Tangmere SPAD - RAIB update

[martin_wynne]

RAIB have today posted an update on the Tangmere SPAD at Wootton Bassett:

 

 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469145/151019_Wootton_Bassett_web_update.pdf

 

original topic (locked):

 

 http://www.rmweb.co.uk/community/index.php?/topic/97644-tangmere-spad-raib-investigation/

 

Martin.

[Bruce Depot]

Having just read the update, it paints a very poor picture. Just wondering how long the AWS isolating cock may have been unsealed for prior to this incident!

[Talltim]

I'd be interested to know where the AWS Acknowledgement/Cancel button was located, especially with regards to the driving position adopted (head out of side window)

Also a couple more questions.
The driver was using the Vacuum brake controls, thus not controlling the brake on air brake fitted support coach. Presumably this would affect braking distances, but not greatly?
Does the AWS control the air brake (and thus the vacuum and steam brakes)?

[Gwiwer]

I'd be interested to know where the AWS Acknowledgement/Cancel button was located, especially with regards to the driving position adopted (head out of side window)

Also a couple more questions.

The driver was using the Vacuum brake controls, thus not controlling the brake on air brake fitted support coach. Presumably this would affect braking distances, but not greatly?

Does the AWS control the air brake (and thus the vacuum and steam brakes)?

 

 

As I understand the rules (which apply to all trains) it is permissible to have the automatic brake inoperative on not more than one vehicle of a train of this length.  In other words 12/13 vehicles braked plus loco and tender was, to my understanding, within the rules which are set to allow the continued operation of a train which may have suffered an otherwise disabling failure of the brakes on a single vehicle.  The braking distance is extended but not by much.

[Siberian Snooper]

It surprises me that the support coach is not dual braked, most of the support coaches that I have seen have been so fitted.

[Glorious NSE]

I agree - especially given it must then have been vac through piped to get functional brakes on the rest of the train?

[Junctionmad]

paints a poor picture, that report does.  It clearly points to allegations that the isolating valve was used on a regular basis to bypass AWS brake demands

 

it raises interesting issues as to the suitability of stream locomotives running on a railway signalling system and signal sighting designed for very different loco cabs 

[PaulRhB]

Suitability? You can isolate it on diesels and units just as easily if you bypass seals. I suggest you read other RAIB reports about SPADS on units and the recent diesel light loco one where DSD systems were isolated by a known failure https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/410723/130916_R162013_Stafford.pdf. The driver has access to isolate TPWS, AWS and DSD for emergencies where there is no other way to release it, it just relies on training and policy being audited to ensure it isn't abused.

The type of traction has no relevance in the SPAD. The isolation switches are deliberately put where the driver on a unit has to leave the seat to operate them.

[Derekstuart]

Some people here must have been reading a totally different report to the one I have just read.

 

In the one I read it stated facts that they have identified. It makes no un-proven accusations nor does it discuss the general viability of steam locomotives on the main line. Nor does it state or imply that the AWS was isolated for any extended length of time or as a matter of routine. It is being looked into but that is not the same as saying it had been.

 

Perhaps those of us who are not qualified to investigate such matters should refrain from unhelpful and potentially damaging comments until further investigations have been confirmed.

 

EDIT: As bold. Pressed send before proof reading.

[Talltim]

Some people here must have been reading a totally different report to the one I have just read.

 

In the one I read it stated facts that they have identified. It makes no un-proven accusations. Nor does it state or imply that the AWS was isolated.

 

Perhaps those of us who are not qualified to investigate such matters should refrain from unhelpful and potentially damaging comments until further investigations have been confirmed.

I think you are right, you were reading a different report.

The driver indicated to the fireman that an AWS brake demand had occurred. His expectation was that the fireman would open the AWS isolating cock in order to by-pass the AWS brake demand and release the brakes. The fireman has stated that he believed that he was following the driver’s instructions when he subsequently crossed the cab and opened the AWS isolating cock

[PaulRhB]

Nor does it state or imply that the AWS was isolated.

 

.

Page 5 bullet point 18

[Derekstuart]

Paul,

 

thanks- I did of course mean that there is nothing to prove it was being left for any length of time, but you are right to pick it up as badly written.

 

Tim,

 

there are people in this thread that are querying the future of steam on the mainline, despite the quite sensible point that modern traction has the same over-rides (as Paul notes). The same people are also queuing up to discuss the suitability of the braking arrangements for the train- despite this not being questioned by the RAIB.

