1. RIGHT FIRST ISSUE!
ISSUE 1 // April 2012
THE NEW ANGLE FOR
PEOPLE OPERATING
THE RAILWAY
INSIDE:
STATION SAFETY
TACKLING SLIPS, TRIPS & FALLS
MIND THE INNER INTER-CAR GAP
UNDERSTANDING DUTY OF CARE
REGULAR FEATURES
SPADTALK
RAIB REPORT ROUND-UP
INCIDENT NEWSWIRE
A NEW APPROACH TO A FREIGHT OPERATOR’S DRIVEN TO DISTRACTION
ROUTE LEARNING TAKE ON POSSESSIONS IN CANADA
Part of the operational safety
programme sponsored by OFG

2. RIGHT
headlamp
What is OFG?
Welcome to Right Track, Right Track is sponsored
the rail industry’s new
by OFG – but what is OFG?
OFG stands for Operations
Focus Group, whose
operational safety magazine. meetings are attended
by operational heads and
specialists from across the
rail industry. By working
Right Track is for: drivers, signallers, shunters, by commenting on why we’ve been doing so together, it helps everyone
station staff, managers, track workers, depot well at reducing SPADs and where the focus make improvements to
staff – anyone and everyone who plays a vital on them came from. Richard Farish also shows safety by sharing things
part in keeping the railway going. how First Capital Connect drivers keep an eye and running joint initiatives
on the situation. – including this magazine.
Right Track is about sharing news, safety
OFG includes Network Rail,
points and good ideas; it’s about being part of Add in our mini-interview with ASLEF health
train and freight operators,
the whole railway network. It’s also about 20 and safety man Dave Bennett, our worldwide
infrastructure maintenance
pages long... news update and RAIB report summaries and
companies, trades unions,
you’ll be wondering how you ever did without
Station safety has shot up the agenda as a the Office of Rail Regulation
us. But the truth is, of course, that we can’t
major issue, a fact which moved the industry to and London Underground.
do without you! Right Track is signalled for
form a dedicated action group. This led to the bi-directional running – it’s your magazine – so
development of the Station Safety Improvement we’re just as keen to hear from you as you will
Programme. On page 4, former East Coast
man turned programme manager Andy Wallace
be from us…
Contents
takes us through some of the work that’s If you have a story, a safety idea, a lesson 2-3 // Headlamp / safety
been going on in this area, while Mike Carr of or initiative, get in touch! Full articles and surveys
Network Rail shows how slips, trips and falls comments are always welcome, but so are
4-5 // No slip ups on
have been successfully cut down at Euston. leads and ideas, which our team will be only
station safety
too happy to follow up on your behalf.
Elsewhere in this issue, Nick Edwards (DB 6-7 // Mind the gap /
Schenker) gives a haulier’s perspective on Why not get on the Right Track, and contact us understanding
possessions, Paul Sutherland (Network Rail) today? duty of care
describes a new approach to the Sectional 8-9 // Euston we had a
Appendix being trialled in Wales and Greg righttrack@rssb.co.uk problem
Morse (RSSB) takes a look at a collision in 10-11 // Mobile phones
Canada that raises questions about drugs and marijuana
and mobile phone use. SPAD guru Roger 12-13 // SPADtalk
Badger (RSSB) kicks off his SPADtalk column
14-15 // RAIB report brief
/ The lowdown:
Dave Bennett
16-17 // Delivering
Right Track is produced by RSSB through cross-industry cooperation. It is designed for the people on the operational front-line the goods on
on the national mainline railway, yards depots and sidings and London Underground. Their companies are represented on the possessions
cross-industry Operations Focus Group, managed through RSSB, and Right Track is overseen by a cross-industry editorial group.
18-19 // An alternative
RSSB route to success
Block 2 Angel Square 1 Torrens Street London EC1V 1NY
Tel 020 3142 5300 Email righttrack@rssb.co.uk www.rssb.co.uk www.opsweb.co.uk
Designed and printed by Urban Juice / Willsons Group Services.
Right Track is designed to share news and views from individual companies in a positive way. However, the views expressed in Right Track are those of the contributing authors; they
do not necessarily reflect those of the companies to which they are affiliated or employed, the editors of this magazine, the magazine’s sponsors - the Operations Focus Group - or the
magazine’s producers, RSSB (Rail Safety and Standards Board).
02 //

3. Safety surveys Newswire...
Need access to up-to-date UK – 5 January: Pans down near
Littleport, 2 injured
stabling point safety surveys? Two passengers were injured when part
of their train’s pan assembly fell from
the roof and smashed saloon windows
some two miles south of Littleport.
The Mechanical & Electrical Engineering specific requirements, they can be used by
RAIB’s preliminary examination found
Networking Group has produced a other railway companies – providing end
that the head of the pantograph lost
series of safety surveys to provide useful users accept that they are responsible for
contact with the OHLE when travelling
information and guidance for those ensuring accuracy and for checking (before
at about 80 mph through an area
setting up safe systems of work. use) that the survey meets their company
blighted by high winds.
requirements.
After conducting a site visit, they draw up a
USA – 6 January: Rear-end
Stabling Point Safety Survey, which includes To find the surveys, go to Opsweb - www.
collision leads to injury
an accurate description of the location. opsweb.co.uk, click on railway operations/
otm operations/sidings-safety surveys and At 14:25 (local time), two freight trains
Though designed to meet the authors’ away you go! were involved in a rear-end collision
near Westville, Indiana. Shortly after, a
third freight – travelling on the adjacent
line – struck the wreckage and derailed,
causing fire and injury. Scant information
about the nature of the goods being
carried led to the precautionary
evacuation of around 50 local homes.
The National Transportation Safety
Board is investigating.
USA – 9 January: Foreman struck
and killed by rail grinder
A welding foreman was fatally injured
Surveys can include location photographs as well as road and rail access plans.
when he was struck by a rail grinder
travelling at low speed in Potter County,
Amarillo. The man was trying to fix a
leak on the grinder when the accident
Number crunch occurred. Initial investigations suggest
The latest figures show that even though passenger and freight numbers keep miscommunication as a possible cause.
going up and up,there’s been a general decreasing trend in the number of safety
incidents and level of risk. Germany – 13 January: One killed
as push-pull service strikes cattle
This means that even though there are record levels of train use, the people who
use and work on the railway are actually experiencing less harm, as they have One person and eight cows were
been year-on-year for some time. killed when a push-pull passenger
train running driving trailer-first struck a
Nobody would ever dare become complacent, but it’s heartening to see the
herd of cattle and derailed. Three other
numbers confirm good safety performance.
passengers were injured. The driver
Safety performance reports can be found on Opsweb – www.opsweb.co.uk and had seen the cattle, but was unable
the RSSB website www.rssb.co.uk to brake in time. The incident has led
some to draw parallels with the accident
at Polmont, Scotland, in 1984, in which
13 were killed when a push-pull express
running driving trailer-first struck a cow
Got something to share? at high speed. See the next issue of
Right Track for the full story.
Right Track would love to hear from you – especially if you have
an initiative worth sharing with readers, or if you want to feed
back on this issue.
Email us on righttrack@rssb.co.uk
// 03

