Plymouth platform collision - RAIB report

[russ p]

Not at the right time though regardless of what the report says

[martin_wynne]

the driver believed that his train could safely proceed to a 4-car stop sign located approximately midway along the platform he would use

 

So no, he plainly didn't understand that the two white lights meant

 

Those two statements don't follow. We don't know that the belief mentioned in the first statement was derived from the signal indication. It may have been no more than his expectation from previous experience. It would be possible to believe that but still obey the signal indication as regards speed.

 

The report says (para 72) that he could have stopped within the distance he could see, so unless that was purely coincidental, he had adjusted his driving according to the signal requirements. It was his route understanding which failed, not his driving.

 

Martin.

[martin_wynne]

Not at the right time though regardless of what the report says

 

If you know better than the RAIB, perhaps you should write an alternative report.

 

Martin.

[PaulRhB]

. It was his route understanding which failed, not his driving.

 

Martin.

The route knowledge and driving are intrinsically linked because you drive according to the route knowledge. Knowing when to shut off, where to brake, where speed restrictions are.

Both failed, what was important was identifying why and that's been well discussed already.

[Glorious NSE]

Those two statements don't follow. We don't know that the belief mentioned in the first statement was derived from the signal indication. It may have been no more than his expectation from previous experience. It would be possible to believe that but still obey the signal indication as regards speed.

 

The report says (para 72) that he could have stopped within the distance he could see, so unless that was purely coincidental, he had adjusted his driving according to the signal requirements. It was his route understanding which failed, not his driving.

Is this one any clearer?

 

73 The training and assessments undertaken by the driver had not resulted in a correct understanding of permissive working.

74 The driver of train 2E68 believed that if a train was to be signalled into a platform such that it could not reach its normal stopping point (ie the appropriate car stop sign) the signaller would tell the driver (paragraph 65). Because the signaller had not told him about this particular intended permissive movement (paragraph 54), the driver assumed the route would be clear as far as a 4-car stop sign.

So again. The driver did not understand those two white lights...

 

Also see above, this argument is irrelevant. 

 

[russ p]

Martin I don't know what answer you are wanting to hear but you have been told by many professional railwaymen what our views are and how drivers should react to signal aspects yet you persist in wanting some other answer.

Or maybe you would find it acceptable next time you travel by train for it to smash into a train in a platform, I would think not.

I think it's about time this post is closed

[Grovenor]

The RAIB report says he did:

 

 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/592094/R022017_170213_Plymouth.pdf

 

Paragraph 72: "the train could have stopped within the distance the driver could see to be clear."

 

Martin.

If you quote the whole sentence you find that it starts with a big If

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

As earlier in the paragraph, it means he could have stopped at the 4-car stop mark,(the 'this' under discussion in the paragraph) which he assumed he was going to do. But figs 13 and 14 show that  the 4 car stop marks would not have been visible until he was further in, but the rear of the HST was visible and identifiably in platform 6. He was going to fast for the conditions and that was primarily attributable to inadequate training.

Regards

[96701]

There is a reason for RAIB Reports being written in the stile that they, and it is in the very first paragraph, my bold:

 

The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. 

[jonny777]

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...)

 

 

 

 

 

I am surprised that the driver is being slated so much for making assumptions, but few mention the first assumption made without which the driver would not have been directed into platform 6 at all.

 

The signalman made an assumption that a 4-car train would fit behind the HST.

[TheSignalEngineer]

The RAIB report says he did:

 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/592094/R022017_170213_Plymouth.pdf

 

Paragraph 72: "the train could have stopped within the distance the driver could see to be clear."

 

Martin.

That is not the whole paragraph and not necessarily what it means if you consider the whole wording. The speed may have been such that he could have stopped if his assumption was correct but it was not necessarily in accordance with what the rule means. I am not sure why, after passing signal P15 at 8mph he felt it necessary to accelerate to 22mph, although some power would have been needed due to the rising gradient and curvature at that location.

Regarding the platform he was going into his route knowledge should have been such that he would expect to be on a line with the platform to be to the right of the train.

Again from route knowledge he should have known it is 3/4/5 through the crossover and 6/7/8 straight on, therefore 6 is the right hand of the three tracks available and the HST on it would actually be the first thing to come into view on that side of the station.

From the point where the HST would become visible it was 135 metres away and at the speed to which the driver had accelerated the DMU should be capable of stopping in 84 metres.

[martin_wynne]

If you quote the whole sentence you find that it starts with a big If

 

Hi Keith,

 

Yes I know there is a big if.

 

My reading of that paragraph is that IF he had been routed into platform 7 or 8 he could have stopped within the distance he could see to be clear, not that he could have stopped only at the 4-car stop board.

 

I have re-read it several times, and I still can't see how it "distance the driver could see to be clear" means the distance up to the stop board.

 

Being able to "stop within the distance the driver could see to be clear" (RAIB's words, not mine), surely means that his speed had been regulated in accordance with the requirements of the signal. It was where he was looking which was wrong.

 

Martin.

[russ p]

If he had regulated his speed accordingly he wouldn't have hit it!

[martin_wynne]

I think it's about time this post is closed

 

I'm not going to argue your other points but that last point I disagree most strongly. I am fed up with members of RMweb appointing themselves as moderators of what other folks can post, and asking for topics to be closed. Angry.

 

Martin.

[russ p]

No one on this is appointing themselves as moderators.

A lot of people have spent time trying to explain to you how parts of he railway work and you persist in trying for alternative answer.

It should be the rest of us that are angry

[Siberian Snooper]

I am have no railway operating experience, but I moved to Plymouth in 1972 and soon learned to read the signals and theatre indicators for Plymouth station, in order to make a quick exit from the train and be standing at near enough the right door for the steps if required, I could also read the semaphores at Exeter for the same reason. I don't think it's rocket science.

