6A11 (Robeston Sidings - Theale Murco) on fire near Llanelli (27/08)

krus_aragon

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Currently working my way through the document. The cover image, showing the track warped out of recognition by the fire, is striking.

The early part of the report spends a lot of time explaining the sundry companies involved in the manufacture, operation, and running of the wagons. It feels a bit like foreshadowing...
 
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fishwomp

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Thanks,@Cowley for spotting I'd requested the wrong thread to be reopened and sorting it out.

The RAIB report shows a woeful lack of oversight of maintenance and failure to learn from previous incidents.

.. and - I found a bit hard to be precisely sure what they were saying but - hotbox detectors are not actually configured to detect anything.

The one at Pembrey was connected to Port Talbot box, but it didn't flag a problem because they don't report anything, they just store data, useful after the event but not actually at all helpful. Too many false alarms in the past apparently. I really hope I read that incorrectly but I fear not.
 

edwin_m

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.. and - I found a bit hard to be precisely sure what they were saying but - hotbox detectors are not actually configured to detect anything.

The one at Pembrey was connected to Port Talbot box, but it didn't flag a problem because they don't report anything, they just store data, useful after the event but not actually at all helpful. Too many false alarms in the past apparently. I really hope I read that incorrectly but I fear not.
I think they were saying an actual hot box would have been reported but they don't report a hot tread, which was the problem here due to friction between the locked wheel and the rail. Probably after a heavy brake application the treads would also be hot, but a locked wheel has a different "signature" on the detector with all the heat being at the bottom.
 

Meerkat

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I think they were saying an actual hot box would have been reported but they don't report a hot tread, which was the problem here due to friction between the locked wheel and the rail. Probably after a heavy brake application the treads would also be hot, but a locked wheel has a different "signature" on the detector with all the heat being at the bottom.
And shouldn’t be significantly hotter than all other wheels
 

Rand.

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An interesting read. As a Mechanical fitter I know very well washers must go behind nut and bolt heads, period. Unless design states otherwise. Any other fitter worth his salt knows this too. Basic good practice.
For safety critical equipment on carriers of dangerous goods to be attached by stud/nut without a further mechanical application ie locking tabs, castellated nut and split pin or wire locking I find boggling. Easy to visually check too.
However, the companies, (various) have some very serious procedural problems indeed. The amount involved too is boggling! For the RAIB to turn up and find the only torque wrench they own (a maintenance facility!) was broken two months previously is totally inexcusable. Pity they didn't have a licence to revoke. What a dangerous mess.
 
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doningtonphil

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From what I understand the RAIB inspectors were pretty shocked to learn that there are detectors that don't report live data, but can be interegated at a later date.

It seems there is plenty of dismay about what the maintenance of wagons on the UK rail network boils down to.
A man sat in his van with his windscreen wipers on in the dark watching several wagons trundle past in the light of his headlights....
 

GB

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It seems there is plenty of dismay about what the maintenance of wagons on the UK rail network boils down to.
A man sat in his van with his windscreen wipers on in the dark watching several wagons trundle past in the light of his headlights....

That is nothing to do with wagon maintenance, that is the pre departure “roll by“ done by the shunter/train preparer on all services entering the network. It’s there to spot anything wrong with the train such as a locked wheel, hanging coupling, insecure load etc.
 

Taunton

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The procedures do appear to be poor.

Quite why hot wheel detectors are found "unreliable" is difficult to understand, beyond maybe the cheapest such equipment has been purchased. In the USA they have long been deployed for multiple functions ("Defect Detectors"), and are felt reliable. Furthermore the way of transmitting any failure, as both the RAIB report and the comments above indicate, is ludicrous (passing defects recorded locally, but someone has to go out to site periodically to download them ... I mean, come on). The USA ones for a long time now have been "talking detectors", which among other things make pre-set announcements over the train radio system of any fault, so it comes to everyone's attention instantly and even before the end of the train has passed the loco driver and the dispatcher has heard exactly what the problem is, on which wheel. It's not rocket science, and the RAIB really should have pointed out that such thoroughly reliable equipment is available off the shelf.

Defect detectors | Trains Magazine

I once again had hoped that, with all the different organisations subcontracting to one another, the RAIB would look at the commercial side of how the various organisations get selected and paid, because I suspect the "bottom bidder" approach to selecting the variouis companies. Certainly for an independent company to be required to validate those doing the work, and then doing blow all to actually check this, should have been pointed out even more forcefully. Then there was the interim report on poor maintenance arrangements, which RAIB went back to check later and found that nothing beyond the bare minimum of what they had pointed out had been done.