4. no slip ups
on station safety
Photo: ATOC / Paul Bigland
Stations are the public face of the railway –
but what can we do to address the safety risks?
Andy Wallace
Station Safety Improvement Programme Manager, RSSB
Numbers game At the same time a poignant dramatisation
featured in the RED 28 DVD, soon after
Statistics show that the rail industry’s RED 28 covered the risks at the
which the industry’s Operations Focus
safety record has improved steadily over platform-train interface. Copies
Group (OFG) formed a dedicated group
time. We all know that a triumph can are still available from RSSB –
for station safety. This in turn led to
come before a fall, so we try to avoid contact susan.cassidy@rssb.co.uk
the development of the Station Safety
complacency by keeping a close eye on for details.
Improvement Programme.
the numbers – from as many different
angles as possible. As its programme manager, I visited a
number of station operators to find out the
Station safety is a classic example, as ‘state of the nation’ in terms of compliance
it was a regular RSSB stats report that with recognised standards and procedures.
highlighted a rise in risk at the platform-train I also wanted to identify the many good
interface. practice initiatives that exist within the
station operator community. All the
150 million people a year use Liverpool examples I found have been uploaded to
Street station in London, with 500,000 the shared Station Safety Resource Area
passing through it every day, twice as many on Opsweb, which went live last year. This
as Heathrow Airport, and with no separation also holds a wealth of research and other
of people arriving and departing. relevant information.
04 //

5. Station safety
Workshop wonder Michael explained that one of the ideas of slip, trip and fall accidents that occur at
FGW fed back to RSSB when the RIS was their managed stations.
One of the best ways of getting the frontline being worked on was that more emphasis
staff perspective and promoting and was needed on the dispatch of slam- Claire Willets and Nigel Carlisle then
sharing good practice is through face- door stock and that the arrival of the train provided an overview of East Midlands
to-face workshops. RSSB held one on should be considered as part of the overall Trains’ winterisation arrangements,
station safety at the end of January, with platform risk control arrangements. explaining the background to the
delegates from 19 different organisations, company’s step-change approach to this
representing mainline train operating Ian gave a practical example of how FGW important risk control. Early indications
companies, Network Rail and the Office of assessed risk during the installation of the suggest that these changes have generated
Rail Regulation. new passenger deck at the ‘country end’ improvement, although further data analysis
of Reading’s busy Platform 7. Hoardings will be needed before any meaningful
The workshop featured a mixture of have been erected 3.5 metres from the comparison of year-on-year performance
presentations and targeted questions platform edge, extending for approximately could be drawn.
to promote topical discussion. Its three 100 metres along the busiest part of the
main sessions focused on platform-train platform. Trials found that guards often lost Delegates identified the elderly and infirm,
interface risk, slips, trips and falls, and event sight of dispatch colleagues in the throngs and those under the influence of drugs
management/crowd control. Discussion of people making their way along the or alcohol as the most likely groups to
groups considered the factors that influence hoarded area. A decision was also made experience a slip, trip or fall accident.
risk in these areas, such as passenger to supplement yellow dispatch tabards Station design, signage, the provision of
demographics, passenger behaviour and with full high-visibility orange jackets. Extra information, robust cleaning/maintenance
seasonality. Delegates were also invited dispatchers were provided to increase the regimes and the use of ‘hot spot’ maps
to share their personal experiences in number of staff dispatching slam-door to identify and prioritise high-risk locations
managing these factors. The workshop trains. were all cited as good practice initiatives
concluded with a tabletop station hazard- presently used to support the reduction of
spotting exercise, completed in small Outputs from the group discussion in this slip, trip and fall accidents at stations.
groups. session suggest that the factors which
impact most on safe passenger train Session 3: Event management and
Session 1: Dispatching passenger dispatch are: crowd control – Network Rail
trains safely – RSSB and First Great
Western • The adequacy of train dispatch risk In Session 3, Peter Collins and Mike Carr
assessments gave an overview of the work associated
After the usual donning of name badges with planning for the Olympics and the
and other necessary activities, the day • A lack of clarity around individual roles challenges of managing passenger flows in
began with John Abbott, RSSB’s Director and responsibilities busy Network Rail Managed Stations.
of National Programmes, welcoming the • Passenger behaviour
delegates and introducing me. I then Peter explained that the Olympics will place
gave an overview of the Station Safety Delegates fed back that these risks can significant increased demand on London’s
Improvement Programme from inception to be controlled by involving staff and other transport network – by Day 7 King’s Cross
date. operators in the risk assessment process Station is expected to handle 6,000 extra
and enhancing the quality of staff briefing passengers per hour during the morning
The first presentation of the day saw arrangements (for example, by using peak. In order to manage this increased
operations specialist John Pullinger explain face-to-face briefing sessions to make passenger flow safely, forward planning
the methodology behind the introduction of staff aware of the risks that exist at each is essential. Station operators need to
a new Rail Industry Standard for passenger location). Other ideas included better use of develop bespoke Customer Service Plans
train dispatch and platform safety measures signage, announcements and information to support the existing ‘business as usual’
(RIS-3703-TOM). He also examined the points to address common behavioural aspect of their operation. These should
practical application of the standard within issues. focus on providing information, managing
a TOC. Operational learning expert Greg queues and crowds, along with the
Morse then took the group through the key Session 2: Managing slips, trips protection of ‘golden assets’ (like signalling
findings from several prominent passenger and falls – Virgin Trains and East equipment) to ensure infrastructure
accidents that have occurred at the Midlands Trains continuity.
platform-train interface. Session 2 examined some of the common Mike explained that ‘managed’ stations
Michael Maddox of First Great Western causal factors that result in slips, trips and aren’t really any different from other stations
(FGW) presented on the development falls in railway stations and explained how – they just experience crowding more often
of train dispatch risk assessments and Virgin Trains and East Midlands Trains are as they traditionally handle more customers.
method statements within FGW. Ian Gunn tackling the problem. Overcrowding during normal operation
then took the group through a ‘case study’ (such as peak travel times or regular
Virgin’s Peter Bowes began by introducing
which focussed on Reading station, which events) can be predicted and planned for;
their Slip, Trip and Fall Toolkit, which has
is undergoing substantial regeneration contributed to a reduction in the number
works. Continued on Page 6
// 05

