RAIB Investigation: South Devon Railway

Isn’t the story of most accidents that systems that should be or are in place to prevent said accident have been ignored or neglected, or a safety culture has come to be eroded. When you look at the accident (thinking also about bigger accidents like Clapham) it isn’t a single act but a whole series of minor and major failings that culminated in a near fatal accident. The major failure was allowing an unfit vehicle to run, but it was also thinking that screwing the door shut would be sufficient (perhaps lesser), not reporting the failure and the accident properly (major). It is almost like a culture of ‘it’ll be alright because there is this backstop’.

Perhaps the really important lesson is not to take safety for granted and assume that the safety culture is satisfactory. I think if one thing railway history tells us, it is that safety cultures erode silently and unseen until there is an accident.

 

Thank you for posting. I was at the air show in question myself: all the crowd knew at first was that a plane had come down on the other side of the motorway. It was certainly a very tense moment for all the spectators.

 

I think to be honest the pilot makes a bit of a pigs ear of it. You can see in the early part of the video he is heading straight towards Duxford. He then turns to the right and flys the downwind leg before turning left on the base leg beyond the motorway. This is exactly what you would do in normal circumstances but it was too far and he was never going to make it at such a low altitude. (which he doesn't). What he should have done in my opinion was turned left and landed it downwind in the opposite direction down the runway especially as the airfield is pretty big and grass field etc. I understand it wasn't his plane so he was probably hoping the Engine would pick up and run normally.

As for preserved railways I don't see any parallel, Pilots are trained constantly for Engine failure situations. For me the lack of a toilet floor was almost certainly known about beforehand and the issue was probably just that they had no labour available to repair it. This is the problem with relying on volunteers. Often they aren't there. If I was going to repair that toilet compartment I reckon it would take me at least 5 weeks as I would only be working on it as a volunteer one day per week (ie 5 days work), but often the train is needed straight away. They probably started the job one Sunday and repaired the vacuum pipe and then ran out of time and went home. Next weekend it was running with the job incomplete.

The only way around that in my opinion is getting some full time C and W staff so any problems can be fully repaired and completed (Monday to Friday) ready for the following weekends running. With volunteers you can't do that as they typically are only able to come say 1 day every 1 or 2 weeks and that is never enough time. That is why restorations take 20 years etc. If it was being done full time then it might only take 2 years.

 

If you read the RAIB report, you will find that it was in fact paid staff who carried out the work to the toilet floor/brake system. There is no mention of any volunteer staff being involved. The decision to reinstate the coach with the repairs incomplete was taken for commercial reasons.

 

Volunteer Directors overruling Paid Staff?

 

How do the lawyers rake up such costs when guilt has already been admitted? Enough has been said about the fine itself, although I think it was harsh. The consequences could have been terrible, but you can say that about many near misses with bad driving on the roads.

John

 

Their level of pay should not be a factor. Any director (paid or unpaid) should have the knowledge and experience required to take executive decisions, whether this overrules paid staff or not.

 

Paid staff obviously far more knowledgeable and experienced than volunteers...

 

Why "obviously"?

The volunteer director might have been involved/working in that field for 40 years or more. The paid staff might be a relatively newcomer to railways, perhaps a younger person who can afford to work for lower pay than a more experienced person.

 

I read @Steve1015 as supporting that view, but through sarcasm

 

Quite possibly, the dangers of conversational wording not giving clues available face to face, whether by facial expression or intonation.

 

Hardly "harsh". Quite apart from the original decision to put the vehicle back in service without it being made safe adequately, the decision to retain it in service for three days after the incident (which was slow in being reported) was jaw dropping. It needed (and got) severe censure. I have heard the view expressed that it could have been more.

PH

 

Just to be completely open, I work in Health and Safety- I specialise in helping out with slightly oddball stuff bit do still do bits of fairly general H&S.

