Cement train derailment in Sheffield

[woodenhead]

Until the RAIB report it's probably best not to blame machines - it could yet turn out that it was human error or delayed maintenance that was the underlying cause.

[njee20]

But I’ll wager fewer people have been killed or injured too with fewer people trackside. 

[Poor Old Bruce]

1 hour ago, woodenhead said:

Until the RAIB report it's probably best not to blame machines - it could yet turn out that it was human error or delayed maintenance that was the underlying cause.

 

I don't think anyone is blaming machines, just commenting that machines may have their limitations, just like people. Also that experience, conscientiousness and intuition are difficult to replace with a machine. Even the best computers are only as good as their programming and can only respond to the information they are given (this is not intended to suggest 'rubbish in = rubbish out' before that gets started, or to start a debate on the efficacy or otherwise of any programming systems).

 

The immediate cause of the derailment is given in the RAIB statement. What led to that situation and how to remedy it will still be under investigation.

[phil-b259]

On 01/12/2020 at 09:12, TheSignalEngineer said:

Today we have a lot of reliance on technology. It is only as good as the knowledge level of those specifying it and writing the algorithm for the computer to analyse the collected data. 

In the period from 1966 to 1996 I spent a lot of time on-track and riding on trains, both passenger and freight. I could spot many potential faults in points and track circuits just by watching how the track behaved and sounded as a train passed over it. Do any of the algorithms know how to pick up the noise of a loose stretcher bolt or track fastening as a train goes through?

With the accent on not having people on track with trains running and loss of local knowledge due to fragmentation and outsourcing that sort of experience has largely disappeared from the industry. 

 

And its going to get worse!

 

Please remember the edict from the ORR that live line working (red zone / lookout protection) is going to be banned from 2023.

 

That means most of the inspections / repairs will (1) not have the ability to observe the track as trains pass over it and (2) will have to be done at night where darkness / shadows can hide all sorts of things.

 

As from last month ALL p-way patrolling has required line blockages on the Sussex route - and that means it all now has to be done overnight!

Edited December 5, 2020 by phil-b259

[Grizz]

At night. So they finally got their way in the end then. I remember how the risk management persons were bleating on about this in 2000. Bearing in mind these weren’t people with any depth of experience of actually working on the track. Planners were recruited off the street.

We were told that all 053 facing switch inspections and detailed S&C inspections were going to have to be done at night, because it wasn’t safe to do inspections in the day time with trains running. 
Fortunately the engineer in charge of our Zone refused to allow it. Stating that the amounting of lighting required to replicate day light conditions made it impractical to ensure that any and all defects would found. 
 

Rail wheel interface, actually viewing the way wheel sets and bogies behave as they travel through S&C and the sounds they make are a fantastic tool in managing maintenance. 
 

I am not advocating going back to the days of Red Zone Kongo packing like we used to, in the middle of the day, in the middle of Clapham Junction and up through Vauxhall to Waterloo. Where our place of safe was another open road. There just aren’t enough long serving staff with enough experience left, having worked in the job from the bottom up. We are heading towards the old Railtrack mantra of anyone can do this job, straight off the street. 
 

Look out protection can work perfectly safely if carrying out inspection work or patrolling, as long as their are places of safety  and experienced consciousness lookouts. 
 

In Normal Times, the Sussex route, BML and branches don’t often get long week day night possessions. Regular manual inspection can be managed perfectly safely. It used to be called local knowledge. There in lies the problem. 

Edited December 4, 2020 by Grizz
Auto correct again....

[corneliuslundie]

So in the interests of safety of staff we are likely to get either a much more expensive railway, because fewer trains can be run to allow for daytime possessions, or a less safe railway. Either way, if it pushes more people off the railways and onto the roads it will have a negative effect on safety.

I remember reading a paper to a European conference on safety where the author made it quite clear that there is no such thing as absolute safety, and that every attempt to get nearer to it puts one on an exponential cost curve.

Not that I advocate putting the lives of those working on the railways at unnecessary risk.

By the way, the most dangerous place to be is in bed. More people die there than anywhere else. So I assume that the "safety at any cost" pundits will say we should never go to bed!

Jonathan

[jcm@gwr]

9 minutes ago, corneliuslundie said:

 

By the way, the most dangerous place to be is in bed. More people die there than anywhere else. So I assume that the "safety at any cost" pundits will say we should never go to bed!

Jonathan

 

Followed closely (I believe) by hospital, maybe we'll be told not to go to them either!

[phil-b259]

12 hours ago, Grizz said:

At night. So they finally got their way in the end then. I remember how the risk management persons were bleating on about this in 2000. Bearing in mind these weren’t people with any depth of experience of actually working on the track. Planners were recruited off the street.

