Incident at Chalfont & Latimer (21/06/20)

[Surreytraveller]

Does a ‘fail to cancel AWS’ go on your safety of the line record?

Goes on the record, just not as a 'Safety of the Line'. Unless its just company dependant

Apologies if I am being dumb but why isn’t a missed AWS a safety issue?

Because its a failure on the side of safety. But its still recorded, as it could show lack of attention

 

[BrianW]

A great RAIB report demanding action. A number of factors here adding up to potential disaster, averted.
Including:
Tired driver
Signals passed
Speeding
Inadequate 'management'
'Death by Powerpoint'
'Kindness'

Apologies if I am being dumb but why isn’t a missed AWS a safety issue?

Would he have got paid less on restricted duties?

Putting things more pointedly (sorry if too much so):
The driver knew he was tired, and 'research' suggests this is common
He needs his job, as we all do.
No-one wants to be 'relegated to light duties'.
Too many 'mistakes' on his record.
Too few 'checks', esp late in the day when tired.
Insufficient care for the driver's health, and safety of him and the public.
Poor training.
Ability to 'manual override' has dangers- automation is safer. Driverless trains?
He needed help, and so did the 'managers'.

Will there be follow-up by RAIB to check that safety HAS been improved?

 

[Nym]

No. The RAIB is not an enforcement agency. That should fall to the RSSB or ORR.

 

[CyrusWuff]

No. The RAIB is not an enforcement agency. That should fall to the RSSB or ORR.

Which ORR did, by issuing Chiltern with an Improvement Notice regarding the Driver Management at Marylebone in March this year.

 

[Watershed]

Which ORR did, by issuing Chiltern with an Improvement Notice regarding the Driver Management at Marylebone in March this year.

To elaborate, the Improvement Notice set out that the ORR considered Chiltern had contravened provisions of the Health and Safety at Work etc. Act, as well as the "ROGS" Regulations. This should go to show how serious of an issue this was considered.

I sympathise a little with Chiltern's position in a way; they had clearly realised prior to the incident that they had problems with their driver management. But the DfT refused to sign off on the changes that were needed to enable them to fix it.

This arguably makes this incident one of the first (near) incidents caused by misdirected DfT cost cutting, even if only indirectly. It's disappointing that the DfT have got off scot free, and I dread to imagine what other skeletons are in the closet in this regard.

 

[TPO]

No. The RAIB is not an enforcement agency. That should fall to the RSSB or ORR.

To ORR not RSSB. ORR is the safety regulator, RSSB is body owned by the mainline industry which helps ensure that all organisations who share the same mainline tracks have shared core safety standards and has a framework to help ensure systems are compatible.

However what also happens is that ORR must explain to RAIB how they are getting rail duty holders to act on their Recommendations, ORR then chases each railway duty holder. Not to respond to a "RAIB Rec" query from ORR puts a rail duty holder on receiving end of the wrong sort of ORR attention, and similarly ORR get challenged if they don't then respond to RAIB.

To elaborate, the Improvement Notice set out that the ORR considered Chiltern had contravened provisions of the Health and Safety at Work etc. Act, as well as the "ROGS" Regulations. This should go to show how serious of an issue this was considered.

I sympathise a little with Chiltern's position in a way; they had clearly realised prior to the incident that they had problems with their driver management. But the DfT refused to sign off on the changes that were needed to enable them to fix it.

This arguably makes this incident one of the first (near) incidents caused by misdirected DfT cost cutting, even if only indirectly. It's disappointing that the DfT have got off scot free, and I dread to imagine what other skeletons are in the closet in this regard.

Quoting the HSW Act as well as ROGS Regs on the Notice does not make it more serious, it just reflects that the Regs are made under HSW Act and its the Act that holds the legal enforcement provisions.

TPO

 

[Watershed]

Quoting the HSW Act as well as ROGS Regs on the Notice does not make it more serious, it just reflects that the Regs are made under HSW Act and its the Act that holds the legal enforcement provisions.

No, but it shows it wasn't just a 'words of advice' situation (as commonly happens with RAIB reports).

 

[theageofthetra]

Oh boy yes:

• Station overrun
• Failure to call (FTC)
• Station overrun
• Wrong side door release
• FTC
• TPWS intervention x4 (the last two on consecutive days)
• FTC
• Overrun
• Reset ATP and proceeded without authority and overrun on the same day
• Restrictes to ECS moves
• Failed to cancel AWS
• Stopped out of course

Makes me wonder what connection they had with management? Were they a depot 'favorite' - one of those who is untouchable?

