RMweb Gold The Stationmaster Posted June 2, 2012 RMweb Gold Share Posted June 2, 2012 The apparent cause could prove to be quite controversial - whether it's judged as an alleged fault which should've been addressed on shed or an alleged driver error not to have known the risk and acted accordingly (ie to lock it in place). Glad I'm not the one who has to make that decision! But at this stage all of that is irrelevant - as I pointed out earlier in this thread ... "it is worth remembering that such incidents can potentially have both civil and criminal legal consequences in which facts would become far more relevant than internet chatter and opinion. " Many of us may, or may not have views on what did or did not lead to this sad event - at present, and until a proper Report is published and any legal avenues - be they civil or criminal - have been exhausted all we might be doing is adding more partially informed chatter to the internet blather. It will no doubt be quite a time in coming but I think there is nothing we can sensibly add until the RAIB have reported. And if anyone has, in the meanwhile, any relevant evidence which directly relates to this event or past matters which they consider might be relevant to it they should get in touch with the official investigators at the RAIB and make such information known to them. Link to post Share on other sites More sharing options...
oOld Harry 666 Posted June 2, 2012 Share Posted June 2, 2012 But at this stage all of that is irrelevant - as I pointed out earlier in this thread ... "it is worth remembering that such incidents can potentially have both civil and criminal legal consequences in which facts would become far more relevant than internet chatter and opinion. " Many of us may, or may not have views on what did or did not lead to this sad event - at present, and until a proper Report is published and any legal avenues - be they civil or criminal - have been exhausted all we might be doing is adding more partially informed chatter to the internet blather. It will no doubt be quite a time in coming but I think there is nothing we can sensibly add until the RAIB have reported. And if anyone has, in the meanwhile, any relevant evidence which directly relates to this event or past matters which they consider might be relevant to it they should get in touch with the official investigators at the RAIB and make such information known to them. But at this stage all of that is irrelevant - as I pointed out earlier in this thread ... "it is worth remembering that such incidents can potentially have both civil and criminal legal consequences in which facts would become far more relevant than internet chatter and opinion. " Many of us may, or may not have views on what did or did not lead to this sad event - at present, and until a proper Report is published and any legal avenues - be they civil or criminal - have been exhausted all we might be doing is adding more partially informed chatter to the internet blather. It will no doubt be quite a time in coming but I think there is nothing we can sensibly add until the RAIB have reported. And if anyone has, in the meanwhile, any relevant evidence which directly relates to this event or past matters which they consider might be relevant to it they should get in touch with the official investigators at the RAIB and make such information known to them. I think you are quite correct here Stationmaster. I think comment or speculation would be unwise until the results of all inquiries and any actions from them confirmed. Whatever anyone's personal views any such speculation could really land you in trouble if any legal charges should be brought following full investigations. Link to post Share on other sites More sharing options...
roythebus Posted June 2, 2012 Share Posted June 2, 2012 Having read the RAIB bulletin, it did make me wonder whether the loco has a steam reverser as some Southern locos have. These have been known to go "the wrong direction" when the reverser has been operated. A lot of locos were built with screw reversers. I went on a WP in India which had one and there is a securing device which goes on the reverser lever to prevent accidental movement. My thoughts also go out to the loco crew. Link to post Share on other sites More sharing options...
Mod4 Posted June 2, 2012 Share Posted June 2, 2012 I think you are quite correct here Stationmaster. I think comment or speculation would be unwise until the results of all inquiries and any actions from them confirmed. Whatever anyone's personal views any such speculation could really land you in trouble if any legal charges should be brought following full investigations. Totally agreed and lets not speculate any further or this thread will have to be locked. Link to post Share on other sites More sharing options...
