Grosmont collision - RAIB report

[Boris]

15 hours ago, SamThomas said:

You assume wrong because you did not read my post correctly.

 

I was simply making the point that a driver of anything should ensure that his manuavering area is clear before he enters it.

 

& before anyone points it out I have spelt manuavering incorrectly.

And you obviously didn't pick-up on the point I made in my post, a movement made in this circumstances is made in a controlled manner, which wasn't the case in the thread we are in.  Getting out and having a look isn't always practical in a railway environment where other movements are being made.  This is where permissive platform working comes in, it is the signallers responsibility to make sure that there is sufficient space for the train being signalled into the occupied platform before the movement is made, then the driver needs to make sure he doesn't hit the stock in the platform and proceed at a safe speed in case of restricted visibility.  Stop within the distance you can see, which you'll be familiar with from the Highway Code.

 

 

[SamThomas]

19 hours ago, Boris said:

And you obviously didn't pick-up on the point I made in my post, a movement made in this circumstances is made in a controlled manner, which wasn't the case in the thread we are in.  Getting out and having a look isn't always practical in a railway environment where other movements are being made.  This is where permissive platform working comes in, it is the signallers responsibility to make sure that there is sufficient space for the train being signalled into the occupied platform before the movement is made, then the driver needs to make sure he doesn't hit the stock in the platform and proceed at a safe speed in case of restricted visibility.  Stop within the distance you can see, which you'll be familiar with from the Highway Code.

 

 

I stand by my comments. I appreciate that it is not allways practical in a railway environment "to get out & look", but in this case there was no risk for the driver to get out - no adjacent running rails, no 3rd rail.

 

I agree that no-one comes out of this "smelling of roses" - maybe one of the "passengers" should have been asked to dismount the locomotive to check distances, maybe the driver should have been going much slower (after all there did appear to be plenty of time to complete positioning move), maybe the driver should have used a different control position.**

 

Reminds me of the time I filled in an accident report when a car driver collided with my stationary truck & the last question on the form was "could you have avoided the accident by any means" & I answered "maybe have been somewhere else" - the driver trainer was not amused.

[woodenhead]

So the RAIB who had all the relevant information to hand have investigated this incident and issued an improvement order on the NYMR in relation to record keeping.

 

To me it appears the matter is closed as long as the record keeping is updated, yet over here on RMWeb........

[pete_mcfarlane]

On 27/12/2021 at 13:11, Oldddudders said:

60 years into the standard-gauge preservation movement, I suspect there are now huge numbers of important but dull and tedious admin tasks, that really do not appeal in any way to the average society member, who wants to help run trains. The fact that without that paperwork the society may be closed down is a tough pill to swallow, especially if the member watches others doing all the jobs he/she had in mind when joining. 

This is a problem for any voluntary organisation, there's an increasing number of people who only want to do the fun stuff rather than the boring admin/cleaning/paperwork that's required to support it. Ideally you share the tedious jobs around so that everyone has a reasonable mix of mostly good stuff, but that's not always going to sit well with various egos. 

[pheaton]

23 minutes ago, pete_mcfarlane said:

This is a problem for any voluntary organisation, there's an increasing number of people who only want to do the fun stuff rather than the boring admin/cleaning/paperwork that's required to support it. Ideally you share the tedious jobs around so that everyone has a reasonable mix of mostly good stuff, but that's not always going to sit well with various egos. 

GWR had a similar issue....the way they got round it was the make the person who handles paperwork a paid employee.

 

It was inevitable after the various high profile incidents that this was going to happen, there's very little I can do in way of repairs now that don't require paperwork....and certain repairs need to be signed off and checked by a second competent person.

 

this is the issue we have now....is defining who is a competent person to sign on certain repairs (in our case brakes and anything that can directly result in a fire or derailment)....in our case we rely on 4 ex and current serving BR fitters, but they a re grumbling about the workload....for example if 45149 or 26043 need an exam...I can  do the majority of it but I cant sign it off. That then takes them away from working on there own locomotives in order to sign my paperwork...

 

the issue occurs when you need the process to deem that someone else/new/additional is qualified to sign off paperwork.

