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

[2251]

2 hours ago, Simon Lee said:

 

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.

 

I am sure you know this, but it is worth noting that Clapham was (unusually if not uniquely) the subject of an enquiry under the Regulation of Railways Act 1871 chaired by Anthony Hidden QC rather than an HMRI investigation. The detailed report, produced after a 56-day hearing, is here:

 

https://www.railwaysarchive.co.uk/documents/DoT_Hidden001.pdf

 

Anyone who reads that report will see the lengths gone to in order to establish not merely the immediate cause of Clapham, but the underlying root causes. 

[Jeremy Cumberland]

2 hours ago, 2251 said:

it is worth noting that Clapham was (unusually if not uniquely) the subject of an enquiry under the Regulation of Railways Act 1871

It certainly is, and the Hidden Report has had a long lasting effect on the working of Britain's railways (including the heritage sector).

 

It was not the only inquiry. Tay Bridge (1879) and the King's Cross Fire (1987) both had public enquiries under the Act, but I cannot think of any others. It is worth noting that King's Cross and Clapham were both ultimately caused by underlying and widespread cultural issues, whereas most other railway accidents were more specific in their causes.

[St. Simon]

On 16/08/2022 at 23:07, 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. 

 

Hi,

 

An initial immediate investigation is completed by the TOC (and possibly Police and the ORR etc) to ensure that actions that are immediately required to ensure safety and to preserve life are taken quickly. All departments even vaguely involved will almost certainly do an immediate review of processes, designs, equipment etc to make sure it won’t happen in the near future.

 

An example of this was that when the Waterloo derailment happened, in our signalling design office (even though we had absolutely nothing to do with it what so ever) we checked any designs we had done for similar circumstances within a couple of days to ensure that we didn’t overlook anything that could cause an unsafe situation despite not knowing for certain the full cause.

 

So don’t think that the rail industry just sits around twiddling their thumbs refusing to act whilst the RAIB completes its report.

 

RAIB reports are more about exploring the deeper cultural and longer term issues that cause incidents that can be missed by an immediate ‘preservation of life’ investigation. This sort of exploration takes a long time and by definition these issues won’t cause an accident quickly (particularly when the immediate causes have been addressed quickly after the quick initial investigation), so yes delaying the investigation does expose the risk of another accident, but it’s a small risk compared with the bigger rusk

of not doing a full, careful and methodical investigation.

 

I can’t think of any major rail accident in recent memory, where it has  one occurred within the timescale of the report being written for a identical or similar incident where the report would have made a difference.

 

Simon

[Michael Hodgson]

5 hours ago, Jeremy C said:

 

It was not the only inquiry. Tay Bridge (1879) and the King's Cross Fire (1987) both had public enquiries under the Act, but I cannot think of any others. It is worth noting that King's Cross and Clapham were both ultimately caused by underlying and widespread cultural issues, whereas most other railway accidents were more specific in their causes.

Another unusual report was the partial demolition of the Severn Bridge, conducted not by RAIB but by judges as a tribunal investigating a shipping accident (two barges collided in fog and then drifted into the bridge).  The report sought to establish whether the masters of the vessels were at fault.

[62613]

8 hours ago, Michael Hodgson said:

Another unusual report was the partial demolition of the Severn Bridge, conducted not by RAIB but by judges as a tribunal investigating a shipping accident (two barges collided in fog and then drifted into the bridge).  The report sought to establish whether the masters of the vessels were at fault.

An unusual feature of the Tay Bridge disaster inquiry was that it involved an Admiralty receiver of wreck (Rothery), because the wreckage ended up in a tidal river, and a prominent civil engineer (Barlow)

 

Didn't the Hixon inquiry involve a tribunal as well?

 

[Michael Hodgson]

15 minutes ago, 62613 said:

An unusual feature of the Tay Bridge disaster inquiry was that it involved an Admiralty receiver of wreck (Rothery), because the wreckage ended up in a tidal river, and a prominent civil engineer (Barlow)

 

Didn't the Hixon inquiry involve a tribunal as well?

