Urgent Safety Advice today from the RAIB

[St Enodoc]

On 04/03/2020 at 01:55, Nearholmer said:

Speaking as someone who owes their continuing existence to good luck, having very many years ago walked out of a cable depot door almost into the path of a shunt

 

On 04/03/2020 at 08:12, jjb1970 said:

I have spent a large part of my life in hazardous industries and when I look back I did stupid things without thinking, but got away with it.

After 45 years (and counting) in the rail industry I reckon I've used up four of my nine lives through that sort of thing.

 

The words of the late Argentine locomotive engineer L D Porta often come to mind: "Make the easy way the right way".

[St Enodoc]

On 04/03/2020 at 06:48, Trog said:

I remember being told to walk 50 or 60' clear of stabled stock during my rather basic safety training in the early 1980's.

 

12 hours ago, TheSignalEngineer said:

When I joined the rule of thumb was if you HAD to cross or work foul of sidings where there was a chance of vehicles being moved then keep at least 20 yards clear of any potential danger.

I'm old enough to have had to "Read the Rules" to wages grade staff. The "50 feet" rule always provoked discussion, as few people had the same idea of how far that was. We clarified it by referring to the length of a coach or a loco, which helped enormously with comprehension.

[jjb1970]

I wonder how much is down to risk based safety management and quantified risk assessment? I have been through so many risk assessment, HAZID processes etc where someone will be determined to avoid some safety measure being agreed based on their assessment that the event will never happen. I am not against quantitative risk analysis but if an event is reasonably foreseeable (especially if there are already examples of it having happened) then it is a risk which should be mitigated. 

Although a loss of corporate knowledge is more likely. Big organisations have become much worse at retaining corporate knowledge in my experience and if someone has no understanding of a safety rule and why it exists it is easy to decide it is not necessary. 

[Oldddudders]

13 minutes ago, jjb1970 said:

Although a loss of corporate knowledge is more likely. Big organisations have become much worse at retaining corporate knowledge in my experience and if someone has no understanding of a safety rule and why it exists it is easy to decide it is not necessary. 

That one strikes a chord. The industry is now populated with people who have come from outside - and thus lack the basic knowledge that comes with starting at the bottom and working your way up. In the few years before I retired, I encountered station managers who had no idea whatever about running trains beyond platform despatch. And a Route Director whose previous job had been with Tie Rack. They were engaged for their skills at managing the bottom line, not running things safely.

[jjb1970]

7 minutes ago, Oldddudders said:

That one strikes a chord. The industry is now populated with people who have come from outside - and thus lack the basic knowledge that comes with starting at the bottom and working your way up. In the few years before I retired, I encountered station managers who had no idea whatever about running trains beyond platform despatch. And a Route Director whose previous job had been with Tie Rack. They were engaged for their skills at managing the bottom line, not running things safely.

 

I saw a similar change emerging in electricity generation. 

[The Johnster]

5 hours ago, St Enodoc said:

 

I'm old enough to have had to "Read the Rules" to wages grade staff. The "50 feet" rule always provoked discussion, as few people had the same idea of how far that was. We clarified it by referring to the length of a coach or a loco, which helped enormously with comprehension.

I was taught to leave a ‘coach length’ space at Canton in the 70’s; coach and wagon lengths were fairly commonly used units of measurement. 
 

I very much doubt that rules, advice,  or training guides have been ‘removed’ from publications, but it’s a stone cold certainty some have not been restated in new publications!

Edited March 5, 2020 by The Johnster

[John Tomlinson]

19 hours ago, The Stationmaster said:

I am absolutely appalled by this.  

