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Between the lines    
Behind the Southall Report         

Between the Lines
Behind the Southall Report
08 March 2000
by Ray State

all the people who could have intervened were either unaware that the problem existed or did not have the knowledge to judge that the an unsafe condition existed

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The Southall Disaster
Seven died in the Southall disaster

The recently issued Southall Rail Accident Inquiry Report, prepared by Professor John Uff QC FREng, was produced under the most difficult circumstances yet sets out the details in absolute clarity and to the high standard which we have learnt to expect from a government appointed Inquiry.
No organisation, with the possible exception of Railtrack, who were involved in the accident on 19 September 1997 escaped without some criticism, but there are others, "behind the lines" who contributed to the creation of the circumstances which made the accident more likely.

The contents of the report and its prime conclusions have been discussed at length elsewhere (see Danger-Ahead - Professor John Uff's report into Southall published (24 Feb 2000)) but it is necessary to explore how some of these events came to pass.

British Transport Police (BTP) and Crown Prosecution Service (CPS)
On the day of the accident the site was quickly raised to the status of a "scene of crime" by the British Transport Police (BTP). Thus Southall East Junction was restricted to competent accident investigators from early on in the investigation. The length of the BTP investigation raised concerns within Railtrack who were naturally anxious to conclude the examination and re-open the line. As a consequence, when the BTP did release the site, restoration of the track was quickly put in hand and some potentially vital evidence was bulldozed into the ballast. Having released the site the BTP then restricted the release of investigation material such that defects in the focus of one of the signals involved went unreported to Railtrack until after the failure of the prosecution in July 1999 nearly two years after the event. The signal had been in use in its defective state for the whole of this period.

The reasons why the Crown Prosecution Service took so long to bring the case to court has not yet been stated. The problem in making a Corporate Manslaughter charge stick with the state of the law as it is must have contributed to the delay. The fact that this uncertainty in the law on corporate responsibility had gone unresolved must be laid at Governments door due to its failure to act on Law Commission report 237 - an issue still outstanding and referred to in acid terms by Mr Justice Scott-Baker in June 1999.

The Inquiry Report rightly points out that the findings of the Inquiry were hampered by the BTP and Crown Prosecution Service in hot pursuit of an unwinable case. After the failure of the court case in July 1999 the BTP released nearly half a million documents to the Inquiry Team and it is to the Team’s credit that this volume was processed in record time and with complete success.

Isolation of AWS
The operation of trains without AWS received much consideration. The attitude of Chief Operating Managers in BR days was that AWS was an aid to drivers not an essential safety device. This led to the wording in the procedures and the classification of the AWS as a system failure which did not warrant an immediate response such as train termination. However, what is not stated is that the attitude in Operating Controls within BR Regional HQ’s and Divisional Offices was completely different. Not only was it absolutely banned to release a vehicle from maintenance with AWS isolated but no train would go forward from a major station without being turned or else provided with a "rider" , a second person to assist in signal observance. These "local" rules were allowed to exist whilst the official line prevailed. As privatisation dawned and Divisional and then Regional Controls were closed, these local interpretations were forgotten. Newcomers may not have been aware that they ever existed.

The success of these local disciplines was reflected in the difficulty which the Inquiry Team found in encountering any historical evidence of near misses or incidents involving isolated AWS systems.

The provision of a second person has been hampered firstly by the allocation of drivers to Operators thus reducing the size of the available pool and secondly by the severe restriction (justified by the cases of distraction) on the permits to ride in the cab. It can be argued that there was a bigger risk in running without AWS than in distraction of the driver and that the only attributes required by the second man was that he was not colour blind and could communicate attributes which probably applied to almost everyone on the train and on Cardiff station on the 19 September 1997.

Group Standards1
The conflicting and ambiguous instructions existing in September 1997 stem from the difference between policy and practice. The problem is that the instruction on AWS wasn’t the only case where practice was different. From the time when Group Standards were first mooted as a means of producing a form of regulation, the tendency has been for any form of proscription to be removed. The situation in BR days when it would be agreed that something applied to all, was replaced by words which allowed a rail operator to use anything so long as it met the general requirements commensurate with safety. Instead of "this shall be 24" the wordy terminology allowing anything was so convoluted that many Group Standards became unintelligible to other than a lawyer.

AWS Reliability
The reliability of the AWS equipment itself was called into question. The large number of No Defect Found (NDF) reports following a failure was referred to as if this was a new phenomenon. The AWS system is almost unchanged from that fitted to the first diesels and electric trains of the 1960s and NDFs were endemic from the start. What the BR engineers of the 1970’s and 1980’s learnt to do was how to handle this in a safe and effective manner. Maintaining records and taking action immediately reports of successive NDF’s were seen and ensuring that suspect equipment was "changed out" was the norm. In the case of "failure to cancel", the "change out" could be restricted to the reset button (the cause of the fault on the power car in the Southall accident). This usually stopped the problem instantly, however, this was, of course at a time of a safety led railway.