6. Continued from Page 05
No slip ups on station safety
mind the inner In order to remove the requirement for
supervised detrainment, the Bakerloo
in doing so, the station ‘system’ relies on
people, processes and technology working
inter-car gap Line decided in late 2011 to retrofit inner
inter-car barriers. These are similar to, and
offer the same functionality as, those on the
together. Following an incident at Liverpool new Victoria Line trains – and those on the
Street in February 2000, where a mainline railway. The design is undefeatable
Station hazard-spotting exercise – passenger was killed while trying by passengers (as it is fixed), not readily
RSSB to alight from an empty train via the removable and very robust (see photo). The
interconnecting doors, a Prohibition barriers are positioned on both ends of the
The workshop ended with a tabletop
Notice was served on London exterior of each carriage adjacent to the
‘Station Hazard Spotting Exercise’. Each
Underground (LU). inter-car doors and extend to approximately
group was provided with a map and
the same height as the door.
operational information for a small, medium The Notice identified the risk from
or large station, typical to the GB rail serious personal injury to passengers The fitment of the inner inter-car barriers
network. A series of prompts was provided who try to alight from trains through has wider safety benefits, as they will
to promote discussion amongst delegates the interconnecting doors and serves also prevent passengers from falling
upon the hazards that exist at each to ensure LU mitigates it by limiting the between carriages should they try to
location, and the measures used to control risk from over-carrying passengers into use the interconnecting doors under any
the identified risks. sidings or depots by either: circumstances. There have also been other
associated benefits, including the reduction
OFG’s Station Safety Improvement Sub- 1. Walking along the platform and of trains blocking back at reversing/
group will discuss and – where practicable checking each car is empty before terminus stations whilst detrainments take
– progress the workshop outputs. A digest closing the passenger doors using place, thereby reducing the potential for
has also been produced to promote the the ‘porter’s buttons’ at the end of SPADs.
transferrable lessons that came out of the each one; or
sessions. This may be found in the Opsweb
Station Safety Resource Area. 2. Any other equally effective means
by prior agreement with the HM
Andy Wallace is RSSB’s Station Safety Inspector of Health & Safety.
Programme Manager. He worked for East
Coast before making the move to RSSB. LU has complied with the Notice by
andy.wallace@rssb.co.uk physically checking every train prior to
it entering a depot or siding to make
sure each car is empty. This involves
the train being checked by the train
Some of the ideas and initiatives operator and up to two members of
from the Station Safety Workshop: station staff, as necessary. Yet even
‘It’s important to identify with detrainment staff in position, over-
high-risk passenger types and carries still occurred, 52 being recorded
behaviours (elderly, children, etc)’ on the Bakerloo Line between January
2008 and January 2011. Whilst none of
‘We need to look at how staff the passengers involved tried to detrain
are supported when dealing with via the interconnecting doors, this was
alcohol-related issues’ clearly a risk.
‘We should move from general Photo: London Underground
instructions for guards to more
specific risk-based instructions’
‘There is a worry that multi-
Be safe – log on to
functional staff might lose focus opsweb.co.uk
on safety critical work (eg,
dispatchers being trained in First
Aid)’
‘We should engage with local The station safety resource centre is
schools to help educate young now available to access on Opsweb
people on safe behaviours’
‘There should be driver
Log on at www.opsweb.co.uk
awareness briefings on train
dispatch risk’ Opsweb is the website of the Operations Focus Group
(OFG) a cross-industry programme facilitated by RSSB
Opsweb is the website of the Operations Focus Group (OFG) a cross-industry programme facilitated by RSSB
06 //

