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Limit the rules to essentials

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Written by Colin Wheeler

Still relevant eight year old homilies?

In the current political and financial climate we all need to make savings whilst improving safety at the same time. Over Easter I cleared out some old paperwork and came across details of a commercial two day conference I chaired in London back in June 2004!

The speakers came from Germany, Denmark, the Netherlands, a British University and the Institute of Safety and Health as well as the UK rail industry itself. Picking out a few homilies from the presentations made me wonder how much things have changed.

Some examples: “those doing the work understand it and have good ideas, limit the rules to essentials, leadership is understanding concerns and addressing them, regular staff meetings never briefings, listen and earn staff commitment”.

Perhaps my two favourites are “always welcome reporting and increases in reports of both accidents and incidents” and “conversation is how humans think, we do not obey we choose to comply-or not”.

Block Roadmen or Possession Supporters?

On March 2nd the relevant Network Rail National Delivery Service “Competence Specialist” sent out a “Line Manager’s Briefing Note” giving notice of the introduction of a new “Possession Support Competence” which must be briefed. I wonder if the author has ever undertaken Block Roadman Duties himself.

The change of name I suggest will not be adopted immediately and may well contribute to resistance to the concept.

The duties are those generally known for Block Roadmen including the placing of protection-detonators, worksite, possession limit and marker boards etc.

Transitional assessments are to take place from 3rd September and PICOP’s, Engineering Supervisors; Controllers of Site Safety etc. will be briefed, another top down initiative. I assume the proposals for change did not come from an experienced current Block Roadman?

The over-heated boiler on the 15 inch gauge railway

It is thankfully rare to receive a Rail Accident Investigation Board (RAIB) report about a 15 inch gauge Light Railway incident.

On 3rd July 2011 a train driver on the Kirklees Railway near Huddersfield failed to check and top up the water in the boiler of his locomotive.

He was newly trained and passed out to drive on June 19th but had previous experience with his own seven and a half inch gauge locomotives.

The timely intervention of “the responsible officer” resulted in the fire being dropped but not before the fusible plug had melted. The driver doubtless had the knowledge but…?

Bridge problems near Bromsgrove

The partial failure of Bridge 94 near Bromsgrove on April 6th last year was discovered by a track inspection just eight days earlier. Maintenance staff sent to monitor the situation saw that ballast falling into the watercourse under the bridge and an Emergency Speed Restriction was imposed.

Although of small span this bridge as detailed in the RAIB report consists of seven side by side track carrying decks comprising five concrete decks and two 3-ringed brick arches.

According to the report by the RAIB the 1993 report had gone missing and with there being a bend in the watercourse under the tracks carrying out a detailed inspection “within touching distance” was not achieved subsequently.

The recommendations stress the importance of carrying out a “reconnaissance visit” when planning for detailed examinations.

The 2005 detailed examination did not include the arch spans and it was one of these that failed and allowed ballast to fall through. Whilst I do not disagree with the RAIB findings I would be surprised if no local staff knew the form of construction in detail.

Local knowledge of structures like these which have been in place for decades is usually available provided local people are involved. Did one of the maintenance team or his father/uncle know more? The RAIB also suggests that Structures Maintenance Engineers should not be wholly office based- I agree.

91 line crossings in one day following calls to the signallers?

There is a lesson to be learnt from the findings of the RAIB Inquiry into the user crossing collision on September 25th 2011 between a tractor hauling a trailer of sugar beet and the Class 365 4-car train from Kings Lynnto Ely travelling at 70 mph at Whitehouse Farm Crossing.

The visibility from the crossing meant that the driver only saw the tractor on the crossing when it was less than 100 yards away.

The second wheel-set of the train was derailed but the train remained upright and fortunately, although the front of the tractor was separated from its cab by the impact its driver only suffered a broken collar bone, lacerations and bruising.

There had been contact between Operations Management and drivers of the tractors bringing in the crop before harvesting began.

Indeed the tractor driver had been given permission to cross before the signaller confirmed that the train had passed, but when one reads that there have been no fewer than 91 recorded crossings the previous day the arrangements made for use of the crossing during harvesting are rightly questioned.

