HomeGeneral InterestDelegation and accountability, making decisions using engineering judgement

Delegation and accountability, making decisions using engineering judgement

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Report by Colin Wheeler.

When something happens on the railway, who is accountable? And who can stop work or trains until it’s safe to run?

Colin Wheeler, in his regular safety column for RailStaff, remembers the time when the engineer in charge really WAS in charge and questions whether the same philosophy applies today.

Working as a railway engineer, I was part of organisations which would now be viewed as autocratic. During years with British Rail, I worked out of offices in Leeds, York, Sheffield, London, Newcastle upon Tyne, Manchester and Liverpool. I recall management meetings at which I was either present at, told about or chaired. There was no question of voting followed by a majority decision leading to corporate responsibility. The engineer was personally responsible for the railway infrastructure and could be held accountable.

There were occasions when I found it necessary to overrule the management team. I recall the railway’s solicitors informing me that, if things went wrong, legal assistance would be provided, but, if found guilty of getting it wrong, I could expect to lose both my job and my pension!

This ensured a personal focus on safety.

The responsibility chain was clearly defined in the out-based districts and divisions. I was impressed by the understanding of track patrollers and supervisors that, if they found an unsafe section of railway, it was their immediate duty to report it and, if warranted, tell the signaller to stop trains running.

Finding a derailment level of track twist, embankment giving way, broken rail, flooded tracks or a bridge damaged by a large road vehicle rendering it unsafe to use are relevant examples.

The decision to close the railway or to impose an axle weight or speed restriction could only be lifted by someone both qualified and senior, who then themselves became personally responsible.

“Lack of engagement”

The investigation included the examination of records of meetings with the local council and Environment Agency dating back as far as the 1960s. In turn, this led to the identification of a “lack of engagement between the various parties responsible for the flood management system”.

In the July/August edition of Railstaff, I reported details of the accident investigation by RAIB (Rail Accident Investigation Branch) of the eight-coach HST passenger train at Corby in Northamptonshire that ran into material that had been washed onto the tracks and subsequently became trapped when more wash out material came down behind it.

I suggest the failure was due to no single, identified individual with engineering knowledge being responsible and accountable for all aspects of line safety.

Willesden High Level Junction freight train derailment

On 25 August, RAIB released its report (07/2020) into a freight train derailment at Willesden High Level Junction that happened on 6 May last year. At around 21:30; a single wagon in the train derailed on the curve, but re-railed itself as it passed over the junction! 

RAIB notes that “such a derailment has the potential to foul lines that are open to passenger traffic”.

The earth embankment had been monitored by Network Rail since October 2016. It was showing “signs of progressive seasonal movement”. The empty two-axle wagon derailed “where cross level had been changing”, having encountered a significant track twist (later measured as 1 in 120 over 3 metres).

The wagon had an uneven load distribution, and a “diagonal wheel load imbalance which had not been detected by routine maintenance”.  Its left-hand wheel flange climbed over the rail head. A check rail would have prevented this, but Network Rail’s risk assessment concluded that this safeguard was not necessary on the small radius curve.

The 21-wagon train was stopped at signal NL 1048. As it pulled away, it reached a speed of 8mph before it derailed. Signallers saw what they took to be an axle counter failure after the train had passed, so brought it to a halt at Hampstead Heath.  The driver was asked to check that the train had not divided. When that had been done, he was given permission to continue. Around 14:00 hours the following day, signalling technicians attending lineside equipment discovered the track damage and severed cables.

One of RAIB’s recommendations deals with two-axle wagon maintenance and is directed at DB Cargo. Network Rail is the recipient of the other recommendations which include “the use and limitations of track geometry measurement trains, track condition and problems with the track bed and supporting earthwork structures.”

Under ‘additional learning points’, RAIB’s report refers to indicators of poor track bed condition and the importance of good liaison between track and earthworks as well as the management of wagon diagonal wheel imbalance. 

