RAIB accident report - Kirkby, Merseyside 13 March 2021 (driver error)

[martin_wynne]

Interesting reading today:

 

https://assets.publishing.service.gov.uk/media/62f1228e8fa8f5032b58cee0/R072022_220811_Kirkby.pdf

 

Martin.

Edited August 17, 2022 by martin_wynne

[Covkid]

With previous incidences of issues in the cab the guy seems not to have learnt

[jjb1970]

A rather worrying report, one of those incidents that resulted in little damage to people but which in ever so slightly different circumstances could have been very nasty indeed.

[John M Upton]

Two errors in fact, one - on his mobile and two - pratting about trying to rescue his bag when he should have been concentrating on where he was going.

[Bucoops]

It also mentions something I've often thought - cancelling AWS hooters without actually thinking about the reason for the notification.

[nightstar.train]

It should be noted that the driver has been charged with endangering passenger safety and plead guilty in court. He received a 12 month sentence, suspended for 2 years. He was also fired by Merseyrail. 

 

https://www.railadvent.co.uk/2022/03/driver-who-used-whatsapp-before-kirkby-train-crash-sentenced.html

[Bucoops]

21 minutes ago, nightstar.train said:

It should be noted that the driver has been charged with endangering passenger safety and plead guilty in court. He received a 12 month sentence, suspended for 2 years. He was also fired by Merseyrail. 

 

https://www.railadvent.co.uk/2022/03/driver-who-used-whatsapp-before-kirkby-train-crash-sentenced.html

 

Got away very lightly considering.

[St. Simon]

On 12/08/2022 at 21:32, Bucoops said:

It also mentions something I've often thought - cancelling AWS hooters without actually thinking about the reason for the notification.

Hi,

 

That’s a known issue and one that meant the Southern Region was very reluctant to adopt AWS (as their peak hour suburban service was running under yellows a lot of the time, so the cancelling of indication would become habitual and so of little use)

 

It is something that we can only design out so much and we have to rely on the professionalism of drivers and their training.

 

There are rules whereby we have to ensure there is at least 4 seconds at linespeed between AWS magnets and that the equipment associated with the indication is visible and easy to locate. We try to reduce the number of unnecessary AWS indications (such as bi-directional ones) through magnet suppression, where they could be a SPAD risk to prevent confusion).

 

AWS indications are reviewed as part of the Driveability Assessment nowadays.

 

Simon 

[DCB]

Come on Elephant in the room here 13 March 2021 accident August 2022 report.

Utter waste of time, if there were lessons to be learned someone would have been injured or killed in the mean time.  This is a disgraceful waste of time. 100 years ago the inquiries were done in 7 days and useful lessons learned.  Not good enough.   No excuse, yadder yadder yadder, total guff disseminated, need to stop police discovering which individual straw broke the camels back by tracing it back by bar codes to the plant it was culled from and a realisation there were just too may straws loaded. Its a good read for enthusiasts but otherwise a complete waste of time and effort. IMHO If you can't get an answer in a week its not worth bothering. 

 

[Ray H]

Accident (and similar) reports were never - to my limited knowledge - ever published that quickly. Every stone needs to be overturned, (possibly) numerous tests undertaken and a thorough investigation has to consider aspects that in many cases don't come to light until those investigations have taken place.

 

My understanding is that the most likely cause of an incident is fairly quickly known and if there is a major risk of repeat then action is taken (often without the general public being aware) within a matter of hours/days/weeks, as appropriate.

 

In the currently litigation crazy world in which we live time the legal profession get involved which is likely to do the opposite of speeding things up. Would you want to be a member of staff who was initially and incorrectly blamed by colleagues and numerous others for an incident that subsequent detailed investigations revealed wasn't your fault?

 

RAIB personnel aren't sitting by the door with their coat on ready to dash out the door the moment an incident occurs. They have numerous other jobs to deal with, any number of which may only generate a minute report but they have to be done to keep the railway even safer than it ever was. 

 

How many times do you read in the press the knee jerk re-action to a situation only for that re-action to be totally unfounded upon a full and proper investigation. Look at how long numerous enquiries take to organise, undertake and publish their reports,

 

I have no association with the RAIB but have enough faith in what they (and numerous parts of the railway industry) do to not worry about rail travel.

[Reorte]

10 hours ago, DCB said:

Come on Elephant in the room here 13 March 2021 accident August 2022 report.

Utter waste of time, if there were lessons to be learned someone would have been injured or killed in the mean time.  This is a disgraceful waste of time. 100 years ago the inquiries were done in 7 days and useful lessons learned.  Not good enough.   No excuse, yadder yadder yadder, total guff disseminated, need to stop police discovering which individual straw broke the camels back by tracing it back by bar codes to the plant it was culled from and a realisation there were just too may straws loaded. Its a good read for enthusiasts but otherwise a complete waste of time and effort. IMHO If you can't get an answer in a week its not worth bothering. 

 

Erm, not really. Any lessons that would've killed people that frequently were learned long ago. Which probably means that any these days will be harder to get to the bottom of anyway, the obvious ones having all been dealt with by now.