Every incident, near miss, hazard spotted has a path that has lead to it occurring and that is the important bit in terms of learning - so yes, as much as I hate the cliche, there is ALWAYS lessons to be learned - even if (occasionally) that lesson is that actually the systems worked- but something has happened so unforseeable we could never have prevented it.

There is still a resistance in most industries to resisting reporting near misses and hazards as it is seen as poor performance when actually these are some of the most importance occurences in prevention of future accidents, and analysis of recurring or similar hazards/near misses can steer policies for the future. This incident at the SDR will hopefully be a reminder to ALL heritage operations to check, and recheck their systems for maintenance to make sure they are operating as they should.

As has been mentioned elsewhere on the thread, a large proportion of accidents happen because of failures in the monitoring and implementation of policies and procedures that are already in place. It is often the combination of a number of small, but systematic failures that lead to a big incident, or in this case a near miss.

I often go to sites/jobs where, yes, they have all the right paperwork and the management can tell you all the right things and use the current 'buzzwords' but actually the implementation and understanding of the systems elsewhere can be very poor, I always go back to the principals of keeping it simple, making sure that folk are not in the mindset of 'this guy is here to cost us money and tell us how to do our jobs' and making sure that those at the top lead by example.

For me the key to good H&S practice is that it is all done as part of an overall management strategy, and a good H&S person does not necessarily need to be an expert in all of the tasks but must be an excellent communicator and be able to ask the right questions of the right people, in order to determine how best to manage each specific task safely.
The H&S person then needs to be able to come up with a method to ensure this information is delivered in accessible way, and that compliance/understanding can be monitored.

Ill get off my soapbox now

Chris

 

I could not agree more, we are constantly upgrading our exam procedures. If a "new " problem comes to light, it is added to the exam procedure and a full fleet inspection is carried out. If we discover a new piece of equipment that make our lives easier and safer we make every effort to acquire them. The example should be set from the top but sometimes it isn't and a stand needs to be made.

I have never seen the difference between paid or volunteer, all should approach the job with same professional attitude.

 

Harsh? Normally events like that would attract a six-figure fine, not five.

What if the ORR and HSE decided that all heritage railways need a paid Board of Management to oversee the correct and safe operation of the railway? How many would survive then?

 

The only difference between volunteer and paid staff on preserved railways is the selection criteria and line management of them.

Selection of Directors solely by being elected may not result in people of sufficient knowledge/ skills/ experience to run a safety critical railway organisation.

 

Except I would expect that to be a major criterion in the appointment of candidates- a demonstrable knowledge of railway operations and the HASAWA.

 

Many railway societies are managed by boards elected by the membership in various ways. Those who the members vote onto such boards may or may not have demonstrable railway knowledge - it's usually down to the membership to decided who to vote for and on what basis...

 

Not necessarily.

They either have to be competent/have prior knowledge themselves

Or;

Must employ/consult a competent person or body


Chris

 

That seems unlikely to me. Setting aside that having a choice would be a nice problem to have for many bodies, and the possibility that the constitution allows persons to be legitimately appointed simply by being proposed and seconded if there is a shortage of candidates (without a vote, or any veto by the incumbent board i.e. no-one is unsuitable barring bankruptcy or mental illness), I suspect that railway operating experience can only be a sine qua non for a particular portfolio(s). Judging by the lamentable standard of annual reports filed by some preserved railways, one might wish for instance that all directors were literate and had financial training (or simply were minded to make the time to read and understand what they were collectively taking responsibility for). It is easy to come up with a cv which requires candidates to be paragons of staff motivation, executive leadership, business, marketing skills etc, which only ensures that no suitable candidate will ever be found. The WSR plc used to publish job descriptions on its website which made for interesting reading. Presumably they were removed to avoid just this sort of gap analysis / discussion.

But, I do think there is a tendency to think that boards of preserved railways have to have all these specific skills within the board, whereas in reality (and @Chris86 seems to be saying this) it seems rather more realistic to employ / co-opt (to board or committee) persons with the relevant skills, but who do not want to be directors / trustees for whatever reason, or be subject to beauty contests.