Monday Accident & Lessons Learned: Incident Report from the UK Rail Accident Investigation Branch: Tram running with doors open on London Tramlink, Croydon

Posted: April 7th, 2014 in Accidents, Current Events, Human Performance, Investigations, Pictures

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There were eight recommendations made by the UK RAIB. here’s a summary of the investigation:

On Saturday 13 April 2013 between 17:33 and 17:38 hrs, a tram travelling from West Croydon to Beckenham Junction, on the London Tramlink system, departed from Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors closed automatically during the journey, but one set of doors remained open throughout the incident. The incident ended when a controller monitoring the tram on CCTV noticed that it had departed from Sandilands withits doors open, and arranged for the tram to be stopped. Although there were no casualties, there was potential for serious injury.

The tram was able to move with its doors open because a fault override switch, which disables safety systems such as the door-traction interlock, had been inadvertently operated by the driver while trying to resolve a fault with the tram. The driver didnot close and check the doors before departing from Lebanon Road and Sandilands partly because he was distracted from dealing with the fault, and partly because he did not believe that the tram could be moved with any of its doors open. The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch. Furthermore, breakdowns in communication between the driver and the passengers, and between the driver and the controller, meant that neither the driver nor the controller were aware of the problem until after the tram left Sandilands.

The RAIB has made eight recommendations. Four of these are to Tram Operations Ltd, aimed at improving the design of tram controls and displays, as well astraining of staff on, and processes for, fault handling and communications. Two recommendations have been made to London Tramlink, one (in consultation with Tram Operations Ltd) relating to improving cab displays and labelling and one on enhancing the quality of the radio system on the network. One recommendation is made to all UK tram operators concerning the accidental operation of safety override switches. The remaining recommendation is to the Office of Rail Regulation regarding the provision of guidance on ergonomics principles for cab interface design.


For the complete report, see:

Was it Taxes, Bad Decicions, or a “Complex Chain of Events” that caused the grounding of the drilling rig Kulluk near Kodiak Island?

Posted: April 4th, 2014 in Accidents, Current Events, Investigations


Alaska winters are notorious. And the seas in the Gulf of Alaska are particularly bad in mid-winter. The Houston Chronicle reported that Rear Admiral Thomas Ostebo said, “the most significant factor was the decision to attempt the voyage during the winter in the unique and challenging operating environment of Alaska.”

Interestingly, Shell may have been encouraged to move the rig because if they didn’t, they might have to pay the state of Alaska a multi-million dollar tax bill. 

See the whole story at:

Preliminary (Spring) SnapCharT® of the Lost Flight MH 370

Posted: March 31st, 2014 in Accidents, Current Events, Documents, Investigations, Pictures

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(Photo of remains from cockpit fire of an Egypt Air 777 while parked at a gate in Cairo)


One of our TapRooT® Users sent the attached PDF of a SnapCharT® for the loss of Malaysia Air MH 370. 

Have a look. See what you think. Then leave comments here…


Three Mile Island Accident Anniversary: The Nuclear Industry Discovers Human Factors

Posted: March 28th, 2014 in Accidents, Human Performance, Investigations


Five days of panic. 140,000 residents voluntarily evacuate. Fourteen years of clean-up.

The 35th anniversary of the Three Mile Island Nuclear Disaster.

On the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I can still remember that morning.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I can still remember that morning. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

Years later, I attended the University of Illinois while also being a Assistant Professor (teaching midshipmen naval weapons and naval history). I was the first in a new program that was a cooperative effort between the Nuclear Engineering and Psychology Departments to research human factors and nuclear power plants. My advisor and mentor was Dr. Charles O. Hopkins, a human factors expert. In 1981-1982, he headed group of human factors professionals who wrote a report for the NRC on what they should do to more fully consider human factors in nuclear reactor regulation.


As part of my studies I developed a course on the accident at TMI and published my thesis on function allocation and automation for the next generation of nuclear power plants.

So, each year when the anniversary of the accident comes around I think back to those days and how little we have learned (or should I say applied) about using good human factors to prevent industrial accidents.


Root Cause Analysis Tip: Why do supervisors perform BAD root cause analysis?

Posted: March 26th, 2014 in Investigations, Performance Improvement, Root Cause Analysis Tips, TapRooT


I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…


Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.

Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!


Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.

What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.

As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.


The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.