Boris Posted June 2, 2012 Share Posted June 2, 2012 The initial press release says 'about 12.30' and RAIB say 'about 12.10' Neither of them are specific and is you take the word 'about' to mean 10 minutes either way then the accident could have occurred at 12.20 - but does that really matter? Surely what is important here is that the initial investigation appears to have identified an apparant fault in the loco that seems to have caused a sudden and unexpected change in direction. Note my use of the words 'appears', 'apparant' and 'seems to' as I don't want to be accused of prejudging the formal enquiry - see Andy post#2 and Mod5 #13 Mike As the signalman who was on duty at the time of the accident at Grosmont and given that I saw and dealt with everything, I find it fairly offensive that the RAIB who are investigating cannot even get the time the incident occurred correct. I've contacted the RAIB about this. Nuff said. Link to post Share on other sites More sharing options...
Boris Posted June 2, 2012 Share Posted June 2, 2012 I'd just like to agree with Mod4 (yes, there is a first time for everything) and say that this is a tragic accident, it is also quite complex and there is quite a bit more involved than the short outline the RAIB give so it probably is best to let the ORR, RAIB and the BTP do their work and await the outcome of the investigations. Link to post Share on other sites More sharing options...
RMweb Gold PhilH Posted June 2, 2012 RMweb Gold Share Posted June 2, 2012 Having read the RAIB bulletin, it did make me wonder whether the loco has a steam reverser as some Southern locos have. These have been known to go "the wrong direction" when the reverser has been operated. A lot of locos were built with screw reversers. I went on a WP in India which had one and there is a securing device which goes on the reverser lever to prevent accidental movement. My thoughts also go out to the loco crew. S15s have a screw reverser. Link to post Share on other sites More sharing options...
Andy Y Posted June 2, 2012 Share Posted June 2, 2012 I'd just like to agree with Mod4 (yes, there is a first time for everything) and say that this is a tragic accident, it is also quite complex and there is quite a bit more involved than the short outline the RAIB give so it probably is best to let the ORR, RAIB and the BTP do their work and await the outcome of the investigations. I think that's a fair point to lock this until such time as the report is available. Link to post Share on other sites More sharing options...
LNERJP Posted June 2, 2012 Share Posted June 2, 2012 Appoligies Andy for re-opening the topic. Can I just appeal for some sensativity when discussing this accident, as well as Boris I was there that day, in fact it was my Guard that was killed. The initial RAIB stamement does not cover a complex series of events. I went to the O gauge guild Halifax show today and whilst watching a nice layout I could'nt help but overheard one of the operators tell another ( as he was not being particularly discreet) give his version of events and who was at fault etc. Mostly inacurate and without knowledge. I had to walk away or I probably would have punched him. I know it's human nature to want to know what happend but please wait for the report. J.P. Link to post Share on other sites More sharing options...
RMweb Gold martin_wynne Posted October 18, 2012 RMweb Gold Share Posted October 18, 2012 The RAIB report is published. I can't add this to the existing topics because they are locked. http://www.raib.gov.uk/cms_resources/121018_R232012_Grosmont.pdf Martin. Link to post Share on other sites More sharing options...
Mod3 Posted October 18, 2012 Share Posted October 18, 2012 This topic has been reopened now the report is available, and Martins new thread has been merged. To prevent it being locked again let's keep the discussion sensible please. Link to post Share on other sites More sharing options...
