Rail Accident Investigation Branch

Transcription

1 Rail Accident Investigation Branch Overview of 2015 IOSH Rail Industry Conference Simon French Chief Inspector (acting) 1

2 RAIB s activities during 2015 By the end of 2015 RAIB will have: o published 23 reports (including 3 bulletins) o started 20 investigations (as of 19 Nov) o made a total of 74 recommendations for the improvement of railway safety o issued 5 urgent safety advices o completed its part of a joint RAIB/BEATT investigation into the fire in the Channel tunnel in January 2015

3 Other events 29 May saw the departure of Carolyn Griffiths, the RAIB s first Chief Inspector of Rail Accidents On 17 October the RAIB celebrated its 10 th anniversary since its powers to investigate came into force RAIB has reviewed and updated its plans for engagement with virtually all parts of the railway industry

4 So how is the railway industry performing? Levels of harm (FWI) Overall Note Workforce Almost no change since when normalised by work hours Passengers A drop of a third since when normalised by passenger journeys Public Includes 10 fatal accidents At the platform/train interface at level crossings All figures normalised by passenger numbers

5 What about train accident risk? last train accident involving passenger fatality was Grayrigg (2007) Overall risk from train accidents (FWI per year) No. of potentially higher risk train accidents No. of SPADs (% of baseline risk) Average No. of FWI per million train km Note Includes collision with road vehicles at level crossings (100) 287 (73) 299 (66) 0.08 Was c.250 in Second lowest in Europe

6 Should we still be concerned about railway safety? Recent events have demonstrated the potential for serious train accidents with catastrophic consequences.

7 Near miss involving track workers near Hest Bank, Lancashire - RAIB report 8/2015 Near-miss at Hest Bank (2/3 secs) with gang of 10 track workers. Red zone with Lookout Operated Warning System (LOWS) protection LOWS shown to be functioning correctly Investigation focused on why trainon was not signalled by the lookout A range of human factors associated with the use of LOWS were identified 7

8 Collision between a train and a collapsed signal at Newbury RAIB report 15/2015 Passenger train struck top of a signal that had collapsed across the railway line near Newbury There were no injuries and the train did not derail but consequences could have been more severe if the train had been travelling in opposite direction because the signal fully obstructed that line and was capable of derailing train Factors include: Undetected corrosion in signal post Investigation focused on: Inspection of hidden parts of metal structures Asset management strategy 8

9 Ongoing investigations Collision between train and fallen debris at Froxfield - February 2015 Bridge parapet pushed onto the Berks and Hants by lorry reversing on the bridge having taken a wrong turning Safety learning includes: Road signage near railway bridges to warn of unsuitable routes for HGVs Bridge strike signs on overbridges The need to reinforce existing police control room procedures for the alerting of the railway following an incident of this type 9

10 Ongoing investigations SPAD near Wootton Bassett junction, Wiltshire - March 2015 A charter train pulled by a steam locomotive passed a signal at danger on the approach to Wootton Bassett junction. The train subsequently came to a stand across the junction shortly after the passage of a high speed train To date the investigation has revealed: A delayed reaction to an AWS warning, followed by train crew actions that bypassed the application of brakes by the AWS/TPWS Incorrect placement of a temporary speed restriction boards This had happened before 10

11 Important areas of learning during 2015 Every year the RAIB reflects on the themes highlighted by the reports published and investigations started during the year types of accident we have seen before recurrent underlying factors risk areas still be to be fully addressed

12 Platform train interface

13 Platform train interface Some issues highlighted during 2015 (issues that have been seen in previous years are shown in red) Do we really understand our train door control systems? [West Wickham].and how passengers interact with them? [West Wickham, Clapham South and Hayes & Harlington] Is the trapping risk fully understood by train crew and other dispatchers? [Hayes & Harlington] Viewing the PTI on crowded platforms [Clapham South]

