November 13, 2012 | Mark Paradies

Old Incident – New Investigation?

Have you ever found out more about an incident long after it happened? Have you ever decided to open or reopen an investigation six months, a year, or more after an incident occurred?

Here’s an example from the UK Rail Accident Investigation Branch where they received new information and decided to open an investigation on an incident more than six months old. (The text below is from their press release.)

Signal passed at danger (SPAD), near Stafford, 26 April 2012

On 26 April 2012 a diesel electric locomotive that was en-route from Washwood Heath to Crewe, reporting number 0Z47, passed signal SD4-81 at danger without authority. This signal is located on the Down Slow line to the south of Stafford on the West Coast Main Line. The signal controls entry into the station and protects any train movements traversing Stafford South Junction. The locomotive passed the signal at a speed of about 30 mph (48 km/h) and came to a stand approximately 80 metres beyond.

The Class 47 locomotive involved in the incident was owned by Riviera Trains and operated by Devon and Cornwall Railways (D&CR) (owned by British American Railway Services) and driven by a driver who had been hired for the purpose.

Although this SPAD incident was included in general information provided by the railway industry, it was not until September 2012 that the RAIB was notified of the full circumstances leading up to the SPAD. By this time the incident had already been the subject of an investigation by an experienced railway professional on behalf of British American Railway Services. This found that the driver had not responded correctly to the restrictive aspects on the signals before SD4-81. As a consequence, the locomotive approached Stafford at too high a speed and there was insufficient distance for it to stop before passing signal SD4-81.

The RAIB has identified a number of areas of concern based on the information that it has currently received. These include:

• the locomotive was driven at speeds above those permitted in the circumstances;
• the locomotive’s speedometer was faulty; this caused it to display a speed lower than the actual speed of the locomotive; and
• there was insufficient documentary evidence of the driver’s competence.

The RAIB will aim to identify the management factors that contributed to this outcome, in particular any management systems that were in place related to the competence of drivers, the safe operation of trains and the management of contracted staff. It will include a review of the relevant elements of D&CR’s safety management system and examine how these had been implemented.

The RAIB will report on its findings at the conclusion of its investigation. This will be published on the RAIB website.

Root Cause Analysis
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