 3 to cover scenarios where the rules either cannot or should not be applied and that approved procedures must be in place. Something to remember is that management are also in the firing line after an incident. I was operations manager in a power plant, I signed off all operational procedures and was one of the signatures on local management instructions and procedures issued under General Provision 3 which I've just mentioned. I also had to counter sign any authorisations to confirm that I considered the individual suitable for authorisation. If ever there was an incident then potentially I'd be assisting the HSE and possibly the Police to explain why the person was considered competent to do their job, why was the procedure considered suitable, why had management agreed to a deviation from rules etc etc. So in short, notwithstanding what I have said about the importance of working within the rules it is not a workers vs. management scenario. And regardless of all of this, the modern approach is to cast the net wider but it is not to exonerate those who ignore rules. Which is the point at Quintinshill, no matter how many additional problems and causal factors are identified it does not affect the culpability of the signalmen. If one of my staff broke rules then I'd be potentially in trouble on a number of levels but it would not alter their own culpability.

[The Stationmaster]

The railway situation is very straightforward, and long has been.  First there is a hierarchy of system wide applicable Instructions - in the past these were the Rule Book, General Appendix (to the Rule Book & Working Timetables), the Signalling Regulations, the working timetable, and numerous other specialused Instructions such as train loads, freight handling and safety Instructions and so on.  

 

We can ignore most (all?) of the latter when considering a Quintinshill like situation because we are basically talking about the operation of a simple track layout at a simple signalbox.  Thus the Sectional Appendix might include items of specific relation to the place and the working of trains at it cross referenced in most instances to specific Rules or Regulations while as far as the working of the signalbox itself is concerned there would be the 'Signalbox Special Instructions' which would either amplify, permit, or prohibit, the application of particular Rules or Signalling Regulations.

 

As Quintinshill was basically an extremely simple and straightfiorward track layout I doubt the 'box Instructions would need to say very much - possibly something about when trains were to be offered forwards (due to relatively short sections), maybe something about what train running information had to be wired to where, maybe something about getting yard acceptance from Carlisle for slow up freight trains, and not much else.  Signalman's changeover times and 'box opening hours would be on a separate sheet.  And that would be about it.

 

As far as the collision is concerned I doubt there were any 'box Instructions which had any relevance at all except those relating to regulation of freight trains - everything related to the collisions was otherwise very simple and straightforward - shunting across the road (for regulating purposes) was common practice all over Britain and the movement itself was covered by standard Rules, the use of lever collars was a separate Instruction (probably a Company one or in the Company's version of the Signalling Regulations?), Blocking Back was in the standard RCH Block Regulations and in the Caledonian version, Rule 55 was in the RCH and Caledonian Rule Book, the standard Clearing Point would be in the Block Regulations and only variations from standard would be in the 'box Instructions.  All in all it was all very simple and basic and as JJB has very clearly identified what took place was down to some very basic parts of the Rules & Regulations not being correctly applied.

 

Signalmen were possibly on biennial re-examination at that time but I can't be sure of that.  Certainly the GWR set about revising its certificate and examination recording system some years later but it is not clear if that is related to Quintinshill although their change to local certification of various safe-working features obviously was.

Yes, it struck me as an odd thing to say at the time, but I know what he was saying. The Rule Book is very prescriptive and few men stuck absolutely to what it said. For example, a bobby admitting a train into a section under Regulation Five (Section clear but quarter mile blocked) usually did so by holding up his hand with five fingers extended, instead of a steady green hand signal. Slight variation made the job run more smoothly or eased out a few wrinkles. Many of the short cuts were known to management, although the wise ones made sure thay didn't actually see them. But if you did take the short cut and something went wrong, then they would throw the (Rule) Book at you.

 

A very long time ago it was made very clear to me that the last thing you should ever do on a Form DP1 (i.e. thhe form on which you made the disciplinary charge) was to charge someone with a breach of a particular Rule or Regulation by either quoting the Rule number or exactly quoting what the book said.

 

The reason for this was fairly simple because if you were really good on that stuff you could very often find an equally valid Rule number or regulation clause which actually contradicted or slightly altered the one you were using for the charge. So the best way was to just vary the wording a bit or simply say what they had done wrong but without saying why it was wrong.

 

I would incidentally argue with the Rule Book being very proscriptive - it certainly is nowadays (over much so in my view) and that has happened for legal reasons far more than anything to do with safety but many of us were brought up on the old Black Book (and then the red one) and were taught that the Rules were for the guidance of wise men (I won't mention what was said about 'fools' in that context).  Nowadays it is much more what one heritage railway manager said of a Rule Book I had written describing it as a procedures and methods manual for running his railway.

[Reorte]

Although it has to happen at times the last thing you want are people following the rules because they're the rules - you want people following them because they're the right way of doing things. As soon as you end up with "I'm only doing this because it's what this piece of paper says I'm supposed to do" then something has gone wrong (which could be with either the person doing it or the rule).

[HeeleyBridge]

The box in question (video was originally pointed out by a member of The Signal Box forum, so thanks to him)

 

https://www.youtube.com/watch?v=YcgX3cyE5vc

 

 1:55 - 6:06

 

That Horizon documentary was so much more informative than the "modern" one. They sure don't make them like they used to.