Urgent Safety Advice today from RAIB

[martin_wynne]

https://www.gov.uk/government/publications/urgent-safety-advice-032018-driver-awareness-of-emergency-speed-restrictions/urgent-safety-advice-032018-driver-awareness-of-emergency-speed-restrictions

[Bucoops]

100mph over restriction? Ouch that could have been VERY nasty.

[Mallard60022]

ESRs used to be the first thing a Driver was given when signing on at their Depot/SOP and there was the information board that was a must read, but that was when they actually spoke to a human IIRC. Can't remember if the Guard used to speak with the Driver as well before the train left wherever?

Blimey, that could have been a major incident at that speed.

Phil

[jonny777]

Goodness me, that is serious stuff. 

[2750Papyrus]

I find it worrying that it was known 10% of drivers were not being advised of Emergency Speed Restrictions in 2014 but that no corrective action was apparently taken.

[cravensdmufan]

It beggars belief that the requirement to issue information about ESRs to drivers was removed from the rule book in 2008.

 

Edit - thinking about it even more, I'm amazed ASLEF let that go.

Edited November 29, 2018 by cravensdmufan

[Ohmisterporter]

The hunt for someone to blame has probably started: along with associated arse covering.

[Oldddudders]

Drivers’ notice cases, and an allowance for reading them before taking the first train of the shift, were mandatory items in my day.

 

How far has the industry slipped?

[ColinK]

Scary, sounds like another serious failure by the industry.

 

There seems to be so much going wrong on the railways (especially in the North West) I do wonder if collectivly we’ll ever get a railway system (today my wife was an hour late for work again).

[peach james]

At least this looks like a case of a systemic failure- which is vastly more disturbing than an individual failure, but leaves the driver with a little bit more room !.  I somewhat thought this sort of thing was what had happened, based on how the whole thing played out, that a driver who was used to a 125 mph limit had ended up at vastly over that over a ESR.

 

The paperwork I have from ~25 years ago on the Canadian included the TSR's that were in force that day, so why shouldn't a driver have been handed something like that?  (it's a fax, which the driver & conductor rx'd in Sudbury...then track warrants from there to Toronto...).  What my guess was when I first saw this was that the ESR was implemented after the train had left, which would have been bad, but understandable.  However, a failure to inform drivers of such a substantial change in route details (and it being systemic, not individual failure) is very serious.

 

I am not shocked that a systemic failure like this has happened.  I am glad it has been found the way it has, without a train going sideways.

 

James

[The Stationmaster]

ESRs used to be the first thing a Driver was given when signing on at their Depot/SOP and there was the information board that was a must read, but that was when they actually spoke to a human IIRC. Can't remember if the Guard used to speak with the Driver as well before the train left wherever?

Blimey, that could have been a major incident at that speed.

Phil

 

However the first question I would ask is if that Driver actually understands the contents of the Rule Book (assuming that restriction was properly signed).  While in this case the speed had been on long enough for Late Notice posting that does not relieve any Driver of their responsibility to comply with the Rules and if they can't see a correctly sited 'metal mickey' Emergency Speed Indicator flashing away at them as they approach then I would be seriously concerned, and even more concerned if a Driver ignores it - here, third picture from the top, with brilliant white lights which flash, these things are very hard to miss -

 

http://www.railsigns.uk/photos/p_tsr1/p_tsr1.html

 

The very simple fact which RAIB seem to ignore is that whilst they are quite correct to draw attention to Late Notice posting it always remains a strong probability that an EROS (Emergency Restriction Of Speed) can be brought in anywhere at any time should circumstances so demand and there will inevitably be Drivers who booked on duty after the EROS was imposed.  Thus the only warning they will get of the EROS is if they are stopped and verbally advised (as should be done before the boards are in place) or by seeing the boards - and if they see the boards and ignore them then we are looking at something potentially as dangerous as a SPAD).  This no doubt is what encouraged the 2008 change to the Rule Book - a reasonable assumption that Drivers can see and will understand signals applicable to their train but it does in this case depend very much on the various boards and the magnet being carefully sited to ensure they do teh job they are provided to do.

 

So two strands here and in my view by far the most serious of them is that the Driver, for whatever reason, seemingly ignored the signing (assuming again that the information it was in place is correct).    As part of this it is critical that any investigation checks how the boards and magnet were positioned and that they were compliant with the relevant standards and procedures - no Driver can be held responsible for missing something which was in a position where he couldn't see it.  Equally it also raises question about defensive driving training with a big question about what that really means in it widest context?

 

The secondary issue is the one of Late Notice information and it is of course pretty obvious that with modern signing-on arrangements, especially in some freight operators, there is little chance of a Driver seeing a Late Notice unless it is transmitted to him/her electronically.  This is yet another shortcoming in the process of unsupervised booking-on for safety critical staff, particularly Drivers, although i doubt the industry as it now is will be very keen to move away from unsupervised booking-on and let's face it it was rife on some parts of BR for many years in order to save money.