RMweb Gold The Stationmaster Posted October 18, 2012 RMweb Gold Share Posted October 18, 2012 As someone who not only has a considerable amount of experience in examining staff on 'preserved' railways but also carries out operational audits on them and drafts Rule Books for them I find some aspects of this Report very puzzling. First of all there is no reference to, or commenting on lessons learned from, two past 'shunting incidents' on the NYMR although there is reference to those on other lines. Secondly although implied there is limited comment about the clear need of any Railway in this situation, or preparing documentation on its behalf, to keep abreast of and informed about what is happening in the wider railway world. In my view there should have been a much clearer reference to the apparent failure to keep their Rule Book up to date - clearly a longstanding situation because some some of the changes referred to in para 61 were made to the BR Rule Book between 28 and 30 years ago, i.e. they are hardly recent. Anyone involved in the management of railway Rule Books should be aware that they need regular revision and need to take into account what is reported to be happening in the wider world - the 1972 book is, for instance, inadequate when it comes to many areas of personal safety simply because it reflects the situation of 40 years ago and not that of today. On greater detail I must admit to being concerned by what the Report does not mention in direct relation to this terrible incident. The drawing is not dimensioned ( a potentially important omission), there is no comment upon the apparently confused situation when both the Fireman and the Guard were carrying out separate shunting tasks at the same time, and there is no mention at all of the '50 foot Rule' (as I call it) which was in the 1972 Rule Book (J 3.20) from its date of issue and which if followed should probably have avoided the incident as it stated Shunters must not go between vehicles less then 50 feet apart without first satisfying themselves --- that no shunting is taking place on the line which they are to cross'. No need - as at para 71 - for a 'supplementary instruction', but clearly a need to reinforce the contents of what is, or should be, in their existing Rule Book. Although not wholly relevant I do not regard the 2 metres figure at Para 65 as sensible or entirely realistic and am rather surprised at the RAIB using it without qualification (I always use 20 feet for as the initial stopping point all movements when a loco loco is approaching rolling stock of any sort but that is based very much on experience of what can happen with the 'interpretation' of distances in such circumstances). Overall, as alas is often the case with RAIB reports, I am not too impressed by some parts of this one nor with some of its observations etc - a feeling which I already know is shared by some with a professional involvement in some of the areas it mentions. Link to post Share on other sites More sharing options...
roythebus Posted October 19, 2012 Share Posted October 19, 2012 Some valid points there Mike. When I was trained by BR the rule was 6' before going between vehicles, having made sure any movement had stopped. I don't remember the 50' rule being taught at that time. One of the railways I am involved with has been talking about updating the rule book for years but has never really had the funding to print it, even though the draft had been in place for quite a while; they do, however, issue amendments when necessary. Unfortunately no amount of paperwork, audit trails or laws will prevent accidents happening. On the subject of screw reversers, I seem to remember locos with steam reversers have a habit of moving in the opposite direction to that shown on the reverser at times. Maybe this is another point that we ought to make known to the wider heritage railway community or we may see a repeat of this incident elsewhere. Link to post Share on other sites More sharing options...
RMweb Gold The Stationmaster Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 One of the railways I am involved with has been talking about updating the rule book for years but has never really had the funding to print it, even though the draft had been in place for quite a while; they do, however, issue amendments when necessary. Unfortunately no amount of paperwork, audit trails or laws will prevent accidents happening. That is a very valid point Roy (the number is usually followed by some noughts) but HMRI seem to take a different view and have in a number of cases that I know of 'required' Railways to update and reissue their Rule Books. In my view a good amendment and supplement process is adequate unless any major changes occur at which time reissue might be needed to ensure clarity - the next one I have on my list is about 12 years since last reissue and will need a lot of work on personal safety. How on earth a book based on the stuff of 40 years ago can be still valid in that respect puzzles me but we don't know all of the amendment situation (although it is obvious that the shunting section has not received the attention it needed). And yes again you are absolutely right - piles of paperwork until you are blue in the face and major deforestation has taken place but that is no substitute at all for training, examination, and supervision/audit checks. Interestingly there still seems to be this demand for 'tick lists' of what has been examined etc in this country whereas in my view you should always examine every aspect of a job/post and no need to note what has been examined because you have done all of it. Fortunately there are moves back towards that sort of approach in industrial etc safety although they have yet to reach British shores it would seem, fingers crossed Link to post Share on other sites More sharing options...
Kenton Posted October 19, 2012 Share Posted October 19, 2012 piles of paperwork until you are blue in the face and major deforestation has taken place but that is no substitute at all for training, examination, and supervision/audit checks. Interestingly there still seems to be this demand for 'tick lists' of what has been examined etc in this country whereas in my view you should always examine every aspect of a job/post and no need to note what has been examined because you have done all of it. However good the supervision, training and documentation from my read of the report this tragic accident was more about simple absent mindedness. All parties concerned were very well aware of what should be done and indeed were doing it in the period leading up to the event. Just a moment's absent mindedness, a taking for granted understanding in communication, possibly just a senior moment and it shows how easy it is for something tragic to happen. I don't see how any amount of training and documentation can prevent those moments. Simply put, too many assumptions made, the reverser was locked, the guard had moved away to the other platform, that the loco+coach was traveling away/had moved far enough, that the driver knew what the next move by the guard would be. Sadly in this case they all coincided to bring about the loss of life. Link to post Share on other sites More sharing options...
