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Post by Nortube on Dec 7, 2016 10:47:42 GMT
The RAIB report into the derailment at Ealing Broadway (District line) on 2 March 2016 has just been published (actually, it was a couple of days ago, but I forgot to post the thread ) and is available here: www.gov.uk/government/uploads/system/uploads/attachment_data/file/574435/R242016_161206_Ealing_Broadway.pdfOne thing that I find disconcerting is that the report states that Station Supervisors are not trained to read a route - i.e. to follow how the wheels of a train would run across the pointwork if travelling from A to B - and ensure that all the points are set correctly for the passage of a train over them. Because they are usually the nearest people available, Supervisors may be the first people involved with securing the route, although other people can do so depending on who is around at the time. I have assisted with route securing in the past and also been involved with refresher training that covered this. Even though a person securing the points are instructed in what direction the points are secured Normal or Reverse, it is not always clear as to what the actual position of the points is. There is normally a letter N or R with an arrow on the track which will indicate the position that the points are laying. The position being where the blade touches an adjacent rail being designated N or R as appropriate. My experience is that these indications aren't always clear for various reasons, such as missing or dirty letter, or when there are several points in a small area. Whoever is scotching and clipping the points to secure them in the required position will usually be following instructions as to what points need to be secured and in what position. This doesn't need route knowledge or the ability to read a route, or even knowledge of the area, just the knowledge to be able to identify what is the Normal / Reverse position of the points and how and where to fit the scotch and clip on those points. However, being able to read the route that has been set up acts as a double check to see that the all points are set in the correct position for the movement of the train over them as it travels from A to B. That way, if the person securing the points has been given the wrong instructions or perhaps mistakenly secured the points in the wrong direction, this should be easily spotted. Depending on how many points need securing, this may be done by one or more people to safe time if there are the staff available. E.g. going north from Hampstead NB, there is only one set of points to secure (6B) at the north end of the emergency crossover. Going south from platform 1 to the SB main involves eight sets of points, or nine if going via an unsignalled route. In this scenario, several people may be securing the route, but there should be one person who, after the route has been secured, is able to read the route to confirm that it is physically set for the train to pass over, not just set according to what points they were told to secure. Whether they were originally trained to read a route as part of their training or whether it was just local knowledge passed on to them at the station, I’ve generally found Supervisors to be very knowledgeable about the track in their area, especially if the station is their home station.
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Post by dave1 on Dec 7, 2016 18:17:45 GMT
I have just read the report and there seems to have been a number of errors by everyone involved. I would have thought that supervisors would know their area but late at night it all looks different and he may have been under pressure from those above. Has training on LU been reduced like some other companies have done.
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Post by railtechnician on Dec 8, 2016 8:26:22 GMT
An interesting read! My instantaneous view is too many inexperienced managers and at least two with enough service to have been able to sort this farce but who were either not fully appraised of the facts or who were so informed but gave incomplete or misleading information to those asking questions.
From the report it would appear that even the Signal Ops Manager did not give a clear and precise response when asked about the points required in the route. The bottom line in that regard is that, regardless of the required 'lay' of the points, all points in the route have to be proved in the selection of the signal. That is fundamental to route securing whether done by clipping and scotching points or by other means (route securing by signal operator route securing pushbutton). Thus 39 crossover and 38 turnout had to be proved and there is no excuse for not considering the three 'ends' when querying the route.
IMHO no management official concerned with the day to day operation of passenger services should be in post without proven knowledge and ability to understand the very basics of points and signalling. Although having N and R plates at a turnout is helpful it is not essential to find them present. Anyone should be able to stand at the tips of the switches looking towards the heel end (i.e. looking towards the crossing popularly called the 'frog') and state quite clearly the lay of the points i.e. 'the left hand switch rail is up to the stock rail and trains are routed to the right' or 'the right hand switch rail is up to the stock rail and trains are routed to the left' or else if neither switch is 'UP' to indicate that. It is also fundamental to know that a track failure at one of the tracks over a crossover or the track over a turnout will cause the points in the route to be tracklocked. The signal operator should have known that the points were tracklocked because his diagram showed CB track 'DOWN'. The controller track diagram had not been updated to reflect the current layout, there is no question that, that information should have been updated on the same shift that the layout was rearranged, it would have been published in the Traffic Circular and all those in the Operating Department of the line should have noted that and modified their copies of the prints accordingly pending issue of the updated drawings from the drawing office. It is simply a red herring to suggest that operating officials are not trained to know or understand 'SLIPS', they are just turnouts like any other points although it is more important that the point designation plates are found at the tips of the switches to identify which switches are which set of points. That said, even without designation in view, either obscured or simply not fitted (very unusual if so) it should be simple enough for an official to state that he is standing at the tips of unmarked switches and 'facing east on the eastbound' or 'facing west on the eastbound' and then to state whether he is observing the left hand or right hand pair of switches before stating which switch of which pair is 'UP' to the stock rail and which way trains will be routed. Also following a rail from the 'UP' switch through the road to the next turnout forming the other end of the slip will instantly indicate whether or not that turnout is lying correctly for the required route. When I was a Technical Officer I came across station supervisors at more than one site who had little or no knowledge of points or how to correctly clip & scotch them or, worse, how to remove clip & scotch when requested to do so. Unlike the old days, when station supervisors were dyed in the wool railwaymen who learnt their trade from the ground up over many years working in many locations and having a rounded and knowledgeable overview of railway operations as they worked through the grades, there has been what I would call a fast track approach to promoting staff to station supervisor and above leaving out much knowledge that can only be gained by time served experience. Ever since devolution of lines the individual lines seemed to 'do their own thing' in terms of training and promotion. I have no doubt that if all operating officials on all lines were fully and properly tested on all that they are licensed to do and know to hold those licenses many would be found wanting. Today's railway operating officials are not railwaymen / railwaywomen so much as they are office managers who want the grade and the salary but without the responsibility.
