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Post by doubletrigger on Feb 26, 2007 18:49:50 GMT
I've had a full read of it, and the conclusion is that the immediate cause of the accident was the condition of the stretcher bars at the points. One of the stretcher bars was missing and the bolts securing another one and the locking stretcher bar were not in place, with no evidence they had been wrenched free. There was therefore effectively no stretcher bars in place, meaning both switch rails were positioned against the stock rails, leading to a narrowing of gauge which was the immediate cause of the derailment. The actual cause of the accident was that someone failed to document or react to the removal of this stretcher bar. The points could still have used but with a very low temporary speed restriction in place. Communication has gone severely wrong somewhere and I think Network Rail are gonna end up paying big time for this one...
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Post by Deleted on Feb 26, 2007 18:54:40 GMT
i cant speak for NR but for LUL if that did happen a stretcher being removed the points would also be out of use as depending on the length of switch you must have 3 not 2
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Post by doubletrigger on Feb 26, 2007 19:05:15 GMT
Out of interest, how would you define out of use in this case? Block or clamped and speed restricted? (Or something else altogether?)
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Post by Deleted on Feb 26, 2007 19:27:57 GMT
I recall aetearlscourt saying that when the facing points in the crossover between the w/b Picc and w/b District (17A points, IIRC, behind either WD32 or WD40) were out of use for a time, they were not only scotched and clipped, but also had their detection circuitry force-fed and the interlocking modified with a fouling mechanism to prevent the lever from being rotated reverse - I think this was done because the points were partially disassembled.
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Post by Chris M on Feb 26, 2007 20:46:50 GMT
I've had a full read of it, and the conclusion is that the immediate cause of the accident was the condition of the stretcher bars at the points. One of the stretcher bars was missing and the bolts securing another one and the locking stretcher bar were not in place, with no evidence they had been wrenched free. There was therefore effectively no stretcher bars in place, meaning both switch rails were positioned against the stock rails, leading to a narrowing of gauge which was the immediate cause of the derailment. The actual cause of the accident was that someone failed to document or react to the removal of this stretcher bar. The points could still have used but with a very low temporary speed restriction in place. Communication has gone severely wrong somewhere and I think Network Rail are gonna end up paying big time for this one... In terminology used by the RAIB (I read all their reports), they distinguish between the "immediate cause" and the "underlying cause(s)" The "immediate cause" is the last thing to happen that physically caused the incident, in this case the train derailed because the points broke in such a way that there was a narrowing of gauge. The "underlying cause(s)" is/are what happened leading up to the incident that caused/allowed the immediate cause to happen. In this case this is likely to be failure of maintenance and/or communication, but this has not been firmly established yet.
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Post by Tom on Feb 26, 2007 21:06:05 GMT
Our Bob stirring for his own political agenda. NEVER With regards to risk, isn't the term called ALARP? As Low As Reasonably Practical. Yes. Unfortunately ALARP isn't always easy to prove. (Maybe I did learn something on the Engineering Safety Management course... )
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Post by Tom on Feb 26, 2007 21:06:58 GMT
I recall aetearlscourt saying that when the facing points in the crossover between the w/b Picc and w/b District (17A points, IIRC, behind either WD32 or WD40) were out of use for a time, they were not only scotched and clipped, but also had their detection circuitry force-fed and the interlocking modified with a fouling mechanism to prevent the lever from being rotated reverse - I think this was done because the points were partially disassembled. Partially dissassembled? Sort of. They had no switch rails and were plain lined.
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Post by Tom on Feb 26, 2007 21:08:07 GMT
Out of interest, how would you define out of use in this case? Block or clamped and speed restricted? (Or something else altogether?) Personally, I'd be thinking clipped, scotched and plated. I'd probably leave the detection alone just in case something did happen.
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Post by Deleted on Feb 26, 2007 21:14:42 GMT
Its a shame that we went with a long period of time without a major accident. Network Rail's good record has been desicrated by this.
I always said to myself, after Railtrack was ejected from managing the infrastructure, that it would only be a matter of time before something else happened...
I shall be reading the RAIB website with interest over the coming weeks.
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Post by Chris M on Feb 26, 2007 22:15:23 GMT
Artery I wouldn't be too quick to say the reputation has been "desecrated", all the facts are not yet known. Also, the time lag between an incident and the final RAIB report into it is typically around 9-12 months, but most of the other reports on there make interesting reading.
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Post by Deleted on Feb 26, 2007 22:21:44 GMT
Aye, I keep looking at RAIB's reports... also Railways Archive has some older Ministry of Transport reports pdf'd up for viewing... If you can stand the longer loading time, these are well worth a read too...
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Post by stanmorek on Feb 27, 2007 22:21:38 GMT
Yes. Unfortunately ALARP isn't always easy to prove. (Maybe I did learn something on the Engineering Safety Management course... ) Would that be the Yellow Book course? In the courts they would probably determine if an action or inaction was ALARP by questioning expert witnesses on the actions of a competent professional of the industry in question. Also the ability of his employing organisation to pay given the circumstances would also be considered. Risk is the product of severity of an accident times the likelihood it occurring. A lot of the current health and safety legislation is based on carrying out risk assessments. The principle of risk assessments for example looking at an activity like working at height from scaffolds. The risk is the likelihood of falling off multiplied by the severity of injury as a consequnce of falling. The risk is reduced by putting in place mitigations such as installing secure handrails or workers wearing safety harnesses to reduce the likelihood of falls. The severity could be reduced by installing a crash net to reduce injuries. Either way the risk has been reduced. How can you determine if a risk is reduced to ALARP? The HSE give guidance in the VPF or value of preventing a fatality. It is a monetary value on the benefits of risk reduction i.e. if the cost of putting in a safety measure to prevent a death is below VPF then it is reasonably practicable. Risk assessments on the railway use a VPF of £1.4M while the figure in road traffic safety is lower, however, this is not the only criteria on ALARP.
