Kirklees boiler incident

Interesting read but it does raise some questions about competences and how they are assessed.

 

Ah, now there's the rub, as the saying goes. I have the same argument with some of my staff on board ship - the SMS has to be followed, & if they think there's something wrong with it, then raise the matter & it can be investigated, with amendments in due course if necessary. In this day & age, not following the SMS leaves you open to all sorts of nasties...

 

I think this is one of the problems with a lot of risk management and health and safety paperwork There is so much of it you plough through it and then put it out of mind for the next lot. Rather defeats the object I think.

 

That's a big problem, yes

 

The level of threat in that report is quite unmistakeable. There is clear concern that the safety management systems on some railways are not up to the job or are not being followed in reality. There will be investigations in depth, and more of them, and prosecutions may follow. We have been warned.

Tim

 

Got to say this bothers me. Lots of speculation after the incident, relatively few posts after the report comes out. Yet, as noted below, RAIB seems to be signalling ORR will be gunning for heritage lines over the next few years. At first, SMS-free lines will escape enforcement until/ unless something goes wrong and puts them in the frame for investigation. But eventually the Man will get everyone. And staff/ volunteer competencies, their initial standards and subsequent regular testing, are going to be right up towards the top of the list for SMS action.

As to Tim's (sleepermonster's) suggestion that proscutions may happen in the future, I'm not so sure. A couple of incident cases in the past few years could have been prosecuted, I believe, but weren't. That's partly because a successful prosecution - even for manslaughter - against a named manager in a company is difficult enough. Even more problematical when the person in charge is a volunteer as at many lines.

Roger

 

I am thinking of S.3 Health and Safety at Work Act 1974, which is extremely wide in its scope.

Google search for Wickstead Park Railway prosecution for the aftermath of an incident in around 2005.

If the SMS is not in order or not being followed, how do you prove that all reasonable steps to ensure safety have been taken?

Tim

 

Am I the only one on this Forum who thinks that the RAIB report is a load of rubbish? I know that amongst heritage railway senior managers, I'm not alone in that opinion. It comes to the remarkable conclusion that the water in the boiler was being used faster than it was being replensihed. Yet it fails to establish why. It does consider such improbables as a leaking boiler but the report doesn't even consider what is a quite probable scenario - that the driver put the injector on and it knocked off without him realising. (How many times has that happened to you?) It doesn't ask why the driver failed to throw the fire out nor why he failed to realise that the fusible plug had gone or make comment on the oft held belief that a fusible plug will put out the fire. Yes, the driver's training and competence is called into question but some interesting and relevant aspects of this aren't even mentioned.

 

I for one thought it was a excellent report ,if you look at page 18 the boiler was hydraulically tested after the incident and was sound so no leaks .The engine was fitted with 2 water gauges and that is the key to the incident no sign of water in gauge glass, in the report it say's with water in the bottom nut there would be 50mm of water over the crown .The incident is all down to inexperience of the driver.

 

RAIB reports are more concerned with preventing these things happening again rather than finding some one to crucify like a tabloid newspaper would. The fact is the lack of a proper SMS will no doubt lead to more serious accidents if it is not corrected that is why the report concentrates on that rather than nit picking at the finer details of the drivers ability. That just isn't constructive or relevant and is typical pub talk that misses the wider issue and i doubt the driver would do it again anyway. No doubt they are particularly keen to point this out after the incident at Foxfield where again the main cause was a poor SMS.

The incident is not down to the inexperience of the driver, it is down to the way the KLR trained and monitored the competence of it's staff, and the fact it had no polices or procedures in place for such an incident or as it turns out any other incident.

I hope those " heritage railway senior managers" you know are going to wake up and smell the bacon with this whole Safety Management System thing. If they don't they will find the only railway they are running is the one in their loft. You just can't get away with the Titfield Thunderbolt attitude to running a railway these days.

Tim

 

Yes, I think that's very possible.

