Signals passed at danger (SPADs) A summary of the rail industry s approach to risk reduction

Transcription

1 Signals passed at danger (SPADs) A summary of the rail industry s approach to risk reduction

2 2 RSSB l Signals passed at danger (SPADs)

3 Introduction A signal passed at danger or SPAD occurs when a train goes past a red signal without authority. Most SPADs have little or no potential to cause harm because they are the result of minor misjudgements of distance or of braking capability, or they occur at low speed. In most cases, the trains stop well within the safety overlap provided, either by the train driver or through system intervention. However, a SPAD still represents a glitch in the smooth running of the railway, causing disruption to operations, and in the worst-case scenario, the potential cause of a serious train accident. Over the past 15 years, SPAD risk has reduced by well over 90%. However, there is no room for complacency and industry continues to monitor and investigate SPADs to understand why they happen and what can be done to ensure the risk is managed. We have published the first phase of a new industry-agreed strategy to make the next step change in reducing and managing SPAD risk, and deliver safety and performance benefits to rail passengers and freight users. You will need to familiarise yourself with this strategy if you are an infrastructure manager or railway undertaking, to ensure you can continue to apply best practice and contribute to better risk management. How SPADs lead to risk In the last 15 years, the rail industry has made tremendous progress in reducing the risk from SPADs, coming down by over 90%. SPADs have been the precursor to some of the most serious fatal train accidents in history, including more recently at Purley in 1989, Newton in 1991, Cowden in 1994, Watford in 1996, and at Southall in The last multi-fatality train accident as the result of a SPAD occurred in October 1999 at Ladbroke Grove. There have, however, been more than 50 derailments and 4 train collisions caused by SPADs since that time. There have also been some notable near miss incidents, the most recent being at Wootton Bassett on 7 March Because SPADs have the potential to cause an accident, each one needs to be investigated thoroughly in a just culture, to understand the root causes and fully benefit from the learning.

4 By their nature, SPADs cause trains to be in an unauthorised place and the driver and signaller must follow safety protocols to capture important information and manage any immediate issues. This causes delays to train services, so even harmless SPADs jeopardise punctuality and customer experience. There are many reasons why signals may be passed at danger on the rail network, and identifying the underlying causes, to develop an effective risk reduction strategy, is fundamental to improving system safety. We recognise that SPADs occur due to a combination of factors such as design of infrastructure, operating and environmental conditions, and factors related to human error. Risk reduction strategies need to touch multiple aspects of train operation that consider, for example, the causal effects of signalling, rolling stock, the timetable, signaller performance, and rostering; as well as driver performance issues, which are the cause of, or contributory to, the majority of SPAD incidents. The use of safety performance data through the Safety Management Intelligence System (SMIS) will help identify trends. These can indicate where further action may be needed to collaboratively reduce the risk to as low as reasonably practicable. This will also help improve duty holders safety management systems, and enhance system reliability, safety, and sustainability of the overall rail network. In the last 15 years, the rail industry has made tremendous progress in reducing the risk from SPADs, coming down by over 90%. The average number of SPADs in the 1990s was 774 a year, peaking at 881 in 1998/99. This compares with the annual average of 292 between 2006 and 2016, and the current level of 272 for 2016/17. The level of underlying SPAD risk has fallen from 8.2 FWI/year in 2001 to 0.7 FWI/ year in 2016/17, a 90% reduction in risk. The risk reduction over this period is so substantial that we now use 2006 as a benchmark, to remove the effect of a train protection system fitted earlier that decade and ensure short term changes in the risk are more visible and can be analysed. Since 2006, there have been short term minor increases and decreases in risk but the trend has generally continued to be downward, reaching an almost all time low risk level in February 2017 at 32% of the 2006 benchmark. The success so far is testament to a sustained focus on this risk by everyone across industry, to get the best out of the installation of the Train Protection and Warning System (TPWS) and an open and mature safety culture among drivers, signallers and managers. It will be crucial for industry to build on this success to continue to reduce the risk. 4 RSSB l Signals passed at danger (SPADs)