[Reorte]

It's all very well to say "don't make assumptions", and fair enough, but we're not always aware that we're making them; they can happen subconciously and we don't realise it until something happens that draws attention to it. Familiarity or lack of can work both ways there too.

 

Whether or not that's relevent isn't something I can say.

[martin_wynne]

No one on this is appointing themselves as moderators.

A lot of people have spent time trying to explain to you how parts of he railway work and you persist in trying for alternative answer.

 

I'm not trying for an alternative answer. Why would I want one? I'm simply pointing out that some of the replies here don't correspond to the statements in the RAIB report.

 

Martin.

[russ p]

It's all very well to say "don't make assumptions", and fair enough, but we're not always aware that we're making them; they can happen subconciously and we don't realise it until something happens that draws attention to it. Familiarity or lack of can work both ways there too.

 

Whether or not that's relevent isn't something I can say.

I'm pretty certain no drivers ever set out to have an incident. What you are saying is absolutely correct, you never know when an incident will arise.

Thankfully today with modern safety systems the results of driver error are largely less serious than say 20yrs ago.

Well in this country at least

[Glorious NSE]

My reading of that paragraph is that IF he had been routed into platform 7 or 8 he could have stopped within the distance he could see to be clear, not that he could have stopped only at the 4-car stop board.

 have re-read it several times, and I still can't see how it "distance the driver could see to be clear" means the distance up to the stop board.

 

It doesn't. 

 

Being able to "stop within the distance the driver could see to be clear" (RAIB's words, not mine), surely means that his speed had been regulated in accordance with the requirements of the signal. It was where he was looking which was wrong.

Where are you going with this? It was okay that he didn't know what to do, as he accidentally complied with part of the rule, at least, if you assume he didn't know where he was going?

 

I'm not trying for an alternative answer. Why would I want one? I'm simply pointing out that some of the replies here don't correspond to the statements in the RAIB report.

You seem to be coming up with an entirely different conclusion to the report Martin! 

[phil-b259]

Martin I don't know what answer you are wanting to hear but you have been told by many professional railwaymen what our views are and how drivers should react to signal aspects yet you persist in wanting some other answer.

Or maybe you would find it acceptable next time you travel by train for it to smash into a train in a platform, I would think not.

I think it's about time this post is closed

 

Well said Russ

 

We (Signal engineers) don't put lights on sticks to make things look nice - they covey SPECIFIC information to drivers. In this case two white lights at 45 degrees next to a main red aspect with a platform number illuminated tells the driver:-

 

The piece of railway ahead is OCCUPIED BY A TRAIN and thus the driver MUST proceed cautiously and be prepared to stop IN THE DISTANCE HE CAN PHYSICALLY SEE TO BE CLEAR - not that which he assumes to be clear!

 

This is a fundamental bit of knowledge every single driver throughout the UK should know off by heart- and its a pretty damning indictment of the training programme that this key message hasn't absorbed - it applies from Penzance to Wick, you don't even have to have route knowledge of the area to understand it.

 

Furthermore one thing the RAIB seem to have ignored in all this is the fact the driver is in fact alleging a serious wrong side failure occurred - namely he was given a route indicator saying "6" but then says he thought he was being routed into a different platform altogether!

 

Those numbers don't just appear at the push of the button - they are an integral as part of the route locking process and as such the first thing the driver should have done when he saw the HST in 6 (and thus believed he was going into another platform) was to make an emergency stop and contact the signaller ASAP to report the failure.

[96701]

Can I refer everybody to post 108? It is not possible to use this report to apportion blame. The report is written in a style which prevents the apportioning of blame.

[russ p]

Nice one Phil

I didn't realise he was alleging he had the wrong platform number.

If you are involved in an incident it's far better to hold your hand up and tell the absolute truth.

Most companies recognise this and if you do admit blame the punishment is often less severe

[phil-b259]

Nice one Phil

I didn't realise he was alleging he had the wrong platform number.

If you are involved in an incident it's far better to hold your hand up and tell the absolute truth.

Most companies recognise this and if you do admit blame the punishment is often less severe

 

The report didn't outright say so* - but as someone who actually undertakes investigation of wrong side failure allegations, it struck me as precisely that. I mean how can he say he has seen the number six displayed then forget all, about it when he sees the HST, and tells the RAIB he thought he was going into platform 7 or 8, etc.

 

That 6 means he was going into platform 6 - where the HST was easily visible from some distance away and as such he should have stopped and queried the route with the signaller or proceeded at extreme caution.

[russ p]

Exactly, you have to wonder where he was actually looking.

And if you can't remember a number for more than a few seconds... well...

[phil-b259]

Can I refer everybody to post 108? It is not possible to use this report to apportion blame. The report is written in a style which prevents the apportioning of blame.

 

The report might not apportion blame - but there is far too much waffling on in therE about pre-planning / risk assessments to do with platform sharing, when the fundamental cause of this had nothing to do with such paperwork, or missong phone calls, method statements and other such rubbish.

 

FACT:- The driver was clearly not driving his train in the manor he should have done given the specific signal instruction he was presented with at P15

 

Yes the driver wasn't advised in advance about the specific arrangements, yes the signaller badly misjudged the distance (I do wonder whether he was thinking the DMU was only going to be a single two car unit), but fundamentally the job of a driver is not to go round making lots of phone calls (nor is it the signallers) - its why we provide route indicators and call on signals out to cover such moves and have a perfectly clear set of rules about what a driver should do in response to said signals.

 

As a general observation people and organisations in this country need to grow up. Humans make mistakes, its something that is impossible to prevent and we don't aid the process of trying to address them by trying to hide the fundamental cause amongst a load of other minor 'yes but' type excuses.