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

[talltim]

A minor point raised in the report, but more micromanaging by the DFT refusing a pay rise for the Driver Manager position and thus helping perpetuate the high churn rate in staffing, affecting safety.
Looks like Chiltern got themselves in a vicious cycle there, short staffing leading to overwork, leading to retention problems leading to short staffing, etc.

 

[matt_world2004]

A minor point raised in the report, but more micromanaging by the DFT refusing a pay rise for the Driver Manager position and thus helping perpetuate the high churn rate in staffing, affecting safety.
Looks like Chiltern got themselves in a vicious cycle there, short staffing leading to overwork, leading to retention problems leading to short staffing, etc.

DfT doesn't be set workplace terms and conditions

Chiltern railways bid based on a cost and assumed staffing level. The DfT does not specify the amount of driving managers.

 

[Surreytraveller]

DfT doesn't be set workplace terms and conditions

Chiltern railways bid based on a cost and assumed staffing level. The DfT does not specify the amount of driving managers.

Things have changed because of coronavirus

 

[matt_world2004]

Things have changed because of coronavirus

If they didn't have enough driver managers at this time during the pandemic it was because they went into the pandemic without enough driver managers. The costs under the emergency measures arrangements were based on their costs as they entered the pandemic .

 

[talltim]

I was under the impression that the DfT did control pay levels towards the end of franchises to prevent outgoing TOCs from giving pay rises all round and leaving the incoming TOC with huge wages bills

 

[matt_world2004]

I was under the impression that the DfT did control pay levels towards the end of franchises to prevent outgoing TOCs from giving pay rises all round and leaving the incoming TOC with huge wages bills

Yes but in December 2019 they didn't know franchises we're going to end.

 

[Meerkat]

Can tripcocks not be retractable, with a test they are in position at the boundary?

 

[talltim]

Yes but in December 2019 they didn't know franchises we're going to end.

Chiltern was always going to end at the end of 2021, even without Covid.
Anyway, the RAIB thought it was worthy of note.

 

[Dstock7080]

Can tripcocks not be retractable, with a test they are in position at the boundary?

There are tripcock testers at Amersham platforms 2 & 3 to check position and correct alignment

 

[matt_world2004]

There are tripcock testers at Amersham platforms 2 & 3 to check position and correct alignment

Which the RAIB identified the driver as using at the correct speed which to me would indicate awareness that he was on Lu property.

 

[Dave W]

It wouldn't be the first case of a driver correctly responding to line features and/or signals, only to then fail to do so thereafter. It seems the management of the driver in this case was a huge contributing factor, and there's almost an element of him being let down by the management system around him. But I've rarely seen an investigation report where direct culpability sits so squarely with the driver - perhaps the Norwich collision report?

 

[100andthirty]

There are tripcock testers at Amersham platforms 2 & 3 to check position and correct alignment

The question of retracting tripcock arms on NR infrastructure comes up from time to time. The key issue is that the tripcock tester is far from being a complete test. As Dstock7080 says, all it does is check that the arm is in the right position and alignment. If the arm isn't in the right place, the white light won't extinguish, and if the arm is a bit out of gauge, the train might be tripped on the tester. There is no in-service test that proves the tripcock actually works; this is something that is done in depot. In today's world, there would be a requirement not to clear a TPWS signal until the tripcock has been proved to set ready to use. As tripcocks are being retained for Chiltern when the Thales Seltrac signalling is extended to Amersham, perhaps this is something that can be incorporated then.

 

[Mojo]

Can tripcocks not be retractable, with a test they are in position at the boundary?

I’m not sure on which circuits they sit on the Chiltern trains, but in order to cut out the Tripcock you would also normally have to select one of the other safety circuits & possibly cut other things out, so is not suitable for normal operation.

 

[Meerkat]

There are tripcock testers at Amersham platforms 2 & 3 to check position and correct alignment

I’m not sure on which circuits they sit on the Chiltern trains, but in order to cut out the Tripcock you would also normally have to select one of the other safety circuits & possibly cut other things out, so is not suitable for normal operation.

I was thinking that the tripcock could be folded away when on NR to prevent spurious applications??

Is this driver‘s safety record abnormal - I thought part of the reason for paying drivers well was the recognition that they didn’t get many mistakes before getting sacked? To this outsider that looks pretty scary.

Can a sleep disorder such as his be picked up in a medical other than by asking (which a career threatened driver is going to be wary of answering honestly)? One of the comments implied (or maybe I inferred!) that he was a big lad and this would contribute to sleep problems - maybe there is a justification for a fitness standard for drivers?

 

[172007]

I believe ATP is isolated north of Banbury using a standard drivers (old style) key safety system isolation switch as 168's always have the blue light in the destination screen when in the Midlands. I also understand Chiltern Drivers also carry the pins to un-isolate the safety system switches that other tocs out right ban drivers from having on their possession.

Maybe a Chiltern member of staff could confirm this. Seems like more strange things that go on there.

