RAIB report : Bognor derailment

[Reorte]

1 hour ago, Pacific231G said:

The possibillty occurs to me that volunteers on heritage railways may actually be more thoroughly trained- or at least spend more time learning specific installations from more experienced colleagues -  than their professional counterparts. What we don't know of course is what other boxes this particular signaller was regularly operating and whether the Bognor Regis box had characteristics that were different from the boxes he was more regualrly operating;  were they perhaps all mechanical?

 

There was a case of a derailment at Quorn a few years back where a signalman had authorised a train to pass a signal at danger and it was derailed as a result, so it can happen on them too.

[PaulRhB]

2 hours ago, Pacific231G said:

The possibillty occurs to me that volunteers on heritage railways may actually be more thoroughly trained- or at least spend more time learning specific installations from more experienced colleagues -  than their professional counterparts.

So someone who does 10-20 turns a year is more experienced than someone who does it every working day?  
Everyone has to go solo in a box at some stage and learn more from there, no one can teach you everything in an industry with so many different scenarios. 

We have a document created by the experienced staff to refer to if something unusual happens but it doesn’t override the rule book and sectional appendix but it does tell you what else to check. It creates thinking time too. 
I’ve been in a large panel box for 19 years, and two manual lever boxes before that, and I still come up against stuff I’ve never seen before. I’m not going to patronise the poor guy as I don’t know all the facts even from the report and I’ve seen very good Signal(wo)men make mistakes even they struggle to comprehend they did. Fatigue is a huge issue and managing the sudden pressure in a failure with multiple calls from drivers etc is not easy. I’ve had people be arrogant to us  about Signallers sitting around be stunned by the sudden explosion of workload when it goes wrong. Do a shift in a busy box when it goes wrong at the end of a long shift and then I bet people would be less judgemental. 
Ultimately he obviously did some of the other essentials which prevented worse outcomes. 
There are other issues I can’t talk about here but I assure you they are talked about between the guys in work. 

[Pacific231G]

43 minutes ago, PaulRhB said:

So someone who does 10-20 turns a year is more experienced than someone who does it every working day?  
Everyone has to go solo in a box at some stage and learn more from there, no one can teach you everything in an industry with so many different scenarios. 

We have a document created by the experienced staff to refer to if something unusual happens but it doesn’t override the rule book and sectional appendix but it does tell you what else to check. It creates thinking time too. 
I’ve been in a large panel box for 19 years, and two manual lever boxes before that, and I still come up against stuff I’ve never seen before. I’m not going to patronise the poor guy as I don’t know all the facts even from the report and I’ve seen very good Signal(wo)men make mistakes even they struggle to comprehend they did. Fatigue is a huge issue and managing the sudden pressure in a failure with multiple calls from drivers etc is not easy. I’ve had people be arrogant to us  about Signallers sitting around be stunned by the sudden explosion of workload when it goes wrong. Do a shift in a busy box when it goes wrong at the end of a long shift and then I bet people would be less judgemental. 
Ultimately he obviously did some of the other essentials which prevented worse outcomes. 
There are other issues I can’t talk about here but I assure you they are talked about between the guys in work. 

Not more experienced obviously after doing the job for a while.  I was thinking more about the amount of training before going solo. It was one of the issues raised in the Ladbroke Road enquiry though that related to driver training. I'm also aware of issues around certain heritage railway operations though those I know personally are extremely thorough. I simply don't know so wouldn't speculate on whether length of training and the amount of time spent working with a more experienced person before "going solo"  is an issue with regard to signalling but it comes up again and again in failures of safety critical systems in many fields so is one of the things the investigation needs to look at.

 

I agree with you absolutely about not being judgemental about a person who has made what appear to be   "unbelievable" (as one post put it) mistakes. Mistakes are not unbelievable at all, we all make them far more often than we like to admit and we make far more of them when we're stressed, tired or during high workloads. 

 

Someone said that this incident sounded like something out of "Red for Danger". Of course it did;  Rolt's book is all about the history of enquiries that looked at the whole system rather than trying to pin blame on individuals; the very process that has made rail travel the safest form of transport there has ever been. 

Edited December 23, 2020 by Pacific231G

[PaulRhB]

That’s why you got the winking emoji, I knew what you were getting at but it lacked the wider context

Training always varies, we’ve tried Mentors and training plans of various types and as I said before over the years we’ve created a very useful document between us to try and share the quirks at our box and it’s part of the training now. Some of the internal discussion can’t be shared here but it is taken very seriously and we do feedback to the management when we see issues. 
I passed out at my first box pretty quickly but I had a very experienced boss who was always at the end of the phone if you needed to check, similarly at my second box I had experienced Signalmen either side and they encouraged you to call them up to check anything. Still happens today and with a couple of recent guys new to our area they’ve given me a buzz at home to check, those who know when to check are usually right and tend to make damn good Signallers. The advantage over a crib sheet is you’ve got that extra head involved. 
 

