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Author Topic: Steam train SPAD at Wootton Bassett Junction, 7 March 2015 - RAIB investigation  (Read 93166 times)
BerkshireBugsy
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« Reply #75 on: October 20, 2015, 09:14:58 »

An update to the RAIB (Rail Accident Investigation Branch)'s investigation into this incident has been published today, 19th October 2015.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469145/151019_Wootton_Bassett_web_update.pdf

Sobering reading. It's not the RAIB's job to apportion blame, but it's quite clear from reading this interim report where the blame lies.

Many thanks for sharing BnM..although I'm no expert in this field I was able to understand the content. I must admit when I got to point 10 I had an inkling as to where this may be going...
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Trowres
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« Reply #76 on: October 20, 2015, 20:42:22 »

The matters relating to the TPWS (Train Protection and Warning System) isolation are undoubtedly of much concern, but it is debatable whether working TPWS would have halted the train clear of the junction in the circumstances described. I will be interested to see what RAIB (Rail Accident Investigation Branch) has to say about the confusion potential of the closely-spaced TSR (Temporary Speed Restriction) and signal AWS (Automatic Warning System) warning magnets, and the relationship of this to the driver failing to see SN43.


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JayMac
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« Reply #77 on: October 20, 2015, 21:26:20 »

It's precisely because a signal may be visually missed that systems such as AWS (Automatic Warning System) and TPWS (Train Protection and Warning System) were introduced. The major cause of this incident was isolating those systems. Fail safe back-ups were rendered useless by the footplate crew. Following the initial brake application after the TSR (Temporary Speed Restriction) AWS activation was not acknowledged in time, the only thing the crew were permitted to do was bring the train to a stand and contact the signaller. Not isolate the safety systems and carry on. Had the crew followed the rule book it's unlikely they would have missed the subsequent signal.
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Chris from Nailsea
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« Reply #78 on: October 20, 2015, 23:08:44 »

However, we're now verging on 'speculation' again, so perhaps it's best to wait until their full report is published by the Rail Accident Investigation Branch.  Lips sealed
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« Reply #79 on: October 21, 2015, 00:52:30 »

It seems this incident was a classic case of the holes (and it seems some extra holes had been added by deliberate human action) almost completely lining up in the Swiss cheese.

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.
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grahame
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« Reply #80 on: October 21, 2015, 08:13:46 »

It seems this incident was a classic case of the holes (and it seems some extra holes had been added by deliberate human action) almost completely lining up in the Swiss cheese.

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.

Where something out of the ordinary / routine is done, there are bound to be extra elements to be considered and got right - without the luxury of long run-in periods to smooth out problems, and with the "one-shot" issues that lots of people want to be involved, most of whom are unfamiliar with what's happening.   And - yes - that does give rise to very serious safety concerns.  Add to that the use of vintage equipment that was designed for a railway of old, on which new systems are designed to work with recent trains without significant consideration for old.

chrisr_75 - I think you're very right to ask the question / express that opinion. It's unlikely to be a popular opinion, but it does have considerable merit.  You are certainly not alone in the concerns, which go far wider than purely the operation issues of and from the steam locomotive itself.
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« Reply #81 on: October 21, 2015, 18:54:41 »

Interesting read. 
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« Reply #82 on: October 21, 2015, 19:19:29 »

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.

Yes, it's an interesting, and emotive, argument.  Adding to the chances of an incident happening there are other factors such as the crash-worthiness of the stock, judging from Phil Wakely's photo the consist was mostly MkI's - should such a train have been involved in an incident you can bet the carriages would have folded up like a pack of cards.

Just today the unions have been complaining that steam hauled services on the Borders Line have been a health hazard due to the carriages not having retention tanks which is of course another issue - though of course there is still plenty of regular service trains still running about like that which for some strange reason wasn't mentioned...  Undecided

As ever, there's a balance to find somewhere.
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« Reply #83 on: October 21, 2015, 19:28:44 »

BBC» (British Broadcasting Corporation - home page)'s take on the RAIB (Rail Accident Investigation Branch) report:
http://www.bbc.co.uk/news/uk-england-wiltshire-34583242

Quote
Safety equipment which was turned off allowing a steam train to pass a red signal had been turned off on previous occasions, a report has shown.

The train passed a signal near Royal Wootton Bassett in March and ended up across a junction.

A Rail Accident Investigation Branch (RAIB) report showed an Automatic Warning System (AWS (Automatic Warning System)) brake demand was by-passed by the train's crew.

The report said it was not the only occasion when it had been by-passed.

The driver of the Tangmere locomotive ignored two AWS warnings, the report showed.




He fully applied the brakes when he saw the red signal but there was insufficient distance to bring the train to a halt.

The report found the First Great Western service from Swansea to London Paddington had "fortunately" already passed through the junction before the stream train came to a halt.

The steam train was operated as a charter service by the West Coast Railway Company Ltd (WCRC).

The editor of Rail magazine, Nigel Harris, said: "Do not underestimate how serious this was. We were a heartbeat from absolute catastrophe.

"Because the driver missed the red signal his train stopped across the junction.

"No more than a minute before that a First Great Western express heading for London was occupying that junction at nearly 100 mph."

The RAIB said it was continuing to investigate the incident and "the extent of the practice" of by-passing the AWS.

The competence of the train crew involved, and how this was managed by WCRC, will also be investigated.
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« Reply #84 on: October 21, 2015, 22:07:56 »

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.

Yes, it's an interesting, and emotive, argument.  Adding to the chances of an incident happening there are other factors such as the crash-worthiness of the stock, judging from Phil Wakely's photo the consist was mostly MkI's - should such a train have been involved in an incident you can bet the carriages would have folded up like a pack of cards.

Just today the unions have been complaining that steam hauled services on the Borders Line have been a health hazard due to the carriages not having retention tanks which is of course another issue - though of course there is still plenty of regular service trains still running about like that which for some strange reason wasn't mentioned...  Undecided

As ever, there's a balance to find somewhere.

There are a few concerns I have with the breaking system, the air break handle operates all 3 breaking systems air (train break but on the support coach), vacuum (train break) and steam (loco break)

The driver by using the vacuum break handle was not applying the breaks on the support coach (or at least that is how I read it)

It would seem from the report the practice of isolating the AWS (Automatic Warning System) was common, I surmise this because the drivers window often got obscured by steam and soot hence the drive having to lean out so be possibly could not reach the break handle in the 2.5 secs the AWS required.

NR» (Network Rail - home page) placing the TSR (Temporary Speed Restriction) board where they did perhaps did not help but was not the cause of the SPAD (Signal Passed At Danger).

I am all in favour of heritage traction operating on the system, its how to integrate modern safety systems into them. 
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JayMac
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« Reply #85 on: October 21, 2015, 23:23:51 »

Please forgive my pedantry but it's 'brake' not 'break'.
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Chris from Nailsea
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« Reply #86 on: October 22, 2015, 00:53:39 »

You mean there's a difference?  Shocked Roll Eyes Huh Grin
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Electric train
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« Reply #87 on: October 22, 2015, 18:43:45 »

Please forgive my pedantry but it's 'brake' not 'break'.

Hay an electrical Engineer we have Breakers so my auto type keeps spelling brake as break  Grin
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« Reply #88 on: October 22, 2015, 19:00:48 »

Hey, that's okay!  Tongue Grin
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IndustryInsider
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« Reply #89 on: October 23, 2015, 11:08:39 »

Give the guy a brake, BNM...  Wink
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