INFORMED SOURCES e-Preview November 2013
There is a theme to this month’s column which focuses on safety. It is that the value of recent Rail Accident Investigation Branch (RAIB) reports has been their exposure of the management culture in which an accident happened rather than the nuts and bolts of incident itself.
Level crossings highlight safety primacy
Crossing fatality reveals legacy risk
Stafford SPAD highlights unprofessional culture
PR 13 – ritual dance nears climax
There has been an interesting philosophical exchange in recent issues of IRSE News, the Institution of Railway Signal Engineers monthly magazine, debating why the ‘Four Cs’ around which the Rail Technical Strategy is based, ignored safety. The official explanation was that ‘Britain’s railways are among the safest in Europe and while it is always important to look for ways of improving safety that is not our most important priority in terms of achieving a major improvement’.
An experienced signalling engineer countered that the issue was not ‘improving’ safety but ‘continuing’ the safety of today’s systems through the transition into the complex high-tech systems of tomorrow. He suggested that ‘Continuity’ of safety performance would be a fitting replacement for the current invisible fifth C, ‘which seems to me to be Complacency’. Ouch!
We are following a classic example of that invisible C in real time, courtesy Network Rail’s introduction of automatic MCB-OD level crossings – the OD standing for Obstacle Detection which replaces the Mk 1 human eyeball scanning a CCTV screen. In Germany these crossings use a radar unit to scan the crossing and ensure that the roadway is clear. But following a safety study, Network Rail decided to add a low-level LIDAR scanner, able to detect, for example, a young child lying on the ground.
As previously reported, LIDAR has had problems with dust and mud obscuring the lens, whereupon it fails safe. This is infuriating for motorists – particularly when the crossing is on a busy road – as at Brandon in Suffolk.
Earlier this year, Network Rail decided to isolate the troublesome LIDAR at Brandon, resulting in an improvement notice from ORR requiring Network Rail to carry out a safety assessment at each crossing where the LIDAR was inoperable. Network Rail immediately backed down and restored the LIDAR detection and is now has staff at the crossing to intervene if the LIDAR malfunctions.
Meanwhile, the second Modular Signalling scheme has been commissioned between Crewe and Shrewsbury. Once again, there is an MCB-OD crossing on a busy road serving a town, in this case at Wem. This crossing has been fitted with the CCTV that MCB-OD was supposed to eliminate. Crewe-Shrewsbury is controlled from the Cardiff Signalling Centre and the CCTV will allow the signaller to make a visual inspection before over-riding the automatic operation and clearing the signals manually if OD has failed safe.
Crossing fatality exposes historic failings
In the July column I devoted a lot of space to analysing the dewirement at Littleport. What happened was obvious: how it was allowed to happen exposed muddle and confusion in Network Rail’s instructions, procedures and processes for inspecting and maintaining the overhead line equipment. Similarly, RAIB report into a fatal collision between a train and a car on the Beech Hill level crossing near Finningley on 4 December 2012 was important for its exposure of similar muddle and confusion in the inspection and monitoring of crossing lights.
While the crossing’s data logger showed that the equipment was operating normally, the driver of the car said that she did not see the flashing road traffic-light signals until she was close to the barriers. What RAIB found was that the ‘wig-wag’ lights at the crossing did not meet the relevant standard by a fair margin. Even worse, RAIB records that the Stott report on the safety of automatic open crossings published in 1987, pointed out that even then the light output of wig-wag signals with 36W lamps, still in use at Beech Hill 25 years later, was about half that of contemporary road traffic lights.
At the time of the accident, the approach to the crossing was into a low sun. Under similar conditions, an RAIB inspector and several Network Rail staff could not see the flashing lights when viewing the crossing from distances between 129 metres and 45 metres’.
Of course, signal engineers have long been aware of the effects of sunlight and background on the visibility of colour lights, during site visits to Beech Hill in 2005 and 2006, the Network Rail inspectors noted that low sun was a problem at the crossing. The 2006 inspection recommended fitting extended hoods to reduce the effect of sun shining into the lights. This was not implemented.
A revised data-gathering form was used for the 2007 inspection. The previous question ‘Is low sun a problem?’ had been replaced by the question ‘Is the horizon looking across the crossing (tick the one most applicable)’. There were two options to tick, either ‘Low horizon – the sun could be below the lights and signs when approaching the crossing’ or ‘The horizon is high – hilly or mountainous terrain, low sun blocked, or horizon not an issue’. There was a cross in both boxes on the 2007 report form but the ‘low horizon’ one was struck out.