[D9020 Nimbus]

Just thinking — this isn't the first time a signaller has made a mistake leading to an accident in the event of a system failure, though on this occasion, without any fatalities. A relief signaller might know how to work the box in normal circumstances, but when something unexpected goes wrong, with the signaller fatigued and under time pressure…

 

It did seem to me reading the report that the signaller was too ready to authorise movement past a signal at Danger. But there may have been many underlying reasons for this.

[PaulRhB]

7 minutes ago, D9020 Nimbus said:

with the signaller fatigued

 

8 minutes ago, D9020 Nimbus said:

there may have been many underlying reasons for this.

That’s certainly one. A relief Signaller can have wider experience than a resident because they also work busier boxes so come across more failures. It’s very much luck of the draw. I was surprised by my very competent colleague who after five years had never dealt with a failed train. While they decided if it was a total failure we went over the best ways to sort it and I let him lead, he was spot on but glad of the second head as a check as it was easier than finding it in the book to check. 
There’s a good reason we put the kettle on when it goes wrong too  

[phil-b259]

On 21/12/2020 at 21:09, 97xx said:

Question: sorry if I missed this, but are the position indicators powered by the same (defective) battery supply?

 

No (With the caveat that what follows is based on 1980s Southern region practice )

 

The drive to point machines is usually 120VDC. That comes from dedicated point batteries charged by a charger * fed by 110VAC busbar or a dedicated transformer rectifier from the main 650V / 415V Three Phase signalling power supply. In mechanically signalled areas the charger can be fed by a 240VAC feed from the signal box.

 

* see http://dmstech.co.uk/red-flash/rail-products/

 

Point detection is powered by are either 110VAC or 50VDC depending on the age of the installation.

 

The 110VAC is derived from said 650VAC signalling power supply while the 50V is derived from the 110VAC. In mechanically signalled areas this 50V supply may be provided by a separate battery installation and as the currents drawn are low this could even be primary (i.e. ordinary 'disposable' type batteries)

 

In power signalled areas, the 650VAC / 415V three phase signalling supply has two ways of being fed - firstly by an input from the local electricity company and the second via the 3rd rail / overhead traction supply feed (or standby generators) for non electrified areas.

 

 

 

[keefer]

3 hours ago, Reorte said:

 

There was a case of a derailment at Quorn a few years back where a signalman had authorised a train to pass a signal at danger and it was derailed as a result, so it can happen on them too.

Was that the one where the train was in the loop, got the tip to pass the signal and promptly derailed on the trap point?

There was a video of it (might still be) on YouTube

[Pacific231G]

6 hours ago, keefer said:

Was that the one where the train was in the loop, got the tip to pass the signal and promptly derailed on the trap point?

There was a video of it (might still be) on YouTube

Yes 29th April 2013. There are several. This one shows the actual incident very clearly

https://www.youtube.com/watch?v=Yr5EztEPJS8

Because it was on a siding and didn't involve a passenger train, the RAIB decided not to investigate the incident. There was some controversy about that at the time but I'm sure the GCR paid it a great deal of attention.

What did strike me about the Bognor derailment was that a passenger train was derailed by a trap point. I thought that lines used by trains carrying passengers weren't allowed to have devices to derail trains whereas passenger carrying lines are required to be protected from non-running lines. 

[PaulRhB]

4 hours ago, Pacific231G said:

What did strike me about the Bognor derailment was that a passenger train was derailed by a trap point. I thought that lines used by trains carrying passengers weren't allowed to have devices to derail trains whereas passenger carrying lines are required to be protected from non-running lines. 

No sand drags are used to protect single lines etc, it’s about preventing collisions where there’s no room for an overlap or it’s operationally limiting. Traps cost extra to maintain due to moving parts that’s the reason an interlocked overlap distance with AWS and later Tpws are more common. 

Edited December 24, 2020 by PaulRhB

[Oldddudders]

Training can only go so far. At Easter 1976 the entire signalling system at London Bridge (E), Cannon St and Charing Cross was replaced, including a new track layout at the key Borough Market Junction. Easter Tuesday the new London Bridge box was abuzz with unfamiliarity, but the signalmen (as they were then known!) were experienced and high-calibre, being a mix of men from the closed boxes and the best relief men, and of course panel boxes make life easy - but if failures occurred it helped having multiple extra colleagues alongside and a back-row regulator (where I was a super-numerary) to support. In succeeding weeks I certainly saw men suffer from a brain-freeze that a helpful colleague quickly thawed. 

 

Contrast that to Bognor on that morning, where we believe the chap was tired - who isn't when booking on at 04.30? - alone, and under pressure from the moment the ECS was stuck outside, with the prospect that the morning working was about to go for a ball of chalk if he didn't react quickly.