I wonder that the wagon owner was allowed back on the national network after all this.
 
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edwin_m

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The procedures do appear to be poor.

Quite why hot wheel detectors are found "unreliable" is difficult to understand, beyond maybe the cheapest such equipment has been purchased. In the USA they have long been deployed for multiple functions ("Defect Detectors"), and are felt reliable. Furthermore the way of transmitting any failure, as both the RAIB report and the comments above indicate, is ludicrous (passing defects recorded locally, but someone has to go out to site periodically to download them ... I mean, come on). The USA ones for a long time now have been "talking detectors", which among other things make pre-set announcements over the train radion system of any fault, so it comes to everyone's attention instantly and even before the end of the train has passed the loco driver and the dispatcher has heard exactly what the problem is, on which wheel. It's not rocket science, and the RAIB really should have pointed out that such thoroughly reliable equipment is available off the shelf.
This suggestion falls foul of the different way radio is used in the UK. In the States it's open channel so everyone can hear everyone else's conversations, very much like air traffic control. This helps drivers maintain situational awareness of the position of other trains, in an environment where there aren't that many trains but also sometimes fewer engineering safeguards against collision. So a HABD can just announce on the general channel and the train that's just passed it will always be listening in.

In the UK a HABD would have to identify the train and initiate a GSM-R conversation aimed at that train. It fits much better with the British operating principles to report to the signaller as this one apparently does, although not to the one actually controlling the track in question. From how I read it, the HABD does report genuine hot axle boxes in real time. The function to report locked wheels has been switched off due to actual or perceived concerns about false alarms, but the core software hasn't changed so it still logs these internally. The graphs in the report suggest that some quite detailed data is logged.

From the report it seems to me quite easy to distinguish a locked wheel (one hotspot at rail level) from a hot tread (two hotspots at axlebox level and one at rail level) or a hot box (one hotspot at axlebox level).
I once again had hoped that, with all the different organisations subcontracting to one another, the RAIB would look at the commercial side of how the various organisations get selected and paid, because I suspect the "bottom bidder" approach to selecting the variouis companies. Certainly for an independent company to be required to validate those doing the work, and then doing blow all to actually check this, should have been pointed out even more forcefully. Then there was the interim report on poor maintenance arrangements, which RAIB went back to check later and found that nothing beyond the bare minimum of what they had pointed out had been done.
There are certainly hints of commercial considerations getting in the way of safety, both in the diligence of inspections and in the lack of oversight when the auditing body is located outside the UK. Perhaps the cost of the cleanup for this incident, presumably falling on the responsible parties either immediately or via higher insurance premiums later, will make some people sit up and take notice.
 

ainsworth74

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In the States it's open channel so everyone can hear everyone else's conversations
Indeed if you watch some YouTube videos of trains in the US it's not that uncommon to find a recording of the defect detectors report for that train or comms from the train to the dispatcher or the engineer to the conductor to be played in the video as the person making it will have been able to tune into the right frequency and make a recording to play back later.

Unimaginable in the UK!

Just in case anyone is interested here is a compilation of defect detectors reporting their results to give an idea of what it's like:


And here is a short video containing some transmissions from train to dispatcher with some more explanation as to what's being described:

 
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Meerkat

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From how I read it, the HABD does report genuine hot axle boxes in real time. The function to report locked wheels has been switched off due to actual or perceived concerns about false alarms, but the core software hasn't changed so it still logs these internally. The graphs in the report suggest that some quite detailed data is logged.
Did I misunderstand it then (I was speed reading). I understood that the original detectors kept giving false wheel temp reports so they switched that off (whilst still sending axle box reports). The detectors were then later replaced/upgraded, which would have reduced the false reports, but for some reason (lack of knowledge of that function?) the live reporting for wheel defects wasnt reactivated.
 

