SVR derailment -- Accident Report

[martin_wynne]

Derailment at Hampton Loade, SVR, 28 September 2009.

 

Accident Report published today: http://www.raib.gov.uk/cms_resources/100408_R72010_Hampton%20Loade.pdf

 

Martin.

[The Stationmaster]

Derailment at Hampton Loade, SVR, 28 September 2009.

 

Accident Report published today: http://www.raib.gov.uk/cms_resources/100408_R72010_Hampton%20Loade.pdf

 

Martin.

 

And alas it makes sorry reading; here's hoping they will learn from the various errors of their ways and that they might now get themselves properly into SMS mode. Perhaps in the light of this the regulating authority will be keener to look more closely at those who have tackled SMS in the same fashion as the SVR as opposed to taking greater 'interest' in those who have followed the more comprehensive route suggested by the legislation itself (sorry, vested interest muttering there ).

 

Mind you I was at least happy to note it confirms that I had managed to correctly suss out from pictures etc at the time that the tender had derailed before it reached the points. But how on earth does someone miss a 1 in 94 adverse twist, surely not even the (long known to be) unstaable formation there moves that quickly?

[Michael Delamar]

i cant open the file

 

Mike

[Leicester Thumper]

to use it you need to go to the Adobe website and download Adobe Acrobat Reader and also all the stuff that comes with it so that you can read, create and publish PDF files as well as read articles on the internet, HTH

[gordon s]

i cant open the file

 

Mike

 

 

Must be with you Mike. I just clicked on the link and it was fine. Might be worth installing/updating Adobe.

[The Stationmaster]

i cant open the file

 

Mike

 

Works ok for me on both links above (despite being on AOL ). Are you actually connecting to it Mike or are you just left hanging?

[Edwin_m]

Perhaps in the light of this the regulating authority will be keener to look more closely at those who have tackled SMS in the same fashion as the SVR as opposed to taking greater 'interest' in those who have followed the more comprehensive route suggested by the legislation itself (sorry, vested interest muttering there ).

 

There do seem to be a lot of RAIB reports relating to heritage railways and tramways, which strikes me as disproportionate to their total size compared to NR though I can't think of an easy way of assessing this. Perhaps incidents like this will lead to greater scrutiny and threats to their exemptions from parts of ROGS?

[298]

I doubt a preserved railway will have it's Light Railway Order revoked through any recommendation from the RAIB, it is their role to find out the cause of the accident and recommend any specific actions. I've always found the training and assessment for volunteers working on preserved railways in the UK to be exemplary, but suppose a serious accident occured, you wouldn't expect them to say that trains can only be operated by paid professional railway workers.

 

There are certain things that we are allowed to do in the UK that would make the country a poorer place if the so-called "Nanny State" stopped us from doing if they thought were excessively unsafe, such as making a kitcar or Airplane in the average domestic garage and operating it in a public enviroment. As long as the vehicle in question has passed the relevant safety checks and is operated by a qualified person, such "hobbies" are allowed. Would we ever hear of classic cars being forced from the road unless they were fitted with seatbelts or airbags, or worse still crumple zones or pedestrian friendly front ends, as such a move would ruin the historical design of the car and consign it to stay in a museum.

[Edwin_m]

I wasn't thinking of the Light Railway Order or the technical standards. I was thinking specifically of the ROGS regulations. While they may be seen as arcane and esoteric, this report in fact illustrates that setting up and follow a proper safety management system is in fact quite important!

[The Stationmaster]

There do seem to be a lot of RAIB reports relating to heritage railways and tramways, which strikes me as disproportionate to their total size compared to NR though I can't think of an easy way of assessing this. Perhaps incidents like this will lead to greater scrutiny and threats to their exemptions from parts of ROGS?

 

 

There are some good reasons for it Edwin; it is believed, probably accurately in my view and experience, that there is a lot of under-reporting of all classes of incidents (e.g from RIDDOR right through to derailments) in the heritage/leisure railway sector. There is undoubtedly a need to reveal some weird and wonderful maintenance practices (as on this occasion) and this sort of thing can extend well beyond that to lots of very basic procedures. Both of these areas seem to stem from inadequate procedures and staff training - hence my view that, notwithstanding some of the bureaucarcy involved, ROGS has its good points and RAIB interest is only to be expected (even if they occasionally come out with some downright daft reports).

