Plymouth platform collision - RAIB report

[Glorious NSE]

But this makes sense ONLY if you know which track to look along for any obstruction.

 

In this case the driver could have stopped in the distance he could see to be clear.

 

The problem is that he was looking along the wrong track. Which is surely the problem here, and not his speed or driving?

He was told the platform he was approaching, and the train sat in that platform was visible*, so his route in reality was occupied, and could be seen to be occupied...

 

He might well have been looking at the adjacent empty platform that better fitted a preconception of what he expected to see, but that's still the drivers error (and yes, still points to training...) 

 

(*And if it had been hidden by a curve or a building or something, again, driving within what you can see to be clear...)

 

 

[martin_wynne]

If a driver doesn't know what to look at or where to look he shouldn't be driving, sorry!

 

Agreed, but that is a completely different point from knowledge of the permissive rules. Why didn't he know where to look?

 

Martin.

[martin_wynne]

He was told the platform he was approaching, and the train sat in that platform was visible*, so his route in reality was occupied, and could be seen to be occupied...

 

He might well have been looking at the adjacent empty platform that better fitted a preconception of what he expected to see, but that's still the drivers error (and yes, still points to training...) 

 

(*And if it had been hidden by a curve or a building or something, again, driving within what you can see to be clear...)

 

I agree with all that, but it is a completely different point from failing to comply with the the permissive rules.

 

Even if he had driven at 1mph, there is still a fault in the system if he ended up on a different track from the one he was expecting. That fault may have been entirely his, but it is nothing to do with permissive driving.

 

Martin.

[russ p]

It wasn't a Graham garish HST he hit it was a full sized one. If you get a sub and a platform number you should be looking for a train in that platform.

I don't know the layout at Plymouth but if there is poor sighting you crawl if necessary to be sure you can stop should something be there

[Peter Kazmierczak]

This seems all pretty straightforward to me.

 

The driver clearly sees (no disagreement over this) the home signal displaying a red aspect, a big illuminated "6" and the white "calling on" lights. Therefore he should drive with caution to stop at some unknown point in plat 6.

 

From the data provided, it shows he slowed down but made the wrong assumption (his key error), that the obstruction was further along the platform than it was. It's probably fair to say that he thought the obstruction was further down the platform by at least the length of his train.

 

If it had been dark, would he have driven with more caution? I think probably yes.

[jonny777]

If a driver doesn't know what to look at or where to look he shouldn't be driving, sorry!

 

Isn't that a bit harsh? The driver wasn't scheduled into platform 6, and may have been momentarily confused into not believing his brain when he saw an HST in the platform that he might have thought was 6, but then began to doubt himself. It may only be a few seconds of doubt but it makes a difference.

[PaulRhB]

Inexperienced drivers, signallers and permissive working are a terrible combination.

Hmmm, I don't agree with that as it's written because it reads as a sweeping statement and suggests Signallers and permissive working are a problem period. An inexperienced driver can be more wary too and we actually encourage them to ask even if it means repeating a message again on a shunt. This case seems to be the driver assuming from experience because he hadn't done it in training and no one had identified the lack of it.

We do many permissive moves a day at Salisbury and we drum into new Signallers that you have to make sure there's room, not assume there is. As long as that simple check is done it covers 95% of the risk. What the Signaller can't predict are errors on the carriage workings or changes not advised on the day. One of the big advantages of cab radio is that during disruption we can call up and check with the driver as they enter the area. Last week I had to permissively work two GW services due to a broken rail blocking the line. I advised the driver of this unusual move in advance so he knew it wasn't a mistake when he got the calling on purely to head off the risk or delay if he stopped to question it. I don't do it for the Salisbury crews because it is a normal move and they know it may be tight and the poor visibility due the curve on certain platforms. When new drivers are training we regularly do all sorts of unusual shunt combinations to get all the possibilities in. That's the advantage of close cooperation between the trainers and Signallers and they are just as happy to do it when we are training new Signallers too.

[PaulRhB]

Isn't that a bit harsh? The driver wasn't scheduled into platform 6, and may have been momentarily confused into not believing his brain when he saw an HST in the platform that he might have thought was 6, but then began to doubt himself. It may only be a few seconds of doubt but it makes a difference.

No it's not really harsh, the training is supposed to eliminate that confusion and why the rule book states to slow to a speed you can stop in the distance you can see. If there's any confusion they should stop and question it or reduce speed to a crawl. It appears he didn't know his routes so it didn't trigger this caution, compounded by an unusual move.