Learn more about TapRooT® Training at:

Monday Accident & Lessons Learned: NTSB Reveals Root Causes of Sissonville Pipeline Failure

Posted: March 24th, 2014 in Accidents, Current Events, Investigations



OH&S Occupational Health and Safety Online reports:

“The National Transportation Safety Board listed two related factors as the probable causes of the natural gas pipeline rupture on Dec. 11, 2012, in Sissonville, W.Va. NTSB posted its accident report in the case March 10 and included in it one recommendation to the federal Pipeline and Hazardous Materials Safety Administration and three recommendations to Columbia Gas Transmission Corporation, which owns and operates the pipeline.”

See the rest of the article here:

NTSB Finds Undetected Corrosion in Sissonville Pipeline Failure

View NTSB’s  full accident report here:

Pipeline Accident Report Enbridge Incorporated Hazardous Liquid Pipeline Rupture and Release


Do you think the NTSB conducted a thorough investigation? Do their corrective actions put the proper safeguards in place?

Share your opinions in the comments below: Photo courtesy of

CSB Pledges to Release the Deepwater Horizon Accident Investigation in 2014

Posted: March 19th, 2014 in Accidents, Current Events, Investigations

This news was in the CSB’s 2015 budget request. It said:

Deepwater Horizon – The CSB’s investigation into the Deepwater Horizon/Macondo accident of April 2010 continues, and the CSB has achieved significant legal victories during FY 2013. In April 2013 a federal judge in Houston upheld the CSB’s jurisdiction to conduct the investigation, and overruled the rig operator Transocean in its effort to block the release of information to the CSB. On July 23, 2013, the United States Court of Appeals for the Fifth Circuit in New Orleans, Louisiana, ruled in favor of the CSB and refused to stay the lower court’s decision. As a result of this ruling, the CSB has gained access to vital documents and information subpoenaed throughout the course of the agency’s investigation. Access to these documents will allow the CSB to evaluate factors that no other agency has investigated in detail, such as the role of human and organizational factors in this catastrophic accident.

The CSB’s investigation findings will be published in three separate volumes. The first two volumes are scheduled to be released in the spring of 2014, and the third volume will be released in the summer of 2014.”

A three volume report … Keep your Summer reading schedule open.

Missing Malaysian Airlines 777 – How Do You Investigate When the “Facts” Are Few & Far Between?

Posted: March 17th, 2014 in Accidents, Current Events, Investigations


Before the news broke, the Malaysia Airlines Flight 370 seemed to have disappeared without a trace. As I watched coverage of the mysterious “accident,” I thought that people might be interested in how one would investigate the disappearance and others like this where the facts are few and far between. Below, I set out how to do that using TapRooT®.

First, all TapRooT® Users know you start with a SnapCharT®.

The first problem you encounter with this incident is … what goes in the circle?

The circle on the SnapCharT® is the incident – usually the worst thing that happened. But in this case we don’t know what happened.

Should the circle be losing contact with the jet?

Perhaps. At least until we find out more about what happened.

Next, we lay out the sequence of events. Some of the events are pretty easy to detail. The flight seemed pretty routine to start with. But then things start to diverge from a normal fight sequence. Tracking equipment is turned off (not lost instantaneously as one would expect if there was a massive mechanical failure or explosion), and the plane then seems to have changed course and descended. As of now, changing course and descending are dotted boxes (assumptions) since we aren’t sure of these “facts”.

This is where the SnapCharT® gets even more difficult to draw. New information seems to be available every day from different sources. One would add this information to the chart using dotted boxes and ovals (events and conditions) keeping track of the source for each piece of information. One would then try to find more evidence to either confirm or eliminate each of these new pieces of information and redirect the investigation to find more information.

The SnapCharT® would become the main source of information and help direct the investigation by suggesting where investigators should focus their attention to help narrow down the seemingly large number of possibilities for “What happened?”
Note that at this point we are nowhere near identifying the “accidents” root causes. Until you have a fairly complete sequence of events, you aren’t ready to identify causal factors and start finding root causes.

I hope this give you some ideas the next time you start an investigation of a mysterious accident. And I hope, for the sake of all those involved and their loved ones, this investigation finds the true root causes of the flight’s disappearance so they can feel some sense closure.

Please leave your comments below. 