 

You might have seen something in 'another place' we both visit where one such railway is expressing concern about finding an independent competent person for their signalling work - and the view expressed by another poster that they should at least have all their paperwork in order, competent person or no and that Rogs hasn't really changed anything in that respect; I think at that point the OP went quiet.

 

As far as ROGs in general is concernmed the regulating authority is paying very close attention but it seems to be unevenly distributed and the impression I get is that those who have followed a similar(ish) route to the SVR have not been getting the attention given to some others. Now that might be a consequence of past 'naughtiness' on the part of the others although there might also be another reason, but which ever it is there is no doubt in my mind that there is need to pay much greater attention to the way some railways have or haven't tried to implement ROGS.

 

Taking training as an example - on two railways where I have carried out independent safety assessments I found their training arrangements to be good (in one case exemplary). But in both cases training records were best politely described as 'haphazard' and there were no written training procedures and standards. Now you shouldn't need ROGS to create that documentation (I had it in place 24 years ago at a site I was involved with) but what correctly implementing ROGS does do is highlight the fact that you haven't got it.

 

Incidentally I am aware that one quite well known Railway was served with an Improvement Notice because of its failure to do anything about ROGS and that several others have been threatened with similar action. Several have had intimations that unless they do what they said they were going to do they face potential Prohibition Orders on part of their activies or operations. And in some cases I understand this sort of thing relates to what they should always have been doing as a railway operator and employer but they simply cannot produce the records or procedures to substantiate that - which takes us neatly back to this incident.

 

[Talltim]

I don't see how

"33 The permanent way staff were not aware of the track twist. This lack of awareness was a contributory factor to the derailment"

 

can be true. Knowing about something and doing something about are two different things. If they had been aware it could still have happened (depending on whether they fixed it or not). Its only if they were aware AND did something that it has any contributary factor.

As an example, you could say that me (as a member of the public) not knowing about the track twist was a contributary factor. It makes as much sense.

 

[PhilH]

it is believed, probably accurately in my view and experience, that there is a lot of under-reporting of all classes of incidents (e.g from RIDDOR right through to derailments) in the heritage/leisure railway sector.

 

I find that hard to believe if only for the simple reason that it is impossible to keep these things under wraps - word always gets around which would make it futile not to report. The 'grapevine' linking heritage railways has to be experienced to be believed, one seems to know about events on other railways almost immediately - regulatory bodies must also be tuned in to this through one way or another . Hence my scepticism that these events are being covered up.

[Glorious NSE]

Knowing about something and doing something about are two different things.

 

True.

 

If they had been aware it could still have happened (depending on whether they fixed it or not).

 

Also true. If they were aware but ignored it that would also have been a contributing factor.

 

Its only if they were aware AND did something that it has any contributary factor.

 

No - if they were aware AND had fixed it it would not have been a contributing factor as there would likely have been no accident.

 

1. For the accident to happen the track defect needed to exist.

2. For the track defect to have been fixed the track crew would need to know it exists.

 

Therefore the track crew not knowing about the fault is part of the chain of events that MUST have happenned before this accident could occur. Which I think is pretty much their definition of a contributing factor.

[Blandford1969]

The report shows up a number of issues that do not just relate to that railway ie

 

1)How many railways have engineering drawings with the tension information for all their springs. It turns out the company who do the springs do them for many other railways including NR.Although that is not to mitigate what is said in terms of changing a design and not following the proceedures

 

2)There is in my opinion the potential for lack of communication between paid staff and volunteers.

 

3) The report makes clear that the track fault in itself did not cause the derailment, it was primarily the fact that one of the tender wheels was nearly off the track due to the spring.

 

I understand from reading the report that alot of work is already being done to sort out the issues and that the railway takes it very seriously.

 

Lets just hope that there aren't too many that just want to put the SVR down, where it is trying to sort things out now, especially as for many others there for the grace of God go they.

[Edwin_m]

I don't see how

"33 The permanent way staff were not aware of the track twist. This lack of awareness was a contributory factor to the derailment"

 

can be true. Knowing about something and doing something about are two different things. If they had been aware it could still have happened (depending on whether they fixed it or not). Its only if they were aware AND did something that it has any contributary factor.

