Moreton-on-Lugg report released.

[Dave]

It's been quoted numerous times on this forum, but the report into the accident at Moreton-on-Lugg has been released.

http://www.raib.gov.uk/cms_resources.cf ... ugg%20.pdf

Appears that the signalman has reset the signals despite train approaching as there was no interlocking

Thoughts?

[AndersI]

Poor guy! Making a human being part of an 'automated' signaling system...

Such a process is guaranteed to go wrong sooner or later. Of course, even fully automated systems may go wrong, but then there's no human having to live with the fact that he took part in killing a person.

[John]

19 years of what sounds like excellent service gone down the drain because of poor risk management done by those who designed the system...

Not to mention the life lost.

[Dave]

I tend to agree. Very sad for a man who now has to live with himself and that one mistake that could have meant nothing and yet has cost a lady her life.

[John]

I also find the AAIB and RAIB seem to be of different standards - despite having the same aims. The AAIB really is famous for the quality of its investigations (unlike its French equivalent...) - how do other Railway communities see the RAIB?


The biggest difference of course is that in air transport you very rarely get a small mistake only costing 1 life, its normally more.


But there are still some interesting differences - in air transport no-one is trusted to remember what to do. Pilots will confirm this by the shear number of checklists they have. Hell, most pilots will know most of them by heart, but they are still forced to follow them - and in emergencies the checklists make a huge difference.
I've only been around a control tower once, but it seemed to be the same there.

In comparison in this signal box, the signaller had to try and remember whether there was a special regulation for having lifestock cross the track. A simple quick reference chart with all the usual (and more importantly unusual) procedures would have perhaps prevented him getting so involved with the phone call.

The other difference is the design of the work layout - the signaller has to turn his back on his key area to answer the phone. This could literally happen at anytime, including when his work load is heaviest. In aviation, the controller has is workstation in front of him and to the sides (the tower i was in was at an Airbus plant, so it had lots of extra equipment for testing aircraft) but nothing required him to turn his back on the view of the runway or the radar screen. No doubt the location of the phone and computer terminal were chosen because it was easiest to install them there, rather then to be most helpful to the signaller.

[Dave]

Agree with all the above. I will say that much of the equipment's use and design is still largely Victorian - you wouldn't get a signaller turning round in a modern box, for example - but that's how the railways work, sadly... Make the best of poor previous design.

The RAIB reports are good if only for their large amount of detail. Sometimes get too interested in avoiding blame but I suppose that's their remit...

[Kevo00]

Like the report about that accident in Cumbria where a man lost his life because he drove across an open level crossing, which claimed that, despite driving over the crossing at least twice or more a day on a relatively busy line, the man may never have encountered a train at the crossing before! Madness.

[John]

The RAIB reports are good if only for their large amount of detail. Sometimes get too interested in avoiding blame but I suppose that's their remit...

The AAIB takes that to a whole 'nother level - rumour has it that the first thing they do is cover up the tail and airlines name, so that the airline reputation isn't tarnished before the fault of the accident is found. With the internet however this no longer happens (maybe some of the other aviation enthusiasts can shed more light on this rumour).

The key advantage in the remit that both the AAIB and RAIB have is they delve a lot deeper. Sure, you could have just said the signal man committed a mistake, its his fault, case closed. But they will both look at how a mistake was allowed to happen, the management structure etc. etc.

I could bore you with details about how France is trying to blame someone for the Concorde crash despite highly controversial evidence, and that the FAA asked them to re-run simulations after the Hudson water landing after they ran the simulations with pilots who knew exactly what was going to happen. But then you lot are more interested in railways (and this is about a railway crash) so I won't

[audigex]

Like the report about that accident in Cumbria where a man lost his life because he drove across an open level crossing, which claimed that, despite driving over the crossing at least twice or more a day on a relatively busy line, the man may never have encountered a train at the crossing before! Madness.

There's no such thing as a "relatively busy line" in cumbria unless you count the WCML in which case I'll agree with the madness quote. The Furness and Cumbrian Coast lines have a 1-2 hourly service most of the time (a couple of 30-45 minute gaps in the middle of the day is the limit) I've driven over crossings on that line literally thousands of times and only ever been stopped twice by a train that I can recall.

[Kevo00]

Like the report about that accident in Cumbria where a man lost his life because he drove across an open level crossing, which claimed that, despite driving over the crossing at least twice or more a day on a relatively busy line, the man may never have encountered a train at the crossing before! Madness.

There's no such thing as a "relatively busy line" in cumbria unless you count the WCML in which case I'll agree with the madness quote. The Furness and Cumbrian Coast lines have a 1-2 hourly service most of the time (a couple of 30-45 minute gaps in the middle of the day is the limit) I've driven over crossings on that line literally thousands of times and only ever been stopped twice by a train that I can recall.

Fair point. It was near Grange-over-Sands on the Furness Line if I recall. I cross over the Bedford-Bletchley line here quite a bit, which has a similar frequency, and get stopped by trains quite often. Anyway, my point was simply that it struck me as something designed to absolve the no-barrier design of the the crossing of any blame, despite it having limited visibility etc., and as a statement for which there could be little real evidence, unless RAIB investigators spent a day driving up and down the road at random intervals to see how many times they would be stopped.

[Dave]

The majority of AOCLs ARE safe if used in the correct manner. From what I understand from the G-o-S report, this crossing is (was) an exception and not the rule. The lights were definitely flashing, but he just didn't see them because of a) sunglare, b) speeding, c) lack of concentration. All that said, the highway code clearly states that at level crossings you should drive carefully and with full care and attention.

Another sad scenario but this bloke had been drinking (although was still under the legal limit) and had no driving license. Odd one.

[Kevo00]

Agree with the above; at the end of the day you can't eliminate human error. Both of these cases are very sad. Having read the Moreton-on-Lugg report fully, I can't possibly imagine how the signalman feels now, all due to a genuine mistake that he will presumably not get the chance to learn from.