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Urgent Safety Advice today from the RAIB


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2 hours ago, letterspider said:

These features are there to protect people's lives. They are already working reliably in other industries as I have already described.

 

The rail environment is unique, and stuff that works reliably elsewhere often fails when (at least first) introduced to the rail environment - and I assume that this also applies to other environments like marine.

 

But it is also the case that all of these things are at the end of the day operated by humans, and thus you need to take the operator into account as well.  Every additional mirror, screen, or other safety feature introduced is conversely yet another distraction for the operator - and we know there are limits to how many things the human brain can deal with at any given time.

 

In this case, if a driver is concentrating on coupling two units together - thus having to judge distance, speed, when to brake, etc. they can't at the same time be constantly checking mirrors and screens.

 

2 hours ago, letterspider said:

If failure of a safety system is causing a train to be out of service for repairs GOOD. Perhaps there needs to be better maintenance intervals?

 

The government (in terms of the subsidies paid) and the customers (in terms of the cost of tickets) are already making lots of noise that they system is too expensive, additional maintenance = higher costs.  Difficult sell.

 

2 hours ago, letterspider said:

If everybody in a depot 'zones out' from warnings - then at least the employer have dispatched their duty to mitigate risks - if the employee does not heed visible and audio warnings - they are unlikely to remember something in a rulebook they may never have read all the way through and possibly forgotten. However those systems would have given them better protection

 

No, they wouldn't.  I mean, most of us learn as children the fable about the boy who cried wolf or some variation.

 

"warning" systems that are constantly going off and thus becoming background noise to not give employees better protection, if anything they create a false sense of security - the driver feels that they don't need to be as vigilante because "a warning horn is sounding".

 

2 hours ago, letterspider said:

What I do not see as acceptable is to use cost as an excuse - when the technology is reliable and available and relatively cheap and what has not been proferred is a better alternative to what is already available.

 

They make sense on lorries, where they are frequently doing an inherently dangerous action - backing up (for which they have little to no ability to see obstructions) in uncontrolled areas (there could be humans walking through the area) and most importantly this is frequently happening in places where the warning sounds are unusual enough that they get paid attention to.

 

On the other hand, warning sounds are less effective in other places.  I have witnessed construction equipment that uses warning sound for driving backwards, but when said equipment is on a noisy construction site and constantly changing direction the sound disappears and thus has become useless as a safety feature.

 

2 hours ago, letterspider said:

In the meantime I would have hoped the accident review board should have been a lot more proactive and forward thinking in its report (I have not read it) and suggested active safety measures (such as these or maybe something better) to be installed in all motive power going forwards and an urgent assessment into the possibility of retro fitting.

 

Google has spent over a decade, and over $1 billion, attempting to get self driving cars.

 

For that investment they have some cars that sort of work in carefully controlled environments, and they are still far away from being practical in the real world.  In particular one of the problems they are having is properly judging the risk of external events (people, animals, other vehicles) and the result that the autonomous cars are far too cautious in their behaviour.

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22 hours ago, letterspider said:

 

It has been mentioned above that all this bleeping would upset local residents - we hear this all the time with bin lorries and we already have audible alarms when doors close on the platforms.

IIRC I am seeing and hearing these alarm warnings everytime luggage handlers, refuelling and tractor units are in the vicinity of commercial aircraft

 

The examples quoted are all vehicles which can move in any direction, which is not true of trains, and bin lorries share space with members of the public, also not true of trains. And all the safety devices on bin lorries did not prevent one killing six people in Glasgow in 2014.

 

Tyseley was a tragic incident, but very rare, and the most effective way of preventing any repeat is, as others have already said, a combination of clear and applied rules, and suitable facilities on the ground.

 

 

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1 hour ago, caradoc said:

 

The examples quoted are all vehicles which can move in any direction, which is not true of trains, and bin lorries share space with members of the public, also not true of trains. And all the safety devices on bin lorries did not prevent one killing six people in Glasgow in 2014.

 

 

 

 

 

And an operative near me a year or so ago.

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On ‎04‎/‎03‎/‎2020 at 19:47, jim.snowdon said:

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. .........

 

Jim

 

I don't think that is always true it is forty years since my original safety training all two hours of it in an coach out in the yard, taken by an old supervisor. Who's unlucky good railwayman mates were all run over the first time they ever broke a rule. But even now the idea of going between two close vehicles makes me go cold.

