Plymouth platform collision - RAIB report

[great central]

As merely a humble guard I and all my colleagues are still required to know, and sign to certify that we know, our routes and the signalling as well as the layout of all the stations at which we call including such things as permissive working and short platforms. If we screw up we expect to get hauled over the coals. I have made the odd very minor mistake not leading to any injuries but the incident was fully examined and I was subject to a period of increased monitoring.

Drivers have to know where they are at all times, how do you think, for instance the timetable (certainly on most of our routes) stays fundamentally intact during fog or at night? Drivers know or should know exactly where they are at all times, if they don't they should slow down or if necessary stop.

If we stop short I should know and not release the doors, if I did, it's down to me, not the driver for stopping short, not the signaller for maybe holding us at a signal partway down a platform (Manchester Oxford Road is a good example). ME and me alone as it's my fingers on the door release buttons!

The driver should have known the totally unequivocal meaning of the position lights and driven prepared to stop wherever he had to. If he didn't both  his signalling and route knowledge is deficient or at least suspect, which is down either to lack of training or insufficient re-inforcement of that training

[bescotbeast]

What you have described here sounds like complacency. 

And complacency is the "mother of all accidents".

Never assume anything on the railway,never assume that the signal will clear when I approach it etc..........I had this hammered into me at training school and then in safety briefs.

The driver made an assumption and paid the price by crumpling two units.

[bescotbeast]

It wasn't a Graham garish HST he hit it was a full sized one. If you get a sub and a platform number you should be looking for a train in that platform.

I don't know the layout at Plymouth but if there is poor sighting you crawl if necessary to be sure you can stop should something be there

Fully agree, Permissive working stipulates, be prepared to stop short of any obstruction, tail light/lamp etc

[bescotbeast]

Nice one Phil

I didn't realise he was alleging he had the wrong platform number.

If you are involved in an incident it's far better to hold your hand up and tell the absolute truth.

Most companies recognise this and if you do admit blame the punishment is often less severe

One of the earliest pearls of wisdom, that the old boy at Waterey Lane passed onto me whilst he was training me was, "hold your hand's up if you f#ck up, they will always find out what happened sooner or later" .

During my 19 years on the Railway it's served me well, getting me out of many scrapes.

Simon

[PM47079]

Nice one Phil

I didn't realise he was alleging he had the wrong platform number.

If you are involved in an incident it's far better to hold your hand up and tell the absolute truth.

Most companies recognise this and if you do admit blame the punishment is often less severe

Yep agree always tell the truth. I have seen people sacked or demoted for lying about spads, I am afraid this driver has dug himself into a huge hole including his casual interpretation of a calling on signal, I've been on this job 31 years and the lesson is always if you are not sure slow right down always check the road lays right and you might just get through your driving career ok.

That's what the old hands used to tell all us young eager secondmen. And you were put in no doubt that if you messed up on your head be it!

[david.hill64]

Perhaps worth recalling that ORR served Improvement Notices on both GWR and NR requiring a better assessment of the risks of permissive working. In GWR's case it seems to me that this is an inherent criticism of GWR's driver training.

 

The railway cannot operate without permissive working: it needs to ensure that the risks in doing so are ALARP. Fixed block signalling systems offer no protection even with ATP: moving block at least gives you the chance to get trains closer together before you lose protection. You could be close to full protection with a UTO system (which allows driverless trains to couple) but the UK mainline is a long way from being able to implement such a system.

[Supaned]

If I could cast peoples memories back to a recent incident at Paddington , involving a driver from the same TOC , in similar circumstances.

 

There has to be questions asked about the training program - both the quality, content and duration. Whilst I appreciate that it is in the business interests to get drivers out on the road as quickly as possible , corners should not be cut in fundamentals such as signals and their meanings. Anyone can recite a rule parrot-fashion to satisfy an examiner, that does not mean that the person actually understands the phrase they are repeating and can then act accordingly in a real situation.

 

Of course , drivers are only human and can make mistakes , and it could just be coincidental that both of these incidents involved recently qualified drivers from the same TOC and training program

[Rivercider]

In this case the training may or may not be at fault, but I suspect the problem is often more in the assessment at the end of the training,

and making sure the new driver actually understands the things he has been taught. 

I suspect nobody ever remembers everything they were taught in training, either in the classroom, or out on the job.

 

During my railway career I had a short spell doing training work, (TOPS data input work - not directly safety related).