7. Duty of care
understanding
duty of care
A TOC perspective on dealing
with PTI risk
Steve Pugh
Head of Operational Safety, Northern Rail
There are over 2,500 stations on the At the Court of Appeal, the train company
mainline network, from which more involved was found to be liable for the
than a billion journeys begin and end negligence of its guard, as the passenger’s
each year – a number that looks set to ‘foolhardy behaviour’ had started while the
rise. Stations are the public face of the guard was still on the platform.
railway – from the ticket office, to the Photo: ATOC / Paul Bigland
retail outlets, from the concourse to the The Court concluded that, as the guard
platform. was aware of the person’s behaviour, the …they’ll have carried out their ‘duty of
guard should not have closed the doors care’.
Most people arrive at a station, buy a and given the ‘right away’.
ticket, maybe have a coffee, and get on a At Northern, we ask that our dispatch staff
train with no trouble at all. But when the In summary, ‘a duty of care’ was still owed. make sure that when they’re dispatching a
numbers of passengers are this big, it’s It’s also worth noting that the same would train, that they look at the whole scene, in
obvious that we’re going to have accidents apply where platform staff are provided for terms of the personal safety of those on the
from time to time. dispatch purposes; they too need to bear platform and on the train. We ask that they
in mind the behaviour of the public and its only dispatch the train when they’re sure it’s
Slips, trips and falls on stairs, concourses potential consequences when carrying out safe to do so.
or platforms are the most likely accident their safety critical duties.
types, and you can read what Network What’s being done?
Rail is doing at Euston to combat them on Everyone owes a duty to everyone else to
page 8. However, incidents at the platform- take reasonable care so as not to cause The answer is plenty, and Andy Wallace’s
train interface (PTI) are a growing area of them foreseeable injury. feature on page 4 deals with much of
concern. the thinking that’s emerged in the last 18
What does ‘duty of care’ mean? months or so on this subject. Many train
It’s a sobering thought that while no companies are doing other things, like
The ‘Legal Dictionary’ says that ‘duty
passengers have died as a result of a SPAD improving platform markings, making mods
of care’ is a requirement that a person
since Ladbroke Grove, in the ten years up to train doors and reviewing door closing
act toward others and the public with
to 2009, 36 people died at the PTI, and we times.
the watchfulness, attention, caution and
know of many more cases since..
prudence that a reasonable person would Our efforts as an industry have significantly
A question of duty in the circumstances. Putting that into the reduced the SPAD problem (see SPADtalk,
context of dispatching a train, it means that, page 19); if we can work together and
In July 2009, an important High Court providing a member of staff has… apply the same resolve to the PTI issue, we
appeal judgement was made about the could see similar results over the next few
‘duty of care’ owed to passengers when • Carried out the correct dispatch
years.
boarding and alighting trains and when procedure in a safe way,
standing close to the platform edge. • Made sure they’ve been mindful of
vulnerable groups, and
The pivotal case involved a passenger who Steve Pugh is Northern Rail’s Head of
was under the influence of alcohol, and who • Halted the dispatch procedure if they’ve Operational Safety. This article has been
fell between the train and platform while seen anything that jeopardises safety adapted from one that appeared in the
banging on the windows during departure. and not re-commenced until it’s safe to Winter 2012 issue of CABS – Northern’s
The person survived, but suffered serious do so, own safety magazine, which is available on
injuries. Opsweb.
// 07

8. euston
we had a problem
Tackling slips and trips at a major London rail hub
Mike Carr
National Operations Safety Manager, Network Rail
With an annual footfall of over 70 million, investigation process. This sharpened the to consider location, time of day, floor
London Euston is the fourth busiest senses of all and helped ensure that future surface, gender, age, weather, lighting, and
station in the country. As you might investigations identified the basic causes so on.
expect, we experience many passenger and any lack of management steer that
accidents on the concourse, around might lay behind them. The escalator analysis highlighted that
the forecourt…and on our 18 platforms. one particular escalator (from the taxi set
In 2010, slip, trip and fall accidents We also found that near misses were down area) was causing 90% of escalator
here were averaging 12 a month. With occurring across the station with no accidents and that most of these were
investigations failing to identify root common way for any staff (be they train related to the carrying of luggage.
causes, local managers knew where the operator, Network Rail, retail, or contract)
to report them. A dedicated local 24- The results for concourse/platforms
accidents were happening, but couldn’t
hour ‘hotline’ was launched by Steve showed accidents occurring at all times
say exactly why. Clearly, a new approach
Lewis, station manager, along with an of the day, in all weathers, involving both
was needed.
accompanying awareness campaign, to genders and all age groups. The only
Three steps to success encourage people to report near misses commonality that could be observed was
and hazards whenever they occur. people were mostly losing grip.
Data gathering
Data analysis In order to understand how safe the floor
We found that our investigations into slip, surfaces were, the Network Rail purchased
trip and fall accidents were not thorough When we looked at where accidents a commercially available measuring device
and stopped at the immediate cause. were happening, we found a natural called ‘SlipAlert’.
To help our team, we arranged detailed split between concourse/platforms and
accident investigation/root cause analysis escalators. To help clarify the situation, we
training for everyone involved in the conducted two separate analysis streams
08 //

9. Slips, trips and falls
The next phase of testing involved
working out the most effective chemical
concentration level. These tests were
conducted on all different surface types.
The results were recorded and analysed.
Having determined the concentrations
and the area of each surface type,
BonaSystems worked with our cleaning
contractor, Rentokil Initial, to agree a
Visual of the ‘SlipAlert’ device method of working that would see all
station surfaces treated across 14 nights.
We conducted tests on all the surface Further analysis showed that the remaining
types we have at Euston. The results were accidents were occurring outside peak
concerning, to say the least. In most hours and involved leisure travellers. A trial
cases, the risk from slipping on a dry floor was then launched that saw the escalator
was moderate-to-low. However, as soon as switched off outside of the morning and
the surface became wet the risk increased evening peaks, thus forcing people to use
to moderate-to-high in all cases. the lift or negotiate a fixed staircase.
Taking action The result was that no accidents occurred
in the area at all (either on the escalator
Escalators or the stairs). The action has remained in
When we monitored human behaviour place for 7 months and, to date, accident In conclusion
around the escalator, we quickly found that levels have remained at zero.
people were getting out of taxis with large By taking a structured approach to the
amounts of luggage, walking straight past Concourse/platforms problem, Euston has been able to gather
the lifts and struggling up the escalator. In Having identified the hazardous data, analyse it and take targeted actions
the majority of cases, when people were characteristics of the floor surfaces at that have already seen a 60% reduction in
asked about using the lifts, they were Euston, we contacted BonaSystems, accidents (see graph below).
unaware of their existence, despite having who specialise in the enhancement of slip
walked past them. resistance factors. As the work programme continues, we
expect the figures to fall further. Our experts
Clearly, the lifts needed advertising and so Bonasystems completed a series of will go on monitoring and analysing the
signage was changed and increased. To pendulum tests to confirm the SlipAlert situation.
compliment this, a motion sensor voice results and help them understand the full
module was installed that announced the extent of the problem. This helped them Mike Carr is Network Rail’s National
location of the lifts and asked people not to identify which chemical solution could be Operations Safety Manager.
take luggage on the escalator. This led to a used to bring the slip resistance level back
reduction in accidents. to its original value.
No. of slips, trips and falls
The graph shows
results from July to
November 2011
against 2010.
// 09