Monday Accident & Lessons Learned: UK RAIB reports on fatal accident at Athelney level crossing, near Taunton, Somerset on 21 March 2013

Posted: March 10th, 2014 in Accidents, Current Events, Investigations, Pictures

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The following this the summary of the accident report from the UK Rail Accident Investigation Brach about a fatal accident at a level crossing in the UK. The full report includes four recommendations to improve level crossing safety. See the full report at:


At about 06:23 hrs on Thursday 21 March 2013, a car drove around the barriers of Athelney automatic half barrier crossing, near Taunton in Somerset. This took the car into the path of a train which was approaching the crossing at high speed. The driver of the car was killed in the resulting collision.

The motorist drove around the barriers without waiting for a train to pass and the barriers to re-open. The level crossing was closed to road traffic for longer than normal before the arrival of the train, because of earlier engineering work that had affected the automatic operation of the crossing. The motorist may have believed that the crossing had failed with the barriers in the closed position, or that the approaching train had been delayed.

He did not contact the signaller by telephone before he drove around the barriers.The RAIB has made two recommendations to Network Rail. These relate to reducing the risk resulting from extended operating times of automatic level crossings andto modifying the location of the pedestrian stop lines at Athelney level crossing. A further recommendation is addressed to Network Rail in conjunction with RSSB,to consider means of improving the presentation of telephones at automatic level crossings for non-emergency use. One recommendation is addressed to the Office of Rail Regulation, to incorporate any resulting improvements which are reasonably practicable into the guidance it publishes on level crossings.



Press Release by the UK Rail Accident Investigation Branch: Passenger dragged a short distance by a train at Holborn station

Posted: March 8th, 2014 in Accidents, Current Events, Investigations, Pictures


Image showing a train in the westbound Piccadilly Line platform at Holborn station


The RAIB is investigating an incident in which a passenger was dragged for a short distance by a train departing from Holborn station on the London Underground system.

The incident occurred on the westbound Piccadilly Line platform at around 19:00 hrs on Monday 3 February 2014. The train had stopped normally in the platform and passengers had alighted and boarded. A member of staff on the platform (station assistant) signalled to the Train Operator to close the doors by raising a baton above his head. The Train Operator observed the raised baton and started to close the train’s doors. At this point a passenger arrived on the platform and moved towards the train, stopping as she realised that the doors were closing. As she stopped, the end of the scarf that she was wearing continued to swing towards the train and became trapped between the closing doors.


The Train Operator was unaware that the scarf was trapped in the door and after confirming that all doors were closed, started to move the train into the tunnel. The passenger was dragged along the platform by her scarf as the train started to move. The station assistant tried to help the passenger by holding on to her and they both fell to the ground. This resulted in the scarf being forcibly removed from the passenger’s neck and carried into the tunnel by the train.

The passenger suffered injuries to her neck and back and was taken to hospital; she is now recovering. The RAIB’s investigation will seek to understand the sequence of events and will examine the arrangements in place for safe despatch of trains from London Underground stations where station assistants are provided on the platform.

The RAIB’s investigation is independent of any investigation by the Office of Rail Regulation. The RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.




Monday Accident & Lessons Learned: Heat Stress and Death

Posted: March 3rd, 2014 in Accidents, Investigations

Time to start planning for hot weather! What are management’s responsibilities to make sure that workers are safe when things get hot? See this OSHA press release:

Heartland Drilling Inc. in Abilene, Texas, cited by
US Department of Labor for exposing workers to heat stress

Monday Accident & Lessons Learned: Penetration and obstruction of a tunnel between Old Street and Essex Road stations, London

Posted: February 24th, 2014 in Accidents, Current Events, Investigations, Pictures

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The UK Rail Accident Investigation Branch investigated the penetration and obstruction of a tunnel between Old Street and Essex Road stations in London. Here is a summary of the report:

“During the morning of Friday 8 March 2013, a train driver reported that flood water was flowing from the roof of a railway tunnel north of Old Street station near central London. The driver of an out-of-service passenger train was asked to examine the tunnel at low speed and check for damage. The driver stopped short of the water flow and reported that two large drills (augers) had come through the tunnel wall and were fouling the line ahead of his train.

The augers were being used for boring piles from a construction site about 13 metres above the top of the tunnel. The operators of the piling rig involved were unaware that they were working above an operational railway tunnel. Its position was not shownon the site plan, or on any map available to either the developer or the local planning authority. As a consequence, Network Rail was not consulted during the planning application stage and was unaware of the construction activity.