There really are no excuses for this incident. IMHO RAIB should apportion blame and clearly in this report they do say quite a lot about what might be seen as a 'comedy of errors' but about which absolutely nothing is funny. Somewhere heads should roll, I do not necessarily blame any of the officials involved but I do believe that something needs a good shake up. One cannot blame anyone for seeking promotion and a higher income to support their family or in fact taking promotion when it is offered but one has to wonder how these officials made it to the grades held without clearly demonstrating the knowledge and professionalism required in those grades. It is not just about basic training but about continuing professional development, ensuring that licenses are upheld with regular experience as required by those licenses or refresher training and retesting. Without such experience or retraining licenses should be withdrawn and if necessary staff regraded accordingly to suit what licenses they still hold. Naturally the unions would not like it but officials need to take their roles seriously. Many seem oblivious to the idea that they could be gaoled if convicted of causing death as a result of their actions leading to an incident involving fatalities.
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Post by railtechnician on Dec 8, 2016 17:20:47 GMT
In another place a so called expert suggests that the signal operator had no way of knowing the normal lie of the points, this is rubbish as the normal lie is clearly shown on the signal operators signalling diagram. Those who cannot see it need either training or a new set of spectacles.
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Post by dave1 on Dec 8, 2016 19:50:03 GMT
In another place a so called expert suggests that the signal operator had no way of knowing the normal lie of the points, this is rubbish as the normal lie is clearly shown on the signal operators signalling diagram. Those who cannot see it need either training or a new set of spectacles. I noticed that as well but as we all know that place there are some who think they know it all.
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Post by Nortube on Dec 8, 2016 23:13:40 GMT
When David Millard was Northern Line General Manager, in 2006 he instigated the creation of Northern Line Failures and Area Information Folders. They were custom designed for each controlled area station (a station where there are controlled signals associated with points). They contained five main sections: A Signal failures - shows how to determine what route is set and what points to secure in the event of a signal before a set of points failing to clear. B Protection Key Switches - details of the signals maintained at danger by the operation of the Protection Key Switches at that station and the areas / equipment that is accessible when the switches are operated. C Traction Current Arrangements - details of the traction current arrangements in that area, what tracks are affected when a pair of section switches or circuit breaker is operated, and what effect this has on the service. D Train Berths - diagrams showing the NB and SB approaches / departures at that station. The diagrams covered four things: – Train Berths – shows the normal position where following trains may be berthed if there is a train delayed in the platform or at a signal. The amount and position of trains that may be trapped during an incident can be clearly seen. - Gradients, Distance and Speed. The diagrams were from the set created by the Technical Support Department and were similar to the Driving Techniques diagrams that they created for drivers. E Local familiarisation Shows the track walk for that stations area that staff were expected to do as part of their familiarisation / refresher so that they knew where equipment etc. was kept and the layout of the track area. Basically, this was the area of the track etc. that station staff may have to attend, equipment that they may need to use, testing and operation of that equipment (e.g. section switches / circuit breakers etc. as appropriate) and so on. The track walk in bigger areas was split into individual parts. Camden Town had three different track walks to cover the area. The idea was that all Supervisors would be fully competent in being able to deal with any rail related incident involving the use of equipment, and that included being able to read the road when securing points. I think that, at the time, the local familiarisation track walks were self-certified, so I don’t know how many Supervisors actually did them fully each time. The folder was a professionally printed A4 landscape ring binder and all the pages were reinforced and wipeable. The idea being that the member of staff dealing with the incident (usually the Supervisor if at a station) could remove the relevant pages and take them with them for reference as necessary. All controlled area stations had a copy and Supervisors were issued with their own personal copy for their location (I think relief Supervisors got a copy for each area they covered). Copies were also kept in the various manager’s offices, DMT locations, Control Room, etc. Below is an example from section A of the High Barnet folder. Of course, the physical signals are no longer there, but points will still need to be secured for a route in the event of a failure. Double click to enlarge Introduction page Showing the route from signal NU3 (home signal) to go to platform 2 Route is in orange. Points to be secured and in what direction ( Normal or Reverse) are circled Diagram showing the possible valid paths from the NU3
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Post by Nortube on Dec 8, 2016 23:33:45 GMT
Below is an example from section A of the Golders Green folder. Golders Green track layout is more complicated and includes several slip points. Double click to enlarge Showing the route from G4 (middle platform) to go to the SB main (past G6) Route is in orange. Points to be secured and in what direction ( Normal or Reverse) are circled Diagram showing the possible valid paths from signal G4 (not necessary signalled moves) Diagram showing the possible valid paths from signal G5 (not necessary signalled moves) - no route diagram
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Post by dave1 on Dec 9, 2016 15:52:09 GMT
Nortube considering that these were done 10 years ago I am sure if something existed like this for Ealing Broadway the derailment would not have happened. I can only go by how where I work a different management and everything changes normally for the bad. Could it be a line thing? although I suspect that training has been cut across the board.
