RAIB report : Bognor derailment

[101]

Don't think this has been posted?

This is almost unbelievable and quite worrying to say the least!

 

https://www.gov.uk/government/publications/safety-digest-082020-bognor-regis/passenger-train-derailment-at-bognor-regis-station-west-sussex-22-october-2020

Edited December 18, 2020 by 101

[Oldddudders]

31 minutes ago, 101 said:

This is almost unbelievable and quite worrying to say the least!

It all seems a bit clownish but staff shortages sometimes require people to be on duty when they may not be at their best. This event, and the comparable events identified in the report seem to have that unsurprising theme. Relative unfamiliarity with a particular frame and its quirks is inevitable when staff do not regularly operate it, even thought they have previously been passed out as competent. I have known some very fine relief signalmen, but not all, like this chap, are very experienced. A driver authorised to pass a signal at danger will usually proceed with caution, as he is required to do, and the 5 mph speed at which this train derailed supports him having done just that. 

 

There seems to be no mention of the battery failure beyond the fact of it happening. One might hope that regular examination of such kit would be scheduled, and that any failure would be flagged up to the signaller, rather like a filament failure. Technicians routinely check all sorts of important stuff - perhaps this needs to be added. 

[101]

It's a complete comedy of errors - a signalman setting the route by pulling levers according to a crib sheet, then when he can't pull the signal off he doesn't question why.

Then when he can't pull a second one off and doesn't question that either

 

Then two drivers are talked past signals but both - unfortunately from an ex drivers point of view - manage to run through / out of catch points 

 

If the first driver had stopped to question why the wrong route was set as he should have,  perhaps it all could have been avoided

Edited December 18, 2020 by 101

[DY444]

52 minutes ago, 101 said:

It's a complete comedy of errors - a signalman setting the route by pulling levers according to a crib sheet, then when he can't pull the signal off he doesn't question why.

Then when he can't pull a second one off and doesn't question that either

 

Agreed.  Reads like something from over a century ago that you might read about in Red For Danger. 

[DY444]

17 hours ago, 101 said:

If the first driver had stopped to question why the wrong route was set as he should have,  perhaps it all could have been avoided

 

Not sure what you mean by that.  The signaller wrongly believed he had set the points for the route from the Down Branch to P2 but the failure meant that 18A was set to the middle siding and 18B was set against the train.  That meant BR63 (correctly) would not clear for a route to P2 so the train came to a stand at it (as it happens it wouldn't have cleared for a route to the middle siding either due to 18B being wrongly set).  The driver was given permission by the signaller to pass BR63 at danger and we assume was told that the points were correctly set for a movement into P2.  Therefore as far as I can see he was given no wrong route to challenge.  

 

 

Edited December 19, 2020 by DY444

[ikcdab]

17 hours ago, 101 said:

It's a complete comedy of errors - a signalman setting the route by pulling levers according to a crib sheet, then when he can't pull the signal off he doesn't question why.

Then when he can't pull a second one off and doesn't question that either

 

Then two drivers are talked past signals but both - unfortunately from an ex drivers point of view - manage to run through / out of catch points 

 

If the first driver had stopped to question why the wrong route was set as he should have,  perhaps it all could have been I'm not

I'm not sure that's a fair assessment. The signalman had done had operated the levers correctly. The points hadn't  moved and he couldn't clear the signals. What else was he to do?  I bet there was no technician handy and he had a train waiting to come into the station. The only thing he could do was to authorise the driver past the signals at danger which seems to have happened correctly. In these cases it's incumbent on the driver to inspect the route before moving over points.  The driver of the down train was ok, he had no wrong route to inspect. It's the driver of the up train who then passed over half open trap points who could have prevented it. But the report says it was dark and he couldn't see. Even so, is that a reason not to inspect the road before passing over it?

[JimC]

An interesting set of questions, perhaps, is what isn't in the report. The signaller gets a big set of issues, and carries on giving drivers authorisation to pass at danger without doing anything to check. Now why is that? Were technical failures resulting in inability to set the route correctly routine? How often does that signalman experience benign failures where he can't set the route but issuing an authorisation to pass the signal at danger is safe? There's a sort of impression that everything that happened was normal and routine until the train derailed, but that might just be the writing style. 