The report establishes pretty conclusively why the incident happened. That's the function of an investigative authority. It's not RAIB but ORR that'll be responsible for picking holes in the training/ compentency regime at Kirklees and - eventually - pretty much every other heritage railway. Because they will be coming for us all. Which might partially explain some ambivalence of Steve's heritage railway senior managers towards this report.

Unlike a forum, RAIB isn't meant to have fun speculating about exactly what might have happened on that footplate. No doubt its interviews with the unfortunate driver and officer in charge will have covered a number of interesting and relevant aspects as to why the incident happened the way it did. Lots of if's, but's and maybe's, and Steve mentions some. You could have a lively debate about the Porta system's effect upon fusible plugs too, if you like -but RAIB can't have thought that relevant either.

As a matter of strategy, I think it sends a bad signal to ORR if responsible heritage railway managers rubbish a RAIB report. Better to make sure the relatively simple lessons are learned and applied.

Roger

 

You will notice the report also says the KLR has completely changed the way it trains it's drivers since the accident. This is what the ORR are really looking for. They want people to be identify problems and show they are doing something about it. Rubbishing the report and patting each other on the back saying how great you are compared to others is the complete opposite to that. And when something goes wrong the ORR will not be best pleased.

Tim

 

On a loco that size you would expect the driver to hear the injector was not on, you would also expect him to notice lack of water in the gauge glasses. But even ignoring for that fact in their "reinactment" they found roughly the same level of water in the tank as after the accident.

Presumably if the injector had "knocked off" the water would have continued to pour out of the overflow droping the level in the tank. Now unless the RAIB also also let the water run out of the tank via the injector overflow during their "reinactment" as the water level in the tank was said to be roughly the same I think it is safe to assume that the injector did not just "knock off"

 

If you read the report you'll see that the water usage from the tank was the same 125 litres but there was 1/3 of a glass left in the boiler at the end of the test. If there was no water in the boiler at the time of the incident, where had it gone? Out of the overflow? Why did the driver claim that the injectors weren't working when no fault was found, even with the shut-off valve nearly shut? I'm merely suggesting that a knocked off and unnoticed injector would give all the symptoms of the incident but wasn't even considered by the RAIB investigator, who seemingly had no knowledge of steam locos. If you put a feed on and think it is working and are concentrating on other things, such as the road ahead and the fire, it is then easy to fall into the trap of thinking that you have a full glass, rather than an empty one. It's still driver incompetence, though.

 

Just to clarify the point made about Foxfield's incident in October 2010 Tim, the problem wasn't with the SMS which had been fully approved by the relevant authorities prior to the incident, it was the implementation of the regime within the SMS that was the issue. And also, to avoid further missunderstanding following poor reporting elsewhere, Foxfield voluntarily suspended operations following the incident until the correct proceedures were in place, it was not closed/suspended by HMRI or any other body.

An SMS should very much be a 'live' document to be used, reviewed and updated regularly as required, not something that is put on the shelf and forgotten about. No SMS will be perfect and incidents such as those at Kirklees, Telford and Foxfield should act as pointers to all Heritage Railways to keep up to date with these matters. There are plenty of other railways who have had to take a long hard look at their SMS and the proceedures required from the documents within it in recent times and possibly found them to be wanting also.

 

Avonside1563, your comments above about a railways SMS are echoed in a news article on the Severn Valley "internal" website ( but it is freely available to all) where you will see in the article posted on 27th March that they recognise the need to ensure everyone/all locations have easy access to the Safety Management System document, and no doubt all necessary persons will be encouraged to be fully familiar with the SMS in the future.

See: News

regards

46118

 

The SMS is now an issued and signed for document on some railways, like the rule book.

 

I thought the second "S" in SMS stood for system. Not Document. Sure the system needs to be documented but it is system. There are too many references to document even from those advocating it be "live".

Anyway, for all the discussion about SMS inplementation, the RAIB report suggests that for all practical purposes the KLR did not have one. Level crossings and schoolchildren scalding themselves, if I recall rightly, were the only points covered.