 

[Bucoops]

With my (usual) non-expert hat on, I think the full report is more for future reference. Learning points are usually distributed within the industry very quickly - informally or formally (safety digest for example). Taking the time to investigate all factors after the incident can throw up things that were not immediately obvious. 

[Wickham Green too]

Might I suggest a change to the thread title, please .... 'today' is already long out of date and an indication of which RAIB report would be useful for anyone coming across this in the dim and distant future ........................... how about "RAIB accident report : Kirby 13 March 2021" ?

 

[ For future reference I think the original title was simply "RAIB accident report  (driver error)" ......... perhaps the note of a change should state what a thread used to be called, rather than what it's called now ? - 'cos it's obvious what it's called now ! ]

Edited August 18, 2022 by Wickham Green too
note

[The Stationmaster]

Nobody has ever waited for a Report to be issued where there is a safety critical matter which needs to be quickly addressed.  Hence you will find in older Reports such comments as 'the railway company has already - etc, etc '

 

Someytimes it went the other way.  For instance following the collision at Knowle & Dorridge in August 1963 (report published February 1964) The Inspecting Officer recommended a reb view of (WR) Absolute Block Regulation 4A.  While it might well have been altered in the Special Instructions at any relevant signal boxes the revised Regulation itself was not published in a supplement until August 1965 despite there being a Supplement issued in May 1964.

 

Incidentally in any incident which involves subsequent legal proceedings against someone involved the Report cannot be published until such proceedings have been completed.

[4069]

7 hours ago, Ray H said:

RAIB personnel aren't sitting by the door with their coat on ready to dash out the door the moment an incident occurs.

Oh yes they are- RAIB staff who are on-call (normally one week in three) are expected to be on the road within thirty minutes of being deployed to an accident, regardless of the time of day or night. It's an onerous requirement given that the Branch covers the whole of the UK, and investigators can be sent anywhere at a moment's notice.

 

The on-site phase is only the first stage of the investigation. The need to tease out the causes and underlying factors, and prepare a report that is thorough, accurate, complete and makes recommendations based on the evidence, plus the obligation to consult interested parties on the proposed recommendations and the final report, means that the process may seem slow.

 

As Mike has said, if something is discovered that  requires urgent action, it will be dealt with quickly. Legal proceedings may or may not hold up the publication of the report, depending on the circumstances. There are several events in recent years for which reports have been published, but for which prosecutions of corporate bodies are still outstanding- RAIB has no part in those.

 

In the nineteenth century reports were completed very quickly, often within a week. In those days the sheer volume of investigations (over 200 a year in the 1870s) meant that the Inspecting Officers had to strictly limit the time they could spend on each case. More recently, from the 1960s until the start of the RAIB era in 2005, reports could take up to seven years to appear, and in the 1990s and 2000s very few were published at all. Hopefully the present system deals with those deficiencies and presents the public with the facts of the event and the lessons that have been learned, in a clear and  consistent way and in a reasonable timescale.

 

Stuart  J

RAIB (retired)

[DCB]

11 hours ago, Reorte said:

Erm, not really. Any lessons that would've killed people that frequently were learned long ago. Which probably means that any these days will be harder to get to the bottom of anyway, the obvious ones having all been dealt with by now.

 

15 months to prove the bloke was on the phone when he should have been keeping a look out, come on,,,,, 

[Wheatley]

25 minutes ago, DCB said:

15 months to prove the bloke was on the phone when he should have been keeping a look out, come on,,,,, 

No, that was proved sometime prior to March this year when he was sentenced for it. Which takes us back to what a couple of people actually involved in this sort of process has already said about the lessons being learned and disemminated as quickly as possible, and the publicly available reports having to wait until the various prosecutions (and appeals) have been either concluded or not proceeded with. 

[KingEdwardII]

20 hours ago, Ray H said:

the legal profession get involved

Yes, they are the "mañana merchants"...

[Reorte]

12 hours ago, DCB said:

15 months to prove the bloke was on the phone when he should have been keeping a look out, come on,,,,, 

That gets you to the immediate cause, which as has already been noted had been dealt with before the report came out. But dig deeper - was this particular driver doing this frequently and getting away with it up until now, were there any reasons to suspect he was that were being ignored, is there a culture issue of not taking inappropriate phone use seriously etc.? I'm not suggesting that any of those may be the case, merely using them as examples, but they're just some of the things that need to be dug in to beyond the immediate cause. Everything that lead up to it is as important as what happened at that particular time.

 

And it's a fact of life sometimes things just take a long time to get moved from a (metaphorical) in tray to out tray, particularly when multiple people with multiple tasks are involved.

 

I've some sympathy to the general idea that we over-react at times (I'm speaking very generally there, well beyond railways) but I feel you're going a bit too much to the opposite extreme.

[Michael Hodgson]

17 hours ago, 4069 said:

 

In the nineteenth century reports were completed very quickly, often within a week. In those days the sheer volume of investigations (over 200 a year in the 1870s) meant that the Inspecting Officers had to strictly limit the time they could spend on each case. More recently, from the 1960s until the start of the RAIB era in 2005, reports could take up to seven years to appear, and in the 1990s and 2000s very few were published at all. Hopefully the present system deals with those deficiencies and presents the public with the facts of the event and the lessons that have been learned, in a clear and  consistent way and in a reasonable timescale.