There were certain occasional TOPS inputs that needed to be made that I knew would catch out even experienced clerks. I made absolutely certain

that I had discussed these inputs and demonstrated them to all the staff I helped train, only to find when they took over the work themselves

that these inputs were not being made,

 

cheers 

[Reorte]

In this case the training may or may not be at fault, but I suspect the problem is often more in the assessment at the end of the training,

and making sure the new driver actually understands the things he has been taught. 

I suspect nobody ever remembers everything they were taught in training, either in the classroom, or out on the job.

How do you assess it? As has been mentioned upthread it's one thing to be able to repeat the rules, another to actually understand them and work with them. I suppose that's a great advantage of simulators, you can set up situations which could result in accidents without any chance of anyone getting hurt.

[phil-b259]

No one disputes that training on its own, including the ability to pass assessments isn't the be all and end all of things.

However based on the RAIB report the point here is that the driver of the DMU had plenty of experience of permissive platform working - indeed at busy stations like Plymouth it would be unusual if they didn't. As such the driver should have been well versed in the rules regarding calling on signals - yet he appears not to have been.

I accept the railway is a complicated working environment but some things are done so frequently it's hard to try and use the lack of experience angle to excuse mistakes.

[Reorte]

No one disputes that training on its own, including the ability to pass assessments is the be all and end all of things.

 

However based on the RAIB report the point here is that the driver of the DMU had plenty of experience of permissive platform working - indeed at busy stations like Plymouth it would be unusual if they didn't. As such the driver should have been well versed in the rules regarding calling on signals - yet he appears not to have been.

 

I accept the railway is a complicated working environment but some things are done so frequently it's hard to try and use the lack of experience angle to excuse mistakes.

Then I guess it's down to whether it's a case of brain thinking one thing, everything else saying something else (a susprisingly easy situation to end up in - assumptions that you're not even aware of making, which are the most dangerous ones because they're the hardest to discover before something goes wrong), or of "there won't be anything else in the way there, there never is when this happens" (very unacceptable).

[Dunsignalling]

Way back when, I remember my Signalling Instructor saying that there are two sorts of railwayman; those that do things safely because that's what the book says, and those that do so instinctively because they understand why it's in the book.

 

His stated preference was for the latter with regard to his own trainees, but I imagine drivers (and others in safety-critical roles) display similar variations.

 

John

[Mark Saunders]

Way back when, I remember my Signalling Instructor saying that there are two sorts of railwayman; those that do things safely because that's what the book says, and those that do so instinctively because they understand why it's in the book.

 

His stated preference was for the latter with regard to his own trainees, but I imagine drivers (and others in safety-critical roles) display similar variations.

 

John

 

My quote on the rule book from a old hand instructor was "for obedience of fools and the guidance of wise men"

 

Mark Saunders

[w124bob]

Just before my early retirement last month XC changed it's permissive working instructions and introduced an additional simulator scenario, since both Piccadilly and New st(for example) would grind to a halt without permissive working it would seem XC have pre-empted the report . And as others have said always answer questions truth fully, but don't volunteer information if it's never asked for!

[Supaned]

Sorry I missed saying goodbye Bob...

[The Stationmaster]

Can I refer everybody to post 108? It is not possible to use this report to apportion blame. The report is written in a style which prevents the apportioning of blame.

 

But that phrase is in there for a very specific, and principally legal, reason in order to prevent the Report being used as evidence in a court case where its existence and wording might be cited as prejudicial by a defending (in particular) counsel or in the event of a civil claim where liability is being discussed or assessed.  The situation was no different in the past with the old HMRI Reports where in almost every instance I can think of or know about they were not published until criminal proceedings had been completed.

 

There is currently a case elsewhere (and please let's leave that in the various threads that relate to it) where criminal proceedings have been commenced but have not yet come to court and the RAIB Report regarding the incident has been published.  In that case the covering wording at the commencement of the Report becomes critical and rules it out as being able to be called as evidence - it is simply a Report, not a witness.

 

Many of the BR Report forms were protected by similar - but far simpler wording - which was, again, specifically on them in order to prevent them being entered as evidence by either party in a criminal or civil case.

 

And none of that is relevant to third parties privately discussing an RAIB Report - we can read in it the facts (or what are hopefully the facts) and there is nothing to prevent us forming judgements based on our knowledge and experience and the content of the Report - which is exactly what we have done in this instance.

 

As many people on here will know I do not have particularly great respect for the manner in which some RAIB Reports have been written and, at times, the laxity of the language they have used and in some respects that is true of this Report.  However certain things are crystal clear from what the Report does say and as far as the Driver is concerned it is clear that he did not drive in accordance with the aspect displayed by signal P15 and his failure to do so resulted in a collision with another train.  Clearly there was something adrift with his perception of what was to happen as he approached the platform and it seems fairly conclusive that certain areas of his competency and knowledge were lacking - and the reasons for that need to be dealt with having been brought to light by this incident.

