Posted 20th November 2018 | 7 Comments
‘Deep seated problem’ revealed by Waterloo crash
THE chief inspector of railway accidents has warned that the low-speed collision between a passenger train and wagons at London Waterloo last summer has revealed ‘a deep-seated problem’.
Simon French of the Rail Accident Investigation Branch said the incident on 15 August, which involved an early morning train and stationary engineering wagons, has aroused fears that the lessons of the fatal triple collision near Clapham Junction on 12 December 1988 ‘may be fading from the railway industry’s collective memory’.
A technician had left signalling near Clapham in a dangerous condition, because new circuits had been installed but the old wiring was still connected at one end and loose and uninsulated at the other. The result was that a signal did not turn to red when the section it was protecting was occupied, and this caused a rear-end collision. A third train running empty collided with the wreckage moments later. The accident happened at the height of the morning rush hour: 35 people were killed and 69 seriously injured. More than 400 others were slightly hurt.
The resulting inquiry found serious flaws in the design, modification, testing and commissioning of signalling systems, and this finding led to major changes.
The RAIB said the Waterloo crash last year, in which no-one was hurt, was also caused by ’uncontrolled’ wiring changes, and this has raised ‘concern that some of the lessons identified by the public inquiry following Clapham may be fading from the railway industry’s collective memory’.
Simon French said: ‘The disastrous collision at Clapham Junction was a turning point. The immediate cause of the accident was poor working practice by a signalling technician, and the public inquiry highlighted serious deficiencies in the management of safety.
‘The recommendations of the inquiry fundamentally changed several aspects of how the railway is run, and for signal engineers one of the most important was the approach to routine tasks, such as testing alterations to signalling installations. It was therefore concerning for RAIB to discover, during our investigation of the collision at Waterloo last year, that some of these important changes were not reflected in the way that signalling modifications were being undertaken.
‘Some of the people involved did not keep proper records of temporary works, or ensure that additional temporary wiring was shown on the design documents. Leaving that temporary wiring when it should have been removed led to a passenger train being diverted on to a blocked line and colliding with wagons. Compliance with the existing standards, developed since Clapham, would have provided the controls needed to stop temporary wiring being installed and used in the uncontrolled manner which resulted in this accident.’
The RAIB has made separate recommendations to Network Rail and the two contractors on site, OSL Rail and Mott MacDonald.
Network Rail said: ‘The Waterloo derailment was a wake-up call for us, and our contractors, and highlighted that we can never afford to be complacent when it comes to keeping our passengers and workforce safe. Today we enjoy an enviable safety record that is second to none across Europe, but that record has been hard won through focus and action.
‘The lessons of Waterloo have already been shared across the industry and these recommendations will help further.’
Reader Comments:
Views expressed in submitted comments are that of the author, and not necessarily shared by Railnews.
Chris Jones-Bridger, Buckley Flintshire
This is probably the most important report that RAIB have produced & should be compulsory reading for all within the industry with a duty to uphold the highest safety standards.
The Hidden report to the 1988 Clapham crash was a watershed for rail professionals brought up on the manta of 'Safety on the Line' & 'Fail Safe'. In practice working practices were found to be way below that expected to adhere to the rules & regulations. What followed was little short of a cultural revolution as BR implemented the Hidden recommendations to overhaul the safety culture and management systems. All too soon so much of that good work was squandered due to the affects of the fragmentation brought about due to the privatisation process. It has been acknowledged that professional skill & knowledge was lost when Railtrack took over BR's infrastructure & reading the detail in the Waterloo report it is clear that NR has a considerable way to go to regain that loss.
Today's industry mantra may be 'The Safest Railway in Europe' but this risks complacency given increasingly evident safety concerns. While fortunately there has been no passenger fatality since the Lambrigg derailment 11 years ago RAIB reports have too frequently documented incidents involving staff & passengers that are cause for concern. Since privatisation there has been a trend to deskill & casualise the workforce to reduce costs. The pressure towards increased DOO operation & employment of contract labour on infrastructure work being two examples of this trend. Behind the glowing safety headline RAIB have reported on disturbing instances of passengers being trapped in sliding doors & of too many near misses involving trackside personnel. Sadly the most recent RAIB release I have seen involves a fatality of a track worker at Stoats Nest Junction.
Fortunately Waterloo was a slow speed but highly embarrassing derailment. Unlike Clapham no lives were lost however I would hope that it acts as a wake up call to recall the lessons learnt from Clapham are not forgotten.
Greg Tingey, London
ALL of the signalling engineers are employed by private firms, who then do the contracted-out work for NR.
I have a sig-engineer friend, who, many years ago, used to work for BR. Since privatisation he has had three ( possibly 4 ) different employers, with people & experience being lost at every change ....
Martin, Haywards Heath
Interesting point but isn't network rail nationalised and owned by the government? I don't think that this should be put down to privatised industries. But there are worrying similarities with Clapham many years ago... Martin
[The point which I think the RAIB is making is not about railway ownership but the high turnover of experienced staff since the privatisation era -- and the fading of collective memory. It's not privatisation which is the problem, but the fragmentation which accompanied it.--Ed.]
david c smith, Bletchley
I'm a bit confused here. People keep referring to privatisation's fragmentation, and the effect of this on safety. Yet, only a few days ago, I came across a statistic that the railway in the UK is currently the safest in Europe.
Is there an assumption in this that a monolithic, "top down" organisation would neccessarily do better?
Andrew Gwilt, Benfleet Essex
Was it to do with the failure of the points on the track that caused the train to derail at London Waterloo.
[I thought we (and the RAIB) had made it very clear that the points were wrongly wired. I don't think that is a 'failure' of the points themselves. Rather, it was the system of working that had failed -- as at Clapham 30 years ago.--Ed.]
cliff kilshaw, lancaster
Another frightening aspect of the fragmentation caused by privatisation, where overall control and management is divided and lost in the myriad of contractors and sub-contractors. Network Rail has lost its core of ex BR S&T professionals, who had been brought up on historic accidents, their causes and subsequent improvements to reduce the likelihood of repeat incident etc.
Steve, Kuwait City
Since privatization, and as a direct result of it, the collective memory of the Rail industry as a whole has been subjected to a slash-and-burn that makes Borneo look like a genie in a matchbox. Lessons aren't learned anymore, they are merely buried.