[martin_wynne]

From the data provided, it shows he slowed down but made the wrong assumption (his key error), that the obstruction was further along the platform than it was. It's probably fair to say that he thought the obstruction was further down the platform by at least the length of his train.

 

But the HST was clear to see, he didn't have to make any assumptions about where it was.

 

The problem is surely that the HST was on a different track from the one he thought he was approaching.

 

Martin.

[The Johnster]

Note that while the report is described here as criticising the driver, those comments should actually be directed at GWR's driver training process which allowed a driver to qualify while under a serious misapprehension about the meaning of permissive working.  The signaller's error was secondary, and as the signalling system doesn't protect against that mistake the same could always happen again.  But if the driver actually understood the meaning of the subsidiary aspect it would result in nothing worse than a few people being led out through the train and some egg on operational faces. 

 

While GWR's training will no doubt be looked at in the light of this incident, and the conditions under which trains running under permissive block stressed to trainee drivers, I doubt if the situation as clear cut as Edwin_m suggests.  I would be very surprised if the driver was not very fully instructed in this matter before qualifying but, when the actual incident occurred, there may have been other factors in play, for instance, had he been routed this way before with this or a similar working, or was he under a genuine but mistaken impression that he had more room than he actually did?  GW's training regime turns out drivers all the time, who by and large are competent, capable, and highly aware of their safety obligations and responsibility.

 

The report mentions that his record, while not long, had been impeccable prior to this incident, and he has not in his statement to the enquiry attempted to shift blame or evade responsibility; he comes across as an 'honest broker'.  As well as the requirement to be able to stop the train in the distance you could see clearly ahead, IIRC in my day, the 70s, a blanket 15mph speed restriction applied to any move such as a calling on or shunting movement of this sort into a section already occupied, in fact to all and any permissive working.  If this is no longer the case and drivers are allowed to come into sections behind other traffic at line speed, then IMHO that wants looking at; as the report does not state that he was breaking a speed limit of this sort so I am assuming it is no longer the case.

 

This is a not uncommon type of accident, and far more experienced drivers have been caught out in this way

[Peter Kazmierczak]

But the HST was clear to see, he didn't have to make any assumptions about where it was.

 

The problem is surely that the HST was on a different track from the one he thought he was approaching.

 

Martin.

 

I hear what you're saying Martin.

So although the driver knows he's been signalled into plat 6, because there's a great big HST already in that platform, he thinks plat 6 must be the one either side of that train (ie plat 7 to his left or plat 5 to his right).

 

So his fundamental error was route knowledge.

[Glorious NSE]

But the HST was clear to see, he didn't have to make any assumptions about where it was.

 

The problem is surely that the HST was on a different track from the one he thought he was approaching.

 

Seems to be largely semantics. He did make assumptions* about where it was. He assumed* the HST could not have been on 'his track', even after being told it was. He was told he was approaching an occupied P6. The HST was right there, visible on P6. The empty track he appears to have been looking at is 7.

 

(*Consciously or not...)

 

 

 

 

[martin_wynne]

I hear what you're saying Martin.

So although the driver knows he's been signalled into plat 6, because there's a great big HST already in that platform, he thinks plat 6 must be the one either side of that train (ie plat 7 to his left or plat 5 to his right).

 

So his fundamental error was route knowledge.

 

Agreed. Nothing to do with permissive working.

 

The key to the whole accident is surely in para 67 of the report:

 

"When platforms 8 and 7 came into view to the left of train 1A91,

the driver of train 2E68 continued to discount the possibility that his train was

proceeding towards the same platform that train 1A91 was occupying because

he firmly believed he was proceeding into one of the platforms to the left of train 1A91."

 

Then in later paragraphs he resorts to counting platforms in disbelief.

 

So the question to be answered is not about how he controlled his train, but why he didn't know which platform was which? A signal with a big illuminated 6 is useless if the driver isn't sure which track is platform 6.

 

Looking at the driver's-eye views in the report there are no big signs giving the platform numbers as final confirmation. If there had been a big number 6 next to the HST the accident would almost certainly have been avoided.

 

Martin.

[Rivercider]

Seems to be largely semantics. He did make assumptions* about where it was. He assumed* the HST could not have been on 'his track', even after being told it was. He was told he was approaching an occupied P6. The HST was right there, visible on P6. The empty track he appears to have been looking at is 7.

