Danger Ahead! Comment
|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
by Stanley Hall
Comment on Behind the Lines
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)
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 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.
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.
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.
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.
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.
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.
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.
This file last updated: Friday, 10-Mar-2000 06:20:34 EST