The report made reference to the contaminate on the reset button contacts as "polish". When diesels were first introduced concern was expressed as to the "blackening" of silver contacts which occurred in service. As a result the liberal application of polishes such as Silvo during maintenance was de rigeur. It was soon learnt that the blackening was a natural by-product of the silver which did not affect the contact operation and the use of polish was banned. Again this ban found its way into good practice and failed to be included in specifications as expressly forbidden. With changing personnel the presence of a bright shining contact may be the last word and polish may be creeping back but we may never know how polish got on the surface. The report fails to comment on whether the contacts showed any sign of being polished.

Comment was also made on the failure track components history. This is another emotive issue. Components on rolling stock fall into three broad headings - consumables (eg brake blocks), tracked components (usually high cost items such as traction motors) and by far the largest group - non-tracked components (eg relays and contactors). Tracked components are followed throughout their life by means of recording their serial numbers and this involves some labour in noting and recording the number at "change out" times. Non-tracked components whilst carrying numbers, are rarely tracked by serial number and this group contains the family of components which form the AWS system.

The report commented on the failure to identify the mode of failure on returned components. This was always true as the link between the failure mode on the train and the test and examination on the bench could not be made in other than with special tests following an accident because of this lack of traceability. Repeated attempts to investigate and improve the reliability of the components came to naught in the monopoly situation which existed. There was no incentive to improve the performance.

However, here technology has an answer. Radio Frequency (RF) tags the size and thickness of a 5p piece and costing about the same are now available which can identify a component throughout its life, record its history, any repairs and the maintenance processes with minimum human intervention. This technology (in even smaller form) has recently been used to register all animals travelling from Britain to and from the continent. Strangely, this concept has been strenuously resisted by the railway industry.

Again the reason is not hard to find and the basis for it was alluded to in the report when it was pointed out that a large number of components are "common user" that is, shared between a number of operators, Rosco’s and repairers. It is simply that no one group wishes to bear the initial cost and there is no mechanism for sharing a technology which is in the common interest.

Safety Cases2
The review and audit of these came in for some criticism. The Government has already moved to transfer those for the TOC’s to the HSE. The problem with this goes deeper than could be explored by the Inquiry and was not , therefore exposed.

At the time of privatisation it was not considered wise, in the interests of maintaining the sale price to force all the successor companies to have a Safety Case. As a result those with a direct operational content such Train Operating Companies and Railtrack had to have one but second line Companies such as the Rail Leasing Companies (ROSCO’s) did not. This is curious because the heavy repair responsibilities of passenger leased fleets rest with the ROSCO’s not with the Train Operating Companies. It was argued that as the Train Operating Companies had a duty of care that they would police the delivery from the ROSCO’s and only accept a vehicle if Group Standards had been applied. How this was to be done was not stated. It might be considered that a Train Operating Company might have to place in trust the work done to component only opened up during Heavy Repair by a contractor who may or may not have had the relevant Group Standard drawn to his attention. What we do know is that GWT, as the operator, had to carry the responsibility for the Maidenhead fire when the failed nuts may only have been visible during the heavy repair. The accountability of the TOC maintenance depot in its ability to test an inaccessible component for internal flaws must place the emphasis of the integrity of the heavy repair element.

Railway Group
This definition of who has the safety responsibility has other side affects. Those with Safety Cases form the "Railway Group" of companies. Technically Group Standards only apply to this Group. Thus a Standard applying to some work in a Train Operator’s depot is mandatory but for the same work carried out by a contractor who is not part of the Railway Group, it is not, UNLESS it is specifically referred to by a Railway Group member. As previously stated some Standards are so complex or filled with jargon that this issue can be overlooked thus leaving the contractor in blissful ignorance that a Standard exists. Attempts to make Group Standards written for rail specific components apply to all who maintain, repair or supply such components has been opposed on the basis that this is the sole prerogative of a Railway Group member.

Railtrack have been tasked with the consideration of inclusion of the Rosco’s and component suppliers in the Railway Group (recommendation 60). This cannot be achieved without the consideration of the applicability of the Safety Case. The squeals of anguish are already to be heard.