In 2016, a supervisor’s report noted that “vertical alignment of track looked to be poor and a nearby OLE mast was leaning”. This was reported to the earthwork’s management team. On 11 July 2018, a section manager inspected and noted that the ballast ordered in 2016 “had yet to be delivered”!

Embankment examinations were carried out on a five-year cycle. On 10 June 2016, after the upside slope had been de-vegetated, it was inspected and awarded an increased earthwork hazard rating of Category C – ‘average’.

Specialist engineering consultants visited site on 15 March 2019. Their 1 May 2019 report gave “several design options” but was awaiting a decision at the time of the accident.

RAIB found a lack of structured liaison between the earthwork management and track teams. It was rare for the earthwork management team to notify the track team of a problem or requirement. Usually others alerted them!

The report does not identify the responsible engineer, who should have had all available facts and taken engineering responsibility, arguably at a date nearer to 2016.

Diesel oil freight train burns for 33 hours at Welsh SSSI

At just before 23:20 on Wednesday 26 August, a freight train derailed at Morlais Junction, Llangennech, near Llanelli. The tanker train 6A11 consisted of 25 wagons, each containing up to 75.5 tonnes of diesel or gas oil. It formed the 21:52 service from Robestson to Theale. Ten wagons, positions 3 to 12, derailed on the Up District line, but just three of them burnt and/or leaked into the nearby Loughhor Estuary. The total spillage was 330,000 litres.

It took the fire brigade around 33 hours to extinguish the blaze. Fourteen pumps were used and the accident was classified as a major incident and Category 1 Environmental Incident. The site is both a Special Area of Conservation and a Site of Special Scientific Interest.

An 800-metre evacuation zone was put in place and around 300 people were temporarily accommodated in Llangennech Community Centre or Bryn School until they were allowed back to their homes at 05:30 the following morning. The initial report of the derailment came from the train driver, who was unhurt and had detached the locomotive and moved it some 400 metres away after seeing the fire start. RAIB’s investigation is underway.

On 21 September, RAIB issued an update. The preliminary examination has established that, during the journey from Robeston, the brakes on all the wheels of the third wagon were applied and remained so until the derailment. Three axles continued to turn, albeit with their brakes dragging, but the leading axle stopped rotating. Consequently a 230mm-long wheel flat spot developed, together with a substantial ‘false flange’.

When the train reached Morlais Junction, the false flange (a raised lip on the outer side of the wheel flange) caught the converging stock rail and was derailed. The locomotive and first two wagons went to the right but wagon 3 went straight on and turned over. Much of the track was destroyed and a further nine wagons derailed as a result.

RAIB’s update says their investigation will include the third wagon brakes, how the fuel was spilt and the maintenance history of the third wagon. 

Near miss Deansgate-Castlefield Manchester Metrolink

RAIB’s report 06/2020 was published on 3 August and relates to a signal passed at danger by a Metrolink tram on 17 May 2019. The tram arriving at the central tram stop platform at Deansgate/Castlefield but failed to make its scheduled stop. It travelled through the platform at 9mph and passed a stop signal into the path of an oncoming second tram approaching the junction as part of a signalled movement.

The driver of the second tram saw the first tram approaching and stopped in time to avoid a collision.

RAIB concluded that the driver of the first tram failed to stop due to “a temporary loss of awareness”. It decided that this was “a result of a medical event or the driver losing focus on the driving task”.

The driver had been involved in previous incidents but the tramway operator, Keolis Amey Metrolink, had not adequately addressed his performance.  RAIB found that the driver’s safety device on the tram did not detect or mitigate the driver’s loss of awareness because it was not designed to do so!

RAIB’s first recommendation is for Keolis Amey Metrolink, to review and update its strategy for managing the risk of trams passing signals at danger. Two other recommendations require them to “ensure medical fitness requirements for drivers are based on an understanding of the risks of their activities and that its fatigue management system meets with relevant industry guidance and best practice”.

Carmont/Stonehaven passenger train accident

At 09:38 on the morning of 12 August, all six vehicles of a passenger train derailed after the train ran into a landslip. Three individuals including the train driver and conductor lost their lives. There were just nine people in total on the train.

