Annual Occupational Health Railway Conference 2008

The Work of the RAIB; emerging safety themes

Carolyn Griffiths

Chief Inspector

Rail Accident investigation Branch UK

Part 1:What is the Rail Accident Investigation Branch UK?

Why was the RAIB established? How was it established? Organisation The investigation process

Part 2: The story so far

Some case history

What is the RAIB?

The independent railway accident investigation organisation for the UK

Reports to Secretary of State for Transport

Sole purpose to improve safety of railways and prevent further occurrences. Does not apportion blame or liability, nor enforce law or carry out prosecutions

Lead Party in rail accident investigations where there is no evidence that serious

criminal action is the cause

Operational for two and a half years

What is the RAIB?

Scope of responsibility Geography Types of railway Types of Accidents and Incidents

RAIB’s geographical area

Which railways are covered by the RAIB?

The RAIB will investigate accidents and incidents on…

Mainline

All operations by passenger and freight train operating companies

Metros

Including London Underground, Tyne and Wear Metro, Docklands Light Railway, Strathclyde Metropolitan Railway

Tramways

in England, Wales and Northern Ireland

Heritage Railways

with a gauge above 350mm

Cable-hauled Systems

of 1km or longer

Derailments or collisions which result in or could result in…

The death of at least one person

Serious injury to five or more people

Extensive damage to rolling stock, infrastructure or the environment

Or any other accident which, under slightly different circumstances, could have the same consequence

Discretion, to investigate other accidents or near misses based on: How serious the incident is; and The likely safety lessons to be learned

What type of accidents will be investigated?

What type of accidents will be investigated?

The RAIB will not investigate…

Worker accidents

/near misses unless involving train movements

Trespass or suicide

Why was the RAIB established?

Why was the RAIB established?

Major accident (Ladbroke Grove) 1999 ; 31 fatalities, 400 injured

• Public Inquiry recommended establishment of national rail accident organisation, independent of:

Government Safety Regulators Prosecutors incl. police All industry parties

Then…in 2004 European Rail Safety Directive Required Member states to establish an independent accident investigation by April 2006

Organisation design, recruitment and training

Dukes Court, Woking, Surrey The Wharf, Derby

How we investigate: Working with other parties

Other parallel investigations:The need for clear and sharing of evidence

RAIB

Safety Investigation

HMRI, DRDNI, Duty Holder

Enforcement of safety legislation

Police

Criminal Prosecution & Sudden Death Investigation

RAIB leads the investigation unless:

How does this work?

There is evidence that a criminal act caused the accident/incident

Criminal investigation normally will take precedence (eg terrorist incident or vandalism)

Police and the RAIB are required to agree if the Police investigation is to take precedence

The RAIB will still have access to the site and evidence, and may still conduct a safety investigation

RAIB recommendations formulated with industry input

RAIB is advised by the Safety Authority of industry parties intent

The industry parties notify the Safety

Authority their intent to

implement.

The Railway Industry has a

duty to consider the recommendations

Safety Authority ensures ALL relevant industry

parties are informed of the recommendations.

RAIB publishes report, sends to those involved

How do RAIB’s recommendations affect the industry?

Experience so far…..

Largest investigation so far

86 Completed; 33 Current Investigations

37 % : Train Derailments

13.25 %: Level Crossings

13.25 %: collision (with a train/or other object)

10.25 %: staff hit by trains/near misses

5.75 % involve runaway incidents

4.25 % unauthorised train movement

4% train door incidents

3.5 % involve Spads

2.5 % fire on Rolling stock

2.5 % train defects

2.25 % involve Unsafe loads

0.75 % involve Possession Issues

0.75 % electrocution

So why DO accidents happen? Examples….

Brentingby, 09.02.06: Driver fatigue

Runaway trolleys/road rail vehicle

Brentingby: 09.02.06

Brentingby: 09.02.06.

Cause: Driver had microsleep(s) and passed signal at danger

2 early shifts (shortened sleep?); rest day ( consumed 5-6 pints of beer) ; night shift- accident after 22 hrs awake.

Main task in 2nd half of shift Arrived early for work No check for fitness on signing on Briefing on fatigue did not deal with first night shift

issues

Brentingby: 09.02.06.

Recommendations: Operator to consider planned napping +facilities- if shift

pattern requires Research most effective sleep pattern when changing from

day to night shift. (Aware of research carried out in the USA)

Investigate feasibility of screening for sleep disorders Guidance for drivers on lifestyle to suit shift working

incl .preparation for first night shift. Include families where possible

Review checking for fitness for duty when ‘signing on’

Larkhall

Brakes - Larkhall

Notting Hill Gate

Notting Hill Gate

Brentwood

Risks…….

Trolleys are not wheel barrows – can carry 2T of rail Incident of one laden trolley runaway onto running rail- by luck operated track circuits and stopped approaching

trains

Road rail vehicles can present risk even though they should operate at slow speed (walking pace in possession) One road rail ran 7 miles, 3miles out of possession,

Runaway trolleys/road rail vehicles

Lack of gradient information in risk assessing the work 2 trolley incidents, 2 road rail incidents

Loss of adhesion due to contamination 1 Trolley incident 1 road rail incident

No adequate on-site functional test 2 trolley incidents

Speed of operation 1 trolley incident 1 road rail incident

Unauthorised alterations brake blocks - Larkhall brake linkage Notting Hill Gate tyre pressure- 2 road rail incidents

Approvals process All road rail and trolley incidents?

Are we making a difference?….

120 investigations; 86 published 83 investigations on Mainline network (2 in the Channel Tunnel) 16 on LRT/trams 14 on Heritage systems 7 on Metro Systems

497 recommendations Circa 95% acceptance

How do we measure up?Survey of stakeholders incl.: those we investigate and those we might investigate

@ senior level @ working level

unions other investigators such as the police and safety regulator

Positive outcome Quality of investigations and reports Interface with industry Highly rated organisation w.r.t. selected similar organisations in UK

But we are constantly trying to develop our capability further………

What’s on the RAIB website?www.raib.gov.uk

Accident NotificationWhat to notify: How to notify: Forms and Guidance

About UsHistory: Formation: Organisation: Powers: Contact

PublicationsInvestigations register: Reports: Safety Advice

NewsMedia notices released by the RAIB: Media contact details

LibraryDownloadable leaflets and information on legal framework

‘People need to know that accidents have been thoroughly investigated and that actions have been take so they don’t happen again

That’s what we do…’

Thank you