 

(*Consciously or not...)

 

 

 

 

Looking at the photos in the report, particularly those on pages 25 and 26 it seems to me that from the end of platform 6 the driver would not have been able to see if the line

was clear as far as the 4-car stop sign on platform 7 either had he been routed that way. Had there been another train in platform 7, obscured by the one he actually hit,

stood only a coach length further back he would probably have hit that one instead. If the driver was uncertain he should have been proceeding more cautiously.

 

 

 

cheers

[Rivercider]

 

Agreed. Nothing to do with permissive working.

 

The key to the whole accident is surely in para 67 of the report:

 

"When platforms 8 and 7 came into view to the left of train 1A91,

the driver of train 2E68 continued to discount the possibility that his train was

proceeding towards the same platform that train 1A91 was occupying because

he firmly believed he was proceeding into one of the platforms to the left of train 1A91."

 

Then in later paragraphs he resorts to counting platforms in disbelief.

 

So the question to be answered is not about how he controlled his train, but why he didn't know which platform was which? A signal with a big illuminated 6 is useless if the driver isn't sure which track is platform 6.

 

Looking at the driver's-eye views in the report there are no big signs giving the platform numbers as final confirmation. If there had been a big number 6 next to the HST the accident would almost certainly have been avoided.

 

Martin.

Agreed that para 67 is important, but by this stage the driver was already in a position where a collision was either probable or highly likely regardless of route.

He was not able to stop short of the train on platform 6, and if there had been another train on either p7 or p8 stood out of his sight but short of the  4-car stop sign

he most probably have hit that train instead as he was travelling too fast in the circumstances,

 

cheers

[martin_wynne]

if there had been another train on either p7 or p8 stood out of his sight but short of the  4-car stop sign he most probably have hit that train instead as he was travelling too fast in the circumstances

 

The report says not, in para 72 (my underline):

 

"The way train 2E68 was driven into Plymouth station was consistent with the driver's belief

he would be going into a platform that was unoccupied at least as far as the 4-car stop sign.

If doing this, the train could have stopped within the distance the driver could see to be clear."

 

Martin.

[Rivercider]

The report says not, in para 72 (my underline):

 

"The way train 2E68 was driven into Plymouth station was consistent with the driver's belief

he would be going into a platform that was unoccupied at least as far as the 4-car stop sign.

If doing this, the train could have stopped within the distance the driver could see to be clear."

 

Martin.

Yes, he might have believed the line was clear to the 4-car stop sign, but he could not actually see that the line was clear to the 4-car stop sign

on any of either platform 6, 7, or 8,

 

cheers 

[martin_wynne]

Yes, he might have believed the line was clear to the 4-car stop sign, but he could not actually see that the line was clear to the 4-car stop sign

on any of either platform 6, 7, or 8,

 

But the report says that regardless of what he thought or assumed, if the train had been routed into platform 7, "the train could have stopped within the distance the driver could see to be clear.". (para 72).

 

In other words, had his belief about his route been correct, he was driving correctly for it.

 

Martin.

[Glorious NSE]

The only reason why he was looking at those unoccupied platforms in the first place is surely because he believed that the signal gave him a clear route up to a given point down a platform when in reality it did no such thing.

 

[The Stationmaster]

That's what I was asking. If the track is called "Platform 6" and is shown as that on the signal box diagram, then clearly the driver should have known where he was going.

 

But if it is called "Up Main" on the signal box diagram and the length of concrete alongside it is simply labelled platform 6 for the convenience of passengers, it seems unreasonable to expect the driver to know that numbering for every station on the line. After all the word "platform" does mean a length of raised staging of some sort, not two rails running side by side.

 

To a railwayman "platform" might mean a length of track, but to the rest of the population it means the bit you stand on. That might include a new driver.

 

Martin.

 

I don't know what it's show as on the signalbox panel but the 1960 commissioning notice showed the line as 'Platform 6', as no doubt did the 1974 signalling rationalisation Notice. and the Sectional Appendix has shown it as Platform 6 (nowadays 'P6') for the past 43 years.  If the Driver doesn't know the platform numbers - particularly and critically when they are used in signal route indicators  - then he should not have signed the road and shouldn't be driving over it unless accompanied by a Conductor Driver.

 

Again we potentially come back to inadequate training and certainly inadequate road knowledge and understanding of signal aspects.