 

Yes, I believe it did.  The report was certainly very different in appearance, the usual blue cover but only half the page size and lots of pages, more like a book. 

 

For the next few years it put a spanner in the works of migrating from conventional gated crossings to modern barriers because it introduced so many more requirements that the cost of conversion became prohibitive.  For example you needed to provide 6 phones - one on each side of the road on each side of the line outside the fence for public use, and one on each side of the line inside the fence for railway use.  It increased the time the crossing was closed (but still not enough to have allowed the Hixon lorry to get clear)

[Barclay]

An interesting read, as they always are. It does seem that warning buzzers often trigger a Pavlovian response where the thing is just turned off without any thought to what it means. I remember watching an episode of 'Air Crash Investigation' where a warning was sounding to tell the pilots that the flaps weren't deployed. They seemingly put up with it for some time before cancelling it because it was annoying. Then they attempted to take off without flaps, and fell from the sky. A good argument for driverless trains (and cars) but do we actually want that? I suspect the human factor saves more lives than it harms.

[KingEdwardII]

31 minutes ago, Barclay said:

I suspect the human factor saves more lives than it harms.

That is an interesting question. Automated systems certainly can go wrong and humans may then intervene to save the situation, but equally, humans may misunderstand the situation and cause disaster.

 

Two aircraft incidents stand out in my mind - the good one, where the BA plane crashed just short of the runway at Heathrow because of a problem with fuel to the engines, but everyone survived due to the skill of the pilots. The bad one, where the Air France plane went into the Atlantic on a journey from Brazil, after icing caused incorrect speed readings and the autopilot disengaged, only for the co-pilot to send the plane into a stall.

 

The first one was especially interesting when they programmed the situation on a simulator and other pilots found it very hard indeed to reproduce what the BA pilots had done and land without a disaster.

 

Yours,  Mike.

[Reorte]

31 minutes ago, KingEdwardII said:

That is an interesting question. Automated systems certainly can go wrong and humans may then intervene to save the situation, but equally, humans may misunderstand the situation and cause disaster.

 

Two aircraft incidents stand out in my mind - the good one, where the BA plane crashed just short of the runway at Heathrow because of a problem with fuel to the engines, but everyone survived due to the skill of the pilots. The bad one, where the Air France plane went into the Atlantic on a journey from Brazil, after icing caused incorrect speed readings and the autopilot disengaged, only for the co-pilot to send the plane into a stall.

 

The first one was especially interesting when they programmed the situation on a simulator and other pilots found it very hard indeed to reproduce what the BA pilots had done and land without a disaster.

The plane that ended up in the river in New York is another example where skilled human ability saved the day.

 

Humans are much, much better than machines (or at any rate can be) at dealing with the completely unexpected and unusual, but not so good at the routine - or at noticing that the routine has been broken. I've no experience driving trains but the idea that people might just get in to the habit of automatically cancelling AWS warnings doesn't strike me as all that surprising. We've only got so much ability to concentrate, and a brain that has the ability to push the routine off to the subconscious to leave the conscious free to deal with the exceptions. That has its advantages (e.g. we can walk without having to think about exactly how to operate the relevant muscles), and its disadvantages, of which automatic buzzer cancelling sounds (to this non-expert) like one.

 

It's possible to make that subconscious habit work in our favour. Take the mechanics of driving (I'm thinking cars because I know how to, but presumably the same applies to trains). When you first learn to drive it was all probably pretty overwhelming, but once the mechanics of it are embedded we've got more time to think about driving well - what we do with the driving, since we don't have to think as much about the how. Or even simply getting in to the habit of locking the door when you leave home. It makes it much more unlikely that you'd forget than if you had to think about it every time, once you're in the almost subconscious habit.

[Mike_Walker]

For those not active within the industry an explanation of how things happen in the aftermath of an incident may be useful.