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Post by railtechnician on Dec 9, 2016 17:50:57 GMT
Nortube considering that these were done 10 years ago I am sure if something existed like this for Ealing Broadway the derailment would not have happened. I can only go by how where I work a different management and everything changes normally for the bad. Could it be a line thing? although I suspect that training has been cut across the board. As I said each line went its own way following devolution and as a result different standards occurred in engineering despite and I have no doubt that the same was true for operating departments. Despite the facts indicated in the RAIB report and the possible mitigation of what appears to be incompetence at worst and sloppy management at best it is an undeniable fact that all the necessary information was or could have been available if those involved in the incident were 'on the ball'. Quite simply for whatever reason, they were not! Having seen the length of service of each of those individuals it is clear to me that they were mostly not long enough in LUL service to have acquired the knowledge and skills required to deal with the failure. We don't know what training was/was not given and I can see in the other place that anyone critisising the actions of those involved is a target for moderation by the so called experts. However, one argues the case someone must be responsible for all that was not done correctly but I stress that I do not necessarily blame the persons involved, my belief is that those who trained and licensed them, tested, assessed and promoted them are to be held to account. The signal operator should have known the normal lay of all the points, his signalling diagram is the master and was correct and showed that information. The station supervisor should have been able to walk the track and follow the road(s) indicating the actual lay of all the points in the route to the signal operator even in bad weather. If necessary he should have been able to call upon another grade on site to accompany him and assist him with additional light. The signal operator and station supervisor were the two key players as far as route securing in this case is concerned. I am well aware that some station supervisors do not feel confident to walk the track or to clip & scotch points but these tasks go with the grade. There can be no excuse for not being able to perform all the duties and responsibilities of the grade. In this type of incident the signal operator has to call the shots as he is controlling trains and must know a route is secure before authorising the signal to be passed at danger. The train driver is in charge of the train and is there to follow the signalling, including the verbal instruction(s) of the signal operator regarding train movement. He is not required to do anything else but when passing a signal under rule should proceed at walking pace and be able to stop. He cannot be blamed for not seeing the points laying incorrectly given the time of day and the weather and even on a bright sunny afternoon could not be admonished for not seeing an incorrect lay of points. If such were a requirement then the train service would be a joke as a driver slowed to walking pace at every turnout before slowly proceeding over it! The line controller is not really in the picture as far as the incident is concerned because a train sitting at WP17 blocks all movements into the site, the traction whether on or off in that regard makes no difference and of course 39 crossover was tracklocked reverse so any train in platform 9 would also have been trapped. When I used to maintain signalling at EBY, 39B were loose points. Thus once the failure occurred the line controller would have concentrated on the service on the rest of the line, as that is his priority, while awaiting resolution of the incident by the signal operator, station supervisor and signal staff as and when they arrive. To me the derailment is a bad management issue, not on the day but in the weeks, months and perhaps years beforehand!