10. mobile phones
and marijuana
The rail industry understands the risks presented
by drugs and mobile phone use – but accidents
can still occur, as seen recently in Canada
Greg Morse
Operational Feedback Specialist, RSSB
Drug taking has long been known as an Collision at KC
enemy of safety critical work. The mobile
phone issue is a younger problem, but At around 14:10 (local time) on 3 March
it’s one that our industry has tried hard 2010, an eastbound freight passed a
to tackle in the aftermath of the SPAD signal at danger and struck the middle of
and subsequent collision at Chatsworth, a westbound consist that was crossing
California, in September 2008. This to an adjacent line at KC Junction, British
doesn’t mean that incidents never occur, Columbia.
but they do remain rare in Britain. An
Three locomotives and 26 wagons were
accident in Canada last March was to
derailed by the impact, which caused
prove even rarer…
considerable damage to rolling stock
and goods. The driver and conductor of
the eastbound train also sustained minor
injuries.
10 //

11. Risk from distraction
the train, negotiated level crossings,
analysed hot box detector broadcasts, and
Between June 1998 and July
2009, distraction through mobile
responded to signals. The drugs problem
phone use was identified as a At least, they did until they came up against
– GB
factor in at least 37 SPADs (from the one protecting a switching move… On 8 January 1991, a passenger
a total of 4,602) on Network Rail train collided heavily with the
managed infrastructure. Evidence from the mobile phone itself and a hydraulic buffer stops at Cannon
nearby communications mast showed that Street, killing 2 and injuring over
the driver had used his phone twice just 500. Officially, the collision was
before the collision. due to the inability of the driver
Loaded train to operate the train brake
Aftermath
successfully. The investigator
The Transportation Safety Board of Canada
The TSBC’s report – coupled with CP’s was ‘unable to reach any firm
(TSBC) and the operator – Canadian Pacific
own investigation – led the freight operator conclusion as to the reasons’ for
(CP) – both launched investigations.
to dismiss the driver and guard. The the driver’s actions, nor whether
One of the major contributors to why the driver later pleaded guilty to a charge of his ‘use of cannabis as the
eastbound train passed the signal at danger ‘Dangerous Operation of a Vehicle’. He cause.’ Nevertheless the report
was that the crew had been taking drugs was fined $500 and ordered to pay a victim recommended that legislation be
whilst on duty. surcharge of 15%. He also apologised to introduced to make it an offence
the people of Golden for the inconvenience for railway employees with safety
Although no traces of drugs or alcohol responsibilities to be impaired by
his actions caused them.
were found on the guard, the driver was the consumption of alcohol or
worried that traces of marijuana might be A CP spokesman said that the accident drugs (hitherto, only alcohol had
detected in his urine. His fears led him to was caused by crew errors and served been covered). This came into
drink almost 10 litres of water, in an attempt as ‘a clear reminder’ why the safety of its force under the Transport and
to flush any traces of the drug from his employees, passengers and neighbours Works Act 1992.
system. This caused hyponetremia (water ‘must be an ongoing commitment.’
intoxication), which in turn led him to lose
consciousness. ‘A detailed safety investigation was
completed by our company,’ he went According to local rules, the use of
After a night in hospital, the driver was on, ‘which reinforced that CP should communication devices must be restricted
formally tested for drugs and alcohol. The continue with a number of Crew Resource to matters pertaining to railway operations,
results suggested – but could not confirm Management initiatives to reduce in-cab and mobile phones must not be used when
– that he had been exposed to marijuana distraction, enhance communication and normal railway radio communications are
prior to the accident. focus attention on critical tasks to maintain available.
situational awareness and safe train
But it wasn’t just the drugs: both crew had Continued on Page 18
operations’.
made extensive use of their mobiles in the
three hours leading up to the accident.
While talking and texting, they worked
The mobile question – GB
On 12 September 2008, a commuter service passed a protecting signal at danger
and collided head-on with a freight train in Chatsworth, California, at a closing speed
of around 85mph. Twenty-five people lost their lives, including the commuter driver
himself.
On the day of the accident, he had sent and received several text messages while
on duty, the last of which came just 22 seconds before the collision. He had received
warnings about improper mobile phone use while in the cab on two previous occasions.
As a result of the accident, the US Federal Rail Agency banned the use of electronic
devices in cabs.
In the UK, much work was done, including the development of a new Railway Industry
Standard and a train driver education programme on mobile phone risk. For further
details, see RSSB’s Operational Feedback Update, which may be located by logging in
to Opsweb and searching on Chatsworth.
// 11