 

The first priority is to assist and remove any casualties and fatalities.  This is obviously the role of the civilian emergency services but at this stage the role of the police, BTP or civil, is to assist and secure the scene not investigate.  Alcohol and drug tests are carried out on all railway staff involved.  Once the RAIB arrives they take charge and their investigation begins, recording the scene in minute detail and gathering possible evidence.  Again, at this stage police involvement is still restricted to site securing.  BTP will only become involved in an investigation role if the RAIB requests it due to there being evidence of a possible criminal act being a cause of the incident, for example if an obstruction had been placed on the line or a member of staff has failed the alcohol or drug test.

 

In more serious incidents, the equipment involved, both the trains and often track/signalling equipment, is often removed to secure location where it can be examined in greater detail.

 

As mentioned by others above, the RAIB does not seek to apportion blame for an accident but to delve into the underlying causes.  It does not prosecute in any case.  This is to encourage those involved (including those not directly involved such as line managers) to speak freely when interviewed by the RAIB investigators without fear of incriminating themselves.

 

Any prosecutions are pursued by the Office of Rail and Road (ORR) and HSE.  The RAIB may be called upon as witnesses to provide expert evidence during any trial which may result.

[Fat Controller]

20 minutes ago, Reorte said:

The plane that ended up in the river in New York is another example where skilled human ability saved the day.

 

Humans are much, much better than machines (or at any rate can be) at dealing with the completely unexpected and unusual, but not so good at the routine - or at noticing that the routine has been broken. I've no experience driving trains but the idea that people might just get in to the habit of automatically cancelling AWS warnings doesn't strike me as all that surprising. We've only got so much ability to concentrate, and a brain that has the ability to push the routine off to the subconscious to leave the conscious free to deal with the exceptions. That has its advantages (e.g. we can walk without having to think about exactly how to operate the relevant muscles), and its disadvantages, of which automatic buzzer cancelling sounds (to this non-expert) like one.

 

It's possible to make that subconscious habit work in our favour. Take the mechanics of driving (I'm thinking cars because I know how to, but presumably the same applies to trains). When you first learn to drive it was all probably pretty overwhelming, but once the mechanics of it are embedded we've got more time to think about driving well - what we do with the driving, since we don't have to think as much about the how. Or even simply getting in to the habit of locking the door when you leave home. It makes it much more unlikely that you'd forget than if you had to think about it every time, once you're in the almost subconscious habit.

I remember talking to one of 'my' drivers, who had recently travelled to Southern France by train. When he and his wife arrived, she asked him why, despite being asleep, he kept tapping his foot on the floor. It was the way he'd tap the VACMA pedal (equivalent to a driver vigilance device).

SNCF have done a lot of research on sleep patterns, mini-sleeps and so on; they shared their research with a university that was researching the effects of tiredness on autoroute drivers. By using cameras focused on driver's eyes, they were able to see that drivers would often shut their eyes when driving. Sometimes this might be for a few seconds, but instances of five minutes or more were observed. Most worrying was that drivers didn't reduce their speed.

[2251]

2 hours ago, 62613 said:

 

Didn't the Hixon inquiry involve a tribunal as well?

 

 

The report is here:

 

https://www.railwaysarchive.co.uk/documents/MoT_Hixon1968.pdf

[Grovenor]

2 hours ago, Barclay said:

An interesting read, as they always are. It does seem that warning buzzers often trigger a Pavlovian response where the thing is just turned off without any thought to what it means.

And two of those buzzers were for trains going the opposite way, just making the situation worse. Presumably not fitted with suppressors to save cost. But giving the drivers the extra task of working out whether the buzzer applied or not.

[4069]

5 hours ago, Mike_Walker said:

Any prosecutions are pursued by the Office of Rail and Road (ORR) and HSE.  The RAIB may be called upon as witnesses to provide expert evidence during any trial which may result.

Absolutely not. The RAIB does not become involved in criminal prosecutions in any way. If expert evidence is required it must come from other sources.

 

Stuart J

RAIB (retired)

[D9020 Nimbus]

21 hours ago, Jeremy C said:

It certainly is, and the Hidden Report has had a long lasting effect on the working of Britain's railways (including the heritage sector).