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Post by railtechnician on Dec 9, 2016 18:03:51 GMT
When David Millard was Northern Line General Manager, in 2006 he instigated the creation of Northern Line Failures and Area Information Folders. They were custom designed for each controlled area station (a station where there are controlled signals associated with points). They contained five main sections: A Signal failures - shows how to determine what route is set and what points to secure in the event of a signal before a set of points failing to clear. B Protection Key Switches - details of the signals maintained at danger by the operation of the Protection Key Switches at that station and the areas / equipment that is accessible when the switches are operated. C Traction Current Arrangements - details of the traction current arrangements in that area, what tracks are affected when a pair of section switches or circuit breaker is operated, and what effect this has on the service. D Train Berths - diagrams showing the NB and SB approaches / departures at that station. The diagrams covered four things: – Train Berths – shows the normal position where following trains may be berthed if there is a train delayed in the platform or at a signal. The amount and position of trains that may be trapped during an incident can be clearly seen. - Gradients, Distance and Speed. The diagrams were from the set created by the Technical Support Department and were similar to the Driving Techniques diagrams that they created for drivers. E Local familiarisation Shows the track walk for that stations area that staff were expected to do as part of their familiarisation / refresher so that they knew where equipment etc. was kept and the layout of the track area. Basically, this was the area of the track etc. that station staff may have to attend, equipment that they may need to use, testing and operation of that equipment (e.g. section switches / circuit breakers etc. as appropriate) and so on. The track walk in bigger areas was split into individual parts. Camden Town had three different track walks to cover the area. The idea was that all Supervisors would be fully competent in being able to deal with any rail related incident involving the use of equipment, and that included being able to read the road when securing points. I think that, at the time, the local familiarisation track walks were self-certified, so I don’t know how many Supervisors actually did them fully each time. The folder was a professionally printed A4 landscape ring binder and all the pages were reinforced and wipeable. The idea being that the member of staff dealing with the incident (usually the Supervisor if at a station) could remove the relevant pages and take them with them for reference as necessary. All controlled area stations had a copy and Supervisors were issued with their own personal copy for their location (I think relief Supervisors got a copy for each area they covered). Copies were also kept in the various manager’s offices, DMT locations, Control Room, etc. Below is an example from section A of the High Barnet folder. Of course, the physical signals are no longer there, but points will still need to be secured for a route in the event of a failure. Double click to enlarge Introduction page Showing the route from signal NU3 (home signal) to go to platform 2 Route is in orange. Points to be secured and in what direction ( Normal or Reverse) are circled Diagram showing the possible valid paths from the NU3 A great idea, which I have never seen before, although it tends to obviate what people in various grades should know. The problem there is that inexperienced new entrants into grades become lazy and rely upon what is in the folders instead of using them to aid the knowledge and experience they should already have. We had folders on signals detaining the ins and outs of all the signal, trainstop, point, relay and other equipment types but anyone who had made it to Technical Officer should have already known the majority of the contents and only needed to refer to the folders for equipment rarely seen. I came across several colleagues whowere found wanting in that regard and always felt it was as a result of a lack of experience in various departments before entering the grade. Unfortunately each line had its own interpretation of what was required to grant licenses to signal grades and I came across colleagues on other lines who were held to a much lower standard than our line signal manager held us to!
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Post by Nortube on Dec 9, 2016 18:54:37 GMT
Dave 1 - One of the problems with having information is whether somebody follows it or not. The idea of the folders was that in the case of a rail / track-side incident, the person dealing with the incident would have the relevant information at a central point for reference. It was up to that person whether they did actually refer to it or not. Mistakes do happen at times, however good a person is, but the aim of the folder was to eliminate as many chances of mistakes as possible and at the same time reducing delays during an incident because the correct procedure would (hopefully) be followed. As the folder was an official issue and should always have been available, a person dealing with an incident who screwed up couldn't use the excuse that they 'didn't know' or 'weren't sure'. As far as I'm aware, the basis of the folder was unique to the Northern line at that time and I don't know if any other lines followed David's example or if the Northern line was the only line to have the relevant information collected together in this way. Apart from being used in anger during an incident, the folders were also a reference point for somebody who wanted to look up something. The Controller's diagrams showed the track layout for the line but if somebody wanted to work out what points were needed in what position for a route, they would have to try and work it out by following the diagram. This was not always easy to do, especially where slip points are involved. Normally shown as a single 'stub' of a line, there was rarely a clear indication of what position they should be in for what route, although it could be guessed. Slip points were one of those things that I seemed to have a mental block over and where they were concerned, I always found it difficult to compare the Controllers diagrams, which show tracks as a single rail, to the real life two rail track shape. I finally twigged it after studying slip points close up at track level! For the sake of completeness, I’ll also cover the traction current section C of the folder as it relates to similar types of incidents except they involve section switches instead of points. This deals with the traction current details with the feeds, switches