RMweb Gold The Stationmaster Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 However good the supervision, training and documentation from my read of the report this tragic accident was more about simple absent mindedness. All parties concerned were very well aware of what should be done and indeed were doing it in the period leading up to the event. Just a moment's absent mindedness, a taking for granted understanding in communication, possibly just a senior moment and it shows how easy it is for something tragic to happen. I don't see how any amount of training and documentation can prevent those moments. Simply put, too many assumptions made, the reverser was locked, the guard had moved away to the other platform, that the loco+coach was traveling away/had moved far enough, that the driver knew what the next move by the guard would be. Sadly in this case they all coincided to bring about the loss of life. Regrettably not Kenton. The whole point of safe systems of working (to use the modern jargon) is that they should cancel out absent mindedness or require a version of it akin to mass hysteria in that everybody suffers it at once and all of their individual contributions to safety fail at the same time. That is pretty difficult to achieve in a situation where everybody is fully aware of how they should behave or carry out certain tasks and where they have been regularly assessed and reminded of the right way to do things. The '50 foot rule' was specifically designed and framed to save lives and it is one which I have hammered into people at Rules exams and in the work situation for more years than I care to remember but it doesn't even get a mention in this Report. Many other things are summed up by the Report and some of them were so basic and so long in the tooth (as I said - 28 to 30 years old in some cases) as to leave me surprised that they were not practiced. Oh and one of the first things you should learn, or be taught, when involved in shunting is that you take nothing for granted; the old fashioned response of 'I thought that ....' instead of 'we agreed that ... ' was banished from this sort of work a long time ago. Link to post Share on other sites More sharing options...
Kenton Posted October 19, 2012 Share Posted October 19, 2012 Yet despite all the Rules and the evident compliance with them only minutes before they seemed to have tragically been forgotten in the instance of this accident. Although it is admirable to attempt to design out everything dangerous, from every conceivable circumstance, sadly humans do make mistakes. I cannot see the conclusion here that the Rules were deliberately not followed, simply that they were forgotten, or the potential consequence simply did not enter the minds of those involved. Link to post Share on other sites More sharing options...
RMweb Gold PhilH Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 As a steam loco driver on another heritage railway it strikes me that there is one inescapable fact. You use the outside world as a reference point to judge motion - for instance you will usually see drivers looking at the ground when starting away, purely and simply to judge that you are moving. I don't intend to make too much comment on this but experience dictates that I have to think that there was a distraction on the footplate, as if there were eyes outside the footplate the change in speed/direction would hopefully have been noticed soon enough for action to have been taken in time to avoid this awful incident. Link to post Share on other sites More sharing options...
RMweb Gold martin_wynne Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 The '50 foot rule' was specifically designed and framed to save lives and it is one which I have hammered into people at Rules exams and in the work situation for more years than I care to remember Hi Mike, How many people can judge 50ft with any accuracy? Wouldn't "one coach length" be a safer rule to hammer home? Martin. Link to post Share on other sites More sharing options...
RMweb Gold The Stationmaster Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 Hi Mike, How many people can judge 50ft with any accuracy? Wouldn't "one coach length" be a safer rule to hammer home? Martin. Absolutely agree Martin - which is exactly what I used to say when training or examining folk more or less as 'If you're not certain what 50ft looks like think of the length of a coach and you'll be on the safe side' and I know others who did the same. Incidentally the other thing was to ram into peoples' minds the bit about no movement taking place or about to take place - in either direction because something might go wrong and it could come back towards you (but I know full well that not everybody emphasised that part. Link to post Share on other sites More sharing options...