 

[Surreytraveller]

I was thinking that the tripcock could be folded away when on NR to prevent spurious applications??

Is this driver‘s safety record abnormal - I thought part of the reason for paying drivers well was the recognition that they didn’t get many mistakes before getting sacked? To this outsider that looks pretty scary.

Can a sleep disorder such as his be picked up in a medical other than by asking (which a career threatened driver is going to be wary of answering honestly)? One of the comments implied (or maybe I inferred!) that he was a big lad and this would contribute to sleep problems - maybe there is a justification for a fitness standard for drivers?

Let's just say on 15 is way over what would be normal in my area before you were banned from driving trains.

 

[Crossover]

Can a sleep disorder such as his be picked up in a medical other than by asking (which a career threatened driver is going to be wary of answering honestly)? One of the comments implied (or maybe I inferred!) that he was a big lad and this would contribute to sleep problems - maybe there is a justification for a fitness standard for drivers?

I believe it would need a sleep study. I can't imagine an apnea is career ending - if an obstructive apnea, it can be managed through sleeping using devices such as a CPAP (Continuous Positive Airway Pressure) "machine"

 

[island]

Let's just say on 15 is way over what would be normal in my area before you were banned from driving trains.

After 13 he got 3 years where he only drove ECS and shunt movements. But I do agree with you.

DfT doesn't be set workplace terms and conditions

Chiltern railways bid based on a cost and assumed staffing level. The DfT does not specify the amount of driving managers.

They do now. As it said in the report, Chiltern asked DfT for a pay increase for them in May 2020 and were turned down.

 

[edwin_m]

As tripcocks are being retained for Chiltern when the Thales Seltrac signalling is extended to Amersham, perhaps this is something that can be incorporated then.

I've posted previously, possibly on this thread, that it seems very strange for LU to be retaining the tripcock system, which is obsolete and this report notes several problems with it. TPWS is designed to be easily interfaced to a variety of signalling equipment, and fitting it would be no more difficult than connecting up the colour lights which will also be needed on this section. I believe tripcocks will still be fitted to S Stock to operate on the parts of the District where the re-signalling has been descoped, so if the S7s remain fitted they would still be susceptible to problems on this section.

 

[matt_world2004]

After 13 he got 3 years where he only drove ECS and shunt movements. But I do agree with you.


They do now. As it said in the report, Chiltern asked DfT for a pay increase for them in May 2020 and were turned down.

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.

 

[Mojo]

I believe tripcocks will still be fitted to S Stock to operate on the parts of the District where the re-signalling has been descoped, so if the S7s remain fitted they would still be susceptible to problems on this section.

Not quite. Whilst trains can still be front tripped in the CBTC area (eg. by an object on the track), and the Scat will still display for three minutes, trains can proceed in ATO or protected manual with the Scat displayed.

 

[CarrotPie]

Is this driver‘s safety record abnormal

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

 

[mike57]

Having read through the report two things strike me: The driver appeared to be totally oblviious to the danger he was putting himself and his passengers in, and Management look like they are going through the motions rather than actually managing. (I am talking here about the senior managers, not so much the managers on the ground, who look as if they are totally unsupported).

I work in a non rail safety critical industry, and what ever your training, or lack of it, if you dont understand something you ask, may be colleauges, maybe managers, maybe Google it, but igornance is not bliss. Looking at the drivers record it seems me to show someonre who is cavalier. The driver may have had medical problems or personal problems, but if he/she cant stay concentrated on the job during work hours then train driving is not the right career for that person. How many strikes do you need before someone says "Sorry but this isnt the job for you". I agree with trying to support people through difficult times, but safety has to come first, and redeployment may be the only solution.

Will any prosecutions result?

 

[MarkyT]

I've posted previously, possibly on this thread, that it seems very strange for LU to be retaining the tripcock system, which is obsolete and this report notes several problems with it. TPWS is designed to be easily interfaced to a variety of signalling equipment, and fitting it would be no more difficult than connecting up the colour lights which will also be needed on this section. I believe tripcocks will still be fitted to S Stock to operate on the parts of the District where the re-signalling has been descoped, so if the S7s remain fitted they would still be susceptible to problems on this section.

Not quite. Whilst trains can still be front tripped in the CBTC area (eg. by an object on the track), and the Scat will still display for three minutes, trains can proceed in ATO or protected manual with the Scat displayed.