and circuit breakers shown. Section C was designed to show what switches / breakers needed to be operated to what position in order to isolate or feed a section of track. As with points, the Supervisor (or whoever) would be instructed on what switches to operat and to what position. As part of their regular familiarisation track walks, they would be aware of the position of the switches and any peculiarities relating to them. If a circuit breaker was involved, such as in certain reversing sidings, they should know the correct procedure to remotely operate them or to manually open / close them as required. Unlike a derailment at very slow speed over incorrectly set points where there are unlikely to be any injuries caused, a switch set to the wrong position has the potential to cause fatalities if part of the track is (returned to) live when there are people on it. Therefore, it is essential that whoever is told to operate a switch is absolutely certain that it is the correct one (pair, + and -) and are able to inform the person instructing them to do so if they think that the instructions are wrong. Therefore, the folders were meant to be a double check for the person given the instructions to look at and confirm the relevant switch number(s) would be the correct ones. Whilst working out traction current paths from the Controllers diagrams was a bit easier, it has to be remembered that the running line is mostly double-end fed and that opening just one section switch (actually a pair – positive and negative - but I’ll refer to the pair as one) would often make no difference unless the feed to the section was isolated from one end. In thesame way that the folder made it easy to work out points involved, it made it easier to work out what switch(es) to open to isolate a section of the running line because it showed what sections were dead when the switch was opened. An example of section switch operation is if there is an incident (or planned engineering works) which involves discharging current in a traction current section (substation to substation) yet disruption to the service is required to be kept to a minimum. By opening section switches it may be possible to isolate the work site and recharge traction current, thus allowing trains to reverse. E.g., if traction current needed to be discharged at London Bridge NB due to an incident, this would mean no service could run between Kennington NB and at least Euston because there would be no traction current on the Elephant & Castle to Old Street NB traction current section. However, by opening one section switch at Moorgate and recharging traction current from the Old St end, trains could be reversed S-N at Moorgate to provide a service NB from Moorgate if required. Below are examples from section C of the Moorgate folder. The section switch arrangements are typical for a reversing point like this. Opening individual switches and recharging traction current from one end of the section allows reversing over the crossover in four different ways. Note - this information may no longer be relevant Excuse any poor quality as, like the signal pictures in the previous posts, they are screen captures. Double click on the picture to enlarge Normal traction current supply Section switch open in order to allow train to reverse S - N to provide a NB service from Moorgate Details of how opening 463 affects the train service at Moorgate
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Post by Nortube on Dec 9, 2016 19:34:57 GMT
From a driver's point of view, although they are expected to always check that the route is set correctly, I think that it's something that is done instinctively, like not noticing all the green signals, but straight away seeing a red one. In normal viewing conditions, such as good daylight / ambient lighting, the drivers view from the cab is usually sufficient, even at speed, to see the lay of the points and be able to read the route ahead. What they will not be able to easily see is if the points are fully over or not. I can't remember if part of the driver's instructions are to check the actual points are set correctly (unlikely), but they are held responsible for checking that they get the correct route at a junction signal etc.(rather obvious I suppose) and can be disciplined if a wrong route is shown and accepted.
Where the driver has to check individual points is when applying the rule. The driver has to check that a) the points are set in the correct position and b), with few exceptions, that the points are secured with both a scotch and clip. Also that the scotch and clip are fitted correctly. There's always the joke about the clip being fitted above the rail instead of below it, but I've actually seen it done this way and luckily it was only during a training session! It can be difficult for a driver to sometimes see the way that the points are set, especially regarding slip points and, in all honesty, the driver may not even realise the points are not set correctly if they are concentrating more on whether the scotch and clip is in place as they pass over the points.
I think that there always has been this problem of laziness in this way with some staff. I think that they get lulled into a false sense of security. On the Northern line, prior to the introduction of the 95 stock, Guards and Drivers were expected to know a lot of the way how the stock worked, including air flows, electrical circuits, fuse ratings, mechanics etc., even though the school did water this down later on. Theoretically, a lot of it was irrelevant as long as you knew the defects procedure for whatever defect that might occur. There was no need to know the air or electric flow that occurred in each brake handle position as long as you knew the procedure to carry out to get round a defective brake. However, I always found the background knowledge very useful because many defects interacted with different pieces of equipment. E.g. no movement – caused by low main line air, low train like air, blown control fuse, blown 30A no.1 fuse, and so on. The way we were taught at school, everything became so engrained that whenever a defect occurred I could usually visualise the relevant diagram in my mind and automatically started going through it. This was often a great help when initially deciding what the actual cause of the defect was and how to get around it.
This all changed with the introduction of the 95 stock. Background knowledge was cut back to a bare minimum and more reliance was placed on the cab monitor displaying that there was a problem and what to do. Whilst this usually worked, it meant that drivers had no real incentive to keep up with any knowledge, the thought being “it will tell me what to do if something goes wrong”. Of course, this wasn't much help when a defect meant that the screen went blank!