I used to work at a TOC, that upon the appointment of a certain Head of Drivers, managed to develop a phenomenal 'churn rate' of Driver Managers - five left in two years from one depot alone! All returned to driving, one staying at the depot, but all the others joined other TOCs or FOCs elsewhere. NONE stayed in Management - obviously completely put off.

A couple of Depot Drivers were offered positions with an FOC to become fully fledged mainline drivers, but this Head of Drivers refused to let his Driver Managers sign the ATOC 'Safety record' form that needs to be filled in when drivers transfer companies, effectively trapping them and hindering progression of their careers.
Morale took a nosedive.

I know he had since left but I wasn't quite sure where he'd gone to. I thought of him when I read that paragraph, and thought, "I wonder if it's him?"
No surprise when I typed his name into a search bar and his LinkedIn page says where and what he's doing now...




I kind of hope so, as bad as that sounds, as that means he isn't where I work now.

Very interesting.

 

[O L Leigh]

Makes me wonder what connection they had with management? Were they a depot 'favorite' - one of those who is untouchable?

I think it points more towards the failings in the driver competency management procedures than anything else. There clearly seems to be reluctance to take any decisive action.

From my own observations, driver managers do seem somewhat reluctant to remove drivers completely from mainline duties without some external stimulus. In most instances this is Nitwit Rail coming down and telling the TOC that they will no longer permit an individual driver from driving over their infrastructure. But even when this happens, the TOCs don't take the "nuclear option" but would rather put them "on the shed" where they can't cause any more problems (or so the theory goes). Sometimes the TOC will decide that the driver is not cut from the right cloth and will either find them another non-driving position within the company or expect them to find one for themselves.

In the case of drivers put "on the shed" for extended periods, I did hear a suggestion that, at the end of this period and before coming back driving again, the driver would have to complete the driver training programme and have their competencies reassessed from scratch. This would make sense to me because the majority of their competencies would have lapsed during this period and it would give the TOC a chance to assess their suitability for driving and, if they fail to come up to snuff, be in a position to rid themselves of them. However, I don't know if that is what actually happens. Either way, before a driver can be returned to mainline duties a driver manager must assess them and pass them as competent.

 

[Taunton]

I think it points more towards the failings in the driver competency management procedures than anything else.

One of the things that comes out is the higher level management was lacking, with considerable amounts of documentation of various points missing, never recorded, poor procedures, etc. These are the things that higher management should be there to ensure are done, recorded, and not "lost".

It is of course the responsibility of the same senior individual who appears to be the one openly described in the report as "bullying". It's one thing to have this character trait, but if the key aspects of the job are not being done as well ...

 

[rebmcr]

In the case of drivers put "on the shed" for extended periods, I did hear a suggestion that, at the end of this period and before coming back driving again, the driver would have to complete the driver training programme and have their competencies reassessed from scratch. This would make sense to me because the majority of their competencies would have lapsed during this period and it would give the TOC a chance to assess their suitability for driving and, if they fail to come up to snuff, be in a position to rid themselves of them.

That doesn't seem to be compatible with a lot of TOCs where (by all accounts) there is already a backlog of newly recruited trainees and not enough training opportunities for them.

 

[ainsworth74]

That doesn't seem to be compatible with a lot of TOCs where (by all accounts) there is already a backlog of newly recruited trainees and not enough training opportunities for them.

Though of course in the case of this incident this would all have been happening pre-pandemic which has been a big driver of the backlog due to rules around sharing a cab.

 

[rebmcr]

Though of course in the case of this incident this would all have been happening pre-pandemic which has been a big driver of the backlog due to rules around sharing a cab.

Even back in the First Capital Connect days there have been reports of it being a problem.

 

[O L Leigh]

That doesn't seem to be compatible with a lot of TOCs where (by all accounts) there is already a backlog of newly recruited trainees and not enough training opportunities for them.

We're not talking about vast numbers here. In my career so far (16 years and counting) I have only known of three drivers who have found themselves in this position, so it doesn't represent a drain on capacity.

 

[Egg Centric]

In most instances this is Nitwit Rail coming down and telling the TOC that they will no longer permit an individual driver from driving over their infrastructure.

Appreciate there's all sorts of reasons you may not be able to say anything more, but could you expand upon this? Had no idea it could even happen, never mind it was a thing that apparently happens more than once in a blue moon.

 

[Horizon22]

I think it points more towards the failings in the driver competency management procedures than anything else. There clearly seems to be reluctance to take any decisive action.

Yes it seems much more this driver "fell through the cracks" at various stages between all the driver management changes as well as being left on the "too difficult to resolve" pile for a long while. Then a lack of institutional knowledge ensured that when decisions were made regarding this driver's future they were a) the wrong ones and/or b) not followed through.

