RAIB summarises the work it did in 2021, looking at some serious incidents, as well as appreciating how some were avoided or could have been far worse had it not been for proper precautions.
In RAIB’s annual report, its chief inspector, Andrew Hall, takes the industry through another year of lessons that have been learned, as well as the hard work and progress of the investigation team during 2021.
Seven main themes provide the structure of the review. They are: the safety of track workers, the safety of people getting on and off trains, railway operations, management of bad weather, freight wagon maintenance, safety at user worked crossings and management assurance.
It was in 2021 that, on 31 October, the accident at Salisbury took place in which two passenger trains collided – the first time that RAIB has needed to investigate such an incident, where two vehicles crashed whilst moving at what the chief inspector calls a “significant speed”.
But there were other important incidents where investigations began or concluded that bring with them important lessons for the railways.
When addressing the safety of track workers, the team began an investigation into one who lost their life in Surbiton, and concluded another looking at the death of a someone struck by a train in Roade on the west coast main line in April 2020 – finding that they were on track doing a task that was not really necessary. It found proper planning would have identified that to be the case, and recommended Network Rail review its processes.
Investigations into incidents surrounding three people – at Torlands Castle, Llandegai tunnel and Eccles – concluded that a mixture of mistakes and a lack of focus led to them jumping out of trains’ way just in time. Hall said “no one should undergo such an experience during a working day”.
Investigations involving the safety of people getting on and off trains included a visually impaired person falling off a platform before a train stuck and killed them. RAIB believed the lack of tactile paving may have been a factor in this accident. Hall said: “there appeared to have been no coherent risk-based strategy for the provision of tactile strips, despite their obvious importance to visually impaired people who value the opportunity to travel independently, without reliance on staff.”
RAIB recommended that Network Rail and the Department for Transport (DfT) develop and progress a time-bound programme to install tactile surfaces at stations, where justified by safety benefits. In response, the DfT told RAIB that it made an additional £10 million available for the priority stations not already funded, to be spent in 2021/22, and that additional funding had been secured to fit tactile surfaces along all Great Britain’s platform edges that are not already scheduled to have them installed as part of another enhancement project or renewal.
Most of the work will be done by 2025.
As part of RAIB’s assessment of incidents affecting railway operations, Hall drew attention to the tiredness of drivers, and of them needing up-to-date information so they don’t inadvertently break speed limits. This includes ensuring signage is in the right place.
Hall said: “The industry needs to improve the methods that it uses to impose speed restrictions at short notice, to take advantage of modern technology to communicate effectively with drivers as the situation develops. Getting this right is critical since the railway is now making more use of local speed restrictions to mitigate the risk to its infrastructure during extreme weather events.”
Freight wagon maintenance came once again to the fore when RAIB investigated the derailment, oil spillage and fire at Llangennech, Carmarthenshire in August 2020, published in January 2022. On this, Hall said: “The rail industry’s approach to the safe management of these trains needs to improve. The accident was probably a result of inadequate maintenance practices, and a failure to appreciate the importance of the correct fastening of the various components of the tanks wagons’ braking system.
“This was not the first time that we have investigated an accident related to the maintenance of the oil tanker trains which pass through Llangennech, and it is disappointing that the recommendation we made in our report published four years ago, that the maintenance processes and facilities at the depot where the tank wagons are based should be the subject of a full risk assessment, had not been implemented effectively.”
It added it welcomed news ORR had looked to reinforce its supervision of entities in charge of maintenance.
Meanwhile, the arrangements (or lack of them) for management assurance about site and operational activities was important to RAIB when it looked into the fatal accident at Roade.
Hall said: “In the accident at Roade, the person who was killed was reputedly in the habit of walking on the line when he didn’t need to. His co-workers knew he did this, but he had not been picked up on it by anyone.
“In all aspects of railway operations, management assurance is important. It matters that what happens on the ground corresponds with what all the carefully devised rules and processes say should happen.”
The issue of data
Data is often seen as a good thing. But in RAIB’s annual report, Hall makes a cautionary note about the railways being “awash” with data not being utilised, saying that “there are numerous examples of where data that provides evidence after a railway accident could, if known about and used to drive action, have been used to avoid the accident happening in the first place.
“The data may be there, but the management wherewithal to best use it to reduce risk, is not always. Also, not recognising this can lead to a false sense of security where having invested in equipment that gathers data, organisations can develop a belief that the risks such data can be used to manage have been mitigated, when they have not.”
The other note is a little more optimistic from Andrew Hall. He said “it is clear from RAIB investigations that quite a number of significant accidents over recent years could, with slight changes in circumstance, have been even worse. Such events are a stark reminder of the need for constant vigilance when thinking about and managing risk in a safety-critical industry like the railway.”