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Post by railtechnician on Dec 10, 2016 14:36:58 GMT
From a driver's point of view, although they are expected to always check that the route is set correctly, I think that it's something that is done instinctively, like not noticing all the green signals, but straight away seeing a red one. In normal viewing conditions, such as good daylight / ambient lighting, the drivers view from the cab is usually sufficient, even at speed, to see the lay of the points and be able to read the route ahead. What they will not be able to easily see is if the points are fully over or not. I can't remember if part of the driver's instructions are to check the actual points are set correctly (unlikely), but they are held responsible for checking that they get the correct route at a junction signal etc.(rather obvious I suppose) and can be disciplined if a wrong route is shown and accepted. Where the driver has to check individual points is when applying the rule. The driver has to check that a) the points are set in the correct position and b), with few exceptions, that the points are secured with both a scotch and clip. Also that the scotch and clip are fitted correctly. There's always the joke about the clip being fitted above the rail instead of below it, but I've actually seen it done this way and luckily it was only during a training session! It can be difficult for a driver to sometimes see the way that the points are set, especially regarding slip points and, in all honesty, the driver may not even realise the points are not set correctly if they are concentrating more on whether the scotch and clip is in place as they pass over the points. I think that there always has been this problem of laziness in this way with some staff. I think that they get lulled into a false sense of security. On the Northern line, prior to the introduction of the 95 stock, Guards and Drivers were expected to know a lot of the way how the stock worked, including air flows, electrical circuits, fuse ratings, mechanics etc., even though the school did water this down later on. Theoretically, a lot of it was irrelevant as long as you knew the defects procedure for whatever defect that might occur. There was no need to know the air or electric flow that occurred in each brake handle position as long as you knew the procedure to carry out to get round a defective brake. However, I always found the background knowledge very useful because many defects interacted with different pieces of equipment. E.g. no movement – caused by low main line air, low train like air, blown control fuse, blown 30A no.1 fuse, and so on. The way we were taught at school, everything became so engrained that whenever a defect occurred I could usually visualise the relevant diagram in my mind and automatically started going through it. This was often a great help when initially deciding what the actual cause of the defect was and how to get around it. This all changed with the introduction of the 95 stock. Background knowledge was cut back to a bare minimum and more reliance was placed on the cab monitor displaying that there was a problem and what to do. Whilst this usually worked, it meant that drivers had no real incentive to keep up with any knowledge, the thought being “it will tell me what to do if something goes wrong”. Of course, this wasn't much help when a defect meant that the screen went blank! If I had to lay blame for this incident I would certainly single out the signal operator in the first instance, however, as I hinted earlier he is 'The One' at the 'sharp end' so to speak but the question is how much blame can be apportioned to him. Having worked in control rooms over the years and been present at Earl's Court CR during incidents I know that at times the pressure on the signal operator by the line controller could be massive, indeed on more than one occasion during incidents I observed heated argument ensuing where calm heads should have been at work. I can only imagine how much worse it must be when the line controller and signal operator are not in the same location with background noise at both ends in busy rooms and other parties all trying to be involved etc. As a Technical Officer dealing with failures at the sharp end I was often badgered by line operating officials for answers before I had completed my investigation or resolved the issue and I had no hesitation in telling them politely where to go, sometimes more force was required so I dropped the 'politely' or shortened the message to a two word expletive. I think perhaps one or two people involved in this incident were simply 'in the way' and as useful as a chocolate teapot. A higher grade official should have seen common sense and taken control, I do not mean relieving those at the sharp end of their duties but simply offering good counsel as to how to elicit the lay of the points. Knowing that all the points in the route had to be clipped and scotched and knowing which had to be scotched normal would have prevented the train moving at all because only a signalling Technical Officer or higher signalling grade would be licensed to normalise 39 crossover in order for it to be scotched normal. I haven't read the RAIB report through to the end or seen the recommendations as yet, reading the preamble, the red herrings and excuses for poor performance etc was enough to consider the situation and see far too many failings. In another place this incident seems to be seen as trivial because there were no injuries or fatalities but everyone including corporate LUL should be thanking its lucky stars, it should be a wake up call to senior management to review training, licensing and promotion as well as thinking about running failure exercises not only in the classroom but also 'on the ground' for those staff and managers in safety critical roles to have to demonstrate their competence at handling such incidents. Theory is all well and good but competence requires confidence and that can only be gained by practical experience and knowledge.