 

Well to be strictly pedantic the only fact supported by independent evidence is that nothing was done about the track twist. This could have been either because the PW staff didn't know (which indicates they are not on top of the job) or they knew and did nothing (which in my view indicates something much worse).

 

I presume RAIB concluded that the PW staff did not know, rather than knew and did nothing, on the basis of interviewing the people concerned and not having found any contradictory evidence in the rest of their investigation. To conclude otherwise would be making an unsubstantiated allegation against the people concerned.

[Chris116]

I am sure that every Preservation Society does everything in their power to avoid any sort of incident. We are dealing with old technology and it is therefore sometimes the case that items are not rebuilt exactly how they should be. That appears to be the case here. The fact that the loco had worked though the Gala proves that the faults were not immediately obvious and it is possible that the loco could have run for many months before anything appeared to be wrong. Working on another line I know just how much time and effort goes into getting things right but sadly sometimes things go wrong and then we all need to look at what we are doing, how we do it and how we can avoid the mistakes in the future.

 

One correspondent says that he thinks the SVR takes the matter seriously. I am certain that not only do they take it VERY seriously but that many other lines will be doing some extra checking to make sure they don't have a similar event happen. Having watched the SVR staff (paid and volunteer) in action and also spoken to them I know how much this incident has upset their professionalism and how they will be pulling out all the stops to make things right.

 

I am looking forward to my visit next Friday to the SVR and my day working on the Mid Hants the following day.

 

Chris

[Edwin_m]

I agree that everyone in the preservation movement is personally committed to safety. If there is a problem it is perhaps that the people in question aren't aware of all they need to know about to ensure that safety is maintained - a management failing rather than a criticism of the workers. Not only is it a necessity in these litigious times to formalise and record everything, but in cases like this a safety management system does actually have a safety benefit!

 

For example the people who fitted the springs didn't seem to be aware that the wheel loadings should have been tested afterwards, and the PW staff weren't aware of the twist problem. Like many railway accidents a number of individual failings had to happen at the same time to result in an incident, and fortunately in this case the incident itself was minor with considerable disruption but no injuries.

[Edwin_m]

I agree that everyone in the preservation movement is personally committed to safety. If there is a problem it is perhaps that the people in question aren't aware of all they need to know about to ensure that safety is maintained - a management failing rather than a criticism of the workers. Not only is it a necessity in these litigious times to formalise and record everything, but in cases like this a safety management system does actually have a safety benefit!

 

For example the people who fitted the springs didn't seem to be aware that the wheel loadings should have been tested afterwards, and the PW staff weren't aware of the twist problem. Like many railway accidents a number of individual failings had to happen at the same time to result in an incident, and fortunately in this case the incident itself was minor with considerable disruption but no injuries.

[Blandford1969]

For example the people who fitted the springs didn't seem to be aware that the wheel loadings should have been tested afterwards, and the PW staff weren't aware of the twist problem. Like many railway accidents a number of individual failings had to happen at the same time to result in an incident, and fortunately in this case the incident itself was minor with considerable disruption but no injuries.

 

The custom and practice was that when changing a spring that was adjustable you counted the treads and then the new spring was put back exactly the same. With those which you could not alter I guess you could say there was trust that the spring manufaturer had made exactly the same strenght spring. For nearly 40 years that has been the case with very few incidents, whatever the rights or wrongs.

 

The railway has already purchased a set of weighing scales and engines will always be weighed after having a spring changed in future (it was not in the proceedure before in case anyone asks)

 

The probably more important thing is that the railway is going to be audited this summer, the railway is putting alot of effort into sorting things out, however once that is done, you can fairly bet that the standard set will be used with other railways so it is a good reminder to all railways

[Edwin_m]

I'm glad the railway is looking to learn lessons from this incident and I hope any others who are in a similar situation also take note.

[ringo]

Blanford 1969, is quite right that in T' good old days we used to count the threads of the spring hangers to the nuts, did this a lot on DMUs, but you could also do dimensional checks on various datum points on the frames.

 

As a rough guide you can also set the basic weight by ensuring that all of the axle boxes are the same in the horns.