 

I checked the relevant sections of theRSSB Rule Book when I first heard about this incident and was amazed to find how totally inadequate it was.  Without wishing to unduly blow my trumpet I have been writing more comprehensive personal safety Rules than the RSSB Book  for heritage and Leisure railways which definitely did include that item, and various others which aren't in the RSSB book.   It was in the BR  Rule Book for years and was always sound advice and something I made sure was thoroughly tested when examining staff in Rules - so why did RSSB take it out of the book?   Quite why RSSB produced such dangerous nonsense I really don't know but they seem to be in need of thorough investigation too if this incident is any guide to their competence (it's not the first time they have published nonsense but this time somebody died).   Probably an illustration too,  in some respects, of just how unwieldy and balkanised the RSSB Rule Book has become over the years.  Plus - to my mind - a clear lack of a sound and effective structure to review Rules through the wider industry  before they are published (and past evidence from certain NR staff indicated that such a structure of review was lacking and it was extremly difficult to get Rules amended to read sensibly through normal feedback channels.

 

But also I am very concerned that RAIB have taken so long since the incident to issue the notice they issued today.  and I know it is the first time they have promulgated it because it only went to the HRA today - which is how a copy of it reached me earlier today.   This really is ground level safety of the most basic kind - there should be no need to train it in now; staff should already have been fully aware of it at theo ir basic training (and be chased for not observing it should that come under notice).

Interesting you say this.

 

I'm sure that back in the day that the GCR issued lineside permits, not crossing tracks near parked vehicles was in there as a stipulation. It is common sense when you think about it, as kids we were all taught not to cross the road between parked vehicles when we couldn't see, however there's absolutely no disadvantage at all to having this as a rule as well.

 

John.

[Pandora]

That one strikes a chord. The industry is now populated with people who have come from outside - and thus lack the basic knowledge that comes with starting at the bottom and working your way up. In the few years before I retired, I encountered station managers who had no idea whatever about running trains beyond platform despatch. And a Route Director whose previous job had been with Tie Rack. They were engaged for their skills at managing the bottom line, not running things safely.

 

Our Depot has a walking route from the car park to the sidings where we stable and prep our OTMs,  the surface is not tarmaced  and frequently sticky and muddy, a driver fell over and had a day off with a swollen ankle,  Weeks later a manager fenced off the car park and installed diversion  signs ( worded with suitable disciplinary action threats )   with his idea of a walking route along an dark unlit width-constrained road ( no pavements)  used by heavy lorries in the depot. Clearly far more dangerous to staff but not to our manager chummy.  Union queried his authority to alter the formal written depot safety policy, "I'm a Manager" . Yes he was a manager, prior to the railway a BT call centre, and his job on the railway, the same,  managing a bunch of telephone operatives.

ps,  the fence did not last very long, the gate was prised  off the hinges and hidden on the roof of the shed

Edited March 5, 2020 by Pandora

[cb900f]

I seem to recollect in the training school we used to discuss  whether the 50ft rule was between the vehicles or 50ft either side of the member of staff i.e. 100 ft between the vehicles.

 

Pete

[letterspider]

I see EMUS's with cameras aiming at the pantograph, ensuring it is in contact. Cameras at the back on the sides of lorries. Cameras on aeroplanes showing pilot views. Many cameras on and in buses for many reasons.

Is there any reason why cameras upon trains couldn't be installed to minimise the risks of these sorts of accidents?

[iands]

8 minutes ago, letterspider said:

I see EMUS's with cameras aiming at the pantograph, ensuring it is in contact. Cameras at the back on the sides of lorries. Cameras on aeroplanes showing pilot views. Many cameras on and in buses for many reasons.

Is there any reason why cameras upon trains couldn't be installed to minimise the risks of these sorts of accidents?

Cost, and who pays for them?

[The Stationmaster]

49 minutes ago, letterspider said:

I see EMUS's with cameras aiming at the pantograph, ensuring it is in contact. Cameras at the back on the sides of lorries. Cameras on aeroplanes showing pilot views. Many cameras on and in buses for many reasons.

Is there any reason why cameras upon trains couldn't be installed to minimise the risks of these sorts of accidents?

How would that stop this sort of incident?  It sounds to me rather like putting forward facing cameras on all motor vehces and saying it;s the driver's responsibility to stop every time some idiot steps out in front of him/her.