12. Continued from Page 11
Mobile phones and marijuana
Opsweb features examples of
posters developed by First Great
However, in response to the KC Junction Western and ASLEF, which have
accident – and ten further collisions – CP been designed to encourage
has revised the rules, which now say drivers to think and stop. This one
that employees are prohibited from using deals with the mobile phone issue
personal electronic devices, and that they very effectively.
must be turned off (with any ear pieces
removed) and stored out of sight in a
location not on their person.
Regarding the drug situation, the CP
spokesman added that the company
looking again
‘meets or exceeds all regulations in place to
ensure safe train operations, [including] pre-
employment screening and post-incident
drug testing’. However, ‘at present, under
Canadian law, no companies (including CP)
can administer random drug testing.’
at SPADs
Richard Farish
The TSBC’s full report may be found by
Operations Standards Manager,
accessing its website, www.tsb.gc.ca, and
searching for report R10V0038. First Capital Connect
Do you double check signal aspects? At
First Capital Connect, we’ve started to
What can I do with identify a recurring feature during some
my phone? of our SPAD investigations. Drivers do
check the signal aspect initially and, for
Apart from the whatever reason, convince themselves
that it is showing a proceed aspect. This
obvious, you could can be caused by a number of factors,
try… such as the signal normally displaying a
proceed aspect.
• Letting friends and family know
you can’t use your mobile while In response, we’ve developed new posters
working – make arrangements (shown here) to help remind drivers of the
to contact them at a safe and need to double check the signal aspect – to
convenient time. be sure that they’re seeing what’s actually
• Setting up a voicemail there in front of them.
message. That way, people
can contact you and you can Our train drivers are proud of their high
retrieve their messages once level of professionalism and competence,
you’re off duty. and mistakes are very rare. This poster
campaign is more of a subtle reminder to
• Switching your phone off and help draw attention to the risks from not
keeping it out of reach. Leaving double checking signal aspects.
it on vibrate is a sure way to Operatio
ns Standard
s
make it hard to ignore when it
does go off!
These posters are available to download
Of course, it’s not just mobiles
from Opsweb (www.opsweb.co.uk) for
– MP3 players, iPods and
anyone who wants to use them for their
games consoles offer the same
own operation or route.
distraction dangers. But don’t
complain too loudly about their For further information contact me on
existence – you’ll sound old Richard.Farish@firstgroup.com.
fashioned!
Operations
Standards
12 //

13. SPADs
SPADtalk Roger Badger with
But when you think that…
Jargon-beater…
…Risk is basically a number
obtained from multiplying the
number of times something
In 2011, there were 281 category happens by a value given to the
• Only one SPAD occurs for around every
A SPADs across the GB rail likely consequences.
50,000 red signals approached;
network – an improvement of
almost 8% on 2010. • The vast majority of train journeys are
therefore SPAD-free; and also hastened the introduction of TPWS,
which was brought forward by a year,
• Only a small minority of drivers are ever fitment being largely complete by the end
High-profile accidents like Southall (1997) involved in a category A SPAD… of 2003.
and Ladbroke Grove (1999) have ensured …it’s clear that the professionalism of the
that ‘SPAD’ is now firmly in the dictionary. Count on it
driver has been key to this improvement
In the aftermath of these incidents, our too! The graph at the bottom of the page shows
industry took a closer look at the causes
that the numbers of SPADs have fallen each
of SPADs, the precursors to SPADs and A journey through time
year since 1999, but have now levelled
the risks that surround them. Groups were
A SPAD was at the root of Britain’s second out to a rate of approximately 300. More
set up nationally and locally to monitor the
worst accident: Harrow & Wealdstone recently, a relatively benign autumn, as well
situation and implement various initiatives to
(1952), when 112 people lost their lives in as a decrease in SPADs over the winter, has
bring the risk down. When this work began,
a three-train collision. First, a sleeper train contributed to this trend.
we were seeing over 500 SPADs a year. We
now see fewer than 300. The many driving passed a signal at danger and struck a
According to RSSB’s latest figures, SPADs
policies and practices brought in by the stationary commuter service. The situation
now make up a very small portion (0.6%) of
operating companies have played a crucial was worsened when an express ploughed
all railway risk. In fact, the risk from SPADs
part in this, combining with the massive into the wreckage.
has decreased over the past few years and
success of TPWS. is now around a third of its level five years
In more recent times, SPADs at Purley
(1989), Bellgrove (1989), Newton (1991), ago.
Cowden (1994), Watford (1996) and
We work with a range of signalling But the potential for a category A SPAD to
Southall (1997) have all resulted in train
technology – from nineteenth- result in a serious incident remains, and as
collisions and fatalities. The landmark
century semaphores and 1930s Ladbroke Grove showed us, it only takes
incident was Ladbroke Grove, which
colour light signals to 1960s one SPAD. Take care to avoid becoming
occurred on 5 October 1999, when a
multi-aspect colour lights and the next SPAD statistic. Or worse.
commuter service passed SN109 signal on
1980s radio electric token block the approaches to Paddington and collided Roger Badger joined BR as a signaller
equipment. head-on with an HST at a closing speed of in 1982. His career progressed through
At the newest end of the signalling about 130mph. Thirty-one people lost their various signalling, supervisory and
spectrum is the European Rail lives. managerial positions, before he was
Traffic Management System appointed to the post of Regional Signalling
(ERTMS), which has been in The resulting public inquiry made
Inspector, Eastern Region. He is now
operation on the Cambrian Line recommendations in signalling design, train
a Senior Safety Analyst with RSSB,
in Wales since October 2010. Off crashworthiness, staff training and the need
specialising in SPADs and TPWS.
Network Rail infrastructure and on for an independent investigation body. It
to High Speed 1, there’s another
in-cab signalling system for drivers
to deal with.
This makes six different systems
that all interface and work together
on the network, but which
nevertheless present challenges to
the maintenance and improvement
of the good progress that
has been made in SPAD risk
management.
// 13