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On ‎05‎/‎03‎/‎2020 at 19:13, letterspider said:

 

If the front cab had

             180 forward facing ultrasound at buffer level

            

 

How would that have helped?

 

The units were we are told were very close together, if your alarm was set to detect proximity it would have been going off anyway.

If the alarm was set to detect movement the driver would have been expecting it to go off as soon as he moved his unit towards the other anyway. So either way it gives no useful warning and is just a potential distraction.

 

The answer is a clear instruction to staff to use safe routes and where there are none, not to cross close to, or even worse between stabled vehicles.

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On 05/03/2020 at 16:38, The Stationmaster said:

Very much so - and there used to be a set of laid-down standards for Authorised Walking Routes and Staff Safety Reps, in particular, were very hot on them.  Those standards included surfacing as well as the procedures for posting details.  and should a manager decide to open a new walking route without complying with those standards he would be in fora rough time - from his superiors.  In view of the raft of nonsensical things which NR seem to regard as 'standards' I'm amazed they haven't got any for Authorised Walking Routes.

Network Rail aren't responsible for all walking routes.

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6 hours ago, letterspider said:
6 hours ago, letterspider said:

You are of course entitled to your views and opinions. To be clear - my question was... if all of this 'impractical nonsense' is already in wide use in other areas of daily lives, then why not on motive power. However I have done some websearching and found out that there are EU projects such as this 

https://shift2rail.org/wp-content/uploads/2018/05/S2R-SMART-project-Vienna-2018-COMPLETE-final.pdf

already in the research phase - (this example appears to be for protecting permanent way gangs during maintenance

My views and opinions were formed during 38 years in the industry, from selling tickets when I left school to being in the Executive Group at BRB HQ before Privatisation. Like at least two others in this thread - St Enedoc and the Stationmaster - I have been responsible for the safe operation of large yards and depots, as well as large tracts of live railway. You have so far failed to furnish evidence of any railway experience whatever. But when did that stop anyone from knowing best?

 

You seem to imagine that the railway industry in the UK has decried technology in the pursuit of safety. In your quoted case of protecting P Way gangs on track during normal operating hours, I can assure you this is far from true. In the '70s there was PeeWee, which triggered warning annunciators. In the '80s there was FATCOWS - Fully Automated Track Circuit Operated Warning System - developed in parallel with the Victoria Area Resignalling Scheme. In the early '90s, a new system employing inductive loops - based upon the work of J C Maxwell, considered one of the world's finest physicists -  was trialled over a period of time at Keynsham. The C21 railway solution for this appears to be, by and large, to keep people off the track while trains run. That doesn't work in depots, where all sorts of staff have every reason to be close to, and to cross on occasion, tracks. 

 

The sort of cheap reversing gee-gaws employed on cars and lorries, and cctv screens, would be entirely useless in a busy yard, as others have explained at length, and would never pass muster as components in a railway safety system.

 

Of course, if you really want to get to the bottom of why this poor man died, perhaps the Coroner's report might be a starting point. He would surely be regarded as impartial?

 

6 hours ago, letterspider said:

 

 

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8 hours ago, Trog said:

 

I don't think that is always true it is forty years since my original safety training all two hours of it in an coach out in the yard, taken by an old supervisor. Who's unlucky good railwayman mates were all run over the first time they ever broke a rule. But even now the idea of going between two close vehicles makes me go cold.

Indeed. I too have encountered a number of safety trainers whose attrition rate of close acquaintances would attract the attention of any half decent detective ;-). 

 

And yes, in a busy industrial environment, where many items of equipment have warning beeper and/or flashing lights, it is a normal human reaction to come to regard an environment that beeps and flashes as normal, and not signifying any particular increase in the general background level of risk. 

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It's interesting that people are comparing yards of old to today's depots/stabling points. Whilst there is movement around a modern depot it's nothing like it used to be in the old style marshalling yards. I suspect that is why this accident happened. Most of the time, outside certain times of day, there are few movements and I suspect taking short cuts between trains was quite common amongst the staff both at Tysley and other depots around the country. 

 

I expect that for a time it will now stop but human nature being like it is it'll no doubt creep back amongst some members of staff who regard time saving above safety. Whatever the powers that be do there's will always be a few who break the rules, perhaps best to leave it there, nothing we can do will change some people's mindsets, all we can do is keep reminding people... Wonder what the subject of the next RED video will be?!

