West Coast Derailment

[TheSignalEngineer]

Somewhere in the back of my mind lurks the idea that this signal originally had a junction indicator (in fact junction indicators because the connection tpwards Oxford was also still there when it was commissioned) but I can't find the drawings which are somewhere on the 'net to confirm or deny my vague memories.

 

It was shown as a theatre in the report on the 1974 derailment. In such cases it was usual not to provide an indication for the straight route if this was over 40mph, thus any theatre indication should be treated as a restricted speed route by the driver. The original Traffic Notice would be 555G of June 1965 if anyone out there has a copy

[The Stationmaster]

It was shown as a theatre in the report on the 1974 derailment. In such cases it was usual not to provide an indication for the straight route if this was over 40mph, thus any theatre indication should be treated as a restricted speed route by the driver. The original Traffic Notice would be 555G of June 1965 if anyone out there has a copy

Thanks SE - I'd already had a look on the Signalling Notices site and although it is listed there is no scanned-in copy of it.

 

As far as a theatre being used without an illumination of route that is - in my experience - a comparatively rare occurrence (Down Relief Line at Reading Main Line East is another example) and just the sort of thing which should stick in a Driver's mind when road learning, or refreshing, or in the information given at a road learning school, which simply reinforces my earlier conclusion.

[Edwin_m]

You get the impression the driver was in a hurry to finish duty and get home, and the report also mentions unspecified personal problems. That's perhaps the sort of mindset that might make someone put the pedal to the floor (or the railway equivalent) as soon as the light goes green.

[Gary H]

You get the impression the driver was in a hurry to finish duty and get home, and the report also mentions unspecified personal problems. That's perhaps the sort of mindset that might make someone put the pedal to the floor (or the railway equivalent) as soon as the light goes green.

I got the same impression Edwin. Reading the rest of it, the way he drove leading upto the accident didn't help his cause. He'd by all accounts done the same job a good few times before but had never been through that x-over. He signed for the WON but still for all intents and purposes missed his que to take the x-over to avoid the possession up ahead (that was in the WON).

 

I wonder if there would have been a differant outcome if there was a 'proper' route indicator there, ie, the feathers.

Anyone know if he held on to his job?

[roythebus]

I'd also suggest that the rostering is as much at fault as the driver. Knowing the way driver's mind work, having been one for about 20 years in the past, 2most2 drivers, when on such a duty, have their eye on one thing, and that is finishing the job as quick as possible! That the loco had exceeded line speeds for a light engine in the "good old days" would have been immaterial, and in my view is still immaterial except at Bletchley crossover!

 

I've been at 120plus on a light Deltic (not me driving); much the same speeds on 81s and the like, and boy, they were bloody rough at that speed. And yes, the brakes on a light engine leave a lot to be desired...

 

However, as S E says, there's been a theatre indicator at Bletchley since the signalling was put in; I worked at Rugby in 1974/5 and worked to London many times. In my view, there should have been a feather on that signal as it would have stood out far more than the theatre indicator. It is usual practice not to show an indication for the highest speed route.

 

Basically, the driver was probably in a rush, his mind was probably elsewhere, he cocked up. You can't legislate for human error.

[Gary H]

Im amazed the loco stayed upright.

 

I'd also suggest that the rostering is as much at fault as the driver.

Yes indeed, some very strange start times drivers have to put up with, i tip my hat to them in that respect, 16.00 hrs starts etc would grate on me and its a recipie for fatigue.

Im thankfull that in my job for NR its either a night turn or day turn, not halfway between the two.

[Pannier Tank]

As Mike has said the Up Slow to Up Fast was originally used to gain access to the Oxford Branch; I too also thought it had a feather signal. Maybe we are confusing it with the original three aspect colour light signal controlled by Bletchley No. 1 which did have a feathers for Up Fast and Oxford Branch? I can't understand why a 'Green' signal is allowed for an up slow to up fast move considering the 15MPH speed restriction. It would have been simple to disable this and only show a single yellow. Bring the engine to a stand and then give a single yellow.

[TheSignalEngineer]

As Mike has said the Up Slow to Up Fast was originally used to gain access to the Oxford Branch; I too also thought it had a feather signal. Maybe we are confusing it with the original three aspect colour light signal controlled by Bletchley No. 1 which did have a feathers for Up Fast and Oxford Branch? I can't understand why a 'Green' signal is allowed for an up slow to up fast move considering the 15MPH speed restriction. It would have been simple to disable this and only show a single yellow. Bring the engine to a stand and then give a single yellow.

