SIMON FRENCH
Deputy Chief Inspector, RAIB
The Rail Safety Summit  2015
Rail Accident Investigation Branch
Lessons learnt from investigations (2014-15)
Rail Safety Summit 2015
Simon French
Deputy Chief Inspector
2
Introduction
• In the last year the RAIB has:
o published 22 reports and 2 bulletins
o made a total of 84 recommendations for the
improvement of railway safety
• So what are the big themes?
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Track worker safety (1)
High levels of discipline and vigilance are vital if safety
is to be maintained on site
•
how is this best achieved, particularly
for those who are experienced and
familiar with the task?
•
there is a need for continued focus on
promoting safe behaviours; how can
this best be achieved?
•
do managers know how their teams
are working?
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[Fatal accident involving look-out near Newark
North Gate station (report 01/2015)]
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Track worker safety (2)
Good advanced planning is
essential to enable the selection
of the safest system of work
The need for safe system of work
documents to be accurate and
clearly presented
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[Passenger train collision with trolley at Bridgeway,
near Shrewsbury (report 25/2014)]
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Managing the vehicle/track system interface
Industry needs to research
and risk assess the uneven
loading of container wagons,
and then to promote
adoption of reasonable
practicable mitigation
measures
[Freight train derailment at Primrose Hill
(report 21/2014)]
Managing the vehicle/track system interface
Residual risk at the VTI
8
Managing the vehicle/track system interface (2)
Total = 38
Train preparation, 3
Condition of rolling
stock, 5
Track condition, 4
Signaller error, 2
Driver error, 3
S&C condition, 2
Earthworks failure, 4
Overspeeding, 1
Interaction of deficient
rolling stock and poor
track condition, 8
Interaction of uneven
wagon loading and poor
track condition, 5
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Track quality
There is a need to identify high risk assets and put in place effective
management systems, implemented by staff with the necessary
competencies [Derailment of passenger train at Liverpool Street (report
27/2014)]
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Track quality
Staff and local managers need to be helped to manage
recurrent track faults more effectively, particularly in the
case of cyclic top faults [Freight train derailment near Gloucester
(report 20/2014)]
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Managing platform/train interface risk
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[Passenger dragged by LUL train at Holborn (report 22/2014)]
Managing platform/train interface risk
Areas of potential safety improvement; eg
•
•
•
•
•
dispatch equipment and procedures
reducing platform edge gaps
design and testing of train door obstruction detection systems
promoting passenger awareness of the risk
managing risk of platforms that slope towards the track
The RAIB is pleased to note that the ORR has worked with the railway
industry to establish a cross-industry group to develop a strategy for the
management of the
platform
train interface
(the ‘Platform Train Interface
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Strategy Group’).
Managing platform/train interface risk
Is there more we can do to manage the risk of platforms that
slope towards the track?
[Wheelchairs rolling onto the track at Southend Central and Whyteleafe (report 17/2014)]
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Driver management
There is a need to better manage the non-technical skills of
drivers and other operational staff; eg
•
•
How best should operators assess such factors?
How best should operators respond when drivers are exhibiting signs that
they are deficient in an area (eg lapses in concentration)?
[Train collision at Norwich (report 9/2014)]
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Safety at user worked crossings
There is a need for the railway industry to better understand how
road vehicle drivers behave at user worked crossings and to
optimise sighting, signage and layout accordingly.
[Collision at Jetty Avenue level crossing (report 28/2014)]
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Safety at user worked crossings (2)
What more should be done to manage risk at times of peak
demand (eg harvesting)?
[Collision at Buttington Hall user worked crossing (report 6/2014 v.2)]
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Signalling design
Exploiting reasonable opportunities to improve safety when undertaking
upgrade projects.
The continued need for engineered safeguards to protect against a single
human error.
[Near miss at Llandovery level crossing (report 11/2014)]
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Signalling design
Exploiting low cost information and communications technology (eg to provide
fault data from locally monitored automatic crossings to maintainers).
[Near miss at Butterswood level crossing (report 12/2014)]
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Low adhesion
What can our trains tell us about low adhesion conditions?
[Buffer stop collision at Chester station (report 26/2014)]
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Engineering safety management in design and
modifications of plant
Quality assurance within suppliers, to ensure plant is fit for purpose
[Runaway of RRV at Queen Street, Glasgow (report 15/2014)]
[Runaway of on-track machine at Bryn (ongoing)]
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Risk management during rolling stock’s life
cycle
Ensuring that operators and maintainers understand and
manage the risks that were identified by designers
[Passenger trapped in train door and dragged at Newcastle Central (report 19/2014)]
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Risk management during rolling stock’s life
cycle
The need to correctly translate design intent into effective
maintenance procedures
[Derailment of Heathrow Express train at Paddington (ongoing)]
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Train protection systems
Train protection systems (AWS, TPWS, ATP etc)
• must be understood by drivers
• must not be isolated, or rendered ineffective, inappropriately
• must not be reset without authority
[Double SPAD at Greenford (report 29/2014)]
[SPAD at Wootton Bassett (investigation is ongoing)]
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Train management systems
Do our train management systems enable crews to manage
emergencies effectively, and are they trained and competent to
do so?
[Uncontrolled evacuation of an LUL train at Holland Park (report 16/2014)]
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Ongoing investigations
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Ongoing investigations
- Lorry fire on Mission 7340 (Jan 2015)
Fire on Eurotunnel freight shuttle in Channel
Tunnel. Currently subject of joint RAIB/BEA-TT
investigation
RAIB web entry update on 05 March
•
Fire caused by electrical arcing event near UK
portal
•
Fire first detected on the approach to the
French SAFE station – but too late to stop
within it
•
Investigation will consider the modification of
carrier wagons (removal of roofs) and the
response to previous arcing events (eg fire in
Nov 2012)
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Ongoing investigations
- Froxfield (Feb 2015)
Bridge parapet pushed onto the
Berks and Hants by lorry reversing
on the bridge having taken a wrong
turning
Investigation will consider the time
elapsed between the first 999 call
and notification of the signalling
centre
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Ongoing investigations
- Wootton Basset (April 2015)
Brake application automatically activated
following a late response to an AWS
warning
Driver and fireman instead took an action
which cancelled the effect of the AWS
braking demand - the action taken also
had the effect of making subsequent AWS
or TPWS brake demands ineffective
Subsequent signal passed at danger
Train came to a stand across a high speed
junction less than 1 minute after the
passage of a previous express train 29
Container blown off trains
- Scout Green (March 2015) and Deeping St Nicholas (April 2015)
Urgent Safety Advice issued by
RAIB concerning:
• the need to review operating
restrictions for wagons with
spigots that do not comply with
the UIC standard; and
• the need for modifications to the
wagons concerned to remove the
possibility of containers being
blown off moving trains
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