Edited by Hobby
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Worth mentioning that Basford Hall Yard at Crewe is now covered by very high fidelity CCTV - woe betide anyone who steps on a sleeper or rail, or steps outside of the mess room without safety glasses on etc. The recorded footage is reviewed several times per shift and any transgression means an appearance 'on the carpet' in front of the beak!

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@Rugd1022

 

Probably the wrong attitude but what a load of ########!

I guess was one of the old BR Dinosaurs that the new breed of managers were happy to get rid of - but I'm glad I'm retited or I would've been on the 'carpet' almost permanently with management like that!

And they probably wonder why they get little respect from those below them!

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Actually the rail industry safety record for staff is remarkably good according to this graphic and the largest increase is in the period 1993 to 2015 - if looking at fatalities per volume of movements.

 

image.png.3243cbc47ee05d030646a17488bf5d5a.png

 

...whether experience within an industry is better than problem solving techniques applied across industries; obviously a mix of both is best. The first problem is that out of those two - one of them more often leads to entrenchment of ideas, while the other by its very nature is looking for innovation; the second problem is that experience is often undervalued.

It is exactly the same in the industry sector I am working in.

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On 07/03/2020 at 13:23, letterspider said:

Actually the rail industry safety record for staff is remarkably good according to this graphic and the largest increase is in the period 1993 to 2015 - if looking at fatalities per volume of movements.

 

...whether experience within an industry is better than problem solving techniques applied across industries; obviously a mix of both is best. The first problem is that out of those two - one of them more often leads to entrenchment of ideas, while the other by its very nature is looking for innovation; the second problem is that experience is often undervalued.

It is exactly the same in the industry sector I am working in.

 

Technology plays a big part in the fewer deaths occurring on the railway. The prevalence of mobile phones means that aid is much quicker to arrive, there are also a greater number of air ambulances; Both of these things mean that when life threatening injuries occur, even in remote areas, a fatality is much less likely than it used to be.

 

The number of train movements is a bit misleading, as whilst there are more train movements overall, there are fewer high risk ones. Compare the amount of shunting that was going on in 1992 with 2014, there was a lot less in 2014. Whether it's freight or passenger, there used to be a lot more movements that resulted in railway workers going between vehicles, which is probably the most deadly job on the railway.

 

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On 07/03/2020 at 13:23, letterspider said:

Actually the rail industry safety record for staff is remarkably good according to this graphic and the largest increase is in the period 1993 to 2015 - if looking at fatalities per volume of movements

The early 1990s was a period of change with regard to safety of on-track work. The deaths of three S&T men at Edge Hill and Brian Ward being hit by an HST at Southall whilst speaking to the PSB on a mobile phone along with others in a very short period led to a complete review of how we did things. For background it's well worth anybody watching Peter Wing's film "Dead Serious About Safety".

 

Around this time I was managing 100plus on-track staff mainly working between Euston and Rugby, also Moorgate to Bedford and the North London Line, so plenty of complex areas.

With BRB HQ S&T we had been developing concepts such as protective temporary speed limits on open lines adjacent to possessions and 'Fenced Green Zones' around trackside locations where staff could  be taken in under a short blockage then work safely behind a barrier next to an open line. Also being developed in the area was a set of briefing sheets for all trackside access points giving line directions, speeds, places of sefety and prohibited areas and a Project Safety Card which gave outline details of safety requirements, telephone numbers of signal panels,  Electrification Control Room and on-call S&T manager, provision of on-site First Aid and directions to nearest A&E.

 

Around the time of the film I moved into the overall Engineering Management of projects so had the task of transferring these into new projects. Around this time we wrote a series of handbooks on how to develop, design and commission projects to try to prevent many years of accumulated knowledge from disappearing when the 'external expertise' was drafted on by Railtrack. I suppose some of that was successful as the current investment rules are quite close to what we wrote. About 10 years ago on a consultancy job I was given one Network Rail document to work to which was almost a straight copy of an instruction I wrote in 1985 just updated to cover changes in technology.

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13 hours ago, Rods_of_Revolution said:

 

Technology plays a big part in the fewer deaths occurring on the railway. The prevalence of mobile phones means that aid is much quicker to arrive, there are also a greater number of air ambulances; Both of these things mean that when life threatening injuries occur, even in remote areas, a fatality is much less likely than it used to be.

 

The number of train movements is a bit misleading, as whilst there are more train movements overall, there are fewer high risk ones. Compare the amount of shunting that was going on in 1992 with 2014, there was a lot less in 2014. Whether it's freight or passenger, there used to be a lot more movements that resulted in railway workers going between vehicles, which is probably the most deadly job on the railway.