I think the trainstops and tripcocks might eventually be replaced by a non-contact balise-based limited supervision (LS) system. Such switched balises could be activated via LEUs (lineside encoding units) connected directly to the same outputs from the Seltrac equipment that are planned to actuate the trainstops. Chiltern's existing 16x fleet will presumably be retrofitted with ETCS and any new trains proposed for the operator will undoubtedly come at least 'ETCS ready', and with the latest baseline software theoretically capable of operating in 'LS mode' on TfL infrastructure, with other modes elsewhere. Berlin S bahn is currently rolling out a similar direct digital replacement of their mechanical trainstops, a system using standard ETCS balises, known as ZBS (Zugbeeinflussungssystem S-Bahn Berlin):

Zugbeeinflussungssystem S-Bahn Berlin - Wikipedia

en.wikipedia.org

The Berlin S-Bahn Train Control System - Zugbeeinflussungssystem S-Bahn Berlin (ZBS) - is a train protection system based on Eurobalises that is designed for the specific requirements of the S-Bahn Berlin rapid transit rail network. It is able to gradually replace the old system based on train stops with overlap safety.

The conversion will be finished on the subnetwork Stadtbahn until the end of 2020, on the subnetwork Nord-Süd until the end of 2023 and on the subnetwork Ring until the end of 2025.[1]

 

[rebmcr]

Will any prosecutions result?

Those who have the facts required to answer that question should not be answering it.

 

[theking]

Not sure how people are getting that management failed the driver there's some personal responsibility needed.

To be blunt if you are too stupid enough to know after twice doing it before that you do not move the train until you contact the signaller or train controller when you have an emergency brake application then you have no business being in possession of a train driving licence.

They should have been sacked after the 2nd offence of resetting and continuing, this is putting people's lives at risk.

 

[bramling]

Not sure how people are getting that management failed the driver there's some personal responsibility needed.

To be blunt if you are too stupid enough to know after twice doing it before that you do not move the train until you contact the signaller or train controller when you have an emergency brake application then you have no business being in possession of a train driving licence.

They should have been sacked after the 2nd offence of resetting and continuing, this is putting people's lives at risk.

The difficulty with that would be that in this case Chiltern have, for whatever reason, made a complete pig's ear of the way this driver's competence was managed. It seems confining him to depot work was simply a way of putting the problem in the "too difficult" box for a while, then eventually someone has come round to the fact that some kind of decision was necessary as to what to do.

If the long list of incidents is being put down to fatigue (which I agree is stretching credibility for the "reset & continue" incidents), then Chiltern would need to be able to demonstrate what they have done to try and address the root causes of that. From the RAIB report it would seem they did something between very little and nothing, which would not reflect well upon them.

 

[Dave W]

Not sure how people are getting that management failed the driver there's some personal responsibility needed.

To be blunt if you are too stupid enough to know after twice doing it before that you do not move the train until you contact the signaller or train controller when you have an emergency brake application then you have no business being in possession of a train driving licence.

They should have been sacked after the 2nd offence of resetting and continuing, this is putting people's lives at risk.

Sure, you're absolutely right. But isn't that what the report's saying? At no point, per the report, was the driver disciplined in such a way as to suggest it was catastrophically bad, until the depot driving restriction. Which was then lifted due to a perceived improvement by management (which, to be fair to him, he didn't want).

Your point that someone of this mindset and attitude shouldn't be anywhere near the controls of a train regardless of circumstances is unequivocally the case.

EDIT: bramling makes the point rather more succinctly than I.

 

[Taunton]

A minor point raised in the report, but more micromanaging by the DFT refusing a pay rise for the Driver Manager position and thus helping perpetuate the high churn rate in staffing, affecting safety.
Looks like Chiltern got themselves in a vicious cycle there, short staffing leading to overwork, leading to retention problems leading to short staffing, etc.

Not quite, the DfT response was to say no to a straight pay rise, as this was against their policy and would lead to other claims, but to "seek another solution", which is thinly-guarded civil service-speak for them recognising the issue, just find something else which can give more money without calling it pay - regrade the staff, devise an Additional Responsibility Element, whatever.

Chiltern's original costings for their franchise would have assumed some ratio, say 1:20, for driver managers, as an overhead of the business. If reality was only 1:40 then that is money into Chiltern's pocket - it's not even as if they didn't have scope to be creative.

Chiltern have, for whatever reason, made a complete pig's ear of the way this driver's competence was managed. It seems confining him to depot work was simply a way of putting the problem in the "too difficult" box

Always understood this was quite normal on the railway. David L Smith wrote that he found Driver Caudle, from ther Ais Gill major collision in 1913, on yard work only at Carlisle 10 years later.

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?

Separately, I don't think I've ever seen a formal accident report before which used the "bullying" word explicitly about a senior management member. It must be quite obvious who was being referred to. Are they still in post?

 

[Dave W]

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?

Partially answered in para 84:

"It is possible that the driver was influenced by a lack of clarity about how tripcock activations are dealt with on the national rail network routes which Chiltern Railways operates over. There are no signals fitted with train stops on these routes, so any tripcock activations are spurious. Chiltern Railways’ data shows more than 100 such events are reported annually"

100 activations annually doesn't sound to me like a driver would see more than one in several years (naturally certain areas would be worse, and some drivers may get unlucky)

Agreed on your last point too - rare is it that an RAIB inspector ventures to such an explicit description of behaviour, which implies - to me at least - that this must be a particularly serious shortcoming.