Urgent Safety Advice today from the RAIB

[martin_wynne]

Just published, after a tragic accident at Tyseley:

 

https://www.gov.uk/government/publications/urgent-safety-advice-012020-passing-between-or-close-to-the-end-of-stationary-rail-vehicles-in-depots-yards-and-sidings/urgent-safety-advice-012020-passing-between-or-close-to-the-end-of-stationary-rail-vehicles-in-depots-yards-and-sidings

 

[woodenhead]

I think all the RAIB are doing here is reminding the TOCS that they need to double down on safety advice whilst trackside in yards.

 

It was a tragic accident, someone lost their life through a lapse, several others will have been traumatised and a family member has been devastated.

[martin_wynne]

39 minutes ago, Wickham Green said:

what about the lack of common sense ? 

 

Why such a hard heart? Everyone makes silly mistakes occasionally.

 

What else can the RAIB do? Any loss of life surely demands a response of some kind, if only for the sake of the person's family and colleagues. Especially the driver of the train which killed him. If I was that driver I would be clutching at any official recognition that I was blameless.

 

Martin.

[The Johnster]

The dangers of cutting between vehicles are well known and tragedies of this sort have been happening since the days of horse drawn tramroads and plateways.  It's sadly very much a matter of familiarity breeding contempt; the victim here had probably done this many times before and never been caught out.  It is up to the employers, the owner of the depot in this instance, to provide safe walkways with suitable surfaces and proper notices and lighting, but it is the responsibility of the staff working at the site to use these facilities.  Walking time is allowed to enable staff to make their way between locations and booking on/off points without rushing using the official routes and waiting for moving traffic to pass, but the temptation to take a short cut if you're in a hurry is only human; as Martin says, everybody does daft things occasionally, and it is only when it becomes habitual that the perpetrator should be classified in the Darwin Award applicant category.  

 

But it can and does become habitual.  The trouble is that you consider yourself a professional to whom the rules necessary to protect others do not apply; familiarity and past success being a potentially lethal combination.  I remember traincrew at Canton in the 70s who would happily duck between coupled vehicles as a matter of course, and step across inspection pits in the process, rather than walk around the length of a 6-car set to get to the proper walking route.  It was scary enough IMHO going in between to couple up and attach brake pipes; even if the driver was in the cab at that end he couldn't see you.  I always made sure my driver knew if I was going in between!

Edited March 3, 2020 by The Johnster

[jjb1970]

It's a reminder that there are good reasons for companies enforcing their safe systems of work and that there is a good reason for 'elf'n safety.

[mdvle]

1 hour ago, Wickham Green said:

 what about the lack of common sense ?

 

"Common sense" would indicated, that after several months of not seeing the trains on a track move after a shift, that it would be safe to cut through between them and save x minutes of walking.

 

In other words, "common sense" is in many ways a meaningless term that can be applied in too many ways, sometimes in conflicting with each other.

 

 

[Nearholmer]

Speaking as someone who owes their continuing existence to good luck, having very many years ago walked out of a cable depot door almost into the path of a shunt that was proceeding silently along the track right outside (no barrier at the time, and ‘straight across the siding’ was the well-beaten path, although not the authorised one I’m sure), but who considers themselves to have reasonable level of common-sense, I’m not a great fan of blaming ‘lack of common sense’ either.

[4069]

2 hours ago, Wickham Green said:

Wasn't there something about not crossing between vehicles less then 50' apart in the 1950 Rule Book ? 

Yes there was,  and in the 1972 Rule Book, but there isn't any more- and that's the point of the advice.

 

Stuart J

RAIB

[Colin_McLeod]

Admin. Was my post agreeing with Wickham Green removed or did I not post it correctly?

 

 

Edit. I notice that Wickham Green's post has also disappeared.  What is wrong with accepting that sad though a fatal accident is. sometimes the deceased is indeed at fault.

Edited March 3, 2020 by Colin_McLeod

[Edwin_m]

Also relevant to designers of yards and depots to consider this issue when laying out walkways etc.  

[martin_wynne]

5 minutes ago, Colin_McLeod said:

Admin. Was my post agreeing with Wickham Green removed or did I not post it correctly?

 

Edit. I notice that Wickham Green's post has also disappeared.  What is wrong with accepting that sad though a fatal accident is. sometimes the deceased is indeed at fault.

 

Were those posts potentially prejudicial to any legal proceedings?

 

Martin.

[Steadfast]

As one who is in and out to couple up multiple times daily, if I'm not in charge of the move (or in contact with the person who is) and certain it is not liable to move, I'm giving that train a wide berth.

Such a sad event, a reminder of how dangerous yards can be for anyone working in them.