 

Mobile 'phones are also one of the biggest safety menaces, and not just the Southall and Edge Hill incidents referred to by SE.   The number of SPADs where it has subsequently come to light that the Driver involved was speaking on a (personal) mobile 'phone became quite alarming a few years back and mobile 'phones became ranked as the most serious, and likely, threat to Driver concentration

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42 minutes ago, The Stationmaster said:

Mobile 'phones are also one of the biggest safety menaces, and not just the Southall and Edge Hill incidents referred to by SE.   The number of SPADs where it has subsequently come to light that the Driver involved was speaking on a (personal) mobile 'phone became quite alarming a few years back and mobile 'phones became ranked as the most serious, and likely, threat to Driver concentration

I remember standing on the platform at Snow Hill just before the commissioning of the Jewellery line. To finish off the northern section we had started running the Handsworth scrap train out to the south under some special instructions. I was talking to a member of the HSE staff who fortunately was facing away from the train as the driver was in the process of making a call on a mobile phone as he approached the Red at the end of the platform. Not an advisable thing to do past a crowded platform although the only thing he would have hit was the ground because the Inspectorate had previously made us install self-normalising trap points ahead of all of the platform starters.

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14 hours ago, Rods_of_Revolution said:

 

Technology plays a big part in the fewer deaths occurring on the railway. The prevalence of mobile phones means that aid is much quicker to arrive, there are also a greater number of air ambulances; Both of these things mean that when life threatening injuries occur, even in remote areas, a fatality is much less likely than it used to be.

 

Improvements in assistance and treatment will have some effect but I think it's probably more a reduction in accidents in the first place (probably due as you say to a reduction in the more dangerous activities such as shunting).  Most of the RAIB investigations relating to staff safety on track are either fatalities or near-misses - it's pretty unusual to be hit by a train and survive it.  

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1 minute ago, Edwin_m said:

Improvements in assistance and treatment will have some effect but I think it's probably more a reduction in accidents in the first place (probably due as you say to a reduction in the more dangerous activities such as shunting).  Most of the RAIB investigations relating to staff safety on track are either fatalities or near-misses - it's pretty unusual to be hit by a train and survive it.  

Most of the really dangerous work has gone.  Freight shunting is minimal nowadays and a lot safer anyway for various reasons.  Passenger stock and tail traffic shunting has virtually vanished and all that's left is coupling and uncoupling unit trains with very often no need to 'go in between' any more.  The number of people 'on and about the line' has reduced drastically due to changes in track maintenance practice and massive reductions in patrolling on foot.  And the sheer reduction in quantity of railway where a lot of the work, especially shunting and goods etc handling used to take place, is almost unbelievable to those of us who knew the everyday railway well within a working lifetime ago.  And of course the total number employed in 'dangerous' jobs in the industry has shrunk by an incredible amount during that same period.

 

In fact some very serious questions would need to be asked if the injury and death rates per 1,000 people employed at ground level hadn't dropped drastically. 

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3 hours ago, TheSignalEngineer said:

The deaths of three S&T men at Edge Hill

 

I knew the driver slightly on that one, been out for a cab ride with him, happened under Picton Road bridge and he didn't know about it until Lime Street, very sad.

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On 05/03/2020 at 17:55, caradoc said:

In any case, how do you think a forward facing camera would have prevented this sad event; The Driver of the moving train was in the leading, not the rear, cab ?

There is nothing in the report to define front and rear of the train concerned but it does specifically state that the driver of the coupling train was in the cab at the end being coupled. ie one of the two cabs the unfortunate was passing between.

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On 06/03/2020 at 15:20, mdvle said:

The rail environment is unique, and stuff that works reliably elsewhere often fails when (at least first) introduced to the rail environment - and I assume that this also applies to other environments like marine.

 

This is of course true, and there's no reason to suppose that a certain technology or method of working must be effective in one context because it works in another. But equally - if a system is proven elsewhere, then you can't dismiss it simply because the railway is different. It may well be inappropriate for any number of reasons, but they have to be identified and examined before a potential risk reduction measure can be eliminated.

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32 minutes ago, Grovenor said:

There is nothing in the report to define front and rear of the train concerned but it does specifically state that the driver of the coupling train was in the cab at the end being coupled. ie one of the two cabs the unfortunate was passing between.