 

[O L Leigh]

Appreciate there's all sorts of reasons you may not be able to say anything more, but could you expand upon this? Had no idea it could even happen, never mind it was a thing that apparently happens more than once in a blue moon.

I can’t really, because I’ve not been directly involved. However, in two out of the three the incident that finally tipped the TOC into action involved Nitwit Rail infrastructure and/or staff.

Precisely what the processes and procedures are in situations like this I cannot say, so I can’t comment on how or why Nitwit Rail get involved in what would normally be a TOC management process.

 

[Horizon22]

I can’t really, because I’ve not been directly involved. However, in two out of the three the incident that finally tipped the TOC into action involved Nitwit Rail infrastructure and/or staff.

Precisely what the processes and procedures are in situations like this I cannot say, so I can’t comment on how or why Nitwit Rail get involved in what would normally be a TOC management process.

I'm sure there was some valid reason (and was likely in collaboration with the TOC), and you calling them "Nitwit Rail" is rather childish. They were probably concerned about costs or damage to the infrastructure which is after all, what the driver is working on.

 

[IanXC]

Yes because the emergency measures were only to pay the operators costs at the point of entry into the pandemic. If they were safety critical Chiltern railways should have paid and shouldered the loss .it would have still been less than the loss would have been if they hadn't entered emergency measures

Chiltern railways knew the conditions of emergency measures when they signed up to it. They were free to continue under the existing system if they wanted but chose not to because it was no longer economic in the pandemic

They under resourced the issue in 2019 and paid for it during the pandemic.

I find this view absolutely shocking.

Yes Chiltern appear to have had a long standing problem in this area, but when they identify it and propose a solution you're suggesting the DfT's answer is 'you messed up in the past therefore you're stuck with the problem, so there'. Your suggestion that Chiltern should have 'shouldered the loss' is also erroneous as the DfT will not authorise this kind of change to pay even if it is paid for by the operator as it forms part of the long term cost base of the operation.

If this really is how the DfT are operating then there must be other similar situations around the country, which really doesn't bear thinking about.

One of the things that comes out is the higher level management was lacking, with considerable amounts of documentation of various points missing, never recorded, poor procedures, etc. These are the things that higher management should be there to ensure are done, recorded, and not "lost".

It is of course the responsibility of the same senior individual who appears to be the one openly described in the report as "bullying". It's one thing to have this character trait, but if the key aspects of the job are not being done as well ...

I've seen this in various structures and industries. The best defence against these kind of record keeping problems appears to be having a clerical role responsible for this kind of administration - very often removing this kind of role this appears to be an easy way of cutting costs.

 

[philthetube]

One thing I didn't see (or missed) was how often does the tripcock actually activate spuriously, on or off LT tracks. Is it happening a common occurence? How often had this driver done so before? Does it become a bit of a reflex action?

Rarely. I think I had 3 occasions when I was front tripped in 25 years of driving, actually rear tripped more often than front. usually, excluding spads the only time the system had to be overridden is following a signal failure. Often when it happens it then affects every train until what ever is causing the issue is sorted so it is only a surprise to the first driver to be affected and a following train will be asked to check the track for obstructions.

 

[Falcon1200]

I'm sure there was some valid reason (and was likely in collaboration with the TOC), and you calling them "Nitwit Rail" is rather childish. They were probably concerned about costs or damage to the infrastructure which is after all, what the driver is working on.

Agree with both points; Having overall responsibility for rail safety Network Rail has every right and indeed duty to take action if felt necessary.

(At least Nitwit Rail makes a change from Notwork Rail, at about the same level).

 

[Bald Rick]

Your suggestion that Chiltern should have 'shouldered the loss' is also erroneous as the DfT will not authorise this kind of change to pay even if it is paid for by the operator as it forms part of the long term cost base of the operation.

A correction there, DfT doesn’t need to ‘authorise’ costs incurred by an operator in matters like this. They auhtoroty is around DfT paying the operator.

 

[O L Leigh]

you calling them "Nitwit Rail" is rather childish

Your opinion is noted, although I would have thought it was the sort of thing you could have mentioned to me privately. However, it is a term I have used consistently for many years and will continue to do so. I see no reason why a thread cannot be leavened with a little light-hearted humour. But my posting style is not the topic of this thread.

In the two incidents I alluded to there certainly were concerns relating to the infrastructure, but not in the third. The common factor in all three was that the drivers had had, ahem, “interesting” careers up to that point which suggests to me that there is some point at which Nitwit Rail become involved no matter what the specific situation.

 

[rebmcr]

They were probably concerned about costs or damage to the infrastructure which is after all, what the driver is working on.