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Post by dave1 on Dec 10, 2016 16:42:19 GMT
Nortube considering that these were done 10 years ago I am sure if something existed like this for Ealing Broadway the derailment would not have happened. I can only go by how where I work a different management and everything changes normally for the bad. Could it be a line thing? although I suspect that training has been cut across the board. As I said each line went its own way following devolution and as a result different standards occurred in engineering despite and I have no doubt that the same was true for operating departments. Despite the facts indicated in the RAIB report and the possible mitigation of what appears to be incompetence at worst and sloppy management at best it is an undeniable fact that all the necessary information was or could have been available if those involved in the incident were 'on the ball'. Quite simply for whatever reason, they were not! Having seen the length of service of each of those individuals it is clear to me that they were mostly not long enough in LUL service to have acquired the knowledge and skills required to deal with the failure. We don't know what training was/was not given and I can see in the other place that anyone critisising the actions of those involved is a target for moderation by the so called experts. However, one argues the case someone must be responsible for all that was not done correctly but I stress that I do not necessarily blame the persons involved, my belief is that those who trained and licensed them, tested, assessed and promoted them are to be held to account. The signal operator should have known the normal lay of all the points, his signalling diagram is the master and was correct and showed that information. The station supervisor should have been able to walk the track and follow the road(s) indicating the actual lay of all the points in the route to the signal operator even in bad weather. If necessary he should have been able to call upon another grade on site to accompany him and assist him with additional light. The signal operator and station supervisor were the two key players as far as route securing in this case is concerned. I am well aware that some station supervisors do not feel confident to walk the track or to clip & scotch points but these tasks go with the grade. There can be no excuse for not being able to perform all the duties and responsibilities of the grade. In this type of incident the signal operator has to call the shots as he is controlling trains and must know a route is secure before authorising the signal to be passed at danger. The train driver is in charge of the train and is there to follow the signalling, including the verbal instruction(s) of the signal operator regarding train movement. He is not required to do anything else but when passing a signal under rule should proceed at walking pace and be able to stop. He cannot be blamed for not seeing the points laying incorrectly given the time of day and the weather and even on a bright sunny afternoon could not be admonished for not seeing an incorrect lay of points. If such were a requirement then the train service would be a joke as a driver slowed to walking pace at every turnout before slowly proceeding over it! The line controller is not really in the picture as far as the incident is concerned because a train sitting at WP17 blocks all movements into the site, the traction whether on or off in that regard makes no difference and of course 39 crossover was tracklocked reverse so any train in platform 9 would also have been trapped. When I used to maintain signalling at EBY, 39B were loose points. Thus once the failure occurred the line controller would have concentrated on the service on the rest of the line, as that is his priority, while awaiting resolution of the incident by the signal operator, station supervisor and signal staff as and when they arrive. To me the derailment is a bad management issue, not on the day but in the weeks, months and perhaps years beforehand! RT you are right here does seem to have been a misunderstanding breakdown of communication between some of the players. A major management issue as always when there ha been some mishap and yes most of the staff seem to have the sort of service although one of the service controllers had over 40 years. I have seen some early training material all had the name A Gorton on and were in the 1950s/60s with Nortube's material we have progressed and perhaps there is much more out there but not being used for whatever reason. I have gone through and put a few things which are mentioned. Too many fingers in the pie and I see that there was no mention of incident control being implemented although I am sure it was. Here is some observations from the RAIB report. 17 District control staff at Baker St-if they were located at Earls Court would it have been better 19/20 District service controller over 40 years’ service had been a service controller since 2010 2nd service controller had been with LU since 1990-what were the previous grades and what lines if different from the District line 21/22/23 Both service managers and the signaller had been with LU since 2002 24 Station supervisor had been with LU since 2007 had been a supervisor since 2013 and been located at Ealing Bdy for the last 2 years! 27 Staff license’s and conformed to the current system-when were they last certified and what did it entail 37 Both the signaller and service controller failed to come to an understanding in regard to their duties-I suspect that this happened a lot but with no incident happening 42 Service manager only mentioned 38 points 43 Is it a requirement to have traction current off? Had traction current been switched off would that have given more confusion about which section(s) going by all the misunderstanding that occurred 46 Station supervisor was at the right points but had not been asked so moved on to the ones he was asked to check-he should have mentioned this 47 Service controller requested 38 points secured no mention of any other points-would 38 points be reversed when 39 points were reversed 48/49 Signaller should have able to confirm position required 50 How could the service controller not understand that the signaller had no means of knowing the position of the points-where had the service controller worked previously 56 DSIM gave incorrect information by mentioning you only need one set of points reversed although he was told what was required and all mentioned later in the report No mention that the station supervisor had checked the route only did what he was told to do 59 Service controller only mentioned that the T/Op would have to check the points were set for the route 60 Misunderstanding of message by T/Op I thought that all involved in the incident would have been able to hear the messages of each other or does it cut out anyone who does not. I am sure I have seen on the web mention of radio groups 63 T/Op failed to check all points in route 65 Cavalry arrive after the event where did the duty manager reliability come from 84 Looking at the photo of the diagram it does show what the normal position is otherwise it would mention it? Looking at both controllers diagram old/new it can be worked out about which points Any alterations that had been carried out would have been in the traffic circular? 97 Service control competency system has either failed or was it just a paper exercise 121 By not requiring traction current off gave the impression he was familiar with the area although it should have been off
