Tell me if this sounds familiar: On October 5, 1999, a three car "Turbo" consist operated by Thames Trains left Paddington Station in London headed to Bedwyn in Wiltshire........
About two minutes after departure, at a speed of 41 mph, the turbo passed signal SN109 displaying "stop" (called "danger" in the UK) located on gantry 8, governing the train's movement. Thirty seconds later the turbo collided with a HST (high speed train) of the First Great Western, killing 31 people. Impact speed was between 130-140 mph.
An investigation headed by the RT Hon Lord Cullen (if that doesn't make you want to move to the UK, something's wrong), the full report of which is available here
The RT Hon Lord Cullen's assessment makes it clear that at every critical juncture, the root cause of the particular deficiencies which determined and over-determined the crash should have been, but were not, picked up by the senior management of either Thames Trains or Railtrak, the then (but now defunct) infrastructure company.
Signal SN 109 was improperly positioned. The red aspect was wholly or partially obscured until the train was 168 meters to the rear of the signal. The permissible speed when approaching the signal if the previous signal was at "caution" was 60 mph.
In 5 years of operation, eight stop signal violations (called SPADs in the UK) had occurred at signal SN 109.
Prior to this collision, the collision at Southall in 1997 caused Thames Trains to consider equipping its trains with ATP, a specific Automatic Train Protection system, but decided not to as...............as a cost-benefit analysis showed the costs outweighing the benefits.
Prior to that, in 1989 a crash at Clapham Junction had made the installation of ATP as a system issue for British Rail, and that too was rejected after a cost-benefit analysis, the real cost being that Margaret Thatcher was intent on breaking up British Rail, liquidating it, and selling off the parts to private companies.
RT Hon Lord Cullen found Thames Train's driver qualification process was "slack and less than adequate."
He found the failure to constitute a signal sighting committee, as required by practice and procedure, when investigating the previous SPADs was due to "a combination of incompetent management and inadequate process."
And what was that inadequate process? That of making certain that those who were responsible for the safe operation of the rail service were doing their jobs.
Remember any of this? Too long ago? OK, maybe this one, from Australia in 2003 sounds familiar, the Honourable Peter Aloysius McInerney QC (that's Queen's Counsel you heathen) reporting.
On January 31, 2003 at 714 AM, a four car outer suburban train, G7, derailed near Waterfall Station. The train's driver and six passengers were killed.
A special commission of inquiry was constituted under the direction of the Hon P.A. McInerney, QC to determine the cause and contributing factors to the derailment; the functioning and deficiencies in the function of the safety management, including regulation, of the rail operations; improvement and remedies essential to preventing futher accidents.
The cause of this derailment was.......overspeeding around a curve. Operation through the curve was authorized at a speed not to exceed 60 kmh (37 mph); actual operating speed of the train was 117 kmh (73 mph).
Sound familiar? Like Spain? Like Spuyten Duyvil?
Unlike those derailments, in the Waterfall accident the train's driver died. Actually he died prior to the accident, a heart attack killing his at the throttle, while his foot, and his 200 + lb body provided enough force to keep the "deadman's" pedal depressed to the floor, suppressing an automatic brake application.
During the investigation, it was discovered:
that the SRA [State Railway Authority] had information for approximately 15 years that the deadman foot pedal in Tangara trains had the inherent deficiency that train drivers over acertain weight could set the pedal inadvertently if they became incapacitated. [Special Commission of Inquiry into the Waterfall Rail Accident, Final Report, Volume 1, January 2005]
Turns out, in investigating the history of rail operations and regulation in New South Wales, Australia, the hon QC determined that in 1996, Australia initiated its own version of "deregulation" called "disaggregation":
In 1995, New South Wales became a signatory to the National Competition Policy Agreement, designed to implement the recommendations of the Hilmer Report on
Two elements of that agreement are relevant to the restructure of the New South Wales rail system. First, public monopolies were to be stripped of any regulatory functions, prior to being exposed to competition. Secondly, a regime was to be established to enable third-party
access to significant Government-owned infrastructure facilities.