The RAIB has determined that approximately half of the piles required for the new development would have intersected with the tunnel had they had been constructed. It has identified two learning points from this incident which are relevant to the construction industry: clients and design teams should be aware of the importance of information shown on land ownership records; and those carrying out investigations for proposed developments should be aware that not all railway tunnels are shown on Ordnance Survey mapping.

The RAIB has also made five recommendations: three are addressed to railway infrastructure managers, and relate to: the provision of information to organisations undertaking property-related searches; the provision of information on the location of railway tunnels and associated subterranean structures; and the identificationof development work by third parties. One recommendation is made to the British Standards Institution relating to the enhancement of a British Standard, and one recommendation is addressed to the Department for Communities and Local Government relating to a recommendation made by the RAIB in 2007 which has not been implemented.”

To see the complete report, visit:

Press Release from the UK Rail Accident Investigation Branch: Fatal accident involving a track worker, near Newark Northgate station, 22 January 2014

Posted: February 10th, 2014 in Accidents, Current Events, Investigations

RAIB is investigating an accident involving a track worker who was carrying out lookout duties near Newark Northgate station. The accident occurred at about 11:40 hrs on 22 January 2014. The track worker was struck by a passenger train and suffered fatal injuries.

The track worker was part of a gang of three engaged in the inspection of two sets of points to the south of the station. The train, a passenger service from King’s Cross, was approaching from the south at around 26 mph (42 km/h) and was heading into platform 3 as scheduled.

RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.

RAIB’s investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

Press Release from the UK Rail Accident Investigation Branch: Serious near-miss involving a welding gang at Bridgeway user worked crossing, near Shrewsbury, 16 January 2014

Posted: February 5th, 2014 in Accidents, Current Events, Investigations, Pictures

From the UK RAIB web site:

RAIB is investigating a serious near-miss involving a welding gang at Bridgeway user worked crossing, near Shrewsbury.

The accident occurred just before midnight on 16 January 2014 and involved train 1J76, the 22:36 hrs service from Manchester Piccadilly to Shrewsbury. At the point of impact the train, formed by a class 175 diesel multiple unit operated by Arriva Trains Wales, was travelling at approximately 85 mph (136 km/h). It braked to a stand in around half a mile (0.8 km).

Seconds before the collision a member of staff jumped off the trolley and clear of the train. A van, inside which another member of staff was unloading equipment, was parked close to the railway and was very nearly struck by the train. Although the train did not derail, it suffered significant damage, including a ruptured fuel tank. The member of staff who jumped clear suffered minor injuries.

The trolley was being loaded on the up line to move equipment southwards, towards Shrewsbury, to undertake a weld repair. However, this line was still open to traffic to allow train 1J76, the last train of the evening, to approach (the down line had been blocked by arrangement with the controlling signaller based in Cardiff).

NewImageImage of trolley underneath the damaged train (courtesy of Network Rail)

 RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules were applied. It will also seek to understand the actions of the track workers involved, and factors that may have influenced their behaviour and attitudes.

RAIB will assess the railway industry’s current strategy for undertaking work of this type, and will review the actions taken in response to previous RAIB recommendations relating to the safety of track workers.

Press Release from the UK Rail Accident Investigation Branch: Engineering train collision at Kitchen Hill, near Penrith, 12 January 2014

Posted: January 30th, 2014 in Accidents, Current Events, Investigations

The RAIB is carrying out a preliminary examination into a collision at Kitchen Hill, 3 miles north of Penrith station on the West Coast Main Line.

At 13:25 hrs on Sunday 12 January 2014, train 6L42 (comprised of 10 ballast wagons and a locomotive at each end) was travelling in a work site when it collided with the back of a stationary ballast train that was standing at the board marking the end of the work site. Train 6L42 was travelling at around 19 mph at the time of the impact. As a consequence of the collision, the buffers of the first wagon on train 6L42 overrode those on the leading locomotive; and the leading bogie of the wagon and the trailing bogie of the locomotive became derailed.

When the driver of train 6L42 saw that a collision was imminent he applied the emergency brake and jumped from his cab, sustaining serious injuries. The derailment caused damage to the track which required local repairs, and some limited damage to the rolling stock involved.  

The RAIB’s preliminary examination will examine the rules applicable to the management of engineering train movements, and the regulation of their speed, in work sites. It will also examine the way in which key information was communicated between the parties involved.