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Post by dave1 on Dec 10, 2016 16:43:39 GMT
Dave 1 - One of the problems with having information is whether somebody follows it or not. The idea of the folders was that in the case of a rail / track-side incident, the person dealing with the incident would have the relevant information at a central point for reference. It was up to that person whether they did actually refer to it or not. Mistakes do happen at times, however good a person is, but the aim of the folder was to eliminate as many chances of mistakes as possible and at the same time reducing delays during an incident because the correct procedure would (hopefully) be followed. As the folder was an official issue and should always have been available, a person dealing with an incident who screwed up couldn't use the excuse that they 'didn't know' or 'weren't sure'. As far as I'm aware, the basis of the folder was unique to the Northern line at that time and I don't know if any other lines followed David's example or if the Northern line was the only line to have the relevant information collected together in this way. Apart from being used in anger during an incident, the folders were also a reference point for somebody who wanted to look up something. The Controller's diagrams showed the track layout for the line but if somebody wanted to work out what points were needed in what position for a route, they would have to try and work it out by following the diagram. This was not always easy to do, especially where slip points are involved. Normally shown as a single 'stub' of a line, there was rarely a clear indication of what position they should be in for what route, although it could be guessed. Slip points were one of those things that I seemed to have a mental block over and where they were concerned, I always found it difficult to compare the Controllers diagrams, which show tracks as a single rail, to the real life two rail track shape. I finally twigged it after studying slip points close up at track level! For the sake of completeness, I’ll also cover the traction current section C of the folder as it relates to similar types of incidents except they involve section switches instead of points. This deals with the traction current details with the feeds, switches and circuit breakers shown. Section C was designed to show what switches / breakers needed to be operated to what position in order to isolate or feed a section of track. As with points, the Supervisor (or whoever) would be instructed on what switches to operat and to what position. As part of their regular familiarisation track walks, they would be aware of the position of the switches and any peculiarities relating to them. If a circuit breaker was involved, such as in certain reversing sidings, they should know the correct procedure to remotely operate them or to manually open / close them as required. Unlike a derailment at very slow speed over incorrectly set points where there are unlikely to be any injuries caused, a switch set to the wrong position has the potential to cause fatalities if part of the track is (returned to) live when there are people on it. Therefore, it is essential that whoever is told to operate a switch is absolutely certain that it is the correct one (pair, + and -) and are able to inform the person instructing them to do so if they think that the instructions are wrong. Therefore, the folders were meant to be a double check for the person given the instructions to look at and confirm the relevant switch number(s) would be the correct ones. Whilst working out traction current paths from the Controllers diagrams was a bit easier, it has to be remembered that the running line is mostly double-end fed and that opening just one section switch (actually a pair – positive and negative - but I’ll refer to the pair as one) would often make no difference unless the feed to the section was isolated from one end. In thesame way that the folder made it easy to work out points involved, it made it easier to work out what switch(es) to open to isolate a section of the running line because it showed what sections were dead when the switch was opened. An example of section switch operation is if there is an incident (or planned engineering works) which involves discharging current in a traction current section (substation to substation) yet disruption to the service is required to be kept to a minimum. By opening section switches it may be possible to isolate the work site and recharge traction current, thus allowing trains to reverse. E.g., if traction current needed to be discharged at London Bridge NB due to an incident, this would mean no service could run between Kennington NB and at least Euston because there would be no traction current on the Elephant & Castle to Old Street NB traction current section. However, by opening one section switch at Moorgate and recharging traction current from the Old St end, trains could be reversed S-N at Moorgate to provide a service NB from Moorgate if required. Below are examples from section C of the Moorgate folder. The section switch arrangements are typical for a reversing point like this. Opening individual switches and recharging traction current from one end of the section allows reversing over the crossover in four different ways. Note - this information may no longer be relevant Excuse any poor quality as, like the signal pictures in the previous posts, they are screen captures. Double click on the picture to enlarge Normal traction current supply Section switch open in order to allow train to reverse S - N to provide a NB service from Moorgate Details of how opening 463 affects the train service at Moorgate I know what you mean when you say official issue but how can something that would make it much clearer when dealing with incidents not be seen as essential when the higher numbers being carried by the system. Staff have their basic training for the grade that they are in and then they receive line training or do they. Service controllers have a high position so why does the training or knowledge not match this, a controller not being able to read his own diagrams. The problem is with the staff on the ground maybe going for so long without a failure or whatever and the management above not ensuring properly trained staff. Having highly trained staff makes all those that use the system feel more comfortable and I’ sure that the staff would feel a lot more comfortable as well but that is in an ideal world and now LU will have to save even more money will just put even more pressure on the frontline staff. Had the supervisor walked the route it would have identified something providing he knew what he was looking for. The T/Op should have progressed the movement as such that he would have seen the points in the wrong position. I went to Parsons Green station and there is a diagram of the area done in powerpoint showing all the points and everything so it look like that part of the District line did do something but wither other lines did I can’t say.
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