 

Weighing locos is a black art, a quarter of a turn of a nut can throw the weights out by miles in another area, Ive weighed steam locos and diesels such as 66s, which are not easy as you cant just adjust a nut on a spring hanger as 66s use coils and not leaf springs. and done weighing to the international UIC specification, which are much tighter than the UK specifications.

 

As for spring specifications, its down to the person ordering the springs from suppliers/overhaulers to ensure that such a safety critical item are purchased/overhauled to the correct specs, and have certificates of conformity.

 

R

[The Stationmaster]

I agree that everyone in the preservation movement is personally committed to safety. If there is a problem it is perhaps that the people in question aren't aware of all they need to know about to ensure that safety is maintained - a management failing rather than a criticism of the workers. Not only is it a necessity in these litigious times to formalise and record everything, but in cases like this a safety management system does actually have a safety benefit!

 

That's pretty near the bullseye Edwin. There is a clear management failing if people are not made aware of the safety etc requirements to which they should be working and what incidents should be reported etc. But that can only be done if the management itself is fully up to speed with what should be reported, what critical safety risks should be managed, and what should be recorded even if it doesn't need to be reported. Achieving all of that is part of the purpose of SMS and if it is then suggested that, say, volunteer staff 'should read it' - as opposed to being given proper information and training (duly recorded of course) - the system is still failing.

 

For example the people who fitted the springs didn't seem to be aware that the wheel loadings should have been tested afterwards, and the PW staff weren't aware of the twist problem. Like many railway accidents a number of individual failings had to happen at the same time to result in an incident, and fortunately in this case the incident itself was minor with considerable disruption but no injuries.

 

Shortcomings of this kind are, I suspect and regret, not unique to the SVR nor is it the first time it has happened with an SVR loco according to some long past information I have (and incorrect spring loadings have happened elsewhere). But - as you say - it's when all the circumstances come together that incidents occur, sometimes with potentially serious results.

 

As far as Phil's comments go about things getting to be known and being impossible to keep under wraps in the preservation world he is, I reckon spot-on. And that, I am led to believe, is one of the reasons why attention has been turned in that direction - because, via the grapevine, reportable incidents have come to light which have never been reported. In some cases stuff has appeared in video on the internet of such things as 'dangerous occurrences' which have not been reported and in one case a Railway got a visit from the regulating authority from exactly that route. In another case a member of the public (with no railway knowledge) travelling as a passenger reported something which they thought 'not quite right' and again it came to light that the Railway concerned had not reported it, because that Railway's own people who saw what happened didn't even know they had to report it.

 

What many people don't seem to realise, or have been told, is that 'safety' now amounts to much, much, more than having and working to a Rule Book to achieve movement safety. It is now a 'system' (for want of a better word) applying to everything from making sure staff report any medication they might be on right through to workshop practice, or carrying tools properly when on the lineside, or making sure coach footsteps don't present a slipping hazard. A lot of it is common sense - but it still needs to be included in the SMS.

[roythebus]

Being involved in a couple of railways in the UK and one abroad, I'm amazed at what some railways get away with. One I work at has a problem with point levers; one incident involved a derailment of a shunting loco. That same railway is overhauling a DMU and has had to replace the springs. Luckily they managed to find the drawings and original spec in the NRM archives, so hopefully the ride will be fine when that project gets underway.

 

A tramway I belong to abroad seems to not even have any sort of protection for working the single line' Back in January I paid a visit for a working party, and there was apparently no PIC of the works, no possession for running the works car...the mind boggles.

 

Must read the RAIB report on the SVR incident.

[The Stationmaster]

 

 

A tramway I belong to abroad seems to not even have any sort of protection for working the single line' Back in January I paid a visit for a working party, and there was apparently no PIC of the works, no possession for running the works car...the mind boggles.

 

 

If what I have seen is any guide then they are not alone in respect of poor (or no) arangements for protecting both the safety of the line and the safety of personnel involved in engineering works. It is an area - fortunately in many respects - which has tended to particularly interest 'the authorities' over the last 18 months or so and that interest remains as far as I know. Oh and I bet you didn't have any procedures briefed to you about the way in which the work should be done ...

[Edwin_m]

To be fair you can use much simpler procedures on a tramway, because the driver will always be able to stop the vehicle short of any obtruction so in theory there is no need for lookouts etc.