SIMON FRENCH Deputy Chief Inspector RAIB The Rail

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? SF-4. 1. 8. 1 v 2 13. 11. 09

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? SF-4. 1. 8. 1 v 2 13. 11. 09 [Fatal accident involving look-out near Newark North Gate station (report 01/2015)]

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 SF-4. 1. 8. 1 v 2 13. 11. 09 [Passenger train collision with trolley at Bridgeway, near Shrewsbury (report 25/2014)]

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) ; 1 Total = 38 ure ail ef r ctu u Str 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 SF-4. 1. 8. 1 v 2

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

Managing platform/train interface risk SF-4. 1. 8. 1 v 2 13. 11. 09 [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 SF-4. 1. 8. 1 v 2 13. 11. 09 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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

Low adhesion What can our trains tell us about low adhesion conditions? [Buffer stop collision at Chester station (report 26/2014)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

Risk management during rolling stock’s life cycle Ensuring that operators and maintainers understand manage the risks that were identified by designers [Passenger trapped in train door and dragged at Newcastle Central (report 19/2014)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

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)] SF-4. 1. 8. 1 v 2 13. 11. 09

Ongoing investigations 26

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) 27

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 28

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 30