SLC001

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There was a huge turbine fire in Australia a few years ago which caused enormous environmental damage. This too was caused by "faulty" detectors and were basically set to such a large tolerance that they failed to detect a real problem i.e. shaft vibration. Other failures magnified the problem but basically the sensors weren't trusted. Faulty detectors or is it that they were working but no-one believed it?
 

edwin_m

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Did I misunderstand it then (I was speed reading). I understood that the original detectors kept giving false wheel temp reports so they switched that off (whilst still sending axle box reports). The detectors were then later replaced/upgraded, which would have reduced the false reports, but for some reason (lack of knowledge of that function?) the live reporting for wheel defects wasnt reactivated.
I think that's right. Figures 29 and 30 show that it would be easy for software to distinguish a locked wheel from a general wheel temperature issue or a hot box, but this function was apparently not provided, or was provided but not activated.
 

XAM2175

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I think that's right. Figures 29 and 30 show that it would be easy for software to distinguish a locked wheel from a general wheel temperature issue or a hot box, but this function was apparently not provided, or was provided but not activated.
As much as everything else in the report wasn't comfortable reading, I am really dismayed by what appears to be the fact that we're allowing our current-day application of safety monitoring equipment to be so heavily influenced by British Rail's being annoyed by some false alarms more than twenty years ago.
 

Meerkat

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A bit concerned that this shambles is a symptom of cost cutting, and that doing it properly is going to make rail freight less competitive.
(Not saying they shouldn't do it properly, maybe we need a RAIB equivalent looking into all lorry crashes, and a similar safety audit system for them!)

The most worrying bit is that the previous incidents weren't learned from and the system didn't notice.
 

Nicholas Lewis

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Excellent report by RAIB which has shone a light on how much more complicated the braking system is on wagons than I thought and how disparate wagon maintenance was. What was concerning isthat yet again they are citing previous reports with recommendations that had they been implemented may have prevented this accident. You can sense RAIBs frustration in their annual reports about the compliance with recommendations being slow and that they are forewarning that this is laying the seeds for repeat events. Also I was perturbed by ORR's stance on oversight after 2018, although subsequently remedied, you would have thought that conveyance of hazardous materials would have been an area that ORR would have tight surveillance over.

The audit and surveillance regime in NR is far tighter and drives right down to the grass roots admittedly in varying degrees of intrusiveness but just the fear of being selected was enough to keep you on your toes. Here we have multiple organisations undertaking various aspects of wagon mtce none of which were getting feedback from each other with even the ECMs not being aware of what is happening. Classic Swiss cheese conditions but thankfully on this occasions its the local environment that was the victim and fortunately not a built up area.
 

Taunton

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A bit concerned that this shambles is a symptom of cost cutting, and that doing it properly is going to make rail freight less competitive.
(Not saying they shouldn't do it properly, maybe we need a RAIB equivalent looking into all lorry crashes, and a similar safety audit system for them!)

The most worrying bit is that the previous incidents weren't learned from and the system didn't notice.
I think you are right to comment that even more oversight and people making a further career out of standing looking at what other people are doing (instead of actually testing and fixing the things in the first place) is just going to add even more cost to rail freight and lose it further. The number of people and organisations that were involved here to handle what a competent mechanic/fitter should be able to handle on their own just makes you wonder. One of the report comments is that with short-term operating contracts there is no incentive to provide proper maintenance facilities or training. Were the wagons just being checked over out in the open instead of in a proper workshop, with all tools and manuals to hand? The fact that the broken torque spanner had not been replaced for months (for goodness sake, you can go and buy them at Halfords) just shows a couldn't care less attitude.

Para 169 is also instructive, that ORR's "certification inspections" concentrated wholly on bureaucracy, the right paperwork, potential for trespass in the yard, etc, and nothing for actually whether safety critical items were being done right. I would guess they were probably done by a "Health & Safety Professional", who however didn't know one end of a wagon from the other.
 
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Nicholas Lewis

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I think you are right to comment that even more oversight and people making a further career out of standing looking at what other people are doing (instead of actually testing and fixing the things in the first place) is just going to add even more cost to rail freight and lose it further. The number of people and organisations that were involved here to handle what a competent mechanic/fitter should be able to handle on their own just makes you wonder.
The issue is the actions of the fitter caused the problem in the first place because the individuals weren't being adequately supported.
One of the report comments is that with short-term operating contracts there is no incentive to provide proper maintenance facilities or training. Were the wagons just being checked over out in the open instead of in a proper workshop, with all tools and manuals to hand? The fact that the broken torque spanner had not been replaced for months (for goodness sake, you can go and buy them at Halfords) just shows a couldn't care less attitude.
What RAIB didn't explain though is why the organisation failed to address that issue and whether there was an endemic culture which meant the workforce couldn't fulfil there tasks properly.
Para 169 is also instructive, that ORR's "certification inspections" concentrated wholly on bureaucracy, the right paperwork, potential for trespass in the yard, etc, and nothing for actually whether safety critical items were being done right. I would guess they were probably done by a "Health & Safety Professional", who however didn't know one end of a wagon from the other.
Para 169 is telling us that is all ORR were doing after May 2018 and it was centred on staff welfare so that individual wouldn't have been versed in wagon mtce and wasn't required to be. In my view this is a major shortcoming of ORR and ive never believed its dual headed role of economic and safety regulator sit comfortably with each other. I also believe when RAIB was created, which was correct, it rather drove a dagger into ORR read Railway Inspectorate and they've never really got a focus on the safety side.