[AncientMariner]

But that phrase is in there for a very specific, and principally legal, reason in order to prevent the Report being used as evidence in a court case where its existence and wording might be cited as prejudicial by a defending (in particular) counsel or in the event of a civil claim where liability is being discussed or assessed.  The situation was no different in the past with the old HMRI Reports where in almost every instance I can think of or know about they were not published until criminal proceedings had been completed.

.

.

Many of the BR Report forms were protected by similar - but far simpler wording - which was, again, specifically on them in order to prevent them being entered as evidence by either party in a criminal or civil case.

 

 

 

If the Marine Accident Investigation Branch operates anything like the RAIB on the issue of apportioning fault - and I suspect it does – then facilitating prosecutions simply don’t fall within their remit.

 

As I understand it, the primary idea (of the MAIB anyway) is to determine the cause of an accident so that lessons can be learnt, and to establish what can reasonably be done to prevent recurrences.  Interviewees are not questioned under caution, but are required to answer questions openly and honestly, even if it means admitting to being at fault.  Obviously this is a big ask if the interviewee, having had possibly the worst day of his/her life, is well aware of the prospect of prosecution.   For this reason, and to encourage openness, none of the information collected by the MAIB can be produced as evidence in any subsequent prosecution case, even though the report may be published and available for all to see.  For marine accidents, the task of initiating any prosecution lays elsewhere, such as the Marine and Coastguard Agency, who must source their evidence separately and independently, with interviewees then having the right to silence.

 

My apologies for bringing my marine background and the MAIB into the discussion, but I would imagine that the RAIB and the AAIB work on similar principles when collecting evidence.

 

John

[Edwin_m]

MAIB reports include a statement that they are inadmissible in evidence according to a statutory regulation.  RAIB reports merely state that it is inappropriate to use them to apportion blame or liability.  So while the intent is the same the two agencies would appear to have different levels of statutory backing and I guess that might become significant if someone tried to use their reports for those purposes. 

[Arun Sharma]

Ancient Mariner's post #142 hits the nail on the head. As someone who has been involved in both maritime and aircraft accident investigation, the fundamental role of the investigator is to find out what happened. To that end, the truth is required from interviewees - That can only be obtained realistically if those interviewed understand that that they are not being interviewed under caution and that anything they say, whilst being written down, is not going to be used against them in a court of law.

This also forms the basis of CHIRP _ Confidential Human Incident Reporting Procedures which is an aviation form of reporting dangerous or potentially damaging work practices and events without prejudice [a similar system of reporting exists at sea].

 

In my opinion, where things have become complicated on roads and railways, is the move to police forces getting involved in eg., SPADs, minor collisions etc., and declaring them potential crime scenes. That cannot be nearly so conducive to determining what actually happened.

[Oldddudders]

I think media pressure has a lot to do with the legislation in respect of rail. A series of high-profile major accidents involving multiple deaths early in the privatised railway was greeted with 'expert' claims that the new arrangements were inherently unsafe, and the media loved the coverage and the legal challenges, and claims on behalf of the bereaved and seriously injured. It was a good fit with the 'gravy train' theme that some lucrative deals had generated.

 

On the one hand we should rejoice that rail remains so inherently safe that accidents are media manna. The downsides in potential distortion or obfuscation of facts to avoid prosecution have been identified above.

[The Stationmaster]

Ancient Mariner's post #142 hits the nail on the head. As someone who has been involved in both maritime and aircraft accident investigation, the fundamental role of the investigator is to find out what happened. To that end, the truth is required from interviewees - That can only be obtained realistically if those interviewed understand that that they are not being interviewed under caution and that anything they say, whilst being written down, is not going to be used against them in a court of law.

This also forms the basis of CHIRP _ Confidential Human Incident Reporting Procedures which is an aviation form of reporting dangerous or potentially damaging work practices and events without prejudice [a similar system of reporting exists at sea].

 

In my opinion, where things have become complicated on roads and railways, is the move to police forces getting involved in eg., SPADs, minor collisions etc., and declaring them potential crime scenes. That cannot be nearly so conducive to determining what actually happened.