14. console flashed a warning, suggesting
a bogie fault. The driver interrogated the
on-board train management system (TMS) Desborough
and found a hot axle box to be the most On Saturday 10 June 2006, an
likely cause. He knew that Meridians had exterior door on a St Pancras–
been suffering from false hot box warnings Sheffield service came open while
of late, but more warnings were followed by the train was moving just north of
more warnings and a passcom activation Kettering, causing the train’s brake
from a worried passenger. to apply automatically. However,
the driver initially overrode this,
The driver knew he had to stop the train,
as indications in the cab of the
but hoped to get through the approaching
‘Meridian’ unit were ambiguous,
cutting at East Langton. But as the
and he wasn’t sure what had
oscillation grew worse, stopping within it
RAIB
happened.
Photo: Peter R Foster IDMA / Shutterstock.com became inevitable.
When the driver realised the
RAIB’s investigation confirmed that one axle situation, he made a controlled
had broken as the train was travelling at 94 brake and brought the train to
mph. This caused it to derail and ‘ride the a stand at Desborough summit.
sleepers’. It had run for almost two miles The door was then closed and
in this state before coming to a stand. It
report brief
secured.
had remained coupled, upright and in line
throughout. There were no injuries among There were no injuries or material
the 190 passengers and 5 crew, although damage as a result of the incident.
there was damage to the track and the However, the fact that the door
High-speed passenger train derailment
train, including a loss of diesel fuel. was open while the train was
at East Langton, 20 February 2010
moving presented a real and
What did RAIB say? unprotected risk to those on
In January, the Rail Accident Investigation
Branch (RAIB) published its report into the board.
RAIB reported that the derailment was
high-speed derailment near East Langton triggered by the complete fracture of
that occurred on 20 February 2010. the powered trailing axle of the bogie in
question (see right). after the incident at Desborough in June
What happened?
2006 ‘did not adequately cover handling
The fracture occurred underneath the safety critical alarms and out-of-course
The Saturday afternoon journey had been
gear-side output bearing of the final drive situations.’
uneventful. A prompt departure from
and was caused by this bearing stiffening
St Pancras had let the seven-car East
up so that it couldn’t rotate properly. This
Midlands Trains service keep good time –
generated a lot of frictional heat between
so much so that Market Harborough was
the axle and bearing, which resulted in
passed three minutes early. After clearing
the axle being locally heated to a high
the local speed limit, the driver accelerated
temperature and weakened to the point
the unit to 85 mph and, on reaching the
that it could no longer carry its normal
next speed board at Great Langton curve,
loading.
accelerated further, intending to bring the
train up to 100 mph. Key evidence about the condition of
the bearing and its fit onto the axle was
At around ten-to-four, the second (powered)
destroyed in the accident. RAIB interpreted
wheelset of the fourth vehicle began to
the available evidence and concluded
behave abnormally, leaving irregular marks
that the most likely cause was a loose fit RAIB made four recommendations, two
on the rail head. The driver felt a slight
between the gear-side output bearing and of which relate to the need to review
‘snatch’, which he associated at the time
the axle. the design and overhaul procedures
with temporary engine fuel starvation.
Believing all to be well, he continued to for final drive gearboxes on Meridians,
The Branch noted that the effect of the
accelerate. including a consideration how overheating
interference fit of the gear wheel on the
output bearings are detected. Another
‘gear end’ output bearing was not identified
However, the carriages behind him recommendation relates to the oil sampling
during the design stage. The fact that there
had started to sway violently, causing regime used for the Meridian fleet, while the
were no records of previous failures of
magazines, papers and bags to fly from fourth deals with the provision of practical,
this type also meant that – to some extent
luggage racks, and composure to fly from simulation-based alarm handling training for
– they were ‘off the radar’. In addition,
passengers, who became increasingly drivers and train crew.
the refresher training on alarm handling
alarmed at the rough ride. The operating
provided to drivers and on-board train crew
14 //

15. The lowdown
What did the TOC do? How long have you worked for the
railway?
One of the things East Midlands Trains
(EMT) did after the accident was take I have worked for ASLEF for 20 years.
another look at the operating instructions it However, my father worked for British
gives to drivers about what to do when the Rail (BR) at Woking Electric Control, as a
TMS returns an alarm and displays a red telephone operator. My grandfather and
‘bogie fault’ lamp. The original instruction, great-grandfather worked at the Midland
to stop the train at the first suitable location, City Depot, just down the road from the
did not prevent drivers from proceeding ASLEF Head Office. One was a carter, and
to the suitable location at high speed. one a checker.
Consequently, EMT clarified the instruction
as follows: I also grew up in the ‘Southern
Railwaymen’s Home for Children and Old
‘In the event of a bogie fault light People’, from 1965 to 1974. So all in all
illuminating, an audible level 3 alarm will
activate. On receiving this warning, the The lowdown: I have a continuous family history on the
railways since the 1870s!
Dave
driver must bring the train to a stand
immediately. If the location at which You must’ve seen a few changes since
the train would come to a stand is not then:
Bennett
considered to be safe and suitable (as The main change has been privatisation.
defined within the Rule Book), then the The Government subsidy is now three times
driver must reduce speed to no more than more than it was under British Rail. What
10 mph in order to bring the train to a halt would have the railway been like if BR had
at the first safe and suitable location that been given that kind of investment?
does meet this criteria.’ Name: Dave Bennett
Where do you see the railway in five
Position: ASLEF Health and safety
years’ time?
advisor
East Langton also formed the main Still expanding, with more trains, more
Describe a typical day for you:
incident reconstruction in RED 32, passengers and, I trust, more freight.
which also featured interviews with That is a difficult question! It can vary:
In ten?
the driver himself, the customer sometimes I respond to enquiries from
host, the train manager and the ASLEF Reps – by telephone, email or Again, still expanding. It’s going to be
head of operations strategy and ‘snail mail’; sometimes I write reports for interesting to see what part new technology
implementation at EMT. the ASLEF Executive Committee. I also is going to play in the future, such as
attend meetings on behalf of ASLEF ERTMS, or even ‘driverless trains’. What
and organise training sessions – from I can predict, though, is that an ASLEF
booking the venue, to arranging release, member will still be on the front end!
and writing and delivering the training.
Finally, describe your most memorable
You’re a key member of the railway experience:
industry’s Operations Focus Group.
What does that involve? The Ladbroke Grove rail crash of 5 October
1999, and the subsequent inquiries (at
My main task is to make sure that the which I gave evidence).
view of ASLEF and our Train Driver
Reps and members is always taken into Until that day, I worked on both industrial
consideration during discussions. relations and health and safety matters for
Article prepared by Greg Morse ASLEF. Since that day, I have concentrated
on health and safety alone.
Ladbroke Grove
On 5 October 1999, a Paddington–Bedwyn passenger service passed SN109
signal at danger and collided with an incoming high-speed service. Thirty-one
people were killed and over 400 were injured. A public inquiry, led by Lord Cullen,
highlighted issues with signal sighting, driver training, vehicle crashworthiness,
the use of automatic train protection systems and recommended the
establishment of an independent Rail Accident Investigation Branch.
// 15