I do hope GBR will be empowered to be responsible for oversight of ALL operators that run vehicles on the network as this is surely where the responsibility should lie. Remember private owner wagons are nothing new and BR undertook this role very effectively.
 

Dr Hoo

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The issue is the actions of the fitter caused the problem in the first place because the individuals weren't being adequately supported.

What RAIB didn't explain though is why the organisation failed to address that issue and whether there was an endemic culture which meant the workforce couldn't fulfil there tasks properly.

Para 169 is telling us that is all ORR were doing after May 2018 and it was centred on staff welfare so that individual wouldn't have been versed in wagon mtce and wasn't required to be. In my view this is a major shortcoming of ORR and ive never believed its dual headed role of economic and safety regulator sit comfortably with each other. I also believe when RAIB was created, which was correct, it rather drove a dagger into ORR read Railway Inspectorate and they've never really got a focus on the safety side.

I do hope GBR will be empowered to be responsible for oversight of ALL operators that run vehicles on the network as this is surely where the responsibility should lie. Remember private owner wagons are nothing new and BR undertook this role very effectively.
With Britain having accepted and implemented the concept of the Entity in Charge of Maintenance (ECM) and all of the accreditation that goes with it I am not entirely sure that having 'The Safety Regulator' (whoever they are) making exactly the same audit checks down to toolbox and maintenance library level is either necessary or appropriate. Nevertheless, this was a very sorry saga at many levels.

I wish I could share your happy view of BR days. As a Traffic Manager I had to deal with some 'interesting' cases. One involved a loaded private owner dangerous goods vehicle being released to traffic in such a decrepit condition that the headstock broke off during shunting of the train. Another involved a loaded toxic gas tanker that had been in store for a while being sent out of a private siding with the entire distributor assembly missing (having presumably been cannibalised to keep another wagon going). OK; so neither of them actually made it out onto the main line but poor standards of workmanship and oversight are not just a recent phenomenon.
 
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Nicholas Lewis

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With Britain having accepted and implemented the concept of the Entity in Charge of Maintenance (ECM) and all of the accreditation that goes with it I am not entirely sure that having 'The Safety Regulator' (whoever they are) making exactly the same audit checks down to toolbox and maintenance library level is either necessary or appropriate. Nevertheless, this was a very sorry saga at many levels.
I should have been clearer that who has oversight the ECM organisations.

Anyhow much positive learning is available from this report about how freight wagons are maintained that should improve things if recommendations are effectively implemented. One has to question why it takes an accident to find out the current regime was flawed and I repeat my earlier view in that surely ORR's role here is to stress test the arrangements in areas of highest risk. Earlier RAIB reports were warnings that all was not well with Touax should be informing ORR where to go looking.
 

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Anyhow much positive learning is available from this report about how freight wagons are maintained that should improve things if recommendations are effectively implemented.
Sadly I'm not that hopeful of this being what will actually happen. It is a very big if and depends on the will being there to accept the need for improvement and to then implement the recommendations.
 

Nicholas Lewis

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Sadly I'm not that hopeful of this being what will actually happen. It is a very big if and depends on the will being there to accept the need for improvement and to then implement the recommendations.
Indeed and as i said earlier RAIB makes this point in there 2020 annual report about the inaction over recommendations with 21% of recommendations made over last five years have yet to be accepted by ORR with a further 21% having no response yet although these are mainly recommendations made during 2020 but was pretty well all recommendations from 2020.

They provide an overview of status here with the report

RAIB_summary_of_recommendation status 2020

I would suggest that ORR need to step up a gear and threaten enforcement action over organisations dragging their feet.
 

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