Safety
rest just at West Ealing, some two miles further on. There were no reported injuries.
RSSB’s inquiry determined that this accident had been caused by a wheel flange striking a piece of broken fishplate that had lodged in the ‘V’ of the points. Though only installed the previous July, the fishplate had been poorly manufactured – the crack in the casting that eventually caused it to break developed over a period of 60 weeks or so. Two of the fishplate’s four bolts also fell out, vibrations from passing trains causing them to unscrew over a number of days. As space between the rails at the ‘V’ of a crossing is minimal, there would have been no way the fishplate ‘half’ could have fallen harmlessly to the ballast, so it was constrained between the rails until more train vibrations shook it into the ‘V’ itself. Maintenance issues, coupled with an increase in traffic – which had doubled since 1996 – also combined to create the conditions in which a derailment was inevitable.
Solidarity between rail companies Immediately after the accident, Network Rail conducted a national survey to check for loose fishplate joints and fractures. As it had by then taken maintenance ‘in- house’, many of the problems surrounding its contractor for the Great Western Main Line had vanished, such as the difficulty in taking possession of the two lines linked by the crossover at the same time. Network Rail also improved the competence and certification processes for staff, drafted a set of ‘track work instructions’ to give greater clarity as to what was expected of a track maintenance engineer, and began a move towards using welded crossings. These are not only less prone to wear than monoblock cast crossings with fishplates, they also require less maintenance, although Network Rail saw no reason to scrap all cast crossings,
which had been proven to be safe when correctly maintained. We don’t know what action SNCF and
French infrastructure owner RFF will take, but RSSB has shared the findings of the Southall East investigation to help them. When he visited the Brétigny-sur-Orge accident site, French President Francois Hollande spoke of his ‘solidarity’ with the families of the dead and injured. RSSB has shown that there’s solidarity too between railway companies – and that is partly due to the fact that companies are people, and when people talk to other people, there is generally empathy, sympathy and understanding.
Learning from incidents globally In my last article for Rail Professional (‘Never too old to learn’, September 2013), I wrote of the challenges of learning in
a fluid industry like ours. I stuck largely to ‘home-grown’ examples, but there’s a whole world of learning out there, learning with a long history. No one can deny the influence that French engineer André Chapelon had on the development of steam locomotive technology in the 1920’s and 30’s, for example, while the world looked to British Rail when seeking to develop trains with active tilt mechanisms some seventy years later. Moves are now afoot – via the UIC and ERA – to improve how railways across the globe share lessons from accidents. The latter has established a ‘quick response’ procedure in a bid to assess whether harmonised actions are needed across the European Union when an accident, trend or near miss reveals a risk that is not being adequately addressed. Elsewhere, RSSB continues to monitor accidents and incidents in the wider world, seeking to share lessons with its members and colleagues in order to improve railway safety and performance. Until the French Land Transport Accident Investigation Bureau (BEA- TT) completes its work and publishes its findings, the actual causes behind Brétigny- sur-Orge remains to be seen. We can, however, be sure of one thing – we’ll all be watching, and all be willing to learn. •
Greg Morse is RSSB’s operational feedback specialist. He is also Rail editor of Right Track, the industry’s internal safety magazine. The views expressed in this article are his own.
Greg’s latest book - British Railways in the 1970s and 80s (Shire, 2013) - is a 10,000- word summary of a difficult period for BR that began with the aftershock of Beeching, but ended with Inter-City becoming the first nationalised passenger network in the world to make a profit.
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