RAIB Investigation: South Devon Railway

The SDR messed up, and have rightly been hit by a fine proportionate to the situation. Time to move on, and as enthusiasts, support the South Devon by visiting. If you see untoward practices here or elsewhere let someone with managerial authority on the line know, instead of posting anecdotes on a public forum long after the horse has bolted. That won't help, but alerting senior staff of potentially unsafe circumstances as soon as you can after seeing them will.

 

Tell me about it - it's the paperclip counters who usually make the biggest noise about it...

 

I suspect that there may be a good few in our movement who should be thinking 'there but by the Grace of God.....' Modern H & S thinking and simple, even mental risk assessments, have long seemed to get a bad press generally and particularly in the preserved railway movement - almost an attitude of 'balancing a wonky ladder on one leg is only dangerous because 'they' have appointed an H & S 'spoilsport' who says it is' at times. My experience is that Health & Safety Professionals have a 'how can we do this safely' approach, but others are often 'barrack room lawyers' who certainly aim to ensure good safety practice but often put peoples' back up in how they do it. I also wonder if too many railways fail to embrace advice from Railway professionals, taking a 'we know what we are doing, we don't need 'big railway' types telling us who it should be done' and failing to appreciate that ORR don't make any great distinction and neither does the effect of several 100 tonnes of train or a hole in the floor, even at 25mph!

I think this case has, as I have previously posted, highlighted an all too common disconnect between Commercial/Traffic needs and engineering delivery which is often due to lack of planning, communication and particularly understanding of the reality of each others' positions. Resourcing carriage maintenance can also be a common shortcoming, as can the engineers even feeling they can make clear the position they are in. Again, this is usually due to a lack of communication and understanding that a well presented case will usually get as sympathetic hearing as is financially possible.

If effective safety systems are to be properly designed and implemented, then these disconnects need to be tackled and I am sure the ORR would prefer top see a simple SMS followed in full to a complex one that realistically can only ever be complied with in part.

Steven

 

Has there been any statement from the higher management? I would cringe if they came out with the old "...lessons to be learnt..." mantra. How often do you hear that these days and quietly think to yourself "Yeah, I bet... "? Far better to hear about and see actual improvements being made.

Talking about heritage railways in general, for this to case do any good it will depend on the individual lines management I suppose. I'm sure some are very good and many are reasonably competent and trying their best (not everyone can afford to pay management or is lucky enough to have skilled managers as volunteers). There do seem to be a few though for whom "could do better" would be a polite way of putting it.

Perhaps the HRA and ORR could get their heads together and publish a working guide for the minimum required standards for the management of and safety safety systems on heritage railways? Not so much a list of rules, more like guidance on what you must be doing and what you should also be doing (for those who know it, a bit like the HSE guidance for the CDM Regulations) Or has this already been done? At least then everyone should be singing from the same sheet and any volunteer would have a reference to give them the confidence to say "...no, this is not right...". It's probably the only way to counter the ingrained "we've always done it that way" attitude which can be very difficult to change - especially for newcomers into some tightly knit groups like C&W or S&T workshops.

 

Perhaps it is the narrative that is constantly being re-enforced in the media and elsewhere of 'excessive rules' that makes people think that there was a golden age where there were only 'necessary rules'. *notes drivers getting suspended for excessive smoke*

You wonder though how it would be possible to firstly identify railways with weak h&s practices and then to bring them up to scratch, especially given that those involved maybe part time casual volunteers.

Interestingly I know someone who volunteers at a local art gallery/museum, each day before the building opens the volunteers are all given a safety briefing (by a full time manager) not because the museum is dangerous far from it, but it seems like a different culture and approach to safety.

I also wonder and this ties into threads about the fate of volunteers, that some smaller lines that struggle to get volunteers end up taking (and over promoting?) volunteers who do not fully embrace modern h&s.

I hope that this lucky escape wakes up people in the industry to realise that h&s is there for a reason and to start to take it more seriously rather than viewing it as some sort of imposition.

 

There is already guidance out there- the HRA have produced several guides on various topics (link here)

https://www.hra.uk.com/guidance-notes/

Equally ORR have produced this

http://webarchive.nationalarchives....ssets/pdf_file/0015/2634/rsp005-minorrail.pdf

The onus is on the operator to decide how to run their railway and in what manner. HMRI/ORR is the enforcing body in the event of an incident so therefore any information they give cannot generally be “advice” as of course this could put them in a conflict situation. This was the whole rationale behind the ROGS legislation about 10 years ago now. The only “mandatory” directions ORR give are prohibition or improvement notices....