 

There have been two incidents (both major) where police involvement and their 'crime scene' approach has resulted in crucial evidence being lost or, seemingly in one case, potentially interfered with (simply through ignorance).  But regrettably, as Ian ('Olddudders') has indicated there are other reasons for their involvement and indeed they go beyond that and back into the history of privatisation where two things happened.   The first of these were whispers being put about that the Railway Inspectorate was 'too close' to the railway industry - quite why this came about might be something to do with the second point (read below) or for some other reason?  But in my experience over years of coming into contact with them in numerous way from both BR and the preservation scene they were undeniably and impeccably independent and they also knew exactly what they were at.

 

But the second factor around in 1994 was probably far more telling and it was basically privatisation being seen as ideal for a  quick victory in a 'turf war' where the HSE was seeking to gather all things to itself and they were undoubtedly not helping the Railway Inspectorate's image.

 

Add to that - even before privatisation - the point made by Ian where some people (again some turf wars taking place I think) were saying 'these new private owners will be a bunch of cowboys bending safety to suit their money saving and we will need the force of the law to deal with their shenanigans' so let's get the BTP in on these investigations because after all they're 'railway experts'.  Which of course was, and really is, a nonsense - they know have to investigate crime scenes, they know how to search out and secure people and property in major incidents but climbing into a  loco cab immediately after a collision they wouldn't have a clue what things they should check while the evidence is fresh.

 

Regrettably the expertise of the HMRIs wasn't immediately translated into what later emerged as the RAIB and equally regrettably the RAIB recruitment process and methods has meant that some of their Reports contain inaccuracies of fact, inaccuracies in allocating legal responsibilities, and nonsensical recommendations while in some (and I'm not alone in saying this) crucial elements in respect of what took place or even in respect of training based on commonsense have been omitted.  I don't doubt they have a learning curve but I sometimes wonder about it and comparing an MAIB Report with an RAIB Report simply in respect of what it describes and its analysis of what actually took place reveals a world of difference although both are theoretically supposed to be doing exactly the same (which as far as the railway industry is concerned is no difference from the purpose of an investigation by a member of HMRI - it wasn't broke and it didn't need altering but expanding and turf wars stopped that happening).

[jjb1970]

The MAIB have a pretty good reputation and have some very good people. They know how to balance the egghead stuff necessary for the serious analytical and technical stuff while keeping sight of what a ship is and how they work (not all investigating agencies do).

 

Investigations should be about establishing what happened and identifying learning points. Then it is for others to consider legal actions and any necessary regulatory changes.

[4069]

Regrettably the expertise of the HMRIs wasn't immediately translated into what later emerged as the RAIB and equally regrettably the RAIB recruitment process and methods has meant that some of their Reports contain inaccuracies of fact, inaccuracies in allocating legal responsibilities, and nonsensical recommendations while in some (and I'm not alone in saying this) crucial elements in respect of what took place or even in respect of training based on commonsense have been omitted.  I don't doubt they have a learning curve but I sometimes wonder about it and comparing an MAIB Report with an RAIB Report simply in respect of what it describes and its analysis of what actually took place reveals a world of difference although both are theoretically supposed to be doing exactly the same (which as far as the railway industry is concerned is no difference from the purpose of an investigation by a member of HMRI - it wasn't broke and it didn't need altering but expanding and turf wars stopped that happening).

Would you like to be more specific? Your sniping at the RAIB without providing evidence to back up what you say is getting rather tiresome. I have been part of the RAIB since it was set up and I don't believe any of these criticisms have been made directly to the organisation.

 

If you have found errors of fact in reports, please let us know- we don't bite and are always happy to correct things and learn from them. The consultation process that all our reports go through means that the industry and ORR/HMRI have plenty of opportunity to spot mistakes, tell us if anything is wrong and object to 'nonsensical' recommendations, before they are published.

[The Johnster]

FWIW, I have always worked to the principle of 'if you f....... up, put your hands up and admit it like a man'.  It has stood me in good stead (for, yes, dear reader, sometimes I have f........ up), firstly because it gains you the respect of your superiors, or at least if they are any good it does, and secondly it completely wrong foots anyone who wants to prove you responsible for a f... up to cover their own muddy tracks.  If an inquiry is involved, it wants primarily to get at the truth of what happened, and will appreciate your assistance.

[The Johnster]

FWIW, I have always worked to the principle of 'if you f....... up, put your hands up and admit it like a man'.  It has stood me in good stead (for, yes, dear reader, sometimes I have f........ up), firstly because it gains you the respect of your superiors, or at least if they are any good it does, and secondly it completely wrong foots anyone who wants to prove you responsible for a f... up to cover their own muddy tracks.  If an inquiry is involved, it wants primarily to get at the truth of what happened, and will appreciate your assistance.

 

BTW, none of my f... ups were of the order that involved an inquiry!