GCR Derailment

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StevieG
LNER A4 4-6-2 'Streak'
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Re: GCR Derailment

Post by StevieG »

sandwhich wrote: " ... Yes in years gone by, no names no packdrill, many yard derailments were soon dealt with, how should we say, very quietly and no questions asked. different world now. "
... Perhaps because whoever was remiss either realised immediately what they had not done/done wrong and, without guidance from others, would be very unlikely to repeat the mistake, or that their senior/more experienced and widely-knowledgeable colleagues, probably close at hand, were practical people, understanding the whole operating environment and what had gone wrong, and keen to make sure that the right way became understood a.s.a.p.

My feeling is that the nowaday 'legal' separation of the parties and their 'interests', which together (not always amicably) constitute the national network, the operating compartmentalisation of its working, and any obligations to meticulously record all for both 'lessons-learnable'* distribution & in case of later come-back, seem to make the frequent, more onerous and long-winded formalisation of investigating incidents unavoidable, if the investigators are to come to understand what happened (particularly in certain methods/details of working with which such individuals are these days much more likely to be unfamiliar), and reach hopefully correct, fully recordable, conclusions and recommendations.

* - (I do not say "lessons learned" as that might imply that they always are, being absorbed fully into future practice, which, in a wide sense, I think, does not always happen when pressures to get the 'now' job done preclude background/retrospective research/reading.)
BZOH

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Andy W
GER D14 4-4-0 'Claud Hamilton'
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Re: GCR Derailment

Post by Andy W »

More likely nobody wanted to dob a mate in for a white paper when he had made an honest mistake and probably wouldn't do it again. If you could square the job up without any aggro, no one gets hurt, no paperwork to fill in, job done.

The problem any supervisor or manager faces is the thought, "will he do it again?". Nowadays, everybody reaches for their lawyer for either revenge, compensation or both. It's not a privatisation thing - we were well there in latter BR days, thanks to the then emerging culture in the wider world but it does add a complexity into what you do next with any incident.

The more you monitor, the more your neck is on the line if things go wrong and if it is proved you did nothing about it, leading to another and more serious incident, you are in big, big trouble. Together with automation deskilling many functions and declining attention spans becoming more prevalent in the workforce, the unusual must be carefully carried out (and managed) by all concerned.

The trick is to balance interest and initiative in the job with doing it safely. Humans are not robots and over-prescribing how someone does the job can have the opposite effect to what is intended. But, at the end of the day, you do have to have some rules and procedures in operating (or maintaining) any railway and there must be some consequences for those that are found to disobey them, even if it just some mandatory re-training and monitoring thereafter.
Mickey

Re: GCR Derailment

Post by Mickey »

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B4411
GER J70 0-6-0T Tram
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Re: GCR Derailment

Post by B4411 »

Bryan wrote:<snip>

9. An accident or incident which under slightly different conditions might have led to a death, serious injury or extensive damage to rolling stock, the infrastructure or the environment. Subjective, but I'd say it wasn't.

Certainly not reportable under Sched 1.
My judgement (as someone heavily involved on a day-to-day basis with safety at a heritage railway - not the GCR - and the principal author of and person responsible for the relevent SMS) would have been to report to RAIB under Schedule 1(9) since the incident happened adjacent to an open running line with passenger traffic, just to be on the safe side. Ther RAIB guidance includes the advice "if in doubt, notify".

I believe also that it is certainly reportable to ORR in accordance with Section 3 (m) of ORR's guidance from Jan 2012 "any incident not mentioned above which receives or is likely to receive media attention" (which nowadays catches just about any event at any gala).

Probably reportable to HSE under RIDDOR as well.

It is better to be on the safe side and report if in doubt, than not to report.

I would have expected that there is an extremely strong likelihood that ORR will take an interest since there appears to have been an appallingly basic breakdown on some very fundamental principles of safe operation. Coming after a spate of incidents, which have included fatalities, on heritage railways in recent years it wouldn't surprise me if there was a very close interest being taken. I think the questions relate less to "what went wrong" (which is fairly obvious) and more to "how was it allowed to go wrong", with the emphasis on training, competence, and hazard perception.