[caradoc]

The RAIB Advice states that 'Marker boards and associated automatic warning system (AWS) magnets were in place to provide warning of the emergency speed restriction', so it would appear that the Driver has missed, or not responded to, the AWS warning for the Emergency Indicator (EI), the flashing EI itself, the AWS warning for the Warning Board and that Board itself, and the Commencement Board (although by that time it was almost certainly too late to comply with the ESR).

 

As regards advice of ESRs, in Network Rail Scotland Route Control we ALWAYS advised all relevant Train and Freight Operators of any ESRs imposed, of course what they then did with that advice was beyond our control.

[Bucoops]

Indeed, if the correct signage and associated equipment was in place then the warning won't be for that as that was correct. No doubt the driver will be individually investigated for the apparent lack of observing the equipment. The alert is regarding the negligence to pass on the notices.

[Robert Shrives]

Sad to report the standard of application of equipment on the ground is variable. I have had drivers repeatedly advise signal operators of issues. Eventually staff have attended and found equipment wrongly or poorly sighted and have had to correct.

 

However once on the Wessex done one set of staff sent could not find anything wrong and after further complaints by driver managers to local NR management a second team sent and were horrified and equipment placed correctly in the Shawford area - several weeks after placement, it was noted only one TOC kept up the pressure - I wonder what other crews did ?   This also happened in RT days at Heathrow junction with OO crews eventually it was put right and again the TOC was advised it was only them who reported it.       

 

A lot of EROS impositions and eventual TSRs once in notices is down to a lack of staff and time to fix faults - Wessex was reported to be down to last few sets of Mickeys a while back and it is not much better when looking at delay attribution with lack of allowance provision for "network delay." So while we have a lucky driver and RAIB noise the problem and solution lays at an others desk fully.

 

Robert     

[martin_wynne]

(assuming again that the information it was in place is correct).    As part of this it is critical that any investigation checks how the boards and magnet were positioned and that they were compliant with the relevant standards and procedures - no Driver can be held responsible for missing something which was in a position where he couldn't see it.

 

From previous RAIB: https://www.gov.uk/government/news/overspeed-at-sandy-south-junction

 

 

Photo showing the 20 mph commencement board and the termination board for the emergency speed restriction (still taken from ffcctv footage from the incident train, courtesy of LNER)

[101]

About 25 years ago I went through a 20mph ESR at around 75mph, I stopped to report it at the next signal (before NRN), which I thought I should as there were about 12 PWay staff stood looking the broken rail as I went through!

It turned out that though warning boards had just been placed they had not been placed on the route I had approached from, after reporting it to the signalman and later writing a report, I never heard another thing, though the correct boards were in place next day

 

So don't go blaming the driver just yet- wait until all the facts are known.

[DCB]

Oh well no harm done.

[roythebus]

I recently read the report on the Nuneaton crash of 1975 where an express went through a TSR at about 90. Two locos on the front, driver didn't notice the TSR and thought it had been lifted. To cut a long story short, several people dead, the warning lights and commencement lights were out. This is before the introduction of AWS magnets for TSRs.

 

It seems progress has gone backwards since then

[Siberian Snooper]

Being a layman, with regards the "big railway" is if such a restriction is in place, why the preceding signal is not set too Amber, thus giving more formal notice of caution is required.

[roythebus]

Being a layman, with regards the "big railway" is if such a restriction is in place, why the preceding signal is not set too Amber, thus giving more formal notice of caution is required.

 

Railways don't have amber signals, they are yellow. In automatic block working it is not possible to set a signal to yellow, they are automatic. A signal would have to be set to red somewhere for the preceding signal to display a yellow aspect, and the one before that a double yellow aspect. that is whey we have the warning board system.

 

Here's the link to the Nuneaton train crash of 1975.      http://www.railwaysarchive.co.uk/docsummary.php?docID=272

[101]

A YELLOW signal (not amber) does not indicate to a driver that he has to do 20 mph - or any other speed - and in any case could be anything up to a couple of miles away from any restriction

[Siberian Snooper]

A YELLOW signal (not amber) does not indicate to a driver that he has to do 20 mph - or any other speed - and in any case could be anything up to a couple of miles away from any restriction

If he was travelling on Yellow at least he shouldn't be travelling at over 100 mph as he should be looking to possibly stop at the next signal as it may be Red, or a SPAD is very likely to occur. He/she may even notice the the restriction, even if incorrectly placed.

[101]

If he was travelling on Yellow at least he shouldn't be travelling at over 100 mph as he should be looking to possibly stop at the next signal as it may be Red, or a SPAD is very likely to occur. He/she may even notice the the restriction, even if incorrectly placed.

Not necessarily I can think of a couple of places where I used to pass a single yellow at 100 and still easily stop at the red.

Signals are not a practical solution for warning of ESR's and TSR's

[TheSignalEngineer]

If the boards and magnets were correctly positioned and the loco gear was correctly operating the driver would have to cancel the warning at the Mickey or he would have been brought to stop with the coffee in the buffet travelling further than the train.

[jonny777]

Maybe it is illustrative of the railway operating psyche, when a perfectly genuine and (to me) eminently sensible question was asked by someone who had already indicated his "layman" status; is answered by pedantry concerning the mistake of calling an yellow signal amber. 

 

I really do despair if this is representative of the "us and them" attitude nationwide.