 

27 minutes ago, RLBH said:

This is of course true, and there's no reason to suppose that a certain technology or method of working must be effective in one context because it works in another. But equally - if a system is proven elsewhere, then you can't dismiss it simply because the railway is different. It may well be inappropriate for any number of reasons, but they have to be identified and examined before a potential risk reduction measure can be eliminated.

The view from a train cab can be very limited and most of the time only needs to be ahead and towards signals that are usually on the left.  I imagine the driver would have had to stand up and lean over the desk to see the coupler, and even if they did so the victim in this case could have stepped between the units while the driver was sitting down and applying power to move the train.  If it had an end gangway then the view to the right would also have been poor, unless the driver crossed to the other side of the cab, when again it would take time to get back to the controls.  

 

My particular context is being currently and recently involved in a couple of projects that have been designing yard and depot walkways, and I've tried to make sure the teams concerned have seen this advice.  Having said that, I've seen websites from the States making the point that some of their pickup trucks and SUVs are so large that a normal-sized person immediately in front will be invisible to the driver.  That's a much greater danger because there are more people around on streets and parking areas, and they won't have had any special training like railway people.  On another of those sites was a study concluding that pedestrian detection systems fitted to road vehicles are pretty ineffective.  Even if 100% effective in a road environment they would not have been so here because they would cause an alarm every time the train was being coupled to another one, as was the case in this unfortunate event.  

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9 minutes ago, Edwin_m said:

On another of those sites was a study concluding that pedestrian detection systems fitted to road vehicles are pretty ineffective.  Even if 100% effective in a road environment they would not have been so here because they would cause an alarm every time the train was being coupled to another one, as was the case in this unfortunate event.

I think that any viable system to to protect against this kind of accident needs to be based around making the pedestrian aware that the vehicle is moving or is about to move.

 

One such system which several of my workplaces have used on forklifts is a projector which throws an arrow on to the ground a few metres ahead of the vehicle in the direction of travel. It's very effective in warehouses and the like as a way of warning people not to walk in front of a forklift. It's hard to see that working in a rail environment - the surface presumably isn't amenable to it.

 

An audible warning might work, but there again it might not. A low-level warning light might be more effective, or possibly both together. I don't know the rail environment well enough to say. Or for that matter, fencing in the 'safe walking routes' to make it more difficult to take shortcuts!

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2 hours ago, Edwin_m said:

Improvements in assistance and treatment will have some effect but I think it's probably more a reduction in accidents in the first place (probably due as you say to a reduction in the more dangerous activities such as shunting).  Most of the RAIB investigations relating to staff safety on track are either fatalities or near-misses - it's pretty unusual to be hit by a train and survive it.  

 

This is true for people hit by trains and you're right about the reduction in dangerous operations. Many injuries on the railways come from other sources. If you're working with power tools and you manage to cut yourself badly, you could be in a location, where pre-mobile phones and air ambulances, it would have taken hours to get you to a hospital, during which time you could die from blood loss. These days you can call the emergency services directly and if the incident is serious and in a remote location, they will dispatch an air ambulance and provide treatment advice over the phone.

 

3 hours ago, The Stationmaster said:

Mobile 'phones are also one of the biggest safety menaces, and not just the Southall and Edge Hill incidents referred to by SE.   The number of SPADs where it has subsequently come to light that the Driver involved was speaking on a (personal) mobile 'phone became quite alarming a few years back and mobile 'phones became ranked as the most serious, and likely, threat to Driver concentration

 

Back in the day it wasn't possible to tell whether a driver was eating, smoking, doing a crossword, chatting to the secondman etc, etc, all of which could be missing from the driver concentration stats, where as mobile phones and service providers have records of all calls made, so every instance is visible in the stats; This skews the statistics. The mobile phone isn't the issue either, it's the people using them which are.


Mobile phones are a factor (not necessarily the cause) in about 35 car crash deaths a year. I don't know how many times they have stopped serious injuries from becoming fatal ones, but anecdotally they definitely offset the number of deaths they were a factor in causing with lives they have saved. Imagine a car crash on a country road in 1992, it could take 20 to 30 minutes to drive to the nearest occupied house, call the emergency services and try to describe the location of the crash. These days, people can call the emergency services the moment the crash happens, someone will have GPS on their phone to give the exact location of the crash and the emergency services can give immediate over the phone advice on treatment to administer. Mobile phones are fantastic tools in saving lives and I believe they more than offset the number of accidents they cause, not to mention the actual cause is the person improperly using the mobile phone, not the phone itself!

 

All the best,

 

Jack

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