 

Giving a green in such circumstances is not unusual, as it was often done to encourage drivers to get a move on after stopping at the station and then going through a low speed crossing. What is more unusual (but may not have been when Bletchley PSB was built) is getting the green so early. At a 15-20MPH crossing I was always inclined to release to green after the AWS magnet had been passed if a suitable TC joint existed. If there was no joint there I would time delay the clearance until the train was in the vicinity of the magnet.

 

If anyone knows what happened to the 'Black Book' of memos from Jim Fews and Eric Lofthouse that used to reside at Carlow Street it would probably give the answer as to what the accepted solution was at the time.

[Titan]

One thing that really makes me angry, and is also something that the report does not mention, is the total mismanagement and money wasting that led to that crossing still being in use - it should have been gone years ago.

 

As part of the WCML upgrade, a set of high speed crossovers were installed at Drayton Road, about a mile south of Bletchley, which allowed any train from any direction to switch to any track at up to 75mph. These crossovers and all OLE works which included many new portal structures as well as the extra wiring were complete circa 2004, but the signalling was not. As there were other priorities it was clear that the signalling would not be commisioned for some time. It was policy that a new crossover must be brought in to service within 6 months of installation, due to difference in wear between the main line and crossover. As it was now likely that this would be exceeded - yep you guessed it - the new crossovers were completely removed and plain lined. the additional OLE wiring was lifted out of running and the remainder adjusted.

 

In the mean time, the crossovers at Bletchley had got in to such a shocking state that it was necessary to renew them in order to continue in use!

 

The Drayton Road crossovers were being reinstalled just prior to the accident.

 

Just how much money, hassle and time would have been saved, not to mention service improvement as well as avoiding this accident had the new crossovers been commisioned in 2004 and these at Bletchley Removed when originally intended?

[TheSignalEngineer]

One thing that really makes me angry, and is also something that the report does not mention, is the total mismanagement and money wasting that led to that crossing still being in use - it should have been gone years ago.

 

I'm afraid that West Coast was a pretty awful project from the day that Railtrack sold it to Virgin and others, then used aerospace and defence contractors with little infrastructure project and no railway product knowledge to manage it. I feel a rant coming on so will shut up before I implicate someone.

[roythebus]

Perhaps the comments made by titan in post 184 should be moved to a thread I started a while ago on here about the money wasted by "the railway" over the years..

[TheSignalEngineer]

Perhaps the comments made by titan in post 184 should be moved to a thread I started a while ago on here about the money wasted by "the railway" over the years..

 

Think I'll keep off that one. It could become a full time job writing on things I saw let alone reading about others..

[6Y99]

Gent's,

 

Having read the report just now it is the drivers fault plain and simple when I have road learned in the past I have sort of made my booklet to assist me because you don't properly know a road when you sign it. You get to know the road better and more indepth the more you go over it and more info you have on the route the better and to me signals fitted with theater boxes stick out and myself I know to a lot this may sound odd but I note the what letters or numbers can be displayed so I know where I am going to end up but that is just me I have an intrest in the rule book and I take road learning serious (But that is just me)

 

I was takling to a guy at work we for a period of time both was at Depots that went over that route and we came to the same conculison Virgin men if they ever went on the slow lines as the report says would hardly ever go through those points they would stick on the slows as far as Milton Keynes or further south and then be turned back on the fast lines so maybe its time for the odd empty stock move to use these cross overs and such to keep peoples route knowleadge up to date so that what happened to lad driving 0A90 don't happen to them.

 

I was intrested to see that Virgin did assess the guy working class 90s given the 1 or 2 jobs that they have with the class I would have though to make sure that they driving them correctly that they would have been assesed instead of just requesting a down load of the locomotives Q Tron Black Box and I would have thought that during the drivers rules and traction exms they would have asked him questions on prep and disposal and faults and failures of class 90s

 

But without a shadow of a doubt I think more importance now has be placed on route learning and learning a road properly I know its un productive hours and all the TOC's and FOC's do not like there men to be un productive but to me and this is only my opioion but the compainies need to bite the bullet on this one and spend time as in drivers hours and let there drivers keep a good route card as they can I know myslef being on the freight side this can be hard to do when contracts are lost only to get them back a few years later but quite of often just a day is needed to refresh yourself and its often a battle to get the day so you keep yourself right so you dont end up having a SPAD or like the Virgin Trains Euston Man found out come off the road.