Safety Criticality
The control, certification, integrity and training of staff designated as being in safety critical or safety related posts is onerous. As a result the drive to reduce the number of posts so designated is understandable. Whilst people whose jobs involve the direct control of equipment which can kill or maim have obvious safety responsibilities there has been a tendency to consider that those who make decisions or who instruct others to make unsafe acts have no safety responsibilities. In this modern age the supply information on which key decisions are made is becoming critical in its own right. This includes computer systems as well as human ones.

As a result of this lack of understanding of the role of the decision process led to a downgrading of the safety criticality of some jobs. The Inquiry Report recommends (21) that Controllers posts should be designated "safety-critical". Anyone with experience in BR Divisional and Regional Controls in the 1970’s and 1980’s would be in no doubt as to their safety role yet at privatisation these were reduced to the status of record clerks often under protest from those with experience. Skills of the Section Controllers, overseen by the Shift Deputy Controller as a monitor of the minute by minute events, were practised and developed. The mere hint of "something isolated" would bring the Deputy on the circuit listening to the exchange between the driver or "Bobby" and the Section Controller. Only after he was satisfied that the appropriate action had been taken would he relax.

Unsafe acts often stem from an irregular event but time and time again a full blown accident is avoided by some-one’s intervention who has detected that "something is not right". Such an intervention would have prevented the Piper Alpha disaster. At Southall all the people who could have intervened either were unaware that the problem existed or did not have the knowledge to judge that an unsafe condition existed. By making the Controller posts not safety critical it ensured that people were placed in positions for which they did not have the knowledge to make those key interventions.

It is difficult to identify any cases in British Railway history (prior to privatisation) where a Controller contributed to an accident. One has to go back to Brundall in 1874 to find one. Not so in the United States where the Dispatcher (Controller) has been deeply involved in terrible accidents such as Ledger, 1991 ( 2 US Head On Collisions), Motley, Devine, 1997 and Fort Worth, 1997.

The Inquiry report has broken new ground previously avoided. In this it is very brave and is likely to receive some howls of protest. This is in the area of fault reporting. Recommendations 16 to 23 and 28 deal with the reporting of faults and their analysis. Records and their analysis is usually at the bottom of the priority pile but it is dawning at last that in today’s world the passing and processing of information is crucial to the wellbeing of an undertaking. The fact that the improvements contained in recommendations 22 and 23 already existed at the time of the accident (but unused by the users) does not detract from the need.

Data Recorders
The application of data-recorders has been highlighted. The high cost of these for vehicles with only a short life is a major issue. As suggested by Railtrack (who cannot enforce compliance by the TOC’s) there are cost-effective short term solutions. The application of technology can solve this but again confusion arises from multiple ownership, the desire not to pay and lack of clarity in respect of the minimum data to be held. Some data-recorder suppliers will provide systems capable of measuring everything but they are expensive. Simple GPS derived/PC recorders with capability of being post-processed to give positional accuracy and recording of core events such as braking, AWS receiver operation (assuming it is switched on) and controller position, costs an order of magnitude of 10 less than a full blown "black box" but it does achieve the desired end.

One interesting development is the allocation of recommendations to ATOC. This was another brave move. The Association claims to speak for the combined TOC’s yet was not represented at the Inquiry. What they will do remains to be seen.

Another interesting development is the firm backing given in the report for the Confidential Incident Recording and Monitoring System (CIRAS). At last some-one is looking at the generation of Near Miss data as a tool for accident prevention. However, it’s implied restriction to drivers limits its capability. It should be raised to general use.

As a conclusion to the whole unhappy affair known as Southall, the Uff Report ably achieves this end. Worryingly however, the Report exposes weaknesses in the transition from a command structured BR to a regulated free enterprise structured privatised railway industry.

These transitional weaknesses have a wider impact than just the narrow issues of AWS, TPWS and ATP and will still be there after the issues of Southall and Ladbroke Grove are dealt with and the pain of the disasters recedes.

Let us hope that the Government, the HSE and the SSRA will take up the wider issues and thereby avoid another accident which may not involve a signal passed at danger but may have the same root cause in lack of knowledge, sloppy and unusable procedures.


1 Group Standards: A standard to be applied to a rail related activity and which is mandatory on all members of the Railway Group. The standards cover engineering, operations, track access or any other process which may be carried out by more than one company.
2 Safety Cases: Enabled by the Safety Case Act 1994 a Safety Case sets out a company's safety policy, risk analysis, management, maintenance and operating arrangements. A company has to have a Safety Case in order to have a licence to operate.

The Uff Report
Professor John Uff's report into Southall published
HSE statement welcomes Uff report
Health and Safety Commission announce tough action after Southall report
First Great Western welcomes publication of the Southall rail inquiry report

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This file last updated: Friday, 10-Mar-2000 06:20:34 EST
Copyright © David Fry 1999, 2000