We were told that all 053 facing switch inspections and detailed S&C inspections were going to have to be done at night, because it wasn’t safe to do inspections in the day time with trains running. 
Fortunately the engineer in charge of our Zone refused to allow it. Stating that the amounting of lighting required to replicate day light conditions made it impractical to ensure that any and all defects would found. 
 

Rail wheel interface, actually viewing the way wheel sets and bogies behave as they travel through S&C and the sounds they make are a fantastic tool in managing maintenance. 
 

I am not advocating going back to the days of Red Zone Kongo packing like we used to, in the middle of the day, in the middle of Clapham Junction and up through Vauxhall to Waterloo. Where our place of safe was another open road. There just aren’t enough long serving staff with enough experience left, having worked in the job from the bottom up. We are heading towards the old Railtrack mantra of anyone can do this job, straight off the street. 
 

Look out protection can work perfectly safely if carrying out inspection work or patrolling, as long as their are places of safety  and experienced consciousness lookouts. 
 

In Normal Times, the Sussex route, BML and branches don’t often get long week day night possessions. Regular manual inspection can be managed perfectly safely. It used to be called local knowledge. There in lies the problem. 

 

To be fair, I don't believe Network Rail or the TOCs are particularly happy with thus move - but are pretty powerless to challenge it.

 

Remember the body setting the 2023 deadline(the ORR)  is the industry safety regulator with the power to heavily fine NR if its lawyers perceives things are not being done in accordance with H&S law*

 

The fact that things may be missed at night doesn't come into it - in their eyes a failures resulting from night work are because NR won't have provided enough lighting, not that night time inspections are inherently less effective than daytime ones.

 

In a similar vein the reaction to paperwork not keeping people safe is to insist on yet more paperwork! Again its all driven by the legal profession who like to pretend that a massively bureaucratic and segmented process is the way to keep people safe rather than admit its all about having someone to blame.

 

If you really want to improve workforce safety then ending casualisation and contracting out of things would make a huge difference - people working in the same area and with the same people are far easier to keep safe.

[phil-b259]

12 hours ago, Grizz said:

 We are heading towards the old Railtrack mantra of anyone can do this job, straight off the street. 

 

 

 

Thats what you get when lawyers start dominating industry policy - and the ORR / HMRI being the safety regulators have no shortage of those...

 

They fervently believe anyone can do a job if given the correct training and documentation. If issues result then either its the fault of the person for not following the documentation / training or the employer has been negligent in their training / procedures.

 

Either way there is blame to be apportioned and thus a court claim to be made....

 

All very lucrative of course...

Edited December 5, 2020 by phil-b259

[corneliuslundie]

"Either way there is blame to be apportioned"

Thus I am afraid is at the bottom of the problem. It creates work for paper pushers and lawyers who have no practical experience of the subject but does nothing to improve safety. Not that I have any experience either, but I would rather rely on an experienced railwayman than a lawyer or a management graduate to keep things  as safe as is practicable for me.

Jonathan

[Reorte]

15 hours ago, jcm@gwr said:

 

Followed closely (I believe) by hospital, maybe we'll be told not to go to them either!

The one my grandpa ended up in did have "So Help Us God" above the door, which didn't speak of much confidence in doctors!

[Talltim]

Although the location of this derailment could be observed from the comfort of a platform

[Wheatley]

Just a thought - by this description "...a series of rail fastenings, intended to maintain the correct distance between the rails, had broken...", do they mean the chairs/baseplates, or tiebars added to stop gauge spreading ? If the latter then the defect had already been identified and was awaiting rectification. If the former then it seems odd to add the second part of the description about them being to keep the rails the correct distance apart. 

[Jonboy]

Regarding the ORR deadline of 2023 to remove red zone working, what would the reaction be if a 2022 provisional WTT was published with nothing moving anywhere between 10am and 12pm daily to allow inspections/minor repairs  planned and reactive???

 

[Fat Controller]

31 minutes ago, Jonboy said:

Regarding the ORR deadline of 2023 to remove red zone working, what would the reaction be if a 2022 provisional WTT was published with nothing moving anywhere between 10am and 12pm daily to allow inspections/minor repairs  planned and reactive???

 

SNCF already operate a system of rolling daytime possessions, known as Periodes Blanches, where no trains are timetabled between given points at set times, allowing track inspections and minor interventions to be carried out in daylight. You can even see the effects of them reaching to St Pancras, as there are two periods between about 12:00 and 14:00, when there are firstly no Eurostar arrivals, and then no departures, for an hour. 

I remember my god-daughter's mother arranging a table, with a good view of the line, at a restaurant south of Lyon. The first train to pass arrived with our post-prandial coffee, rapidly followed by an influx of SNCF staff intending to take the Menu Ouvrier. I would say they had prewarned the patronne of hand-back, as the first plates were on the table before we'd paid...

