lessons learned from disasters in uk rail
TRANSCRIPT
CSRE Limited
Railway Safetyin the UK
Lessons Learnedfrom Disasters in UK Rail
3rd China Urban Rail Development Summitby David Shipley, CSRE Limited
22nd September 2011, Tianjin, PRC
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1. INTRODUCTION
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Introduction – David Shipley
• Background 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.
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2. SUMMARY OFHISTORIC DISASTERS
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Disaster Timeline, 1830 - present
• Since the birth of passenger railways in 1830, disasters have plagued the general safety record
• Railways are, and have always been far safer than road travel, however, public service responsibility gets in the way and distorts the facts
• Presentation will show that whilst the number of accidents has remained pretty constant, the number of deaths has dropped substantially
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UK Train Accidents – 1830 to 2010
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d15th September 1830First Passenger serviceFirst fatal accident!
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UK Train Accidents – 1830 to 2010
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d1840s to 1860sRailwaymania!Rapid growth, but little or no signalling or safety in general
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UK Train Accidents – 1830 to 2010
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d1870s to 1900sContinued growthInvention of fixed signalling with interlocking
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UK Train Accidents – 1830 to 2010
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d1914 to 1919First World WarMassive troop movements by rail, shortage of trained staff
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UK Train Accidents – 1830 to 2010
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d1920s and 1930sTechnical advances in train designReplacement of wooden bodied cars with steel bodied cars
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UK Train Accidents – 1830 to 2010
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d1940s and 1950sSecond World War bomb damagePost war austerity, plus shortage of trained staff
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UK Train Accidents – 1830 to 2010
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d1960s and 1970sFurther technical advancesDevelopments in safety systems, improved car body strength
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UK Train Accidents – 1830 to 2010
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d1980s to presentImproved crash worthinessMovement towards risk-based Safety Management Systems
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3. THE TREND TOWARDSA SAFER RAILWAY
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Statement.
Improvements in safety are usually the result of a
catastrophe.
Discuss.
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UK Train Accidents – 1830 to 2010
1830s 1840s 1850s 1860s 1870s 1880s 1890s 1900s 1910s 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s0
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Shipton-on-Cherwell, 1874
34
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Shipton-on-Cherwell• Train 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.
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UK Train Accidents – 1830 to 2010
1830s 1840s 1850s 1860s 1870s 1880s 1890s 1900s 1910s 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s0
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Quintinshill, 1915226
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Quintinshill
• Three 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.
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UK Train Accidents – 1830 to 2010
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Harrow & Wealdstone, 1952112
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Harrow & Wealdstone• Three 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 SPADs
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So, 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.
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4. RAIL PRIVATISATION –LOSS OF CONTROL
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Rail Privatisation – Loss of Control
• UK 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!
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Fatal accidents – 1980 to present
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Polmont, 1984
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Polmont• Train 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.
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Fatal accidents – 1980 to present
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Clapham Junction, 1988
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Clapham Junction• Three 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.
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Fatal accidents – 1980 to present
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Ladbroke Grove, 1999 31
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Ladbroke Grove• Two 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.
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5. CULLEN –REGAINING CONTROL
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Cullen – Regaining Control
• Following 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.
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The 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.
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The Present – Stable Structure
Sets standard
s
Ensures complian
ce
Investigates
accidents
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7. CONTINUOUSIMPROVEMENT
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The Present – Stable Structure
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Fatal accidents – 1980 to present
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Ufton Nervet, 2004
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Ufton Nervet• Car 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.
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Fatal accidents – 1980 to present
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Grayrigg2007
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Grayrigg• Pendolino 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.
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8. SUMMARY
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Summary
• Accidents 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.
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THANK YOU!Questions & Answers