 

At least it saves them standing behind curtains watching who is going into Mrs Miggins house on a Monday evening I suppose.

[Talltim]

No, it doesn't implicitly say how long the AWS cock was open for, but it does say that the train was not stopped by the magnet for the signal at danger because the AWS system was still disabled. That's long enough for me...

[PhilH]

Looks like the experts will be out in force for this one.

[phil-b259]

Paul,

 

thanks- I did of course mean that there is nothing to prove it was being left for any length of time, but you are right to pick it up as badly written.

 

Tim,

 

there are people in this thread that are querying the future of steam on the mainline, despite the quite sensible point that modern traction has the same over-rides (as Paul notes). The same people are also queuing up to discuss the suitability of the braking arrangements for the train- despite this not being questioned by the RAIB.

 

At least it saves them standing behind curtains watching who is going into Mrs Miggins house on a Monday evening I suppose.

 

Overide controls are indeed fitted to other motive power and nobody is contesting that point.

 

The significant paragraph for me is number 26 which states:-

 

 

The evidence available to the RAIB indicates that the SPAD at SN45 was not

the only occasion on which the AWS isolating cock was used by a train crew

operating Tangmere in order to by-pass an AWS brake demand. The extent of

this practice continues to be the subject of further investigation.

 

TOC drivers are under no illusions about such practices - they are banned and will result in dismissal and at least one former TOC driver is / has spent time in prison for such antics. Steam charter providers should not be allowed in the main line if they cannot put in place a similar monitoring and disciplinary regime.

[martin_wynne]

This seems to me to be the most significant detail:

 

The railway rule book permits the drivers of trains that are in service to isolate
the AWS system only if it has become defective or if it is inoperable due to the
configuration of the infrastructure.  In these circumstances, the railway rule book
requires drivers to immediately bring their trains to a stand and then contact the
signaller.  Certain conditions must then be met before the train can proceed any
further.

[Glorious NSE]

there are people in this thread that are querying the future of steam on the mainline, despite the quite sensible point that modern traction has the same over-rides (as Paul notes). The same people are also queuing up to discuss the suitability of the braking arrangements for the train- despite this not being questioned by the RAIB.

Actually no, different people. You can tell by the different names...

 

The coach braking appears to me to be a query plus an observation, not a criticism, so I don't really see why you are getting quite so worked up over it...

[PhilH]

 

 

TOC drivers are under no illusions about such practices - they are banned and will result in dismissal and at least one former TOC driver is / has spent time in prison for such antics. Steam charter providers should not be allowed in the main line if they cannot put in place a similar monitoring and disciplinary regime.

 

DBS crews are used by a lot of the 'Steam charter providers'.

[Derekstuart]

Phil,

 

For me the part saying "...continues to be the subject of further investigation..." is the important part.

 

It is not for people here to either defend or rebuke the company. Is this a case of one or two train crews or is it a widespread case with the support of management into breaking rules. I don't know and I wouldn't want to speculate. Neither will the RAIB.

 

It's the same when an aircraft lands in an emergency and daily mail/express/etc readers all suddenly become air accident investgation specialists "was this happening/ was that happening/might have been this/might have been that."

All I am saying is that speculation is at best un-helpful; even people who ARE qualified in this matter will surely be unable to judge unless they have been party to the investigation and have the evidence available to them.

 

Derek

[Derekstuart]

I'm not getting worked up over it at all.

 

I just find people speculating and infering matters in relation to a potentially very serious accident to be un helpful at best. This is a commercial company and their reputation could well be damaged by people making such statements and implying 'facts' which may or may not be correct.

 

The RAIB together with the ORR is far better placed to decide what the outcome should be than anyone on this forum.

 

Actually no, different people. You can tell by the different names...

The coach braking appears to me to be a query plus an observation, not a criticism, so I don't really see why you are getting quite so worked up over it...

[The Stationmaster]

I'd be interested to know where the AWS Acknowledgement/Cancel button was located, especially with regards to the driving position adopted (head out of side window)

Also a couple more questions.

The driver was using the Vacuum brake controls, thus not controlling the brake on air brake fitted support coach. Presumably this would affect braking distances, but not greatly?

Does the AWS control the air brake (and thus the vacuum and steam brakes)?