AberdeenBill Posted October 19, 2012 Share Posted October 19, 2012 I am certainly(!) not an expert professional like Mike, but I have read a fair few "historic" accident reports on the Railways Archive site, and this tragic incident has eerie similarities with many of these in terms of a combination of several relatively minor human errors or small (if that word is appropriate) transgressions of the rule book, which by themselves would have no serious consequences, but together led to disaster. That, of course, is why Rule Books are called just that. Bill Link to post Share on other sites More sharing options...
RMweb Premium The White Rabbit Posted October 19, 2012 RMweb Premium Share Posted October 19, 2012 As Bill points out above, many accidents only happen due to a combination of factors. Having read the report today, I can see how 'easily' this happened. As a working volunteer (elsewhere) myself, I have some experience of shunting and know how easy it can be to make assumptions and take short-cuts. 99 times from a 100 there's no problem, but that 100th time - oh dear... We deal with carriages weighing 30-35 tons and locos 50-200 tons - they are large, hard, unforgiving objects even when stationary. I was taught the 50' rule and after seeing the consequences of a train hitting a cow (vandalised lineside fence) I never take chances. I'd sooner look a bit of a prat by asking a 'silly question' and checking than put myself & others at risk. Apparently, Japanese lineside workers have to stop and point in both directions before crossing a line - this shows they have looked [properly] both ways rather than just glancing and going. As well as keeping the rule-makers happy, this is supposed to concentrate the mind so you do actually look rather than just glance. When shunting, we usually use radios (even in daylight) and check each move before it's made. It might cause passengers to smirk and make comments about ex-Navy personnel, but repeating the instruction back to the person making it shows you've understood it and gives a chance for any mis-understanding to be corrected before anyone 'goes between' or puts themselves in a potentially dangerous position. That's not in (our) rule-book (yet?), it's a SOP the Operating Department introduced to minimise the chance of mistakes. Link to post Share on other sites More sharing options...
roythebus Posted October 19, 2012 Share Posted October 19, 2012 It is easy when shunting to plan to do "A" the "B", then on the way decide to do something slightly different because it's on the way. I know, I've done it myself when shunting. The poor chap at t'Moors seems to have done that. In future I'll stick with plan A then plan B. anything else can wait. Even under instruction things can happen. WhenIi was being passed out as shunter on the ***R, the 08 spilt the points and ended up on the ground. whose fault? The examiner saw me check the points, I know i checked the points..but I won't discuss that any further here except to say I passed! On rules, LT used to say when applying Rule 55 (passing signals at danger) to pass the signal, reset the trip cock, and travel at such a speed at which you could count the sleepers. Whcih is what one driver on the Bakerloo did, and ran into the train in front because he was counting sleepers... the training was changed a bit after that. Link to post Share on other sites More sharing options...
coachmann Posted October 19, 2012 Share Posted October 19, 2012 On rules, LT used to say when applying Rule 55 (passing signals at danger) Maybe its old age on my part, or past my bedtime, but I seem to remember Rule 55 meant something entirely diferent, like standing at a signal for something like three minutes then going to the signalbox to remind the bobby we were there, plus checking that safeguards were in place to protect our train and signing the train register to confirm this. Apologies in advance if Rule 55 meant something different on the LT. Link to post Share on other sites More sharing options...
RMweb Gold The Stationmaster Posted October 19, 2012 RMweb Gold Share Posted October 19, 2012 Maybe its old age on my part, or past my bedtime, but I seem to remember Rule 55 meant something entirely diferent, like standing at a signal for something like three minutes then going to the signalbox to remind the bobby we were there, plus checking that safeguards were in place to protect our train and signing the train register to confirm this. Apologies in advance if Rule 55 meant something different on the LT. Rule 55, Clause g was exactly the same in the 1949 LT Rule Book as it was in the 1950 BR Rule Book in respect of passing certain types of signal at danger but there are one or two subsequent additions (which make no difference to what was explained by Roy - apart from tripping the Trainstop of course). However where Coachman was on the footplate I would be surprised if that clause would ever need to be applied as the type of signals to which it referred (automatic signals) weren't exactly common in that part of the world back then. Link to post Share on other sites More sharing options...
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