At a more immediate level, although I have seen plenty of references to the crew being authorised to pass the signal at danger, I haven't seen any explanation of why this would be necessary. I imagine that the turnout in the running line and the trap points are worked as a crossover off a single lever (why on earth would they not be?) in which case the turnout on the running line, in plain sight of the driver, was incorrectly set. If, as is likely, the signal is mechanically interlocked with detection on the trap point switches, any movement past it at danger is an extremely dangerous operation since there is no switch detection, and I cannot understand either the crew or the signalman allowing it in this cavalier manner! If there was a TC failure which resulted in the interlocking not working as intended, then everyone shoudl have been on high alert.

It is actually an appalling incident suggestive of errors at a very fundamental level, and one which will inevitably raise questions about the competence of staff, training, and safety management at heritage railways. If, as presently seems likely, there is no RAIB report I hope that the GCR will "man up" and release a report to the heritage railway community if only to be seen to be acting in a professional manner. There is, of course, always the possibility of making a request under the FOI Act to see the internal report.
Andy W
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Re: GCR Derailment

Post by Andy W »

I don't think the GCR are covered by FOI. But a short factual GCR statement (regarding the sequence of events) at the appropriate time will probably suffice.
John Palmer
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Re: GCR Derailment

Post by John Palmer »

B4411 wrote:I imagine that the turnout in the running line and the trap points are worked as a crossover off a single lever (why on earth would they not be?) in which case the turnout on the running line, in plain sight of the driver, was incorrectly set. If, as is likely, the signal is mechanically interlocked with detection on the trap point switches, any movement past it at danger is an extremely dangerous operation since there is no switch detection, and I cannot understand either the crew or the signalman allowing it in this cavalier manner! If there was a TC failure which resulted in the interlocking not working as intended, then everyone shoudl have been on high alert.
A photograph of the diagram at http://tillyweb.biz/gallery/qq/quorn.htm confirms that both the trap and the running line connection are controlled by lever 7, with no.6 being the signal passed at danger. At the time the diagram was photographed the points by which the down lie-by is connected to the running line were apparently not track circuited..
Mickey

Re: GCR Derailment

Post by Mickey »

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cambois
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Re: GCR Derailment

Post by cambois »

Micky

That is some story. Never heard that before, but can see how it might happen. I bet the driver of the 47 was a bit worried until it all came out during the investigation. Presumably it was an Immingham-Langley oil train.

Thanks for sharing it with us
Mickey

Re: GCR Derailment

Post by Mickey »

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cambois
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Re: GCR Derailment

Post by cambois »

I used to manage the Immingham - Langley oil traffic - a bit before your incident which is why my interest. My suspicion is that a collision would not have happened as it would all have been very slow speed and the drivers would have seen what was happening. But I can imagine what you felt like as you rushed over to the window with the red flag -

It probably shows that Clapham was not an isolated incident - I wonder how many more "non-incidents" there were, and how many faults were found. It puts the current very rigorous testing in context
Mickey

Re: GCR Derailment

Post by Mickey »

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manna
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Re: GCR Derailment

Post by manna »

G'Day Gents

Just goes to show Micky that 'Trap' points are there for a very good reason, but there just something to be removed because someone thinks there irrelevant............B***** bean counters :evil:

manna
EDGWARE GN, Steam in the Suburbs.
Mickey

Re: GCR Derailment

Post by Mickey »

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Saint Johnstoun
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Re: GCR Derailment

Post by Saint Johnstoun »

Did anyone notice the position of the points leading from the siding to the main line at the time of the incident? If they were set for the siding then mechanical failure was the cause, but if not it was sheer carelessness on the part of somebody?

The catch points should be interlocked with the points leading from the down line onto the siding and that in turn interlocked to the signal.

??
Mickey

Re: GCR Derailment

Post by Mickey »

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