The RAIB will consider previous similar accidents; in particular the collision between two engineering trains at Leigh-on-Sea in April 2008 (report 24/2009), and a stoneblower and ballast regulator near Arley in August 2012 (report 12/2013).

The RAIB’s preliminary examination is independent of any investigation undertaken by the Office of Rail Regulation.

At the conclusion of the preliminary examination the RAIB will publish its findings on the RAIB website.

What Happened to the CSB investigation of the Macondo Blowout and Explosion (Deepwater Horizon Accident)?

Posted: January 29th, 2014 in Accidents, Investigations, Pictures

Screen Shot 2014 01 29 at 2 08 34 PM(Picture from the CSB web site page on the Macondo Investigation. See:

You might remember that on April 20, 2010, the Deepwater Horizon experienced a blowout, explosion, fire, and sank shortly thereafter.

You might also remember that several members of Congress asked the Chemical Safety Board to investigate the accident.

What you don’t remember is the investigation report.

Why? Because the report has not been published.

In 2012, the CSB announced that a draft report was imminent (due in July) and the final report would be published in 2013. 

It is now well into 2014 (closing in on two years later) and no draft report has been released.

If you were assigned to investigate an accident and almost four years later you hadn’t published a draft of your report, what would your management say?

Also, if a report is published four years after an accident, how much impact can it have? Hasn’t the industry moved on by the time the report is released?

Timeliness of investigations and findings are certainly issues that need discussion. 

Perhaps the CSB should adopt timeliness guidelines for investigations and reports. What would you suggest as the longest time that an investigation should be allowed to continue? Leave your comments here.

- – - 



Some of the comments have focussed on the delay caused by Transocean deciding to fight the jurisdiction of the CSB subpoenas, Therefore, I’ve attached the March 2013 decision. Note that the CSB knew about Transoceans’ decision to resist the subpoenas when they abounded that they would be releasing a preliminary report in 2012. 


Monday Accident & Lessons Learned: Derailment at Castle Donington, Leicestershire on January 21, 2013

Posted: January 27th, 2014 in Accidents, Investigations, Pictures

Screen Shot 2014 01 21 at 1 39 58 PM

Here is the summary from the UK Rail Accident Investigation Branch report. Note that the full report contains two recommendations.

At about 19:55 hrs on 21 January 2013, a freight train consisting of 26 empty wagons, hauled by a diesel locomotive, derailed at Castle Donington, Leicestershire. The eighteenth wagon derailed first, followed by the nineteenth and twentieth wagons. Subsequently, the train divided between the nineteenth and twentieth wagons, causing the brake to apply. There was extensive track damage, but no-one was hurt.

The immediate cause was that cyclic top before the point of derailment excited the suspension of the eighteenth wagon causing the left-hand leading wheel to become unloaded and to derail to the left. There had been a recurrence of cyclic top faultsin the vicinity of where the derailment occurred, and the routine inspection and maintenance had not kept the track in an acceptable condition. In particular, planned stoneblowing on 20 November 2012, which should have included the track through the point of derailment, stopped before reaching it due to shortage of time.

An underlying factor was that the ballast supporting the track was fouled, causing the track to be inadequately supported and leading to the recurrent cyclic top. The need to renew the ballast had been identified, but the work was not programmed to be carried out until 2016/17. This was in line with Network Rail’s policy for renewals on the route.

The RAIB has made two recommendations, one directed to Network Rail and oneto RSSB. The recommendation to Network Rail covers reviewing, and if necessary, improving the planning of stoneblowing so that there is sufficient time to completethe work. The recommendation to RSSB (in conjunction with the rail industry) is to review the current Rule Book requirements relating to the action required following an abnormal brake application, and to make any changes found necessary to reduce the risk of trains colliding with a derailed rail vehicle.

The RAIB has also identified three learning points about:

• checking track, following the passage of trains, after lifting and packing work;

• using appropriately qualified staff to raise speed restrictions following work to remedy poor track condition; andl

• staff communicating safety information so that it is clearly and accurately understood.

See the complete report at:

Press Report: “Cause of deadly Omaha plant explosion unknown”

Posted: January 21st, 2014 in Accidents, Investigations

The Norfolk Daily News reported on the deadly blast at The International Nutrition plant. The report stated:

Authorities don’t know what caused the blast. Omaha Interim Fire Chief Bernie Kanger said at a news conference Monday night that he couldn’t say for sure there was an explosion, though workers and other witnesses described hearing a blast.”