[roythebus]

I think another part of the problem is in bringing in drivers "off the street" as it were who have little or no knowledge of railway operation. the role of the secondman may have been seen as unproductive in many ways, but at least the secondman had a good idea of how the railway works before being let loose with a train travelling at up to 140mph with only 6 months in the classroom. but i digress. Lucky no-one was killed in this case.

[beast66606]

Thanks SE - I'd already had a look on the Signalling Notices site and although it is listed there is no scanned-in copy of it.

 

I'll take a look through my collection when I get chance, I have some Bletchley commissionings

[298]

I was intrested to see that Virgin did assess the guy working class 90s given the 1 or 2 jobs that they have with the class I would have though to make sure that they driving them correctly that they would have been assesed instead of just requesting a down load of the locomotives Q Tron Black Box and I would have thought that during the drivers rules and traction exms they would have asked him questions on prep and disposal and faults and failures of class 90s

 

 

Whoever has been doing the sums at Virgin will probably tell you there isn't the financial case for re-assessing, hence the data downloads from the limited pool of drivers who were selected to retain their class 90 knowledge instead of going with what to me would have been the more sensible option, hiring from Electric Traction Ltd. This would have required re-training on 86's and the 87, but surely would have been cheaper than the current plan that sometimes uses up to 500 miles of ECS and Light engine moves for a single train from Euston to Crewe...

[Supaned]

I'd imagine that 86s and 87s were taken off VTs safety case when the last round of franchise changes occurred - when the XC Preston work was incorporated.

Then there is the PR and image issue to consider namely having crowed about finishing with 86s and 87s , they wouldn't really go back to them , even though on paper the idea does seem to be more sensible in terms of where the locos concerned are nominally based.

 

Back to the original incident - one thought that does come to mind regarding the signal at Bletchley. As drivers , these days we are taught that there is no such thing as an "approach control" signal , owing to incidents in the past where drivers have assumed the signal at the junction would "step up" which then didn't. Fair enough , and it's our job to drive to and obey the signal aspects displayed. Quite often though , I find myself brought to a stand at a controlled signal (such as this one at Bletchley) , and just before coming to a stand , the signal will clear to a green when there is no obvious reason for it having been at danger in the first place. Whilst in a location with a junction , it would be a reasonable assumption that a train has crossed over or the signal is in fact an "approach controlled" type , on plain line railway there seems to be no real reason for this that I can see within the limits of my understanding of signalling. My point being , if the driver had had this take place during his journey , especially when wanting to get home , this could have led to a sense of frustration culminating in the incident itself.

[roythebus]

Discussing this matter with a South Eastern driver today, we reckon this is another downside of the fragmentation of the railway. Pre-privatisation/sectorisation, drivers would have worked a variety of trains on this route on the fast and slow lines, making this type of incident less likely to happen. Instead, we now have "super whizz train" drivers keeping to the fast lines, while freight and local train drivers keep to the slow lines and ne'er the twain shall meet, hence the loss of route knowledge.

[Edwin_m]

It did mention in the report that Freightliner now deliver the hired loco for the Pretendolino, so VT drivers may have no chance of driving a light loco at all. Not sure if this is a good or a bad thing...

[The Stationmaster]

Discussing this matter with a South Eastern driver today, we reckon this is another downside of the fragmentation of the railway. Pre-privatisation/sectorisation, drivers would have worked a variety of trains on this route on the fast and slow lines, making this type of incident less likely to happen. Instead, we now have "super whizz train" drivers keeping to the fast lines, while freight and local train drivers keep to the slow lines and ne'er the twain shall meet, hence the loss of route knowledge.

Not necessarily the case - we had 'sectorised' (for want of a better word although not in a business sense) depot workloads on the Western well before privytisation and some of the apparent mismanagement at the root of this incident shows exactly why we did it then and why the matter needs to be properly managed now. We worked on a standard of 5 days over a road in 12 weeks and the depot's work and its link structure had to allow that. In well managed operating companies this rather tight original basis was made far more sophisticated by establishing route assessments and having a norm for each route which recognised its complexity and the way in which things could change plus we also applied a similar criteria to handling - a situation where Virgin appears to be somewhat lacking and which the RAIB Report is more than a little remiss in addressing.

 

Once you have properly established norms you stick to them, you review them where considered necessary and you make sure your link structure and - where necessary - booked Route Refreshing days reflect them and you keep proper records to ensure compliance. All of this should be built into the organisation's safety structure and its level of compliance should also be tested - in a well managed company - by external audit as well (and some companies still do exactly that).