But this makes sense ONLY if you know which track to look along for any obstruction.

 

In this case the driver could have stopped in the distance he could see to be clear.

 

The problem is that he was looking along the wrong track. Which is surely the problem here, and not his speed or driving or understanding of the permissive rules?

 

Martin.

 

So, once again, if he didn't know the road adequately and know which platform line was which at Plymouth he should never have signed it on his Route  Card.  Signing that document, or acknowledging it on an electronic equivalent, is a Driver's personal confirmation that he is satisfied that he has the necessary detailed knowledge and competence to drive safely over a particular stretch of railway.  If that wasn't drummed into him during his training then the training was at fault but surely he should - assuming he could read (and he wouldn't have got the job if he couldn't) at least have understood the relevant Rule?

[caradoc]

He mistakenly thought platform 7 was platform 6 due to inexperience and poor training, neither of which was his fault. Since he could see that what he thought was platform 6 was clear, he was driving at a speed appropriate for that platform.

 

He does not have to check the points at all, it is just good practice, which in this case reduced the speed of the collision. Or would you prefer that all the near misses due to this additional driver vigilance became accidents?

 

No, I would prefer that instead of unnecessarily checking points, and possibly distracting himself in the process, the Driver had driven at such a speed that he could stop safely, having been clearly advised by the signalling that (a) He was routed to Platform 6 and (b) There was another train already in that platform.

[guillemot]

 

So the question to be answered is not about how he controlled his train, but why he didn't know which platform was which? A signal with a big illuminated 6 is useless if the driver isn't sure which track is platform 6.

 

 

Which is something he should know of course for every station on every route he has signed to say he is competent over. He should also know all the names of the lines, eg up slow, down eastern, up main or whatever. If he did not know which line was platform six, then that would suggest an issue with training and/or assessment standards.

[The Stationmaster]

 

Agreed. Nothing to do with permissive working.

 

The key to the whole accident is surely in para 67 of the report:

 

"When platforms 8 and 7 came into view to the left of train 1A91,

the driver of train 2E68 continued to discount the possibility that his train was

proceeding towards the same platform that train 1A91 was occupying because

he firmly believed he was proceeding into one of the platforms to the left of train 1A91."

 

Then in later paragraphs he resorts to counting platforms in disbelief.

 

So the question to be answered is not about how he controlled his train, but why he didn't know which platform was which? A signal with a big illuminated 6 is useless if the driver isn't sure which track is platform 6.

 

Looking at the driver's-eye views in the report there are no big signs giving the platform numbers as final confirmation. If there had been a big number 6 next to the HST the accident would almost certainly have been avoided.

 

Martin.

 

So, rather damningly and unless the Report is poorly drafted, that indicates that he hadn't got a clue where he was going which in turn indicates distinct weakness in his road knowledge as well as the obvious weakness in his Rules knowledge.  Approaching Plymouth from the west is hardly a difficult or complicated approach, unless you crossover to the Down Main on the facing crossover on the underbridge you have a clear view of three potential routes - numbering from the right Platform 6, Platform 7, and Platform 8 and you'd have a pretty clear view - that closely in - of anything standing near the west end of Platform 6.

[martin_wynne]

The only reason why he was looking at those unoccupied platforms in the first place is surely because he believed that the signal gave him a clear route up to a given point down a platform when in reality it did no such thing.

 

But if he knew for certain those were platforms 7 and 8, and he had received a signal for 6, he wouldn't have been looking at them, surely? Just because they are unoccupied doesn't mean something else isn't signalled into them.

 

Either he believed platform 7 was platform 6, or he didn't know which platform was 6, or he failed to notice and remember that he had been signalled into 6.

 

Do drivers have any memory device they can use in the cab? Remembering red or green or yellow is easy. Remembering a number from 1 to 8 is less so.

 

Martin.

[Rivercider]

But the report says that regardless of what he thought or assumed, if the train had been routed into platform 7, "the train could have stopped within the distance the driver could see to be clear.". (para 72).

 

In other words, had his belief about his route been correct, he was driving correctly for it.

 

Martin.

I agree that is what the report says, and we will never know that answer.

 Looking at figure 15 (which admittedly is small) to my mind the driver would have left it very late to be actually be able to see that platform 7, 

the one he seems wrongly to have thought he was entering,  was clear as far as the 4-car stop sign,

 

cheers