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RAIB: ‘Bad habits’ creeping in on renewals work almost caused fatal collision

The RAIB has released its report into a serious irregularity which occurred at Cardiff East Junction in December 2016 which could have caused trains to collide with each other.

The incident occurred whilst Network Rail carried out extensive re-signalling and track re-modelling work in and around Cardiff Central station, from 24 December 2016 to 2 January 2017.

RAIB explained that “bad habits” had creeped in to working practices, meaning that crucial safety checks had not been completed, and the risk of a fatal collision had gone up.

Some of the new layout was brought into use on 29 December, and on that morning the driver of a train from Cardiff Central to Treherbert saw that points in the route he was about to take were not set in the correct position.

They stopped the train just before reaching these points. Fortunately, no one was injured during this incident.

The report states the points at which the train stopped were in fact redundant in the new layout and should have been secured, in preparation for their removal at a later date.

The works had required that eight sets of points, in two separate locations, be secured.

However, it was found that only six of the points had been secured prior to the line being re-opened to traffic.

The omission was not picked up by the testing team during the normal checking process which should take place as a part of this work.

The points, which had been left unsecured and undetected by the signalling system, were set for the diverging route.

Had the driver of the train not stopped, the train would have been diverted onto a line which was open to traffic and can carry trains in either direction.

Another train ran on this line around three minutes after the train involved stopped.

The new signalling system uses axle counters for train detection, and RAIB reported that in this situation the system would not have immediately identified that the train was in the wrong place.

The investigation found that the points had been left in an unsafe condition because they had not been secured by the team responsible for this job.

Route proving trains, a tool used to ensure that the system was working correctly before carrying passengers, had been cancelled.

It was also found that long standing members of the team had developed “insular thinking” about work methods and operational risks.

Consequently, the report states that the team relied on verbal communication and assurances.

It also found that insufficient project governance and ineffective fatigue management may have contributed to the incident.

Simon French, chief inspector of Rail Accidents, described the incident as “alarming” and “a timely reminder of how easily things can go wrong when the railway infrastructure is being upgraded and renewed.”

He said: “Well-meaning people were taking each other’s word that things had been done, instead of insisting on seeing the proof.

“The end result, in this case, was that no-one checked that redundant points, due to be removed altogether in a few days or weeks, had been locked in the correct position.

“Good project governance includes making sure that the right procedures are in place and that people follow them, at all levels, all the time.

“We have concluded that the project governance arrangements, and the processes that should provide Network Rail with assurance that these are being followed, need a thorough review in the light of what happened at Cardiff.”

French also stressed the importance of managing fatigue, harking back to the Clapham Junction disaster of 1988, which killed 35 people in a collision caused by a signal failure: “It is also important, when organising intensive periods of commissioning work, to properly manage the working hours of the people doing the job.

“Back in 1988, the disastrous collision at Clapham Junction happened in part because working for weeks on end without any days off was part of the culture in some areas of the railway.

“Rightly, things have changed a lot since then.

“However, the events at Cardiff showed how easy it is to forget the lessons of Clapham and slip back into those habits under the time pressures of a big commissioning.”


Huguenot   30/10/2017 at 14:12

This is the same thing that happened at Waterloo in August. Points were not clamped during engineering works and an EMU collided with a ballast train. Incidentally, not too appropriate a picture to illustrate Cardiff Central. Would that the wires were up already!

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