[caradoc]

We used to do similar during the day on the WCML 4-track sections; I had the pleasure of a cab ride from Glasgow C to Euston courtesy of Virgin Trains, and from IIRC Bletchley we ran via the Up Slow to allow planned inspection of the Fast Lines. One thing I have always remembered is that we returned to the Up Fast at Tring, through a 15 (fifteen) mph connection. 

[cheesysmith]

A question I would ask is what is the death to cost ratio of banning red line working? Does it meet the ORR cost\benifit ratio?

[2251]

The report is now out:

 

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1022958/R072021_211005_Sheffield.pdf

 

The key conclusion appear to be this on page 7:

 

"The track gauge had widened because a number of track screws, that secured the rails and baseplates to the wooden bearers, had broken, allowing the rails to spread apart under the loads from passing trains. The track screws had failed several weeks, or perhaps months, before the derailment, but the failures had not been identified by Network Rail’s maintenance inspection activities.

 

Although this was a location with a potentially high risk of derailment, it had not been recognised as such because Network Rail’s guidance for identifying such risk had not been applied. Additional mitigation had therefore not been considered. "

[Bucoops]

Very scientific

 

62 The failures of the multiple track screws were not immediately obvious when
RAIB attended the derailment. The upper part of each broken screw was held in
its associated baseplate by a plastic ferrule that had been compressed around
it during installation. These ferrules held the broken screw heads tightly in the
baseplates, so that they could not be turned by hand, and felt solid when given a
kick. The failed state would similarly have been hidden from visual inspection, and
from any test kicks from a patroller’s boots, making detection by a BVI difficult.

 

[alastairq]

On 05/10/2021 at 13:42, 2251 said:

The key conclusion appear to be this on page 7:

 I think the broken screws were the result of something far more important going wrong, so to speak...the failure of NR to ensure implementation of procedures, the failure of the existing testing technology, etc etc. etc all conspiring to relegate the track maintenance down  to somebody plodding along 'kicking' the fixings. So to speak.

In other words, a Systemic failure within NR, which fed down to the staff on the ground.

[woodenhead]

15 hours ago, Bucoops said:

Very scientific

 

62 The failures of the multiple track screws were not immediately obvious when
RAIB attended the derailment. The upper part of each broken screw was held in
its associated baseplate by a plastic ferrule that had been compressed around
it during installation. These ferrules held the broken screw heads tightly in the
baseplates, so that they could not be turned by hand, and felt solid when given a
kick. The failed state would similarly have been hidden from visual inspection, and
from any test kicks from a patroller’s boots, making detection by a BVI difficult.

 

But sometimes the most basic obvious thing is the most suitable for the check, to me the only other check would have been to unscrew it which adds all manner of new risks.

 

Perhaps some sonic testing of screws would have identified the fault, it's interesting that an issue was spotted because it was noted there had been shuffling of the baseplates and rectification was planned just not soon enough.  Also it seems perhaps having the same people performing the visual checks led to complacency as it was an unfamiliar checker who spotted the shuffling.

[Bucoops]

1 hour ago, woodenhead said:

But sometimes the most basic obvious thing is the most suitable for the check, to me the only other check would have been to unscrew it which adds all manner of new risks.

 

Perhaps some sonic testing of screws would have identified the fault, it's interesting that an issue was spotted because it was noted there had been shuffling of the baseplates and rectification was planned just not soon enough.  Also it seems perhaps having the same people performing the visual checks led to complacency as it was an unfamiliar checker who spotted the shuffling.

 

I can understand it being an accepted (if not correct) manner of checking on a track walk - but I read the first mention of a kick being by the investigators.

 

Would a tap with a hammer give any clues, similar to the old check for broken tyres? Probably wouldn't ring out even if good but it might be possible to tell. Those screws are pretty strong - do they break often?

[woodenhead]

12 minutes ago, Bucoops said:

 

I can understand it being an accepted (if not correct) manner of checking on a track walk - but I read the first mention of a kick being by the investigators.

 

Would a tap with a hammer give any clues, similar to the old check for broken tyres? Probably wouldn't ring out even if good but it might be possible to tell. Those screws are pretty strong - do they break often?

When the track will have shifted quite a bit (there was shuffling evidence I) so perhaps kicking it was an output of one of the initial investigators  going 'Look at that, that chair has shifted" and then he/she kicked it to stess where they meant and noted the screw was still firm in it's socket when patently it was not connected to the sleeper any more.

[Michael Hodgson]

Perhaps RAIB need to be issued with bigger boots.

[corneliuslundie]

Is this failure something which could be detected by any of the current inspection methods, "manual" or on-train? If not, then the components which failed need to be redesigned so that a failure can be detected. But how may of these components are in use on the railway?

And it sounds as though a night-time inspection (as per the coming regime) would make detection even less likely.

Jonathan