Getting ADAR on our radar
EMR’s Simon Whittingham and GWR’s Jack Collins discuss a rise in ‘attempted dispatch against red’ (ADAR) incidents
Remember 1979? Many of you probably don’t. The odd TV documentary will point you to the widespread public sector strikes, the arrival of Margaret Thatcher, and the changes that came thereafter. The programme probably won’t mention Paisley Gilmour Street. But on 16 April that year, a train was dispatched from the station, passed a red light, and struck a train coming the other way. Seven people were killed and 67 more were injured. The investigation showed that the guard had sent the ‘train ready to start’ to the driver. Neither had realised that the platform starter was red. It's because of this ‘attempted dispatch against red’ (ADAR) incident that the rules were changed to make sure the guard checked the signal aspect before giving the Right Away.
Despite this, trains are still being dispatched against red signals. We see incidents like this in the control logs if not every day, then certainly every week. At both East Midlands Railway (EMR) and Great Western Railway (GWR), rises have been recorded. Distraction is emerging as a common issue and events involving platform staff and guards are up across a range of operational contexts. Most of the incidents were low‑harm, promptly identified, and managed safely. The increase provided both companies with an opportunity to better understand the factors at play and strengthen the systems that support safe dispatch.
To try to understand what was happening, a review was made of all incidents. EMR talked to front line staff, the unions, and its management teams to gain more insight. It also reached out to other operators to share thoughts and ideas. Early analysis at GWR highlighted some localised hotspots. The most notable trend, however, was that over half of the staff members involved were either still in training or within their first post‑qualified assessment (PQA) year. Many were within their first 6 months of qualification. A number also lacked understanding and awareness of human factors and their influence on performance. GWR found that levels of understanding varied, particularly around non-technical skills (NTS). This prompted a review of the human factors elements of its current processes at the organisational, workplace, and individual levels.
GWR and EMR use a Personal Safety Strategy (PSS) to help staff identify and manage operational risks proactively. It’s well-embedded, but the company’s review saw opportunities to strengthen how PSS conversations are facilitated—especially during training and assessment.
GWR is now refining how often and how deeply PSS is discussed with trainees and qualified personnel, ensuring it becomes a regular theme within all aspects of competence management. It is also developing new materials to enhance NTS understanding and support trainers in having richer conversations with trainees about the cognitive side of dispatch. In addition, managers will receive more training in incorporating NTS into competence management, enabling more targeted support after incidents and reducing the likelihood of repeat events.
GWR is also reviewing its post‑incident response, to make sure it is proportionate and measured, reflecting how much of the dispatch process had been completed, and considering relevant factors such as staff history, context, and circumstances.
EMR’s findings led it to produce some top tips and best practice videos for dispatchers. More specifically, it enhanced its signage at Kettering, a known hot spot location on the EMR network. EMR also worked with RMT health and safety reps to introduce mandatory NTS (in the form of ‘point and call’) for new starters. To help reinforced the ‘point and call’ risk-triggered commentary message, the company held a session at the Great Central Railway in Loughborough. It simulated a dispatch against red incident and the potential consequences with 20 mentors, trainers, and members of the on-train management and assessment team.
To help understand the level of the problem, EMR also categorised its ADAR incidents:
Low risk – the dispatcher has provided the Station Work Complete signal while the platform starter is red.
Medium risk – the guard has given the Train Ready to Start signal to the driver while the platform starter is red.
High risk – this is when a train movement has taken place.
There’s no question that rolling stock is safer today than it was in 1979. Design standards have improved, but this—and the fact that there is more automat on—means that the nature of dispatch has changed. Although the overall risk profile has come down, the cognitive demands have shifted. Staff are now required to manage attention, situational awareness, and workloads, to make confident decisions in environments where fewer technical prompts and cues are present.
This means our focus must now grow beyond technical and functional skills (and underpinning knowledge), ensuring we also strengthen the NTS that underpin safe performance. Our aim is to make sure colleagues have the right tools, support, and confidenceto operate safely in this modern dispatch environment.
You can help by reporting whenever an incident takes place, giving as much detail to the investigator as possible.
For RSSB’s resources on non-technical skills, go to rssb.co.uk and search ‘non-technical skills'.