 

The basic aim must be to prevent such incidents from happening in the first place and that is a very simple process -

1. Put in place a clear and readily comprehended Rule and/or procedure staing what must or must not take place. (in this case before crossing any line or siding),

2.  Properly train-in that procedure with everybody who is likely to be affected by it in any way shape or form,

then comes the more difficult but just as essential part,

3. Monitor compliance, enforce it,  and remind people of what they should do.  But don't change or drop the Rule/procedure  just because nobody observes it.

 

I am 100% with with Ian ('Oddudders' and JJB) above, I am sure what we are looking at is in large part a loss of corporate memory and hard won experience.  But not wholly so because removing the preparation of the Rule Book from those actively and directly involved in day-to-day running of the railway and giving them a very limited chance, if any, to peer review any changes or additions before they are published has additionally wiped out making use of probably the last vestiges of corporate memory which still exist.  This is perhaps one example of that.  An even crazier one, albeit less directly unsafe as far as personal safety is concerned, was the procedure for  dealing with train a movements past a signal at danger when facing point detection was lost - and a look at the relevant Rule Book item after the Harrogate run-through showed that some total idiot had transposed part of the actions required of a Signalman(ler) and Driver -  idiotic, juvenile, mistakes like that do not happen in a properly peer reviewed Rule Book.

[letterspider]

1 hour ago, iands said:

Cost, and who pays for them?

 

Yes my point here is that we think it is not too expensive to have a camera aiming at a pantograph..

[letterspider]

27 minutes ago, The Stationmaster said:

How would that stop this sort of incident?  It sounds to me rather like putting forward facing cameras on all motor vehces and saying it;s the driver's responsibility to stop every time some idiot steps out in front of him/her.

 

The basic aim must be to prevent such incidents from happening in the first place and that is a very simple process -

1. Put in place a clear and readily comprehended Rule and/or procedure staing what must or must not take place. (in this case before crossing any line or siding),

2.  Properly train-in that procedure with everybody who is likely to be affected by it in any way shape or form,

then comes the more difficult but just as essential part,

3. Monitor compliance, enforce it,  and remind people of what they should do.  But don't change or drop the Rule/procedure  just because nobody observes it.

 

I am 100% with with Ian ('Oddudders' and JJB) above, I am sure what we are looking at is in large part a loss of corporate memory and hard won experience.  But not wholly so because removing the preparation of the Rule Book from those actively and directly involved in day-to-day running of the railway and giving them a very limited chance, if any, to peer review any changes or additions before they are published has additionally wiped out making use of probably the last vestiges of corporate memory which still exist.  This is perhaps one example of that.  An even crazier one, albeit less directly unsafe as far as personal safety is concerned, was the procedure for  dealing with train a movements past a signal at danger when facing point detection was lost - and a look at the relevant Rule Book item after the Harrogate run-through showed that some total idiot had transposed part of the actions required of a Signalman(ler) and Driver -  idiotic, juvenile, mistakes like that do not happen in a properly peer reviewed Rule Book.

 

Yes I understand that. However better visibility would lessen the risks. We have lorries that emit a loud beeping sound when they are about to move - this is to warn unwary pedestrians of dangers - this could have saved this man's life

 

Cost to install these items is not reason enough - they are cheap enough for bin carts - it should be cheap enough for a locomotive

 

[The Stationmaster]

7 minutes ago, letterspider said:

 

Yes my point here is that we think it is not too expensive to have a camera aiming at a pantograph..

Those cameras are there because the cost of providing them is no doubt considerably cheaper than the consequences of not having their recordings available for evidence in certain situations.  Plus of course on one GWR 387 set they are also being used for a particular monitoring experiment.  Some trains already have forward facing cameras but like the  pan cameras they are there for recording information, not giving the Driver a live view of anything, which would in any case dstract him/her from what they are supposed to be looking at..

Edited March 5, 2020 by The Stationmaster
addendum

[iands]

3 minutes ago, letterspider said:

 

Yes my point here is that we think it is not too expensive to have a camera aiming at a pantograph..