At subsequent inspections between years 2008 to 2012 the ‘high horizon’ box was ticked. Needless to say the crossing is in flat fenland.
Following an accident at an automatic open crossing at Wraysholme in Cumbria in 2008, RAIB recommended that Network Rail should revise inspection methods to identify road traffic signals that were difficult to discern because of the effect of sunlight, lamp unit performance and alignment. An improvement programme was required.
This included 50 AHB crossings based on the data in the All Level Crossing Risk Model on road signal conspicuity. But because the wrong box had been ticked, Beech Hill crossing did not show up. And at the time of the latest accident, RAIB records that Network Rail had no plans to generally replace 36 W lamps in wig-wag signals.
RAIB has made four recommendations, the most important being the replacement of all remaining 36W wig-wags at level crossings. Network Rail issued A Special Inspection Notice In May this year to locate all such crossings and this inspection was to have been completed by September 27.
Stafford SPAD challenges competence
A month after a light-engine SPAD near Stafford in April 2012, someone raised concerns with the RAIB about the incident and the subsequent internal investigation. On the information provided RAIB concluded that it had been a ‘low risk event’ and suggested that the informant should contact the Office of Rail Regulation, successor to the Railway Inspectorate, which was responsible for inspecting the operator.
And there it would have rested had not someone from another train operator subsequently emailed ORR, RAIB and RSSB, with further details of the incident. This second whistleblower claimed that the driver of the locomotive had subsequently been unable to provide documentary evidence of his route knowledge.
Here, we are in the world of open access passenger and freight operators, licensed and inspected by the Office of Rail Regulation, running heritage traction, a Class 47 in this case, staffed by ‘zero hours contract’ drivers. And if you think the main-stream industry is fragmented, just study the tables in the column listing the companies, operators, maintainers and drivers associated with this one event.
There is a recurring phrase running through the article – ‘it gets worse’. This culminates in confusion at the Office of Rail Regulation when considering the license application from Devon & Cornwall Railways.
ORR identified two priority issues, one of which was that staff competence at the operator should be inspected before operation went ‘live’. But this was overlooked and the inspection had still to be carried out when the SPAD occurred nearly two years after the recommendation was made.
Four of RAIB’s recommendations refer specifically to DRC and ORR and have been addressed. But the fifth could affect all of the industry – if it is taken seriously.
RAIB recommends that the Rail Standards & Safety Board (RSSB) should amend the industry standard ‘Management of route knowledge for drivers, train managers, guards and driver managers’ to require an assessment of the training needs of new staff. In particular the amendment should clarify how ‘transferred-in’ route and traction knowledge should be assessed by the new employer. Particular attention should be given to the management of train drivers on ‘zero hours’ contracts and those who drive for more than one company.
Under British Rail, a single organisation recorded a driver’ career and kept track of traction and route knowledge. Today, the major passenger and freight operators are big enough to still do this, and check with the previous employer when drivers change company.
But for smaller operators it raises various questions on how you verify competence? And RAIB appears to have missed completely the parallel issue of maintenance staff competence. For example, of one technician RAIB says that he was ‘deemed competent by his previous employers to maintain locomotives of classes 31, 47 and 56’. No mention is made of supporting documentation.
Licenses
In the aviation industry these matters are regulated. All pilots have log books, there is a structure of examinations, licenses, demonstrations of competence at each stage, such as instrument ratings. You have to convert to each new type of aircraft, there are regular checks of emergency procedures on the simulator. Airlines have Training Captains and new pilots can fly a number of routes with a check pilot.
Similarly, aircraft maintenance engineers are licensed, whether working in the hangars at Heathrow or looking after the Pipers and Cessnas at my local flying schools.
Mandatory licensing is a powerful tool. Because if you do something wrong you risk losing your license and your livelihood. Applied to railways, were a driver to be involved in an incident on a route for which he was not signed, his license could be withdrawn. Equally, a log book containing details of experience, signed routes and locomotive and train type endorsements would provide hard evidence of experience for small employers.
