Read this edition's RAIB report.
There hasn’t been a fatal SPAD and collision since Ladbroke Grove in 1999, but we could have been 10 seconds from another one, reveals this issue's RAIB report.
Just seconds 05:30 on the morning of 5 May 2021, a rail grinding train passed LR477 signal at danger near Sileby.
The signal was red because an ECS formation was crossing the line up ahead. The grinder ran on for 350 metres before fouling the junction that the stock train had passed through less than 10 seconds before. Think about that for a moment.
There hasn’t been a fatal SPAD and collision since Ladbroke Grove in 1999, but we could have been 10 seconds from another one. He was walking in a crossover near Surbiton station. He was one of four track workers involved in inspecting crossovers in the area.
RAIB pointed out that while the TPWS made an automatic emergency brake intervention, it didn’t stop the grinder before it reached the conflict point. After the incident, Network Rail commissioned a review of TPWS effectiveness at LR477, deciding that repositioning the overspeed sensor on the approach to LR477 would solve the problem.
But what of the underlying cause? According to witness evidence, the driver had finished his previous shift early on the morning of 4 May and slept from around 07:00 to something like 11:30. He grabbed two more hours in the early evening before booking on remotely at 21:30. This meant he’d had about 6.5 hours’ sleep – not bad for some of us, but less than the average requirement of 8.2 hours cited in the latest ORR guidance.
The driver said he felt fine when he booked on and was no more tired than usual toward the end of the shift. But signalling technician Brian Hemingway said he hadn’t been tired at the inquiry into the Clapham accident (1988), which was caused in part by a wiring error he’d made after working almost 13 weeks solid without a break. As such, there may be a number of reasons why frontline staff do not report fatigue or fail to recognise fatigue symptoms.
The Clapham inquiry led to a set of working time limits, but the Railway Group Standard that incorporated them was withdrawn as long ago as 2007. Yet the grinder operator’s fatigue risk management processes – while reflecting newer ideas – still relied on some of the old criteria.
From August 2021, however, the operator started issuing monthly fatigue briefings, some of which referred to wider industry guidance, which included advice on napping during breaks. RAIB said Silbey was in fact ‘a reminder that, under appropriate circumstances, frontline staff may use napping as a mitigation where they have been unavoidably affected by fatigue’. While it should never be relied upon to control fatigue, said RAIB, ‘train operators should ensure that their employees are aware of the role of napping within their wider fatigue risk management systems, including its relative merits as a fatigue countermeasure’.
Fatigue can affect anything and everything, from SPADs like Sileby, to overspeeding events, platform incidents and placing track protection incorrectly.
To read RAIB’s full report, including the recommendations it made, search for ‘RAIB Sileby’ in your chosen search engine.