 

Jo

[Broadway Clive]

Very sad  indeed - a few seconds either way and it might never have happened. Certainly a bad omission in the rule book not to cover it though. However, it must have been obvious the loco was 'live', so maybe he mistakenly thought the other driver had seen him. In the darkness anyone inside a lit cab is very visible from outside, but reflections often make it much harder to see out. Back in my sixties spotting days I remember a shed permit for York being cancelled following a lad being killed inside by a new class 20 the previous day. Many in the coach party were quite cross about it but we were able to visit again later in the year as the culture then was somewhat different and people were expected to take responsibility for their own actions.     

[AY Mod]

1 hour ago, Colin_McLeod said:

Admin. Was my post agreeing with Wickham Green removed or did I not post it correctly?

 

 

Edit. I notice that Wickham Green's post has also disappeared.  What is wrong with accepting that sad though a fatal accident is. sometimes the deceased is indeed at fault.

 

Both were a little inappropriate given affected colleagues may be reading this.

[Colin_McLeod]

1 hour ago, martin_wynne said:

 

Were those posts potentially prejudicial to any legal proceedings?

 

Martin.

 

No.

 

 

[Trog]

I remember being told to walk 50 or 60' clear of stabled stock during my rather basic safety training in the early 1980's.

 

Makes you wonder that such an obvious and simple precaution has been removed from the rule book.

[keefer]

When were the old rules removed from the Rule Book? Was it fairly recently?

I ask as I remembered a previous incident where it emerged that relevant rules were removed/relaxed at the behest of one of the FOCs.

An overspeed at a temporary speed restriction at Sandy last year occurred primarily due to a driver taking ill, but the investigation revealed that the Rule Book had been changed so that the Operating Companies did not have to automatically inform staff of the restriction i.e. the driver did not know about it beforehand. The reasoning being that trackside warning boards etc. would be sufficient.

https://www.gov.uk/raib-reports/report-10-2019-overspeed-at-sandy-south-junction-bedfordshire

 

In the depot incident, it would seem that Trackside safety training was deemed to be adequate, with no specific provision for depot/sidings etc. off the mainline.

As others have noted, it seems strange not to have any Rules covering this generally and specifically, movement between/near to the ends of vehicles.

[jjb1970]

I am always minded of the biblical story regarding letting the person without sin cast the first stone. I have spent a large part of my life in hazardous industries and when I look back I did stupid things without thinking, but got away with it. There were certain moments in my life where if circumstances had been very slightly different I wouldn't be here today. So I try to refrain from being too judgemental about momentary lapses and poor judgement. Nobody deserves to die for a moment of poor judgement. 

[96701]

This bit "Based on evidence obtained as part of this investigation, the RAIB believes that some transport undertakings are using GE/RT 8000 Rule Book Module G1 ‘General safety responsibilities and personal track safety for non-track workers’ as the only basis for establishing the competence of train drivers in personal track safety. This means that the safety arrangements used by train drivers may not effectively control the risks to which they are exposed when walking or working in depots, yards and sidings." is actually quite subtle.

 

I believe that the point is that RAIB are saying that TOCs and FOCs generally assume that their drivers are safely ensconced within their cabs when on running lines and training them on how to deal with a Signaller to take line blocks in order to examine any defective / damaged trains is enough.

 

It would seem to me that the bit that is missing is training when walking around sidings or depots. If that is the case (and not being train crew, I don't know), then there may well be an introduction of briefing on sticking to walking routes and not walking between vehicles, followed up by introducing it to the induction process. I may be wrong because each TOC / FOC will undoubtedly form their own solutions to fulfilling the RAIB Recommendations.

[The Stationmaster]

I am absolutely appalled by this.  

 

I checked the relevant sections of theRSSB Rule Book when I first heard about this incident and was amazed to find how totally inadequate it was.  Without wishing to unduly blow my trumpet I have been writing more comprehensive personal safety Rules than the RSSB Book  for heritage and Leisure railways which definitely did include that item, and various others which aren't in the RSSB book.   It was in the BR  Rule Book for years and was always sound advice and something I made sure was thoroughly tested when examining staff in Rules - so why did RSSB take it out of the book?   Quite why RSSB produced such dangerous nonsense I really don't know but they seem to be in need of thorough investigation too if this incident is any guide to their competence (it's not the first time they have published nonsense but this time somebody died).   Probably an illustration too,  in some respects, of just how unwieldy and balkanised the RSSB Rule Book has become over the years.  Plus - to my mind - a clear lack of a sound and effective structure to review Rules through the wider industry  before they are published (and past evidence from certain NR staff indicated that such a structure of review was lacking and it was extremly difficult to get Rules amended to read sensibly through normal feedback channels.

 

But also I am very concerned that RAIB have taken so long since the incident to issue the notice they issued today.  and I know it is the first time they have promulgated it because it only went to the HRA today - which is how a copy of it reached me earlier today.   This really is ground level safety of the most basic kind - there should be no need to train it in now; staff should already have been fully aware of it at theo ir basic training (and be chased for not observing it should that come under notice).