16. delivering the goods on
possessions
Photo: DB Schenker
A FOC perspective on keeping both the freight
moving and everyone safe
Nick Edwards
Professional Head of Drivers, DB Schenker
Engineering possessions are an integral controlled by signals, but also by radios and signal at danger - only the signaller can do
part of our industry in the 21st century hand signals. People have to be closer to this.
and, as we move towards the ‘seven trains and road vehicles in order to carry out
day’ railway, the safe and punctual the majority of tasks on site. In some complex areas (or other locations
delivery of possessions becomes even where authorised), what is known as
more important. Over time, various initiatives and rules ‘substandard protection’ can be placed.
changes have taken place to help eliminate This is where the 400 metres between the
Possessions usually go unnoticed by the the problems that can be encountered signal and the PLBs cannot be achieved.
general public, unless they are travelling at during engineering work. However, This type of protection is identified in
weekends and find their train replaced by incidents are still occurring all-too- Section B of the Weekly Operating Notice
a coach – never welcomed as warmly as frequently. (WON) with a hash symbol (#). In some
a rail-borne vehicle. They also notice when cases, the PLBs may be just a few metres
things go wrong and they are late for work One of the main reasons for incidents is from the signal and the hand signaller
as a result! the driver not getting permission to pass may be using the signal post telephone
the protecting signal before proceeding to contact the signaller. In all cases, the
The principles of a safe railway – that trains to the possession limit boards (PLB). The driver must contact the signaller to obtain
are kept apart by signals and that people proximity of the PLBs to the signal and the permission to pass the signal at danger.
and trains are kept apart from each other – presence of a hand signaller can result in
are turned around within possessions. the driver being misled by instructions from Trains passing through possessions
that hand signaller. And of course, the hand towards the PLBs often encounter different
In a possession, trains are not solely signaller cannot give permission to pass the types of level crossings. Before starting
16 //

17. Possessions Newswire...
the movement, the PICOP will instruct the of any activity of machinery that may be USA – 25 January: Staff member
driver what actions must be taken at a taking place. The nature of the loads can falls to death from bridge in St
level crossing. In most cases, this happens also cause problems. Some of the main Louis
without incident however CCTV controlled issues to have arisen are overloaded trains,
level crossings have proven problematic. If incorrectly loaded or secured material A Terminal Railroad of St. Louis
no attendant is provided and the signal is at and incorrectly prepared plant. It’s often employee fell through a walkway while
danger, the driver must contact the signaller very difficult to check the contents of working on the MacArthur Bridge in St.
before proceeding. vehicles from the ground, so suitable and Louis, Missouri. The walkway had been
safe vantage points (such as overbridges, loosened for removal; a cone had been
Leaving both the worksite and the station platforms) should be considered placed to prevent usage. The employee
possession can also be problematic when checking trains. Always refer to sustained fatal injuries.
if communications are not carried out loading patterns when preparing trains
correctly. Although there are fewer UK – 28 January: 15-year-old girl
conveying track panels and ensure that any
incidents, the impact on the safe railway killed at footpath crossing
residual ballast is removed before the train
can be great as engineering trains could departs. Specialist plant and equipment A teenage girl was struck and killed on
enter the ‘live’ railway without authority. that may be in the train formation should be Johnson’s red/green footpath crossing,
On occasion, the protection has been made ready for hauling by the operators, near Bishops Stortford, after she walked
missing and drivers have continued beyond however if staff are in doubt they must seek into the path of a passenger train. RAIB
where it should have been and effectively advice before moving it. is investigating.
entered the ‘live’ railway. The location of the
protection and protecting signals are shown UK – 2 February: Class 90 derails
in the WON and if drivers are in doubt they In summary, the keys to safe at Bletchley South Junction,
should stop and contact the signaller. possession working are world-class driver injured
communications and attention to
detail. Remember who is in control of At 02:28, a light locomotive derailed at
movements and, even though there Bletchley South Junction while crossing
may be pressure, always take time to from the Up Slow to the Up Fast line,
make sure that safety is paramount. ending up foul of the Down Fast. The
driver was injured and needed medical
attention. There was significant damage
Nick Edwards is Professional Head of to the OHLE and track. Both Fast lines
Drivers at DB Schenker as well as chair of were also displaced laterally. In all, over
OFG. 23,000 minutes’ delay was accrued.
RAIB’s preliminary examination found
that the derailment occurred because
Photo: Network Rail For full information refer to Rule the locomotive was driven significantly
Making movements within a worksite can Book Module T3. However the key faster than the permitted speed of
also increase risk. The proximity of trains authorities are shown below: 15mph over the junction.
to people and equipment means that staff Passing the protecting Argentina – 22 February: 49
have to establish what is expected very signal and moving killed in Buenos Aires buffer stop
clearly. All movements are made under the towards PLBs Signaller collision
authority of the Engineering Supervisor
(ES). World-class communications are To pass the PLBs and On 22 February 2012, a passenger train
essential to ensure safety. Adhering to enter possession PICOP struck the buffer stops at Once station
methods of control are also vital as just a To pass worksite in Buenos Aires, during the morning
couple of seconds can make the difference marker boards and rush hour. At least 49 people were killed
between safety and an incident. When enter worksite ES and more than 600 were injured.
movements are to be controlled by radio, The collision occurred at around 12mph
both parties must be very clear about what To pass worksite
(20km/h), destroying the front end of the
their identities are, and if any confusion marker boards and
train and causing the carriages to ‘over-
occurs the movement must be brought to enter possession PICOP
ride’ in similar fashion to those involved
a stand immediately and not restarted until To pass PLBs and in the Cannon Street accident of 1991,
a clear understanding has been reached. leave the possession Signaller in which two were killed and 542 were
Movements must be made at a very low injured when a train of three EMUs (two
speed. of Mk I design, one a hybrid based on
older stock) collided with the buffer
The preparation of trains in worksites and
stops at around 10mph.
possessions is also made more difficult
by site conditions. Trains often have to
leave the site before the main activity has
finished; therefore staff should be aware
// 17