Despite bipartisan support for this legislation, neither the Government’s nor the Opposition’s expectations for a significantly improved railway industry were realised.
The 1996 Act constituted two State-owned corporations, the Rail Access Corporation (RAC) and FreightRail Corporation, and two statutory authorities, the Railway Services Authority (RSA) and the State Rail Authority (hereafter referred to as SRA). The effect was to replace a
single vertically integrated statutory authority with a horizontal structure. With the subsequent corporatisation of RSA, the SRA remained the only part of the railway that was not corporatised.
The principal objectives of the SRA included the operation of efficient, safe and reliable railway passenger services. Operation of rail services by the SRA continued to be subject to the 1993 Act.
None of the intended outcomes of the restructure eventuated for the RAC, RSA or the SRA.
Let me repeat some of those last two paragraphs in case your eyes glazed over: The principal objectives of the SRA included the operation of efficient, safe and reliable railway passenger services. and None of the intended outcomes of the restructure eventuated for the RAC, RSA, or the SRA.
I think hon QC had trained as a boxer and brought that punch all the way from Tasmania.
I am personally familiar with both of these accidents, having studied the reports. And I'm personally familiar with the hon Peter Aloysius McInerney, QC, as back in the day when he was conducting this investigaton and examining operating safety management programs on other railroads, he paid me a visit in my office in Grand Central Terminal. Apparently someone from the NTSB had directed him to the director of safety at Metro-North, who brought him to me.
We had a very interesting conversation about the tools we used in New York to review and monitor crew compliance and operating safety, including the use of random downloads of event recorder data after a train's run.
The hon QC stated that attempts to install and utilize event recorders had met considerable resistance from the rail labor organizations in Australia, on the grounds that such instrumentation was an "invasion of privacy."
Call me gob-smacked, because gob-smacked I was. I had never heard such a thing; nor could I believe that any railroad management anywhere would listen to such utter nonsense.
Well, after I relocated my jaw back into its socket and we resumed our conversation, the hon QC leaned over to me and said, "So tell me, in your tenure, how many fatalities have occurred?"
My jaw started to drop out again, but this time I caught it and was able to respond, "You mean passenger fatalities?"
"Yes," replied the QC.
"Passenger fatalities due to crew operating rule violations?"
"Yes," he replied again.
"Zero," I said.
"Come on, " he replied. "I don't believe that."
"Zero," I repeated.
"You are serious?"
"Serious as a heart attack," I responded, congratulating myself for linking my response to the Waterfall derailment.
"Let me tell you how serious I am," I continued. "If I had one, just one, I wouldn't be here. You'd be talking to someone else in this position, right now."
Call him gob-smacked, because gob-smacked he was.
"I can't believe that," he said.
"Believe it," someone else, either the NTSB person or the MNR director of safey said. "This is how we conduct this business."
I repeat that story with not a little chagrin even though I'm 5.5 years into my retirement, given what has recently taken place on MNR.
I repeat the story not simply because labor organizations, intending to act in the best interests of their members, might act in the worst interests of everybody including their members.
I repeat the story because the failures reported in the investigations of these two accidents are not just the failures of incompetent management, but of management that is designed to be incompetent because other priorities have been established.
At Ladbroke, it was the priority to install bi-directional signaling and overhead electrification with precedence over operator unbroken sight distance to signal. It was the priority to produce train driver's as quickly as possible. It was the priority to assess the risk of collision on the basis of cost of prevention, rather than as the threat to the vital process of the railroad.
In Australia, the priority was to maintain performance and....well, read the report.
I recall these investigations because every operating decision is a financial decision, and vice-versa, every financial decision is an operating decision. Sudden deteriorations in railroad operating safety are not sudden deteriorations. They are the result of economic processes.
RT/LT Hon David Schanoes, non-QC
December 16, 2013
If cost-benefit analysis had been around in 1876, we'd still be debating the installation of track circuits.