Between 05:00 and 09:00 that morning, over two inches of rain had fallen; the August average is for less than three inches in the whole month. The HST (High Speed Train) set had left Aberdeen on time at 06:38, travelling southwards on the Up line, and was on time when stopped by the signaller at Carmont.

The signaller received a report from the driver of a northbound train on the Down line that a landslip was obstructing the Up line between Carmont and Lawrencekirk. The northbound train stopped at Stonehaven and its passengers disembarked. It was decided that, as the southbound train could not continue, it would return north to Stonehaven (See Map).

Permission was given for it to use Carmont crossover. After crossing over, its speed increased to 72.8mph before it ran into a Down line bank slip and derailed. It then travelled on for 77 yards before running into a bridge parapet. The leading power car fell down a wooded embankment as did the third carriage. The first passenger carriage rotated across the track and ended up on its roof whilst the fourth carriage remained upright. The rear power car derailed but also remained upright. RAIB’s investigation is underway.

Worlingham near miss

RAIB’s Safety Digest concerning a near miss at Worlingham user-worked crossing (UWC) was published on 27 August. Its messages stress the importance of reducing the risks from signaller errors at UWCs, in particular those controlled from Saxmundham signal box, ensuring signallers are briefed when changes are made and that they do not rely on a perception of lapsed time when making safety critical decisions due to the potential for them to be distracted.

At 13:18 on 8 June, the driver of the 13:07 Lowestoft to Ipswich passenger train applied the emergency brake on seeing a vehicle towing a trailer on Worlingham UWC. The train was 350 metres from the crossing and travelling at 55mph – just 14 seconds running time away. The Saxmundham signaller had given permission on the understanding that the vehicles would take less than two minutes to cross. The call ended 77 seconds before the train would have reached the crossing had its driver not applied the emergency brake.

Back in 30 March 2017, the Office of Rail and Road (ORR) served an Improvement Notice on Network Rail, identifying signal boxes on the Anglia Route where “signallers have no means of consistently and reliably determining train movements in the area of a UWC before authorising a person to cross”. The notice required Network Rail to carry out a risk assessment and identify measures to control the risk.

On 23 January 2018, ORR issued a second Improvement Notice, with a compliance date of 31 March 2021, requiring Network Rail to implement preventative protection measures identified in a schedule. These included axle counters to enable the positions of trains to be determined more precisely.

In May, Network Rail introduced additional axle counters subdividing the long sections controlled by Saxmundham Box. Signallers were briefed that this was to provide “more confidence when telling level crossing users if it was safe to cross”. As may be seen on the diagram, signal section BOS(X) was divided into BOS1(X) and BOS2(X).

When these axle counter sections were established, signallers were provided with a table indicating that permission should not be given for Worlingham crossing after a train approaching from Oulton Broad South had occupied BOS2(X). The signaller’s display does not give additional information about the location of the train. The train occupied BOS2(X) 130 seconds before the driver of the road vehicle requested permission to cross.

The signaller involved on 8 June had not been trained in the use of the additional information provided by the display and table.

In the ten minutes before taking the call from the vehicle driver waiting to cross, the signaller had taken six calls from other UWCs, two of which were after the train had left Oulton Broad Station. When giving permission to cross, the signaller did not realise how much time had elapsed since the train left the station.

When the axle counters were added into the Saxmundham scheme, no assessment of signaller workload was made. It was decided that the call volumes and signalling workload would not be altered.  I suggest the signallers were unconvinced of the value of the additional information made available.

The authority to stop trains

Even dedicated and competent railway engineers, operators, supervisors and trained staff will make mistakes. Involving those with superior knowledge to coordinate and become personally responsible is a key requirement. For rail infrastructure and rolling stock, I suggest this is best achieved by using qualified people who can be held personally and professionally responsible for their decisions. This would surely result in a coordination of accountable professional management.

Responsible railway individuals carrying these responsibilities need the authority to stop trains running unless satisfied that the infrastructure, rolling stock and operating conditions are safe and suitable.