Yes, but pantograph "viewing" only requires one camera. To effectively view the area at the front  of a unit/loco to mitigate the type of incident being discussed here would require more than one camera at each end (to make sure all relevant views are captured) - on the entire UK mainline fleet. Significantly higher cost than just providing cameras to view pantographs.

[letterspider]

Yes agree with you. If there was legal recourse for the injured party - the cost of a barrister for one day alone is likely to be greater than the cost of retro fitting a locomotive - and we are not considering the wider injuries to family and workmates

[letterspider]

1 minute ago, iands said:

Yes, but pantograph "viewing" only requires one camera. To effectively view the area at the front  of a unit/loco to mitigate the type of incident being discussed here would require more than one camera at each end (to make sure all relevant views are captured) - on the entire UK mainline fleet. Significantly higher cost than just providing cameras to view pantographs.

 

For sure I agree with you this could be a problem on retro fitting - but not if it was a legal requirement on designs going forwards.

It cannot be crazy amounts of money because my car has radar and ultrasound and cameras front rear and sideways to protect from all sorts of crash hazards as well as radar speed control on the motorway and in traffic.

If you consider the costs of minor collision damage repairs where radar control would apply brakes earlier - well I don't have the figures but I bet it costs a few thousands to tens of thousands when a loco hits something - maybe someone on here can put a cost to it?

 

[woodenhead]

In America they use bells when the locomotives are anywhere near a crossing or exiting a yard - perhaps like has been said audible warnings when something is shunting.

 

However, expect complaints from the locals!

[martin_wynne]

15 minutes ago, letterspider said:

my car has radar and ultrasound and cameras front rear and sideways to protect from all sorts of crash hazards ... ... I bet it costs a few thousands to tens of thousands when a loco hits something

 

It's not that simple because the train was intended to hit something -- it was coupling up to another one.

[The Stationmaster]

15 minutes ago, letterspider said:

 

For sure I agree with you this could be a problem on retro fitting - but not if it was a legal requirement on designs going forwards.

It cannot be crazy amounts of money because my car has radar and ultrasound and cameras front rear and sideways to protect from all sorts of crash hazards as well as radar speed control on the motorway and in traffic.

If you consider the costs of minor collision damage repairs where radar control would apply brakes earlier - well I don't have the figures but I bet it costs a few thousands to tens of thousands when a loco hits something - maybe someone on here can put a cost to it?

 

I don't think this is a situation in which we should be chasing red herrings while overlooking some very basic personal safety procedures.

 

As Martin Wynne has very succinctly observed one of the sets involved was in the process of coupling to another and that was where the Driver's attention would have been - not looking at a tv monitor in case somebody stepped in front of his train (in all probability when it was too late for him/her to do anything about it anyway).  Whether or not there is a restriction in that area on the sounding of a train horn before a movement is made is another possible fringe issue but even if the horn should have been sounded and it wasn't (a fact we are not aware of) none of it relieves the person crossing the line from taking the necessary precautions for their own safety.

 

However if that person has not been properly instructed in the safety procedures for crossing lines or sidings and if the section of the Rule Book specific to personal safety for his grade does not include comprehensive provision (which it doesn't) we are looking at a slightly different matter.  And potentially, although it is a legal matter and thus beyond our opinions, there might be a question of wider culpability.

[iands]

23 minutes ago, letterspider said:

 

For sure I agree with you this could be a problem on retro fitting - but not if it was a legal requirement on designs going forwards.

It cannot be crazy amounts of money because my car has radar and ultrasound and cameras front rear and sideways to protect from all sorts of crash hazards as well as radar speed control on the motorway and in traffic.

If you consider the costs of minor collision damage repairs where radar control would apply brakes earlier - well I don't have the figures but I bet it costs a few thousands to tens of thousands when a loco hits something - maybe someone on here can put a cost to it?

 

I understand the point you make regarding "new designs". However, I think to use a car as an example is an over simplification of what can happen in a depot/yard/station. Cars are not meant to couple up to other vehicles (okay, caravans/trailers excepted) and car drivers are (or should be) always on the lookout for other road users/pedestrians, whereas trains are designed to couple to other rail vehicles - which could be described as a "controlled collision". 