14 Track worker safety

15 Track worker safety (1) Some issues highlighted during 2015 (issues that have been seen in previous years are shown in red) Maintenance of site discipline and vigilance, particularly for experienced staff carrying out routine work [Newark] Do we ask too much of our lookouts? (eg maintaining concentration over long periods of time) [Hest Bank] The need to better understand how humans interact with track safety equipment (eg Lookout Operated Warning System) [Hest Bank]

16 Track worker safety (2) Safe management of the interface between railway construction sites and adjacent lines that are open to traffic [Heathrow Tunnel Junction] Who checks that the line is safe for trains to run following engineering activities? [Watford Tunnel] How to minimise working on lines that are open to traffic, particularly on busy lines? [Newark and Redhill] Safe design and operation of trolleys and ironmen [Raven Crossing]

17 Track quality

18 Track quality Some issues highlighted during 2015 (issues that have been seen in previous years are shown in red) How best to ensure the quality of re-used rail [Porthkerry] Management of long-term and recurrent track faults [Paddington and Heworth] How should management assurance regimes detect, and then rectify, under performing track maintenance teams and deteriorating track quality [Paddington and Heworth] Management of track faults on connections between sidings and running lines [Angerstein]

19 Engineering protection and train movements in possessions

20 Engineering protection and train movements in possessions Some issues highlighted during 2015 (issues that have been seen in previous years are shown in red) Are long work sites are a factor in collisions between trains in possessions? How practical is it to drive a heavy train by line of sight in a work site or possession? Are the rules relating to train speed in work sites really understood, and what are the levels of compliance? The number, and types, of irregularities associated with the protection of engineering work sites

21 Freight train preparation and condition (1) Some issues highlighted during 2015 (issues that have been seen in previous years are shown in red) Preventing and removing residual loads in aggregate wagons (which can cause uneven loading of wheels) [Angerstein] The need to investigate the use of wheel load measurement devices (eg GOTCHA) to provide data on uneven wheel loading [Angerstein] How should the railway industry manage the risk from twisted frames and/or bogies? [Angerstein]

22 Freight train preparation and condition (2) How best to inspect and maintain pedestal suspension? [Angerstein] The need to ensure the wear rates of key components are understood and used to define the necessary inspection and maintenance regime [Washwood Heath]

23 Emerging themes

24 Other themes (issues that have been seen in previous years are shown in red) Weaknesses in the processes used to validate the safety of the design and associated approvals, particularly for modifications [Bryn and Channel Tunnel] RAIB remains concerned about the robustness of safety management systems for certain minor operators who are authorised to operate on the national network [Wootton Bassett] Variable quality of investigations carried out by the railway industry Effectiveness of new regime governing the activities of Entities in Charge of Maintenance (for freight rolling stock) [Washwood Heath]

25 How is industry responding to some of the big issues? Area of concern Risk at the platform/train interface Track worker safety Industry initiative Cross-industry initiative to review platform/train interface risk and to identify reasonably practicable measures to address it Ongoing implementation of Planning and Delivering Safe Work ; introduction of Safe Work Leader and new permit system Track quality Continued roll out of new and improved train-borne track measurement systems

26 How is industry responding to some of the big issues? Area of concern Freight train condition and the management of derailment risk Industry initiative Cross-industry initiative to review freight train derailment risk and to identify reasonably practicable measures to address it Network Rail and freight operators examining capability of existing wheel load detection equipment to provide data to wagon owner/operators/maintainers Line of sight driving in possessions and work sites RSSB research is ongoing

27 New annual report structure RAIB s annual report is changing The status of responses to all our recommendations will be updated at least once every three months and then posted on RAIB s web site this will enable easy access to up to date status information without the need to wait for the next annual report Section 2 of the report is therefore to be abolished

28 RAIB s plans for the future Ongoing review of engagement with all parts of the railway industry The RAIB is developing other ways of publishing and disseminating key information associated with investigations New concise outputs to provide key safety information (where full investigations cannot be justified) Greater use of web site updates to disseminate safety information Dissemination, and collaboration with industry, on areas of good practice for investigation