 

It was not the only inquiry. Tay Bridge (1879) and the King's Cross Fire (1987) both had public enquiries under the Act, but I cannot think of any others. It is worth noting that King's Cross and Clapham were both ultimately caused by underlying and widespread cultural issues, whereas most other railway accidents were more specific in their causes.

Before the 1980s there were only two accidents that were not carried out by HMRI: Tay Bridge and the 1968 Hixon level crossing accident. In both cases this was because HMRI had inspected and approved the arrangements and were not therefore sufficiently independent. Kings Cross was not really a railway accident as such. 

 

The trend toward judge-led public inquiries began with Clapham and continued for quite some time. This change was not welcomed by BR; its safety director Stanley Hall in particular. He did write a book on railway accidents called Hidden Dangers. Part of the reason was that at some point a change in legislation prevented an HMRI inspector holding a public inquiry, as they had done in the past, though I believe this was after Clapham. HMRI inspectors had held public inquiries, but unlike the judge-led kind there were no lawyers present. (They also held private inquiries, too.)

 

HMRI inspectors investigated the serious accidents at Harrow & Wealdstone and Lewisham. There were no lawyers present and no representation of the injured then. Would that be acceptable today?

[4069]

3 hours ago, D9020 Nimbus said:

Before the 1980s there were only two accidents that were not carried out by HMRI: Tay Bridge and the 1968 Hixon level crossing accident. In both cases this was because HMRI had inspected and approved the arrangements and were not therefore sufficiently independent. Kings Cross was not really a railway accident as such. 

 

The trend toward judge-led public inquiries began with Clapham and continued for quite some time. This change was not welcomed by BR; its safety director Stanley Hall in particular. He did write a book on railway accidents called Hidden Dangers. Part of the reason was that at some point a change in legislation prevented an HMRI inspector holding a public inquiry, as they had done in the past, though I believe this was after Clapham. HMRI inspectors had held public inquiries, but unlike the judge-led kind there were no lawyers present. (They also held private inquiries, too.)

Oh dear. There's a lot of mythology there.

 

The Regulation of Railways Act 1871 gave the Board of  Trade power to appoint inspectors to inquire into accidents (previously they had relied on force of personality alone), and also the opportunity to appoint additional persons "with legal or specialist knowledge" to assist an inspector in their investigation, and in such cases the appointed group was known as a court of inquiry. The power was first made use of for the investigation into the Wigan derailment of 1873, and was used on a handful of further occasions in the 1870s. It fell out of favour, probably because it was cumbersome and added little to the quality of the investigations carried by Inspecting Officers alone, and the Tay Bridge inquiry was the last time it was used in the Victorian era. In that case the additional expertise employed was in civil engineering, and not law.

 

The Court of Inquiry process was revived for the Hixon investigation because of the high level of public concern about automatic level crossings, which were seen as a foreign-inspired novelty which had been endorsed by the RI (which did not become HMRI until 1990), and the multi-agency failings which the accident had shown up, involving the police and the  Ministry of Transport as well as the railway itself.

 

The use of the procedure at Clapham and subsequently reflected the growing realisation that there was a conflict of interest between the  role of the RI as safety regulator and investigator. Stanley Hall was not BR's safety director: he retired in 1982 as the Board's SIgnalling and Safety Officer, long before Clapham. After the Health & Safety Executive absorbed the RI in 1990 it completely revised the legal framework for railway safety. The provisions of the 1871 Act for public inquiries (both by individual inspectors and by courts of inquiry) were repealed in 1997: the last 1871 Act inquiry was into the Ais Gill collision of 1995.

 

All the inquiries held under the 1871 Act were theoretically public, even those into minor personnel accidents. In such cases the public had little chance of finding out that the inquiry was taking place, and the resulting reports were (after WW2) no longer published by HMSO, but only circulated within BR.