The lack of a continuous brake on the support coach was within the old Regulations which would have allowed 1 in 6 to be unbraked (but obviously piped).  However it does pose an interesting question because if the support vehicle was marshalled next to the engine (the usual place) how would the train be moved when it became the rear vehicle (and therefore not compliant with the Regulations)?  The consequences of running with an unbraked vehicle on the rear of any train are potentially very serious and I'm a little surprised (in some respects) that it has not been addressed by the RAIB Report.

 

So this one is just as important a question for West Coast as all the others as the train was presumably going to have to reverse at Southend and might well have reversed earlier in the day - or was the support vehicle shunted from end to end (and if so how)?

[phil-b259]

Phil,

 

For me the part saying "...continues to be the subject of further investigation..." is the important part.

 

It is not for people here to either defend or rebuke the company. Is this a case of one or two train crews or is it a widespread case with the support of management into breaking rules. I don't know and I wouldn't want to speculate. Neither will the RAIB.

 

It's the same when an aircraft lands in an emergency and daily mail/express/etc readers all suddenly become air accident investgation specialists "was this happening/ was that happening/might have been this/might have been that."

 

All I am saying is that speculation is at best un-helpful; even people who ARE qualified in this matter will surely be unable to judge unless they have been party to the investigation and have the evidence available to them.

 

Derek

 

Yes I know it says investigations are ongoing BUT the RAIB would not have put down in words what they did in paragraph 26 UNLESS they had SUFFICIENT EVIDENCE to back up their statement. As such its fairly obvious that Tangmere's crew were, on this particular run guilty of some serious shortcomings with regard to the use of isolation procedures.

 

Whether it was a one off or systematic of wider failings will no doubt be revealed in the full report and in that sense I fully agree we cannot apply blame to any particular individual as it were - but you cannot deny that based upon what the RAIB has published thus far, the crew operating Tangmere on that day, to put it bluntly shouldn't have been on the footplate as they should have been complying with the rules and stopping  + advising the signaller EVEY time the got an AWS / TPWS intervention rather than by-passing it..

[PhilH]

The lack of a continuous brake on the support coach was within the old Regulations which would have allowed 1 in 6 to be unbraked (but obviously piped).  However it does pose an interesting question because if the support vehicle was marshalled next to the engine (the usual place) how would the train be moved when it became the rear vehicle (and therefore not compliant with the Regulations)?  The consequences of running with an unbraked vehicle on the rear of any train are potentially very serious and I'm a little surprised (in some respects) that it has not been addressed by the RAIB Report.

 

So this one is just as important a question for West Coast as all the others as the train was presumably going to have to reverse at Southend and might well have reversed earlier in the day - or was the support vehicle shunted from end to end (and if so how)?

 

Support coach usually goes with the engine, although there are obviously exceptions. Turning is usually done on triangles there not being many turntables left, this can sometimes mean running many miles just to turn.

[martin_wynne]

I'm a little surprised (in some respects) that it has not been addressed by the RAIB Report.

 

Hi Mike,

 

This isn't the RAIB Report. It is only a "Web site update".

 

Martin.

[The Stationmaster]

Phil,

 

For me the part saying "...continues to be the subject of further investigation..." is the important part.

 

It is not for people here to either defend or rebuke the company. Is this a case of one or two train crews or is it a widespread case with the support of management into breaking rules. I don't know and I wouldn't want to speculate. Neither will the RAIB.

 

It's the same when an aircraft lands in an emergency and daily mail/express/etc readers all suddenly become air accident investgation specialists "was this happening/ was that happening/might have been this/might have been that."

 

All I am saying is that speculation is at best un-helpful; even people who ARE qualified in this matter will surely be unable to judge unless they have been party to the investigation and have the evidence available to them.

 

Derek

The answer is very straightforward - the update (for that is all it is) refers to continuing investigations within the operating company and it is public knowledge that said company has brought in consultants to review its Safety Management System and also that because of this incident following previous shortcomings it was not permitted to operate over NR's network for a period .  All of that is known.  

 

What is not known as yet (other than in occasional snippets which have become public knowledge) is what the RAIB has found during its investigations of procedures and practice within the company.  No doubt the outcome of those investigations will be part of the RAIB's Report into the incident when it is published.  However Para 26 does suggest that the company might have a history of shortcomings in respect of AWS isolation procedures and that is one aspect of the ongoing investigation