Post by railtechnician on Dec 12, 2016 3:32:02 GMT
I read the complete RAIB report a few hours ago and I really don't think the recommendations and learning points go far enough. There were too many 'cooks' and one thing that really does stick out is the improper handling of the situation exacerbated by poor communications.
A couple of questions that came to mind were:-
Why was the signal operator busy signalling trains elsewhere while the incident with train 011 was ongoing? One would've thought he'd have all sites running in programme mode except Ealing Broadway of course. He really should not have been having to divide his time and concentration between the incident and routing trains elsewhere. An operator at an adjacent desk could have been able to 'keep an eye' on the Ealing desk, just as they used to back in the day. It was not as if it was rush hour, many trains would've already been back in the depots.
Presumably the Earls Court control room TO had already left to do routine maintenance on the Picc otherwise I have no doubt that he would have been able to put the signal operator 'straight' regarding the 17(1) route, the normal lay of the points in the route and in what position they should be scotched. Picc signals maintained Acton Town to Ealing Broadway on the District when I was a Picc TO and the control room TO would no doubt still have all the District bookwirings to hand in the TO depot. Of course the signal operator is supposed to know but in my time as a control room TO I would be closely observing what was going on while standing by to offer assistance if required, as my colleagues would be en route to site from the call depot and I would be the liaison between them and the signal operator as far as the signal failure was concerned.
I am wondering how the signal operator was going to get 39 points normal without the aid of signal staff on site to 'blow them over'. Of course he hadn't considered 39 points but had he realised that he needed them scotched normal he would surely have had to wait for signals staff. I know of no way for operating staff to normalise points except by the proper operation of point lever (not in an IMR unless accompanied by signal staff), which would not have worked as the points were tracklocked reverse, or by pulling up the route and taking a release. The signal operator had already pulled the route and taken a release but that could not restore the points (39 lever locked reverse) and the fact that CB track was failing down should have made him realise that 39 points were failing reverse. He should also have realised that the starters could not be cleared because CB track was down and so attempting to do so was a pointless exercise.
It is interesting that what used to be a set of loose points had become 39B points after the crossover to the Central and the sidings were removed. Had they remained loose points the signal operator would not have had a train stuck in the platform trapped by 39B tracklocked reverse although it would have had to pass a starter at danger under the rule because CB track had failed down and that prevented any of the starters being cleared.
In my view the signal operator had all the information he required to correctly set up the route and all he should have required to know from the station supervisor was the lay of 38W and 39W in order to issue the proper instructions for clipping and scotching of those sets of points. Clearly the signal operator did not know that he had the information required to correctly set the points in the route even though it was staring him in the face on the signalling diagram. As I said before this failing has to boil down to knowledge, experience, training, promotion and pressure but does beget another question.
How does an individual get to level 4 (complex site) signal operator without being able to deal competently with a relatively simple incident of this kind? The answer to that question is to be found in several levels of management !
A couple of questions that came to mind were:-
Why was the signal operator busy signalling trains elsewhere while the incident with train 011 was ongoing? One would've thought he'd have all sites running in programme mode except Ealing Broadway of course. He really should not have been having to divide his time and concentration between the incident and routing trains elsewhere. An operator at an adjacent desk could have been able to 'keep an eye' on the Ealing desk, just as they used to back in the day. It was not as if it was rush hour, many trains would've already been back in the depots.
Presumably the Earls Court control room TO had already left to do routine maintenance on the Picc otherwise I have no doubt that he would have been able to put the signal operator 'straight' regarding the 17(1) route, the normal lay of the points in the route and in what position they should be scotched. Picc signals maintained Acton Town to Ealing Broadway on the District when I was a Picc TO and the control room TO would no doubt still have all the District bookwirings to hand in the TO depot. Of course the signal operator is supposed to know but in my time as a control room TO I would be closely observing what was going on while standing by to offer assistance if required, as my colleagues would be en route to site from the call depot and I would be the liaison between them and the signal operator as far as the signal failure was concerned.
I am wondering how the signal operator was going to get 39 points normal without the aid of signal staff on site to 'blow them over'. Of course he hadn't considered 39 points but had he realised that he needed them scotched normal he would surely have had to wait for signals staff. I know of no way for operating staff to normalise points except by the proper operation of point lever (not in an IMR unless accompanied by signal staff), which would not have worked as the points were tracklocked reverse, or by pulling up the route and taking a release. The signal operator had already pulled the route and taken a release but that could not restore the points (39 lever locked reverse) and the fact that CB track was failing down should have made him realise that 39 points were failing reverse. He should also have realised that the starters could not be cleared because CB track was down and so attempting to do so was a pointless exercise.
It is interesting that what used to be a set of loose points had become 39B points after the crossover to the Central and the sidings were removed. Had they remained loose points the signal operator would not have had a train stuck in the platform trapped by 39B tracklocked reverse although it would have had to pass a starter at danger under the rule because CB track had failed down and that prevented any of the starters being cleared.
In my view the signal operator had all the information he required to correctly set up the route and all he should have required to know from the station supervisor was the lay of 38W and 39W in order to issue the proper instructions for clipping and scotching of those sets of points. Clearly the signal operator did not know that he had the information required to correctly set the points in the route even though it was staring him in the face on the signalling diagram. As I said before this failing has to boil down to knowledge, experience, training, promotion and pressure but does beget another question.
How does an individual get to level 4 (complex site) signal operator without being able to deal competently with a relatively simple incident of this kind? The answer to that question is to be found in several levels of management !