You can argue that this would impose a further level of bureaucracy on the major TOCs, FOCs and maintenance providers, but I think the professionalism it would bring to driving and maintenance not to mention the safety benefits would justify the move. It would also place a premium on training. We should not assume that what worked before privatisation applies to today’s industry.
PR13 poker game
Every five years, the Office of Rail Regulation determines Network Rail’s income for the next Control Period. Towards the end of the cycle Network Rail publishes its Strategic Business Plan (SBP) which says ‘this is what we want to do, these are the enhancements the Government wants and this is the absolute bare minimum of money we need to make it all happen’.
Then, ORR publishes its Draft Determination which says, ‘Pull the other one, you are horribly inefficient and can deliver that and more for a lot less and this is our generous offer’. Network Rail then has a chance to restate its case before ORR’s Final Determination, which in the case of Control Period 5 is due to be published in 10 days time on 31 October.
Network Rail’s response to the Draft Determination is the regulatory equivalent of the all Blacks Haka before a rugby match. Both stamp around a lot and make blood curdling declarations of what they are going to do to the opposition. The only difference is that Chief Executive David Higgins and his team don’t stick their tongues out – well, not to date.
So how blood-curdling are Network Rail’s threats this time around? Well, its response assesses 13 out of 22 of ORR’s components as ‘unrealistic’ when compared with the SBP. I won’t bore you with the detail but the difference between the SBP and the Draft Determination is around £2.4 billion over the five years of CP5. Network Rail wants £1.4 billion restored in the Final Determination.
Or what? Network Rail’s doomsday option is to reject the final Determination and refer it to the Competition Commission, but it hasn’t happened yet.
Back in January 2001, Railtrack’s board did decided to go nuclear over Tom Winsor’s final determination, but backed down when offered more money through a political fudge. Which only goes to show the danger of accepting sweets from strangers, because it soon turned out to be the Government’s equivalent of the neutron bomb – wiping out the company but leaving the assets in place for Network Rail to take over.
In the 2008 Periodic Review the Draft Determination was £3.38 billion short of the SBP and included £1.13 billion of efficiency savings. This was described as ‘unreasonable and unrealistic’ by Network Rail. However, the Final Determination closed the funding gap to under £2.8 billion and this was accepted.
My bet is that ORR will make some concessions that Network Rail will be able to live with. But in today’s railway industry you have to expect the unexpected. Anyway, all will be revealed next week.
Roger’s blog
First of all, a welcome to all the new subscribers to e-Preview who responded to the note in last month’s column. You took the total through the 2,500 mark, which had been tantalisingly close for some time, and new subscriptions are still coming in.
Since the last blog I’ve had three cracking site visits. At Derby, Bombardier brought me up to speed on the new Aventra EMU and showed me the manufacturing work which is being brought back in-house. There is a clear trend to this ‘in-sourcing’ across the train builders and maintainers.
From Litchurch Lane I had a sunny walk over the bridge to the Tech Centre for a session with REVEL. Highlight of the shop-floor tour were the two Class 20s being re-engined with packaged diesel generator sets. The quality of the structural refurbishment was very impressive and I also had a sneak preview of the new cab layout which had just been approved by drivers’ representatives.
Early in October Virgin organised a press trip to see Voyagers being maintained at Bombardier’s Central Rivers facility. This was my first visit and expectations were raised by the selection of ‘spanners’ in the trophy case in reception.
These modern ‘machines for maintenance’ continue to fascinate me, the management and facilities equally. To these guys, as at the other top depots, keizen – continuous improvement - is now part of the depot DNA.
As mentioned last month this coming week is unusually busy. There’s Traffic Management with Hitachi on Monday, and the update from SWT on Tuesday is now followed by a lunchtime judging session of the Rail Future User Group Awards with my fellow Vice Presidents. Then on Wednesday I’ll be with First Great Western for the second article in our new series on operators’ plans for their new Direct Award franchises.
On 29
October there’s my presentation to the RSA
and CILT at London
Metropolitan University. Kick-off is at 18.30 in Room SHG-01 in the
building in Holloway Road.
Early in November I’m catching up with Eversholt and on the 22nd it’s the Fourth Friday Club which incorporates the Golden Spanners awards. Time for my annual visit to my friendly local motor factor. In addition to the five categories of rolling stock, the awards include my own ‘wild card’ Golden Spanner. This year it goes to the most reliable sprinter.
That’s all for now.
Roger