OSHA will be conducting an investigation of the accident.

Monday Accident & Lessons Learned: Investigation of a Track Worker’s Death

Posted: December 30th, 2013 in Accidents, Current Events, Investigations, Pictures

Screen Shot 2013-10-29 At 12.30.54 Pm

This is a summary of the investigation from the UK Rail Accident Investigation Branch…


At 13:50 hrs on Tuesday 4 December 2012, a train travelling from Scunthorpe to Lincoln struck and fatally injured a track worker at Saxilby, near Lincoln. The individual concerned was acting in the role of Controller of Site Safety (COSS) at the time of the accident. He was involved in work taking place on one of the two tracks at this location which was closed to rail traffic, but standing close to the adjacent line over which trains were still operating.

The RAIB’s investigation found that the COSS stepped back into the path of the train as it passed the site of work. The following factors led to the accident:

  • the COSS had not implemented a safe system of work for the task that was being undertaken at the time that the accident occurred;
  • none of the other track workers on site challenged the absence of a safe system of work or the actions of the COSS who was working within an unsafe area;
  • the COSS became distracted and did not see or hear the approaching train; l no effective action had been taken in response to the involvement of the COSS in two other safety incidents in the two months preceding the accident;
  • the COSS had not been subject to an effective formal performance review by the agency (SkyBlue) that had hired him for COSS duties for the work taking place on 4 December 2012 and on other occasions; and
  • deficiencies and omissions within SkyBlue’s management systems had not been identified by its parent company (Carillion).

The RAIB has also observed that the processes employed by the railway industry during its own investigation into the accident at Saxilby may have taken insufficient account of the trauma that some of the witnesses were suffering as a result of their proximity to the accident.

The RAIB has made four recommendations. Three recommendations have been made to Network Rail regarding the use of agency staff in safety leadership roles, measures to address the risk arising from the use of agency staff in any role that involves working on and around the track and its processes for interviewing witnesses after serious incidents and accidents. One recommendation has been made to Carillion in conjunction with SkyBlue in respect of reviewing the effectiveness of changes made to safety management arrangements following the accident at Saxilby.

For the complete investigation report, see:

Press Release from the UK Rail Accident Investigation Branch: Locomotive failure near Winchfield, Hampshire

Posted: December 22nd, 2013 in Accidents, Current Events, Investigations, Pictures

 Cms Resources Winchfield-Image-1

Image of 34067 “Tangmere” locomotive

The RAIB is investigating the failure of a steam locomotive hauling a passenger train, which occurred between Fleet and Winchfield stations on Saturday 23 November 2013.

At about 18:50 hrs, train 1Z94, the 17:48 hrs charter service from London Waterloo to Weymouth, was approaching Winchfield, where it was due to stop for the locomotive to take on water. While the train was travelling at about 40 mph, the right-hand connecting rod of the locomotive, former British Railways (Southern Region) 4-6-2 34067 “Tangmere”, became detached at the leading end (referred to as the small end), and dropped down. The end of the detached rod struck the conductor rail, and there was some electrical flashing. This was noticed by the locomotive crew, and the driver stopped the train immediately, about one mile outside Winchfield station. After running along the conductor rail for some distance, the connecting rod dropped onto the sleeper ends just before the locomotive came to rest.

The locomotive’s support crew dismantled the connecting rod, and the train was then assisted by the diesel locomotive that was attached to its rear as far as Basingstoke, where the passengers transferred to another train to continue their journey.

The RAIB’s preliminary examination found that the small end assembly, in which the connecting rod is secured in the crosshead by a gudgeon pin and associated nut and cotter, had come apart. The gudgeon pin was found intact, lodged on the locomotive, but the nut and cotter have not yet been recovered.

The RAIB’s investigation will seek to identify the sequence of events leading to the connecting rod becoming detached. It will include the design, manufacture, installation and maintenance of the components making up the crosshead and piston assembly, and relevant aspects of the operation and maintenance of the locomotive.

The RAIB would be pleased to hear from anyone who has a photograph or video recording showing detail of the right-hand side of Tangmere, taken at Waterloo or subsequently on the journey during the evening of Saturday 23 November.

The RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.

The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

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