Regards

Matt

 

Seems somewhat unfair to make a generalism about H & S on smaller lines ; as others have noted the whole industry has to “get it right”. We may think about the mythical “premier league” of heritage lines but ORR also deal with enforcement on the national network which is vastly more complex.

Regards

Matt

 

My job description as C&W Foreman allowed me and my Chargehand to Red Card vehicles, that power was not in anyone else's job description. Therefore we could not be overruled. Taking a 90 seat coach out of traffic just before the peak of the season is not an easy one but if it has to be done, it is done. However you must have a plan in hand to rectify the defect A.S.A.P.

 

Quite right, size is no determiner of good safety practices. Indeed the bigger the organisation arguably the harder it gets to instill the practices and police them. The best organisations aren't always the biggest. I dont envy the SDR management the task of creating the right culture now.

 

But presumably the train crew could refuse to take a train that they were not happy with at least until they had received reassurance?

 

They could yes, but their is always a Duty Fitter for those very situations who is at liberty to call the C&W foreman or Chargehand for conformation or not.

 

We have a very strict regime of exams and inspections of the body and the underframe, most calls for the duty fitter are due to droplight straps breaking !

 

There is a quote at the end of this http://www.bbc.co.uk/news/uk-england-devon-44112957 which I didn't think helped their cause a great deal and was generally along the lines you suggested.

Whilst the discussion of H&S is useful it doesn't seem particularly relevant in this case as I imagine the safety system will include a daily inpsection and if a kid managed to open the door why didn't the Inspector?

What I don't understand is why couldn't the hole have been covered temporarily even if the toilet was supposed to be locked out of use, even just with a piece of chipboard or something lodged in or attached to the frame with no more nails or self tappers or something would have given a belt and braces approach?

 

A very good post. My overwhelming feeling on reading through this thread and noting the fine imposed on the SDR was one of sadness. A serious mistake was made which could have had far worse consequences. There is no question about this. Was the fine imposed on the SDR commensurate with the potential catastrophe which was only narrowly avoided? As a layman, not for me to say but clearly things were amiss and the fine is an unambigous statement that certain procedures on the railway will need to change - indeed, one hopes they already have.

But for all the evidence that a serious safety lapse took place, I too hope the SDR can learn from its mistake and move on. I last visited the line about four years ago - my first visit in some years. It was a very wet gala event with 30053 visiting. I had forgotten just what a splendid little line it is - and everyone was so friendly. Hence the reason for my sadness - that a line with so many good points has found itself in this situation. I hope that the staff and volunteers will pick themselves up from what must be a heavy blow and that the line will flourish in the future - but without any further incidents such as this to dent its otherwise good reputation.

 

Obviously this whole sad saga only came to light due to the mothers concerns and subsequent action. Full marks to her considering the traumatic experience she must have had when her son fell in such dangerous conditions.

 

Sorry it wasn't my intention to convey that. I don't think size of operation is any evidence of professionalism. I think professionalism is a wider issue - not just about H & S but also financial issues, treatment and training of volunteers within the preserved railway industry (after all, both WCR and DCR have had major safety issues come to a head in recent years). My concern about railways with a smaller volunteer pool to draw are putting too many demands on that pool.

What concerned me about the SDR was the attitude of the duty controller when the incident was first reported.

Also, it would have been very easy to go to the tabloids with 'thomas nearly killed my toddler' headlines. Full marks for a response which I think will help all the preserved railways in the long run. (And thanks to her persistence).

 

Perhaps I used the term red card too loosely. However if I was not happy with a vehicle, even after assurances from C&W I would remove the vehicle from the set and dump it somewhere with a report to the train crew manager. However the situation is unlikely to occur as the standards of maintenance where I volunteer are very high and are better than some mainline vehicles I have come accross. Part of this must be down to the facilities available. One road in our cariage shed has a pit where FTR s can be done on full sets without splitting

 

Here's a glimpse of a completely different approach to the safe operation of historic machinery. It's a pilot's review of an in-flight engine failure at an airshow at Duxford last year. It's also the most compelling 30 minutes-worth of Youtube I can remember watching.



I know railways and aviation are different, but I think that's the point. This is the kind of culture that can develop where people have to make safety the top priority. Is there anything railways can learn from them?

 

But we shouldn't have to learn lessons, everything that will prevent such happenings should have been in place for years at each and every railway. Either that or they should not be running trains, that might sound harsh be that is how it should be.