The cab was left hanging by hoses and electrical cables

Worrying too are the incidents and accidents currently under investigation by the RAIB. At Blatchbridge Junction near Frome in Somerset on 12th March this year a seven year old track relaying machine being hauled by a diesel locomotive destroyed part of a footpath crossing as it approached the Junction.

The under-slung cab of the machine had become detached and swung out to beyond the normal train gauge. It was only restrained by electrical cables and air hoses and the subsequent examination revealed that all eight of its restraining bolts had sheared off.

Five sheared bolt ends showed evidence of metal fatigue. The other three were not recovered. The potential effects on passing trains or as the train passed through station platforms is perhaps not worth thinking too much about!

The RRV that ran away into Bradford Interchange Station

Perhaps this March was not so good from the perspective of accidents. At 0650 hours on the morning of Sunday March 25th a Road Rail Vehicle (RRV) ran away at Bradford. It was at the end of the shift when the accident occurred.

The RRV was being off-tracked at an access point. According to the preliminary RAIB report the operator “placed it into a state where the unbraked rail wheels were not fully pressed against the road wheels at one end of the vehicle and completely clear of the road wheels at the other end”.

The vehicle ran away from the access point travelling downhill some 380 metres before crashing into the buffer stop at the end of platform 1 of Bradford Interchange Station. The operator managed to jump clear before the impact and suffered only minor bruising as a result.

The overridden interlock system

In their preliminary report the RAIB also comment that “the vehicle is fitted with an interlock system that is intended to prevent this situation from arising. However the interlock can be overridden using a push button mounted in a box on the side of the vehicle; the time this was being pressed by a member of the gang standing alongside. As the vehicle started to roll the interlock override button was released. The Operator was then unable to alter the position of the rail wheels to stop the vehicle.”

Whilst not wishing to prejudice the usual detailed inquiries of the RASIB in any way, I wonder if there is a danger that over sophistication has prevented the use by the operator of his competence, knowledge and skills.

Safety Central Website reports

Two recent incidents are reported in Network Rail Infrastructure Group Safety Bulletins. On February 2nd a Section Manager, Supervisor and Lookout gained access to the track via the Bricklayers Arms access point to inspect track between London Bridge and New Cross.

On completion of the inspection the Manager and Supervisor moved to the cess to discuss their findings with the Lookout standing alongside them.

They stood so close to the track that when a train passed it hit the Lookout’s equipment bag and knocked him over. He suffered only very minor injuries and the incident was caught on the cab camera. If they had not been seen from the cab would this incident have been reported?

Culture, rules and trust

Last month I emphasised the need for a change in safety culture, the importance of everyone feeling they want to report incidents and accidents in the belief that by doing so they may stop someone else from making the same mistake.

I am still waiting to see Network Rail’s new “Vision for Safety” which we are told to expect this month! I am also keen to see the mere handful of life saving rules we are promised.

Listening and trusting those who work outside day in and day out I still believe is the key to achieving zero accidents.

That trust has to be earned by local management being seen and by them being empowered to make things happen. I recall a time when each section was given a small safety spending budget to improve or eliminate a hazard on their patch.

Most made something safer but the real benefit was the change of attitude driven by the fact that someone in authority was providing the finance and encouraging them to be safe. “We do not obey, we choose to comply or not”.


  1. At some stage in any large organisation there is a transition from standard, knowledgeable management to inflexible rules based bureaucracy. This often comes about through the need to comply with external rigid regulation and is also not helped by fast track narrow skills direct intake of top level staff.

    Another way of looking at this is that management understand the whole business whilst bureaucracy only understands the workings of bureaucracy. This always results in a self serving perpetuation of the bureaucracy. Ever wondered why reorganisations tend to leave the top levels untouched?

    Those outside the bureaucracy can often become less efficient in their work as they become fearful of using job based experience and common sense without first gaining permission which will, even if forthcoming, take too long to be granted and reinforce the view of those on the ground that those in the office know nothing. This leads to a steady decline in morale and efficiency often leading to the loss of experience within the organisation.

    This brings us to the most difficult stage of a bureaucracy. At regular intervals, due to inherent shortcomings, the bureaucracy must be torn down in a back to basics manner. It will resist this until it is too late for the organisation as a whole, and it will grow again but there will be an opportunity for a real window of innovation in the meantime.


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