5 Next steps in reducing risk The GB railway to set the standard for SPAD risk management across Europe, to achieve zero harm by a sustainable reduction in residual SPAD risk - to 35% by 2020, and to 25% by 2025, against the benchmark year of Based on the SPAD baseline set at September 2006 this will be achieved by enhanced understanding of the SPAD issue, derived from detailed analysis, research and learning, and implementing reasonably practicable solutions and good practice across the GB railway. The strategic vision is for the industry to work collaboratively to reduce train accident risk and optimise train performance, promoting long-term system safety improvements for the mainline railway, and benefitting those who use it. This supports the overall rail industry health and safety strategy on train operations risk. The strategy will be approved through phases, and this is only the first phase. This first phase aims to identify immediate and short-term deliverables for the mainline railway system as a whole, through good practice that can influence: Management of people involved in SPADs and the culture in which they work. Processes for SPAD management. Existing and future infrastructure and rolling stock. In delivering the core aim, this phase identifies existing good practice and tactical interventions that: Reflect the wide range of operational, engineering and behavioural issues surrounding the SPAD issue. Consider, and take into account, the immediate, short-, medium-, and longterm needs of the industry. Reflect the existing research available and where necessary, define new research to develop and deliver the future phases of the strategy. Facilitate collaboration across the industry for implementation.

6 Five areas were identified as priorities for the industry in improving SPAD risk management and gaining maximum benefit from learning. Identifying existing industry good practice and further developing reasonably practicable solutions to address their causes are the most likely to lead to improvements in SPAD performance. The five priority areas are: The role of the driver manager and signaller manager Driver and signaller self-management Competency management systems The use of on-board data systems The impact of the infrastructure The overall strategy: Takes account of both safety and train performance impacts of SPAD incidents. Considers measures to reduce the train accident risk as a result of SPADs. Considers mitigations that will reduce the risk of fatalities and weighted injuries (FWI) to passengers, workforce and the public. Takes account of future technologies that will reduce or remove the risk of SPADs. Proposes future opportunities to improve existing infrastructure and systems, such as re-signalling schemes. Considers the impact of expected increases in train paths over time. Takes account of third party impacts on SPAD risk, such as vegetation and street lighting. Factors to be considered: Train operation the operation of the train, including the actions of onboard staff, dispatch procedures. Signalling operation the actions of, among others, signallers, groundframe operators, handsignallers, and shunters. Infrastructure including the layout design, signalling design, interlocking, maintenance, ETCS, ATP, TPWS, AWS, and vegetation. Rolling stock including design, braking systems, in-cab signalling, ATP, AWS, DRA, sight-lines, trip-cock, and train-stop. Other industry staff the actions of a third party either exclusively or contributory to the incident. Third party vegetation (outside boundary), street lighting, vandalism. 6 RSSB l Signals passed at danger (SPADs)

7 Taking Safe Decisions A cornerstone of the success in reducing risk to date has been the application of a consistent approach in Taking Safe Decisions. This model is the rail industry s consensus on how safety decision making should be tackled in relation to regulatory obligation to ensure proportionate, targeted action and value for money. All proposed good practice deliverables described in this phase of the strategy (generally immediate and short-term) should be developed and implemented in line with the guidance set out in Taking Safe Decisions, using the Common Safety Method for Monitoring and the Common Safety Method on Risk Evaluation and Assessment (CSM RA). As recognised good practice has already been used elsewhere in the rail industry, the approach should be light touch. Where appropriate, and if necessary, deliverables will be subject to a standardised management of change process to provide consistent implementation and monitoring of change. The results of this monitoring will be reviewed and used to inform any further management of change processes, and help eliminate the possibility of changes having unintended negative impacts in other areas. Adopting this approach will mean all decisions and changes to achieve the objectives and targets outlined as Phase 1 ensure safety, operational performance, and availability of access, so far as is reasonably practicable. More information The full strategy document is available to RSSB members and associates only at If you are not an RSSB member and would like more information about the strategy or SPADs and operational risk more generally, contact us via our website.

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