 

 

Yes, and there has been a changing trend in what the reports say.  The early reports tend to say this accident was the driver's fault, that one the signalman's.  It was mostly which employee to blame.  The company didn't really care - it was hardly ever management's fault, and the rule book saw to that.  It was not unusual for a report to have a footnote that some employee had been charged with (and usually acquitted of) manslaughter or similar.  The courts seems to have accepted the poor bloke who had made a mistake was doing his best.

 

Recommended safeguards tended to reduce the risk of signalling mistakes and equipment failures, but were unable to do as much to protect crews from human error.  So later reports tended to say there was conflicting evidence as to whether the signal was on or off, but on balance it is likely the driver missed the signal which was difficult to see because of poor siting, distractions or whatever.  Much more emphasis on management's duty to provide a practicable working environment that enabled the staff to do their jobs safely.  Current reports start with a very tedious intro which says we're not trying to apportion blame, but trying to seek improvements to prevent recurrence, and to help learn where mistakes are being made.

[AY Mod]

15 hours ago, DCB said:

15 months to prove the bloke was on the phone when he should have been keeping a look out, come on,

 

Whereas you only need a few seconds on a keyboard to communicate what you are. Wind the typical ill-informed and ill-considered 'outraged on Facebook' attitude in please.

[bécasse]

For an amazing example of what is possible in the speed of response to a railway accident, one has to go back to 1889. On the 12th June that year there occurred an accident at Armagh in Ireland which killed 80 people (the worst British railway accident of the 19th century).

 

The response was the defining 1889 Regulation of Railways Act which finally gave the Board of Trade the powers it needed to properly regulate the railways on safety issues. That Act was formulated hastily, passed all its parliamentary hurdles in both Houses (in the height of summer, remember), received the Royal Assent and came into force on the 1st September that year, barely eleven weeks after the accident that triggered it.

[Simon Lee]

On 17/08/2022 at 00:07, DCB said:

Come on Elephant in the room here 13 March 2021 accident August 2022 report.

Utter waste of time, if there were lessons to be learned someone would have been injured or killed in the mean time.  This is a disgraceful waste of time. 100 years ago the inquiries were done in 7 days and useful lessons learned.  Not good enough.   No excuse, yadder yadder yadder, total guff disseminated, need to stop police discovering which individual straw broke the camels back by tracing it back by bar codes to the plant it was culled from and a realisation there were just too may straws loaded. Its a good read for enthusiasts but otherwise a complete waste of time and effort. IMHO If you can't get an answer in a week its not worth bothering. 

 

 

So using your theory, after Clapham once the cause of the rogue wire was established that should have been it then ?

 

"Cause found, carry on as normal fellas, whos up for 18hrs next Saturday night ? wait for the next event hopefully night not loose so many next time"

 

I was involved in the aftermath of a collision on the Southern in 89 with two fatalities, yes the cause was soon established, but the culture that enabled the cause to kill those men needed a lot longer to establise and then work towards eliminating. 

 

Over the years I have worked with men and women from HMRI, RAIB, Derby Research, various police forces,  BTP and civil, at a variety of incidents, I wonder exactly how much experience you have in major incidents on the railway in real life as opposed to making ill informed rants in the middle of the night.

 

  

 

 

 

 

 

[Oldddudders]

15 hours ago, DCB said:

15 months to prove the bloke was on the phone when he should have been keeping a look out, come on,,,,, 

So why not put your thoughts on paper to the RAIB, telling 'em what a rubbish, slowcoach job they are doing? I'm sure they'd be interested, and will mend their ways forthwith. Obviously.

 

Those of us who spent an entire career in the industry have every reason to be grateful for the external examiners of  mishaps great and small, because in many cases they have unearthed cultural and circumstantial issues that have, or even could have, given rise to accidents and other undesirable events. We learnt, and the railway became a safer place. 

 

Your ridiculous, petulant tutting merely indicates a woeful lack of understanding of the importance of painstaking forensic investigation and considered reporting. 

[D9020 Nimbus]

It seems to me that there is a fundamental difference between the HMRI investigations of the 19th and (most of) the 20th century in that they were looking for direct causes: who was to blame, and what measures needed to be taken to prevent a recurrence. The causes were often relatively simple — and the measures to prevent a recurrence had often been called for over a long time: protection against signaller's errors, AWS and its predecessors, and so on.

 

Most of the obvious measures have now been taken, so to eliminate the remaining accidents is harder, and there is now more concern to find the underlying causes. That inevitably takes longer. Consider for a moment the similarities between the Bourne End accident and that at Harrow and Wealdstone. Both overnight sleepers, both with a colour light distant being missed, leading to running through the semaphore stop signal. Any lessons learned from the first failed to prevent the second (although the obvious prevention mechanism was known anyway — "fit AWS".

 

This line had AWS and TPWS but the accident still occurred.

 

It's to the credit of HMRI, and more recently RAIB, that the British railway system is one of the safest in the world, particularly given its current fragmented nature.