[The Stationmaster]

18 hours ago, 96701 said:

 

 

It would seem to me that the bit that is missing is training when walking around sidings or depots. If that is the case (and not being train crew, I don't know), then there may well be an introduction of briefing on sticking to walking routes and not walking between vehicles, followed up by introducing it to the induction process. I may be wrong because each TOC / FOC will undoubtedly form their own solutions to fulfilling the RAIB Recommendations.

It should never have been taken out of the induction process.  I wonder which idiot did that?

 

On 03/03/2020 at 14:39, jjb1970 said:

It's a reminder that there are good reasons for companies enforcing their safe systems of work and that there is a good reason for 'elf'n safety.

But the whole problem here is that 'somebody' removed it from a safety Rules and safety training.  It is not in the Driver's personal safety Rules section of the RSSB Rule Book. (and a former Regional Movements/TOC General Manager was incredulous when I told him that over lunch a couple of months back.   I had at one time been the operational Safety Manager of the TOC he led.

 

I quite accept that it is far from commonsense to walk between vehicles on a siding but that is not wholly the point.   There are plenty of newcomers on the railway who have no 'railway sense' or knowledge so have to be trained from the ground up,  And to train them you need to have the procedures and Rules there in the first place.  And having trained them you have to recognise - as others have already posted above - that people can be stupid at times so you need to police/enforce procedures (in this case a personal safety Rule) and remind people why they are there.  But that is difficult if you don't have such rules there to start with - which was the heart of the problem here and which unfortunately led to a potentially needless fatality.

[TheSignalEngineer]

14 minutes ago, The Stationmaster said:

But the whole problem here is that 'somebody' removed it from a safety Rules and safety training.  It is not in the Driver's personal safety Rules section of the RSSB Rule Book. (

I was surprised that I couldn't find any reference to it in the sources I  looked through at the time of the accident.  When I joined the rule of thumb was if you HAD to cross or work foul of sidings where there was a chance of vehicles being moved then keep at least 20 yards clear of any potential danger.

[jim.snowdon]

We should not forget that however much these sorts of precautions are put in rule books and in training, when the events that they are guarding against consistently don't happen, people become complacent and forget why those rules are there. Complacency is possibly a greater hazard than ignorance. No one ever wants people not to go home unharmed at the end of their working day, but the fact that periodically someone doesn't, or gets hurt by not doing what they were taught  does serve as a reminder to everyone else that they are not immortal and that rules are there not just to fill the pages of rule books.

 

Jim

[kevinlms]

11 hours ago, The Stationmaster said:

I am absolutely appalled by this.  

 

I checked the relevant sections of theRSSB Rule Book when I first heard about this incident and was amazed to find how totally inadequate it was.  Without wishing to unduly blow my trumpet I have been writing more comprehensive personal safety Rules than the RSSB Book  for heritage and Leisure railways which definitely did include that item, and various others which aren't in the RSSB book.   It was in the BR  Rule Book for years and was always sound advice and something I made sure was thoroughly tested when examining staff in Rules - so why did RSSB take it out of the book?   Quite why RSSB produced such dangerous nonsense I really don't know but they seem to be in need of thorough investigation too if this incident is any guide to their competence (it's not the first time they have published nonsense but this time somebody died).   Probably an illustration too,  in some respects, of just how unwieldy and balkanised the RSSB Rule Book has become over the years.  Plus - to my mind - a clear lack of a sound and effective structure to review Rules through the wider industry  before they are published (and past evidence from certain NR staff indicated that such a structure of review was lacking and it was extremly difficult to get Rules amended to read sensibly through normal feedback channels.

 

But also I am very concerned that RAIB have taken so long since the incident to issue the notice they issued today.  and I know it is the first time they have promulgated it because it only went to the HRA today - which is how a copy of it reached me earlier today.   This really is ground level safety of the most basic kind - there should be no need to train it in now; staff should already have been fully aware of it at theo ir basic training (and be chased for not observing it should that come under notice).

Possibly it was taken out because they read the all too common posts here and elsewhere, that 'We' should all rely on 'Common Sense'.

[Pandora]

I have worked for the Railway for 30 years, managers seem to operate with  fantasy levels of faith ,  I am reminded of the  Richard Feynman  appendix to the Rogers  report on the Space Shuttle disaster,  the culture of managers had led to some strange concepts and misinterpretation of safety factors in flying the Shuttle,  theyhad convinced each other the Shuttle was as safe, or safer than a Jumbo jet, could be flown daily for 275 years per loss, engineers on the ground knew it was as risky as a fighter jet in war combat. 50 flights per loss 

 

http://www.feynman.com/science/the-challenger-disaster/

 

https://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/Appendix-F.txt

Edited March 5, 2020 by Pandora