Edited December 29, 2021 by pheaton

[woodenhead]

But a return to the old laissez faire days will never happen, not since a child nearly died falling through the missing floor on a Mk1 coach toilet or the tragic event on the NYMR about a decade ago.

[Grovenor]

But its not the missing paperwork that is the problem, that is just a symptom, the problem is the missing competence.

[avonside1563]

On 27/12/2021 at 17:06, Wheatley said:

 

Let's face it, keeping the bloody paperwork straight is the easiest bit of managing competence ! 

Really? Have you any idea of the amount of paperwork involved?  It’s  not just loco crews, there are records required for all sorts of rolls such as safety critical maintenance, machine tool operators, Pway inspections. As others have said it is becoming a full time job for even the smallest of organisations. I don’t disagree that it’s a dangerous hobby and needs to be taken seriously but I suspect there will be many more improvement notices issued to heritage lines with regards to the maintenance of competence and associated paperwork.

[Wheatley]

1 hour ago, avonside1563 said:

Really? Have you any idea of the amount of paperwork involved?  

Yes. For nearly 35 years now. 

[woodenhead]

Youtube served up this video, a reminder of just what can go wrong if you don't train people and you don't maintain your railway as it should be.

 

 

[roythebus1]

In this case the fireman should have left the loco and hand-signalled the driver towards the stationary train from a place of safety.

 

As for paperwork, one of the heritage lines I'm involved in had a nasty accident in a machine shop which involved a machine shop operator nearly losing an arm when his sleeve got caught in a rotating piece of work. Paperwork doesn't only include train movements, it's the whole show these days.

 

I was working on one of those lines a few years back when one of the "stakeholders" demonstrated his lack of safety knowledge by wandering across the running lines in the station at night with no hivis, running steam heat extension pipes across running rails. But he gets away with it because he is "always there", has been there a long time and has shares in some of the loco owning groups. His full time job is on the big railway and part of his duties involve managing traction current isolation. The night of the above incident he was off to do his full-time job all night then back to the heritage line the following morning. Obviously he'd not read the Hidden Report after the Clapham disaster.

 

[faulcon1]

Having read the RAIB report, you can have all the experience you like but unless you have the paperwork to back it up, then that experience counts for nothing. It doesn't matter how many years you've been a volunteer on a preserved railway and how many different classes of locomotive you've driven. Unless you have the up to date paperwork that reads that you're competent to drive those locos, then you're NOT competent.

[AY Mod]

14 minutes ago, faulcon1 said:

Unless you have the up to date paperwork that reads that you're competent to drive those locos, then you're NOT competent.

 

Competence and compliance are different things.

[jjb1970]

The paper work trail doesn't need to be that onerous, it just needs to be suitable and sufficient. Some organisations seem much better at it than others. I worked as shift charge engineer at a nuclear plant authorized as AP, SAP and control person and the competency and authorization process was very tight, it was robust and taken very seriously but it emphasized actual competency and with the paperwork trail very concise. On the other hand the competency matrices and paperwork trail when I did ship design approval at one of the classification societies was painful. And for the MoD it was much more painful again. My own view is these things work better when kept to the point.

Edited August 14, 2022 by jjb1970

[jjb1970]

The really difficult thing in my experience is maintaining focus on safety and systems supporting that rather than falling into compliance culture. It may seem a semantic point but systems start to fail when people are primarily interested in maintaining compliance rather than keeping on top of the actual competency, safety etc issues.

[keefer]

The trap of focusing on making sure the boxes are all ticked, while losing sight of why they need to be ticked in the first place.

[jjb1970]

A theme which appeared in the electricity generating sector was a trend in accident investigations to find that person knew what they were supposed to do, but not why they were supposed to do certain things, which is a staff competency and management culture issue with significant safety implications and is part of the move to a compliance culture. Once that sets in it takes an awful lot of work to correct.

[Chris M]

On 14/08/2022 at 16:12, faulcon1 said:

Having read the RAIB report, you can have all the experience you like but unless you have the paperwork to back it up, then that experience counts for nothing. It doesn't matter how many years you've been a volunteer on a preserved railway and how many different classes of locomotive you've driven. Unless you have the up to date paperwork that reads that you're competent to drive those locos, then you're NOT competent.

If you something that you know is there, regardless of paperwork, that suggests not competent.