 

In 1871 Act inquiries, whether or not there were any lawyers present rather depended on the seriousness of the event. The Unions would often provide legally qualified representation for their members in fatal cases. The expectation, though, was that issues of blame would be gone into at the Coroner's inquest. It was usually following an inquest that prosecution of railwaymen took place.

 

The creation of RAIB made it possible for the safety investigation to be completely separated from the inquiries of the regulator and the police. The inquest process remains as a controversial legacy of the old way of doing things.

 

Stuart J

RAIB (retired)

[jjb1970]

I think it is almost universally recognized that the functions of regulator and investigator should be separated given the inherent conflict of interest that arises if a regulator investigates itself. The railway model seems pretty similar to air and maritime investigation with the AAIB and MAIB and works well.

[jjb1970]

Accident investigation has improved so much in so many years. When I started in the work place it was normal to see accidents ascribed to human error, people who were basically thick, or narrowly focused on technical failures such as boiler over pressure. Now the focus is on understanding the wider context and causal factors. At that time many of these things were mockingly referred to as Darwin awards and there was a culture that in a heavy industry you have casualties. Now, thankfully, things are very different, and accident rates are massively lower than when I entered the work force. I once put someone's nose properly out of joint in Houston in a meeting by stating that my view was that any incident report which just points to human error should be re-investigated as in almost every case I'd bet such a report wasn't worth the paper it was written on. Being an oil man his view was that there are procedures etc and if someone makes a mistake, doesn't follow procedures etc then it's their fault and no need to look any further. The idea that procedures might not be fit for purpose, work cultures poor (the oil sector in the Gulf of Mexico was notorious for a just get the job done culture), issues with competency assessment and training and the fact that if a safety critical system is vulnerable to anyone making a mistake crashing it all then it has a serious problem was an anathema to him. Just blaming it all on the poor sap making a mistake has no place in most incidents, human error may be the proximate cause but it is extremely rare for it to be the only cause and just blaming idiots does nothing to improve safety and prevent repetition. Another thing which has changed is a tolerance for mistakes, that's not the same as zero consequence but if people are terrified to report issues they go unreported and next time the same mistake is made it could result in a disaster. Near hits are golden opportunities to identify and fix issues before a disaster, and to do that needs a certain indulgence for failure rather than throwing the book at every infraction. I remember some of the standard operating procedures I was saddled with, it would indicate sub-normal intelligence if people didn't figure out a procedure which had 101 steps taking several hours couldn't be done more efficiently in 5 steps taking ten minutes, the problem is in some cases there are good reasons for long winded processes. Which again is a reason to build confidence in the work force, look if these procedures are **** come and tell us and then we can do a management of change process for the work around you've figured out to see if it is fit for purpose and if it is we can approve it. 

[jjb1970]

Funnily enough it was something I found the unions very useful for. Electricity generation and nuclear was unionised and some of them were rather active for want of a better word, but when it came to safety I found I got on very well with the union reps and we often had discrete discussions where both sides could raise concerns in a candid way and look to improve things.

[eldomtom2]

On 18/08/2022 at 19:13, Jeremy C said:

It certainly is, and the Hidden Report has had a long lasting effect on the working of Britain's railways (including the heritage sector).

 

It was not the only inquiry. Tay Bridge (1879) and the King's Cross Fire (1987) both had public enquiries under the Act, but I cannot think of any others. It is worth noting that King's Cross and Clapham were both ultimately caused by underlying and widespread cultural issues, whereas most other railway accidents were more specific in their causes.

Strictly speaking any accident can be blamed on cultural issues if you go back far enough...

[The Stationmaster]

On 18/08/2022 at 12:56, bécasse said:

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.

But don't forget that the 1889 Act built on previous legislation and BoT requirements on the railways to regularly report progress on the on stalltion of block working and the fitting of continuous brakes.   Thus what it did was  basically turn what might best be defined as 'strong encouragement' into a legal requirement with a period of time allowed to implement it.  The other thing about the 1889 Act was that it was comparatively brief and, building on previous stuff, simple to word - but I agree that it did appear quickly.