Lessons Learned from Disasters in UK Rail

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PowerPoint PresentationRailway Safetyin the UKLessons Learnedfrom Disasters in UK Rail3rd China Urban Rail Development Summitby David Shipley, CSRE Limited22nd September 2011, Tianjin, PRCCSRE Limited1. INTRODUCTIONCSRE LimitedIntroduction David ShipleyBackground in design of safety systems for oil & gas and nuclear industries, prior to railways;Advised UK Department for Transport on train safety issues;Assisted in the development of rolling stock standards, raising safety levels in passenger trains.CSRE Limited2. SUMMARY OFHISTORIC DISASTERSCSRE LimitedDisaster Timeline, 1830 - presentSince the birth of passenger railways in 1830, disasters have plagued the general safety recordRailways are, and have always been far safer than road travel, however, public service responsibility gets in the way and distorts the factsPresentation will show that whilst the number of accidents has remained pretty constant, the number of deaths has dropped substantially CSRE LimitedUK Train Accidents 1830 to 201015th September 1830First Passenger serviceFirst fatal accident!CSRE LimitedUK Train Accidents 1830 to 20101840s to 1860sRailwaymania!Rapid growth, but little or no signalling or safety in generalCSRE LimitedUK Train Accidents 1830 to 20101870s to 1900sContinued growthInvention of fixed signalling with interlockingCSRE LimitedUK Train Accidents 1830 to 20101914 to 1919First World WarMassive troop movements by rail, shortage of trained staffCSRE LimitedUK Train Accidents 1830 to 20101920s and 1930sTechnical advances in train designReplacement of wooden bodied cars with steel bodied carsCSRE LimitedUK Train Accidents 1830 to 20101940s and 1950sSecond World War bomb damagePost war austerity, plus shortage of trained staffCSRE LimitedUK Train Accidents 1830 to 20101960s and 1970sFurther technical advancesDevelopments in safety systems, improved car body strengthCSRE LimitedUK Train Accidents 1830 to 20101980s to presentImproved crash worthinessMovement towards risk-based Safety Management SystemsCSRE Limited3. THE TREND TOWARDSA SAFER RAILWAYCSRE LimitedStatement.Improvements in safety are usually the result of a catastrophe.Discuss.CSRE LimitedUK Train Accidents 1830 to 2010Shipton-on-Cherwell, 187434CSRE LimitedShipton-on-CherwellTrain derailed, carriages fell from bridge;Railway Inspectorate inquiry held, finding: -Old design of cast iron wheel, fractured;Poor brake system design, the engine only braking with the weight of the rear coaches crushing the front ones;Led to: -New design of wheels, much more durable;Through train braking on all passenger trains.CSRE LimitedUK Train Accidents 1830 to 2010Quintinshill, 1915226CSRE LimitedQuintinshillThree trains collided and burst into flames;Board of Trade inquiry held, which found: -Old wooden carriages used because of shortages;Signaller, who had worked long hours changed shift;Signallers (2) sent to prison for manslaughter.CSRE LimitedUK Train Accidents 1830 to 2010Harrow & Wealdstone, 1952112CSRE LimitedHarrow & WealdstoneThree trains collided, many cars crushed;Railway Inspectorate inquiry held, finding: -Signals passed at danger (SPAD - reasons unknown, both driver and fireman killed);Led to: -Introduction of Automatic Warning System (AWS), preventing uncontrolled SPADsCSRE LimitedSo, the answer is yes!Accidents, and the detailed post accident investigations led to: -Through train braking being introduced;Cast iron wheels being replaced;Wooden carriage bodies being phased out;Automatic Warning System (AWS) being developed and introduced.CSRE Limited4. RAIL PRIVATISATION LOSS OF CONTROLCSRE LimitedRail Privatisation Loss of ControlUK railway system privatised in 1993/4;British Railways replaced by: -Twenty five passenger operators;Four freight operators;One infrastructure controller;Three train leasing companies;A mass of services companies.82 companiesin total!CSRE LimitedFatal accidents 1980 to presentPrivatisationPolmont, 198413CSRE LimitedPolmontTrain derailed after hitting cows on line;Independent public inquiry held, finding: -Low axle load on leading vehicle in push-pull train caused derailment;Driver could not see an adequate distance in front of the train.Led to: -Minimum axle load limits on leading vehicles;Mandatory high intensity headlights.CSRE LimitedFatal accidents 1980 to presentPrivatisationClapham Junction, 198835CSRE LimitedClapham JunctionThree trains collided, many cars crushed;Independent public inquiry held, finding: -Defective signalling following maintenance the root cause of accident;Poor crashworthiness in cars led to many deaths.Led to: -Improved crashworthiness in new designs and ultimately replacement of more than 1000 cars.CSRE LimitedFatal accidents 1980 to presentPrivatisationLadbroke Grove, 199931CSRE LimitedLadbroke GroveTwo trains collided at junction;Independent public inquiry held, finding: -Inexperienced driver, passed signal at danger;Serious procedural failures on the part of operators, infrastructure controller and safety authority.Led to: -Complete revamp of railway safety management, establishing current working systems.CSRE Limited5. CULLEN REGAINING CONTROLCSRE LimitedCullen Regaining ControlFollowing a series of serious accidents in late 1990s;UK Government ordered public inquiry;Lord Cullen appointed as chair;Report from inquiry made important recommendations relating to safety management, most of which were implemented;Present safety management regime resulted, with an outcome of very low levels of fatal train accidents.CSRE LimitedThe Present Stable Structure UK rail system remains privatised, with many players;Safety management regime is stable and well understood;Checks and balances in the various organisations ensure openness when an incident occurs;Very few deaths now occur in UK railway system as a result of train related accidents.CSRE LimitedThe Present Stable Structure Sets standardsEnsures complianceInvestigates accidentsCSRE Limited7. CONTINUOUSIMPROVEMENTCSRE LimitedThe Present Stable Structure CSRE LimitedFatal accidents 1980 to presentPrivatisationUfton Nervet, 20047CSRE LimitedUfton NervetCar driver decided to suicide at level crossing, causing derailment at 200 km/hr;RAIB investigation held, finding: -Car driver maliciously caused derailment, which was unavoidable.Led to: -Most deaths and serious injuries caused by people being ejected through broken windows. RAIB recommendation that all new trains have laminated glass in all passenger windows.CSRE LimitedFatal accidents 1980 to presentPrivatisationGrayrigg20071CSRE LimitedGrayriggPendolino derailed at 155 km/hr, some vehicles rolling down embankment;RAIB investigation held, finding: -Defective points were root cause of derailment, due to poor maintenance.Led to: -Only one fatality, in an extremely serious crash, as a result of all recommendations previously made having been implemented, including laminated glass, which saved many lives.CSRE Limited8. SUMMARYCSRE LimitedSummaryAccidents have always happened from time to time, and probably always will;The best we can hope for is to learn from an accident and feed what we learn into future engineering designs and working procedures;An open approach, involving independent organisations that work in partnership with common goals has drastically reduced the number of deaths as a result of train accidents.CSRE LimitedTHANK YOU!Questions & AnswersCSRE Limited