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Post by CSLR on Feb 28, 2007 13:05:47 GMT
The BBC has recently posted a story relating to the Cumbrian derailment. Full story here news.bbc.co.uk/1/hi/uk/6403573.stm Part of it says:- Video images of the faulty track in the Cumbria derailment were taken by an inspection train two days before the crash but not viewed at the time. Infrastructure operator Network Rail said its measurement train passed at high speed through Grayrigg on the West Coast Main Line on 21 February. The train's purpose is to alert the firm to defects in the track's metal. A spokesman said filming took place at the same time but the shots could only be used as "backwards reference". It would probably take someone most of the month to watch one day's-worth of data," he said. The inspection train's equipment can automatically alert technicians on board to defects in the condition of the track's metal but would not pick up on missing stretcher bars. It travels too fast to allow anyone to visually spot such faults at the same time through the video camera. The Network Rail spokesman confirmed that the inspection train's video recording showed one of the stretcher bars and some of the bolts were missing. But he said the video is only viewed after an incident. The train runs at up to 125 mph and any such problems could not be picked up in "real time", he added.Note that this is the BBC take on the story and not part of the inspector’s report. The text appears to have some inconsistencies. One sentence says that the video would not pick up on missing stretcher bars while another says that the recording “showed one of the stretcher bars and some of the bolts were missing.” There is also the question of Network Rail’s alleged response in which an un-named spokesman reputedly claimed that it would take someone most of the month to watch the 18 hours of data that was collected at a speed of up to 125 mph. Why would "one person" have to watch the entire recording? Could the job not be allocated to several people? That would still cost the same, but the job would be completed quicker. Also, it does not take 18 hours to make one journey down the West Coast main line at full speed which suggests that there are other locations on the recording. Anyone who uses a computer will know how easy and fast it is to send digital data around the world. Surely it would be possible to automatically split this recording into sections that match the maintenance areas and pass that information on to each one for checking? It is also easy to automate a large part of the process by using comparative software of a type that has existed for years. By comparing the captured image with what the camera is expecting to see, software can automatically highlight anomalies that can then be checked by a real person. This technology is commonplace in precision manufacturing industries where items are regularly checked at speeds in excess of several thousand a minute; and because it is used so much, the equipment is available off-the-shelf and cost is minimal. With the amount of money that has been spent equipping and operating this train, surely Network Rail should make full use of the resource? Or does the fact that "The inspection train's equipment can automatically alert technicians on board to defects in the condition of the track's metal" mean that this is exact what it is doing? If that is the case, then there are other issues to be looked at. Edited typo
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Post by Tom on Feb 28, 2007 19:27:48 GMT
Yes. Unfortunately ALARP isn't always easy to prove. (Maybe I did learn something on the Engineering Safety Management course... ) Would that be the Yellow Book course? The one and only (I won't use some of the other words previously used to describe it here...) ;D
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Post by stanmorek on Feb 28, 2007 21:51:11 GMT
I'm told that the AVI system used on LU has 10 different camera angles though not all are always operational on a run and the recording is not always realtime in that the fps rate is sometimes limited. The system is also capable of viewing the web of the rail.
Metronet SSL used AVI to catalogue all its track assets such as sleepers, conductor rails etc and it has been used to survey wetbeds in the four foot so I can't see why it can't be used to view junctionwork.
However, all the footage has to be visually checked by a person where video software links all the different camera angles to a particular chainage. Defects still need to be physically inspected and it is more of a supplement to the basic inspection methods.
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Post by Deleted on Feb 28, 2007 22:00:29 GMT
What amazed me, is that in todays paper, they suggested that it would take a month tho view a days recordings... So, how come they suddenly found someone to view the footage of that stretch, and make available a picture of a broken/twisted rail, assuming that this photo relates to the actual incident?
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Post by stanmorek on Feb 28, 2007 22:16:21 GMT
I haven't looked in today's paper. What was in it?
But the LU AVI video system can be programmed to flag up particular types of rail joint or train stops or analyse rail wear. It can be hooked with data picked up by the TRV runs to examine any irregularities. It normally takes 72 hours for an analysis report so there may be the human element that takes time. Afterall it was reported that the Sperry Landrover trials for rail ultrasonic inspections were giving far more data than could be normally coped with.
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Post by Deleted on Feb 28, 2007 22:21:43 GMT
The paper in question ran a page headed Rail Bosses knew points were broken, two days before the accident occured. mention was made of a special £5m train running at super-slow speed that takes and records Images via cameras looking at the track, but the recordings of the area, were not examined...
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Post by stanmorek on Feb 28, 2007 22:36:44 GMT
Oh right. I saw the one the day after about freight trains carrying nuclear waste material over the same line.
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Post by Chris M on Oct 3, 2007 21:39:54 GMT
Major thread bump, but this seems an appropriate place to note that the RAIB have released an interim progress report about the investigation into this crash. A summary, and link to the full report, is at www.raib.gov.uk/latest_news/071003_pn_grayrigg.cfm
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