RSSB
Greg Morse discusses the challenge of securing corporate memory for rail accidents O
n 26 February 2012, three men were in the cab of a locomotive heading through the Canadian countryside. Their train – a
regular passenger service – made a scheduled stop and powered up for the journey ahead. As the speed climbed, the crew saw a group of technicians working on the line. The driver sounded the horn but – unbeknown to him or his colleagues – the signaller had routed the train round the
worksite...via a 15-mph crossover. The locomotive hit the pointwork
at 67 mph and derailed. It slid down an embankment, where it collided with a building abutment, killing the crew outright. The subsequent investigation revealed issues around train protection, train crashworthiness, human factors and a lack of in-cab video recording equipment.
Some have called the accident ‘Canada’s Ladbroke Grove’. Yet no sooner was the report out than a cut of crude oil-carrying tankers ran away before derailing, catching fire and killing 47 people in Quebec. These two events led GB rail professionals back to those dark days at the turn of the century, when Hatfield followed Ladbroke Grove followed Southall – all in the space of three years. We know that accidents can bring safety improvements in the longer term, but though Hatfield, Ladbroke Grove and Southall led (variously) to improvements in track maintenance, track renewal and train protection, the fact is that we have been learning from accidents since railways began more than 200 years ago. By 1900, we – and our various regulatory bodies – had ensured the adoption of interlocking, block signalling and continuous brakes, while more recently we’ve seen increasing mechanisation and safer rolling stock contribute to the impressive drop in train accident fatalities recorded over the last 50 years. That doesn’t mean learning is easy – how many times have you hit your hand hanging a picture, told yourself you'll never do that again, only to put on a repeat performance the very next day? In a company, it’s even harder: companies comprise a number of different and disparate memories, which don’t always interface perfectly, and which can change as staff retire, move on, or move in from elsewhere. When you expand the idea to a complete industry like rail, it becomes even more complicated. One thing I’m always saying in my job is that ‘we combat
complacency with continued vigilance’. But we do – and in a fluid industry like ours, it’s the only way. Through RSSB, I’ve been able to remind the railway of lessons it learnt in the past – and those learnt by other industries, including episodes as diverse as the Nimrod air crash of 2006, the Deepwater Horizon oil rig explosion of 2010, the inquiry into care at the Mid- Staffordshire NHS Foundation Trust and the Fukushima nuclear accident of 2011.
Biggest safety story still the PTI Another way we help the learning process is by producing a Learning from Operational Experience Annual Report (LOEAR) to capture some of the lessons learnt during a given fiscal year. The latest issue, covering 2012-13, shows that the biggest safety story is still the platform-train interface (PTI), where major injuries have risen, despite a 10 per cent drop in overall harm. Behind every statistic, however, is a face. In November, we were reminded
of Georgia Varley, when RAIB published its report on the James Street fatality. Georgia died on the night of 22 October 2011, after falling between the platform and the train she had left 30 seconds earlier as it pulled out. The manslaughter
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