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Blog - How the rail industry learns from accidents

Greg Morse23 November 2016


Greg Morse D.Phil AIRO,

Operational Feedback Specialist, RSSB


Just before 20:15 on 23 February 2007, a ‘Pendolino’ bound for Glasgow derailed at 95 mph near Grayrigg in Cumbria. All nine vehicles left the line, eight of them jack-knifing down an embankment. The first ambulance and fire crews arrived just after a quarter to nine; many more rescuers would join them before night became day. 

Their work was tough, their task essential and – though hindered by rain, darkness and access problems –evacuations had been completed by eleven that night. Of the 109 people that had been on board, 28 were seriously injured. Most of the survivors were soon discharged from hospital. Not so 84-year-old Margaret Masson, who sadly succumbed to her injuries whilst being airlifted to safety.

RAIB’s investigation confirmed that the train derailed on a crossover, shining a spotlight on the condition of the points. It also confirmed the immediate cause to be the condition of the stretcher bars, which hold points’ moving blades the proper distance apart.

Part of the problem had been about inspections: the weekly one scheduled for 18 February, just five days before the accident, had not occurred. The supervisor on the ground had agreed to make a change to his inspection plan, and then forgot he’d done so. But it wasn’t just down to him: at the time, Network Rail didn’t understand that points like these, with non-adjustable stretcher bars, behave differently from other designs. This ‘resulted in an absence of clear and properly briefed standards’ for setting up and adjusting such points, according to RAIB.

The train came out of this report much better than the infrastructure: the crashworthiness of the ‘Pendolino’ allowed it to avoid various hazards ‘almost completely’. The robust couplers generally held the carriages together, the anti-roll bar links ensured that most of the bogies remained attached, and the bodyshell resisted penetration. Most of the passengers were contained in the train by its laminated windows, although two were injured after they’d been ejected through breakable emergency exit panes (the standard at the time permitting one non-laminated window per carriage for egress).

The report included 29 recommendations to improve safety. Network Rail also amended its instructions, management and checks on basic visual inspections, and started to analyse the loads and forces in its non-adjustable stretcher barassemblies.

That was 10 years ago, and – thankfully – there hasn’t been a train accident that killed a passenger or member of rail staff since. But that doesn’t mean they’ve gone for good: an accident could still happen, and similar sorts of incidents have occurred overseas and on the London tram network just last November. Yet it is testament in part to the rail industry’s appetite and ability to learn from history that we’ve got to this point.

Major train accidents like Grayrigg are a vital part of that process, though it was in fact ever thus: early incidents like the death of William Huskisson MP at the opening of the Liverpool & Manchester Railway in 1830, for example, led to the first Railway Regulation Act (1840). Within 50 years, block signalling, interlocking and continuous braking on passenger trains had been made mandatory. The 20th century saw further advances, from continuous welded rails and multi-aspect signalling to the AWS and TPWS and improvements in crashworthiness.

We all know there’s no substitute for good data and analysis, but sometimes you need to look behind the trends – especially when they’re so positive – to avoid the risk of complacency setting in, keeping a watch for things that don’t look quite right and to check you’re not missing weak signals of a risk building up.

We live in an uncertain world: as safety expert James Reason wrote in 1997, the ‘large random component in accident causation means that ‘safe’ organisations can still have bad accidents, and ‘unsafe’ organisations can escape them for long periods. Bad luck can bring down the deserving, while good luck can protect the unworthy.’

James Reason also explained how breaches in defence against hazards can line up, like holes in Swiss cheese, to let a tragic accident occur. There are always things you can do to create more layers, and block more holes up.

RSSB looks at the lessons learnt from Britain and around the world, from railways and other sectors, tying much of this together in the Learning from Operational Experience Annual Report. It doesn’t guarantee an incident-free railway, but it does consider specific issues that can impact on rail operation and maintenance and suggests how to avoid them.

So even though you may not be a steam charter operator, you may still have something to learn from the SPAD at Wootton Bassett. You may not be an airline or a refuse collection company either, but what do the Germanwings plane crash and Glasgow bin lorry accident tell us all about managing mental health? These learning points and more can all be found in the latest LOEAR – why not check it out?

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