I suspect there must be cases where the signallers press grievances to their management. They certainly would not want extra opportunities to make additional safety-critical mistakes due to a driver repeatedly making their own, and creating unusual situations that the signaller must aid in resolving.

 

[philthetube]

I suspect there must be cases where the signallers press grievances to their management. They certainly would not want extra opportunities to make additional safety-critical mistakes due to a driver repeatedly making their own, and creating unusual situations that the signaller must aid in resolving.

If the driver makes a serious error the signaller would be expected to report it.

 

[Horizon22]

Your opinion is noted, although I would have thought it was the sort of thing you could have mentioned to me privately. However, it is a term I have used consistently for many years and will continue to do so. I see no reason why a thread cannot be leavened with a little light-hearted humour. But my posting style is not the topic of this thread.

In the two incidents I alluded to there certainly were concerns relating to the infrastructure, but not in the third. The common factor in all three was that the drivers had had, ahem, “interesting” careers up to that point which suggests to me that there is some point at which Nitwit Rail become involved no matter what the specific situation.

In the 3rd though if there was no issue relating to the infrastructure then how would NR have been aware? Obviously things are logged, but if the signaller was involved maybe he had concerns about other things like say, the quality of voice comms? There's quite a few non-technical skills that could have potentially (not knowing the incident) given various levels of NR staff some considerable concern, especially if - as you say - they've got a long record book. That information would have been forthcoming from a TOC. It's not just an "us and them" mentality, especially in Control centres where its obviously much more integrated now.

 

[matt_world2004]

I know this didn't happen in this circumstance. But if the driver reset a tripcock in a moment of panic but didn't move the train would they have been in more trouble than if they didn't reset the tripcock

 

[O L Leigh]

In the 3rd though if there was no issue relating to the infrastructure then how would NR have been aware? Obviously things are logged, but if the signaller was involved maybe he had concerns about other things like say, the quality of voice comms? There's quite a few non-technical skills that could have potentially (not knowing the incident) given various levels of NR staff some considerable concern, especially if - as you say - they've got a long record book. That information would have been forthcoming from a TOC. It's not just an "us and them" mentality, especially in Control centres where its obviously much more integrated now.

Well, that’s why I suspect that there must come a point at which Nitwit Rail’s interest gets piqued, although precisely what the trigger for that is I couldn’t say. Driver safety records are centrally held on a database as well as locally at the depots, so maybe that is the channel. I just don’t know. The third may have had no Nitwit Rail interference at all and may just have been a consequence of none of the local managers being prepared to sign him off.

Voice comms and the like should be picked up by TOC’s competency management structure, as that may affect a first incident as much as a sixth or seventh. It would not be unusual for a TOC to request the voice tapes in the event that it might be pertinent to an incident investigation as well as downloading the data recorder (OTMR) and/or CCTV.

 

[bramling]

I know this didn't happen in this circumstance. But if the driver reset a tripcock in a moment of panic but didn't move the train would they have been in more trouble than if they didn't reset the tripcock

Not really.

On LU it is regarded as good practice to make resetting the tripcock the last thing before moving, as it's from that moment the slow speed enforcement timer starts. This doesn't seem relevant to Chiltern as their units don't have the timer. The relevant LU rule books (which technically the driver was working to at the time of incident) does sort of allude to this, but only in a rather vague way. The most important things are receiving the correct authority to move, and proceeding at a speed where able to stop short of any obstruction until two consecutive stop signals have been passed showing proceed aspects.

Chiltern may well have TOC-specific instructions on top of this (though by the sound of it perhaps not!), however I'd say resetting the tripcock prematurely is a point of good practice, not following the correct authority and movement procedure is the safety incident.

*However*, the muddies are watered slightly as LU don't actually have a specifically laid-down procedure for "tripped not in vicinity of signal", which is what this driver seems to have - erroneously - assumed was what had occurred. Given the density of signalling on LU, it is quite rare for trains to be tripped with no signals nearby, so in reality this hasn't really been much of an issue over the years, as simply everyone will assume "tripped in vicinity of a signal", call it in, and the control staff will make the call over what to do next based on their knowledge of the location. In this case the problem arose because nothing was reported, and the driver's own judgement was clearly lacking. I'm surprised the RAIB haven't really touched on this.

 

[greatkingrat]

I know this didn't happen in this circumstance. But if the driver reset a tripcock in a moment of panic but didn't move the train would they have been in more trouble than if they didn't reset the tripcock

There's nothing wrong with resetting the tripcock, or TPWS. The issue is moving the train without permission from the signaller. Depending on the unit, there may well be some sort of audible alarm sounding, so if you don't reset it first, it can be very difficult to hold a conversation with the signaller.