[DY444]

25 minutes ago, ikcdab said:

I'm not sure that's a fair assessment. The signalman had done had operated the levers correctly. The points hadn't  moved and he couldn't clear the signals. What else was he to do?  I bet there was no technician handy and he had a train waiting to come into the station. The only thing he could do was to authorise the driver past the signals at danger which seems to have happened correctly. In these cases it's incumbent on the driver to inspect the route before moving over points.  The driver of the down train was ok, he had no wrong route to inspect. It's the driver of the up train who then passed over half open trap points who could have prevented it. But the report says it was dark and he couldn't see. Even so, is that a reason not to inspect the road before passing over it?

 

That's just wrong on so many levels.  It is pretty clear that the signaller didn't understand how the box worked which meant he did not know the points hadn't moved despite there being indicators which would have told him.  It's kind of basic stuff that you don't authorise a train to pass a signal at danger if you don't know the lie of the points ahead of it.

Edited December 19, 2020 by DY444

[DY444]

1 minute ago, JimC said:

An interesting set of questions, perhaps, is what isn't in the report. The signaller gets a big set of issues, and carries on giving drivers authorisation to pass at danger without doing anything to check. Now why is that? Were technical failures resulting in inability to set the route correctly routine? How often does that signalman experience benign failures where he can't set the route but issuing an authorisation to pass the signal at danger is safe? There's a sort of impression that everything that happened was normal and routine until the train derailed, but that might just be the writing style. 

 

It was because he didn't understand how the points worked.  He gave them permission to pass because the levers in the frame were in the right position for the route, which with the set up at Bognor doesn't mean the points are lying correctly.  There were indicators showing the lie of each point which he should have checked but failed to do so.  Had he checked them then the incident would not have occurred.

[101]

43 minutes ago, DY444 said:

 

 

 

43 minutes ago, DY444 said:

 

 

 

43 minutes ago, DY444 said:

 

Not sure what you mean by that.  The signaller wrongly believed he had set the points for the route from the Down Branch to P2 but the failure meant that 18A was set to the middle siding and 18B was set against the train.  That meant BR63 (correctly) would not clear for a route to P2 so the train came to a stand at it (as it happens it wouldn't have cleared for a route to the middle siding either due to 18B being wrongly set).  The driver was given permission by the signaller to pass BR63 at danger and we assume was told that the points were correctly set for a movement into P2.  Therefore as far as I can see he was given no wrong route to challenge.  

 

 

 

It clearly says that the points were damaged by the train running onto the middle siding instead of platform 2. 

Unless the rule book has changed in the couple of years since I retired , it is the drivers responsibility on passing a signal at danger to approach points cautiously and check that they are set for the movement, clearly he didn't do this or he wouldn't have taken the wrong route into the middle siding running through the points in the process , and its a red herring to say that it was dark!

Edited December 19, 2020 by 101
Dont know what happened with multiple quotes!

[LMS2968]

That's how it was in my day, too, admittedly as a guard in the mid-1970s. If the points couldn't be seen from the cab, the driver would (and did) aske me to go down on the ground and check, although I realise that the rules around doing this have since changed. 

 

This was the issue at Quorn on the GCR, 27/04/13. The initial error was the Bobby's in having failed to set up the route, but the driver's failure to check the route was the final ingredient.

[Supaned]

Having read the report , one thing that does stand out to me , and this seems to be a factor in a lot of incidents I've read about , is that of time loss & performance , and the pressures on staff to reduce delays to a minimum.

 

Granted , passengers and freight customers expect a punctual railway , but they also expect a safe one , and it certainly seems to me in this particular case that the time pressures are one of the contributing factors to this incident.

 

I've said on many occasions that the delay attribution "industry within an industry" and the downwards pressure that stems from it onto those actually operating the railways having to explain for every percieved lost minute of time because there is a cost attached to that is in fact detrimental to safety , and this is a case in point.