 

When investigating an incident of this nature there are two initial factors to look at - one is the signal and its compliance with whatever standards were relevant when it was commissioned or altered and whether or not it should have been altered in any way to comply with any retrospective changes to standards. The Report is not at all clear in that respect having a lot to say about current standards etc and little about what applied when the signal was commissioned or altered. The only other question is the approach control timing.

 

The investigation should be addressing the standards in use for route and handling in the TOC employing the Driver, how those standards are maintained, how they were (or weren't) maintained in respect of this incident and the extent to which this individual had complied with them? The Report fails to, in my view and past experience, adequately address those safety critical items but looks at it from a far less sophisticated and very incomplete viewpoint - and falls desperately short of where it should be in that respect and thus fails to address the root cause. Hopefully another RAIB investigation of a nasty SPAD elsewhere might be addressing those critical areas but alas I fear they will be looking tto hard at numerous other factors (some of which are very relevant) and are likely to miss the root cause yet again; but I do hope they will get it right next time.

[Guest Phil]

I'd also suggest that the rostering is as much at fault as the driver. Knowing the way driver's mind work, having been one for about 20 years in the past, 2most2 drivers, when on such a duty, have their eye on one thing, and that is finishing the job as quick as possible! That the loco had exceeded line speeds for a light engine in the "good old days" would have been immaterial, and in my view is still immaterial except at Bletchley crossover!

 

Sorry roythebus. Have to disagree with you there. There was no fault with the rostering otherwise the RAIB report would have highlighted it. I think what you had intended to say was that the Euston drivers had a ###### Thursday "night turn" which booked on at ten o'clock at night to fetch a light engine from Crewe. Not so ###### though because if you disregarded your PNB at Crewe and had a dash, you could be done in six hours and a taxi home to boot.

 

It is unfortunate that the driver wasn't concentrating on his task in hand, made a very expensive mistake, and a lot of other people have suffered the consequences. I wouldn't mind betting there were a couple of Euston drivers who really enjoyed that little job - what with night rate, and a chance to drive a loco light. But the overall costs of the mistake will be shared between the taxpayer and the companies who had to repair the track, OLE and loco.

 

The bit that is disconcerting is that 2K99 on the Down Main was stopped by emergency broadcast, but a few seconds later may have been in serious collision with the class 90. Not the kind of thing you want to think too much about.

 

Perhaps a stern reminder to footplate staff to pay attention to their signals.

[roythebus]

I'd tend to agree with you Phil, the rostering itself wasn't at fault, maybe the CONTENT of the work on the roster which would maybe encourage (literally in this case) cutting corners. I could probably recount numerous rosters on the SR where "fiddles" were worked out as soon as the rosters were planned, all of which were ok as long as everything went ok. Most worked to the drivers' benefit, and the management let it happen because if the driver was going to "get something out of it" then he'd turn up and do the job. Is what I meant!

['CHARD]

...But the overall costs of the mistake will be shared between the taxpayer and the companies who had to repair the track, OLE and loco.

 

As I type this there's a set of 'industry standard' Insurance Provsiions on my desk for attention, with some high limits stipulated. Surely VT's insurers had to stand out for the direct losses incurred as a result of this mishap?

[Edwin_m]

Strictly speaking the companies repairing the loco and the track would benefit from having the work. The losers would be the respective insurers*, VT for loss of revenue and reputation, and not least the many thousands of passengers whose journeys were disrupted.

 

*but they probably get it back by bumping up next year's premium.

[The Stationmaster]

Sorry roythebus. Have to disagree with you there. There was no fault with the rostering otherwise the RAIB report would have highlighted it.

 

In fact the Report didn't even address it! There is no mention at all of what the norm is for the route (or, to be precise, the Slow Lines) or how it was established or how it is linked let alone how it might be rostered or otherwise maintained by RR days etc. And when - in this day and age - an investigation is looking at anything involving a SPAD or misreading incident that should be one of their very first lines of inquiry.

 

Next week I shall be investigating a recent incident (not on NR I hasten to add) and one of the first things I will be checking is compliance with various relevant requirements and the provision of adequate instructions which would have any relevance to the incident.

 

And yes - as far as costs are concerned I would agree with 'Chard and place this one very firmly at the Train Operator's doorstep and the liability of their insurers. This sort of incident is one of the very reasons why operators have to be insured and the costs involved in this one are going to be pretty hefty.