[Bernard Lamb]

4 hours ago, Pandora said:

 

 

Our Depot has a walking route from the car park to the sidings where we stable and prep our OTMs,  the surface is not tarmaced  and frequently sticky and muddy, a driver fell over and had a day off with a swollen ankle,  Weeks later a manager fenced off the car park and installed diversion  signs ( worded with suitable disciplinary action threats )   with his idea of a walking route along an dark unlit width-constrained road ( no pavements)  used by heavy lorries in the depot. Clearly far more dangerous to staff but not to our manager chummy.  Union queried his authority to alter the formal written depot safety policy, "I'm a Manager" . Yes he was a manager, prior to the railway a BT call centre, and his job on the railway, the same,  managing a bunch of telephone operatives.

 

He might well have called himself "A Manager" but he clearly was out of his depth. Why the hell was the Safety Manager not called. Where I worked nobody would have used the alternative route until there had been a written notice from the person qualified to issue it, stating the exact details of the new procedure. I have never come across a case of  a diversion, but I have been on site several times when a driver has refused to start a FLT or a lorry on safety grounds. The difference I suppose was that our safety officer would always back the person at the sharp end was in turn always backed by Top management.

Bernard

[The Stationmaster]

3 minutes ago, Bernard Lamb said:

He might well have called himself "A Manager" but he clearly was out of his depth. Why the hell was the Safety Manager not called. Where I worked nobody would have used the alternative route until there had been a written notice from the person qualified to issue it, stating the exact details of the new procedure. I have never come across a case of  a diversion, but I have been on site several times when a driver has refused to start a FLT or a lorry on safety grounds. The difference I suppose was that our safety officer would always back the person at the sharp end was in turn always backed by Top management.

Bernard

Very much so - and there used to be a set of laid-down standards for Authorised Walking Routes and Staff Safety Reps, in particular, were very hot on them.  Those standards included surfacing as well as the procedures for posting details.  and should a manager decide to open a new walking route without complying with those standards he would be in fora rough time - from his superiors.  In view of the raft of nonsensical things which NR seem to regard as 'standards' I'm amazed they haven't got any for Authorised Walking Routes.

[Rods_of_Revolution]

23 hours ago, The Stationmaster said:

It should never have been taken out of the induction process.  I wonder which idiot did that?

 

But the whole problem here is that 'somebody' removed it from a safety Rules and safety training.  It is not in the Driver's personal safety Rules section of the RSSB Rule Book. (and a former Regional Movements/TOC General Manager was incredulous when I told him that over lunch a couple of months back.   I had at one time been the operational Safety Manager of the TOC he led.

 

I quite accept that it is far from commonsense to walk between vehicles on a siding but that is not wholly the point.   There are plenty of newcomers on the railway who have no 'railway sense' or knowledge so have to be trained from the ground up,  And to train them you need to have the procedures and Rules there in the first place.  And having trained them you have to recognise - as others have already posted above - that people can be stupid at times so you need to police/enforce procedures (in this case a personal safety Rule) and remind people why they are there.  But that is difficult if you don't have such rules there to start with - which was the heart of the problem here and which unfortunately led to a potentially needless fatality.

 

I've been through inductions for many depots and often nothing is ever said about moving between vehicles, this is because these days every depot has designated 'authorised walking routes' which are supposed to be used at all times (this is also mentioned in PTS training and the railway rulebook). So the assumption is that no one, other than those in control of the vehicles and required to do so for a specific purpose (coupling a train, brake test etc), will move between or around vehicles. Therefore the driver in question would have been expected to be using the authorised walking routes across the depot. The problem with the authorised walking routes is that often rail vehicles are parked across the nearest route, so a longer route must be taken, this causes people to take short-cuts between rail vehicles, rather than the proper route provided. 

 

I agree it would be worth going into greater depth in the rules to deter people from cutting corners, but also to provide guidance should an authorised walking route not available for some reason.

 

Regards,

 

Jack