[DY444]

11 minutes ago, 101 said:

 

It clearly says that the points were damaged by the train running through 

 

It clearly 

 

It clearly says that the points were damaged by the train running onto the middle siding instead of platform 2. 

Unless the rule book has changed in the couple of years since I retired , it is the drivers responsibility on passing a signal at danger to approach points cautiously and check that they are set for the movement, clearly he didn't do this or he wouldn't have taken the wrong route into the middle siding running through the points in the process , and its a red herring to say that it was dark!

 

2 minutes ago, LMS2968 said:

That's how it was in my day, too, admittedly as a guard in the mid-1970s. If the points couldn't be seen from the cab, the driver would (and did) aske me to go down on the ground and check, although I realise that the rules around doing this have since changed. 

 

This was the issue at Quorn on the GCR, 27/04/13. The initial error was the Bobby's in having failed to set up the route, but the driver's failure to check the route was the final ingredient.

 

"If possible, you must make sure that any points, switch diamonds or swing-nose crossings are in the correct position for your train"

 

 

[Supaned]

2 minutes ago, LMS2968 said:

That's how it was in my day, too, admittedly as a guard in the mid-1970s. If the points couldn't be seen from the cab, the driver would (and did) aske me to go down on the ground and check, although I realise that the rules around doing this have since changed. 

 

This was the issue at Quorn on the GCR, 27/04/13. The initial error was the Bobby's in having failed to set up the route, but the driver's failure to check the route was the final ingredient.

 

Whilst I'm naturally inclined to defend drivers being one myself , one factor to consider here is the third rail and darkness here. There is potentially a far greater risk having a driver wandering around on the floor surrounded by live rails in the dark - yes , we are PTS trained and yes that is part of our duties to do such things , however not something I'd fancy myself.

[phil-b259]

19 hours ago, Oldddudders said:

 

There seems to be no mention of the battery failure beyond the fact of it happening. One might hope that regular examination of such kit would be scheduled, and that any failure would be flagged up to the signaller, rather like a filament failure. Technicians routinely check all sorts of important stuff - perhaps this needs to be added. 

The point batteries ARE checked every 48 days, however the railway has moved away from traditional 'wet cell' type and to banks of 'dry cell' Cyclon batteries pre fitted into banks that that are linked up to give the 120V high current output which have a tendency to go bang without warning.

 

* http://dmstech.co.uk/red-flash/rail-products/

Edited December 19, 2020 by phil-b259

[DY444]

1 minute ago, Supaned said:

 

Whilst I'm naturally inclined to defend drivers being one myself , one factor to consider here is the third rail and darkness here. There is potentially a far greater risk having a driver wandering around on the floor surrounded by live rails in the dark - yes , we are PTS trained and yes that is part of our duties to do such things , however not something I'd fancy myself.

 

Beat me to it.  That's exactly what I was going to say.

[101]

1 minute ago, DY444 said:

 

 

"If possible, you must make sure that any points, switch diamonds or swing-nose crossings are in the correct position for your train"

 

 

 

Really?  If so I'm astounded by that.

 

[phil-b259]

37 minutes ago, ikcdab said:

I'm not sure that's a fair assessment. The signalman had done had operated the levers correctly. The points hadn't  moved and he couldn't clear the signals. What else was he to do?

 

CHECK HIS POINT INDICATORS!!!!

 

Had the signalman done this most basic of tasks he would have SEEN the points were not correctly set and not authorised the train over them until the points had been secured in the correct position for the intended move.

 

We provide point indicators on the block shelf (or signalling panel for a reason) - movement of a switch is no guarantee that the equipment has physically done what it has been commanded to do out on site.

 

Its one of the most basic things which all signalmen should be aware of before they get let lose signalling trains - if you cannot get a signal to change to a proceed / pull a lever for any reason then you must examine your indicators carefully for issues.

 

I understand that fatigue may well make this difficult - which is why the management of Sussex route cannot escape blame by not having sufficient relief staff available.

[phil-b259]

10 minutes ago, Supaned said:

 

Whilst I'm naturally inclined to defend drivers being one myself , one factor to consider here is the third rail and darkness here. There is potentially a far greater risk having a driver wandering around on the floor surrounded by live rails in the dark - yes , we are PTS trained and yes that is part of our duties to do such things , however not something I'd fancy myself.

 

Agreed its not the job of train drivers to stumble about in the dark* - but I guess the signaller could have told them "proceed slowly and stop short of XX points, only proceeding if they are set correctly for your train.

 

That however would need the signalman to have looked at his point position indicators on the block shelf (like he was supposed to by the rules) though......

 

* The normal situation with point failures is to get trains to sit tight until a NR MOM has arrived to clip points in the correct position - not get drivers to do it.

[Supaned]

10 minutes ago, 101 said:

 

Really?  If so I'm astounded by that.

 

Rulebook Module TW5 Passing a signal at Danger has exactly that wording. In the dark in certain traction types it may not be physically possible to see the position the points are facing.

 

 

[Supaned]

2 minutes ago, phil-b259 said:

 

 

That however would need the signalman to have looked at his point position indicators on the block shelf (like he was supposed to by the rules) though......

 

* The normal situation with point failures is to get trains to sit tight until a NR MOM has arrived to clip points in the correct position - not get drivers to do it.

 

which then leads back to my point about time pressures. 

[phil-b259]

22 minutes ago, 101 said:

 

Really?  If so I'm astounded by that.

 

 

Yup.

 

Train drivers are NOT RESPONSIBLE FOR THE CORRECT WORKING OF POINTS OR SIGNALS.

 

The rule book has to be quite clear  - it is THE SIGNALMANS RESPONSIBILITY to check points are correct BEFORE authorising trains past signals.

 

In the Bognor situation, given the signalman did not have detection on a set of points he should not have been cautioning trains in the first place!

 

The reason the rule book also asks drivers to check the position of points is simply a 'belt and braces' mentality and is more geared around the situation where they have been incorrectly set for the intended route (but are safe for the train to pass over). It in no way transfers liability from the signalman to ensure the train will be routed safely.

Edited December 19, 2020 by phil-b259

[101]

4 minutes ago, phil-b259 said:

 

Yup.

 

Train drivers are NOT RESPONSIBLE FOR THE CORRECT WORKING OF POINTS OR SIGNALS.

 

The rule book has to be quite clear  - it is THE SIGNALMANS RESPONSIBILITY to check points are correct BEFORE authorising trains past signals.

 

In the Bognor situation, given the signalman did not have detection on a set of points he should not have been cautioning trains in the first place!

 

The reason the rule book also asks drivers to check the position of points is simply a 'belt and braces' mentality and is more geared around the situation where they have been incorrectly set for the intended route (but are safe for the train to pass over). It does.

 

I'm not questioning it but I'm surprised, perhaps 'possible' was always in the rule book - I threw mine away a long time ago! - but I can vividly remember having it drummed into us on our MP12 that if you pass a signal at danger to stop and check points before you literally drop yourself in the s*** !

[Oldddudders]

41 minutes ago, Supaned said:

 

Whilst I'm naturally inclined to defend drivers being one myself , one factor to consider here is the third rail and darkness here. There is potentially a far greater risk having a driver wandering around on the floor surrounded by live rails in the dark - yes , we are PTS trained and yes that is part of our duties to do such things , however not something I'd fancy myself.

I was never a driver, but did spend some time wandering (legitimately) around in the 6' and 4' way on various errands and duties. Most of that was in third-rail territory, and you quickly become accustomed. As for the dark, in my day every driver was issued with a handlamp, albeit a majority were left in the back of the car in case of breakdown! All that said, I find it hard to condemn either driver for accepting the signaller's assurances and proceeding cautiously.

 

50 years ago, Bert Thayre, a mild-mannered sort of chap, was Area Inspector for this part of the railway. I wonder how he would have reacted to this series of events. 

[bigherb]

The report said the indicators where not illuminated, is this another case of asking someone to notice something not there as opposed to a positive indication?