Train incident management - serious safety concerns

Your Trains Safety Council reps write ... The letter below from HM Inspector of Railways to London Underground raises serious concerns about how seriously LU treats the safety of its staff and passengers alike. The Rule Book has been thrown out the window and safety systems after a SPAD have been ignored. Please bring this letter to the attention of all our members.

I refer to the letter to Mike Strzelecki, Director of Safety, from Tom Wake, Principal Inspector of Railways, of 28/11/07; and to a number of train/signal incidents earlier this year, reported to ORR by a health and safety representative.

The letter raises concerns over the response to a signal passed at danger in the High St Kensington area. A particular concern was the failure to follow rule book procedures (securing points) and the failure to involve the RDO in the deviation from the rule book.

Three examples of incidents are as follows:

West Kensington 23/02/09; Eastbound District line train 60 front tripped in the vicinity of semi-automatic signal WC32. I have listened to the voice recordings. By the time the service controller (SC) spoke to the service operator (SO) the signal was clear. It was not established whether the signal was at danger as T60 approached, but the train was tripped and the rule book states that if this happens it must be assumed that the signal was at danger and the appropriate instructions for passing the signal at danger must be carried out. Since WC32 protects points, this involves securing the points. Instead, the SC told the driver that he was happy for him to proceed if he could see that the signal was clear. The driver did not confirm that the signal was clear, but said he would continue as normal. Given the delay between the SC asking for the signal number and the driver calling back it appears the driver could not see the signal from the cab. Points were not secured and the train was lamped into the platform. There is no indication from the communications or the IRF that the RDO was involved at all. The safety-critical communications during the incident were poor, particularly from the SC.

Earl’s Court 24/02/09; Westbound District line train 121 passed semi-automatic signal EC32b at danger. I have listened to the voice recordings. The driver reported the incident to the SC and spoke to the SO. The SO could see that the signal was now clear and authorised the train to proceed. She confirmed this with the SC. Again the driver could not see the signal from the cab, points were not secured and the RDO was not involved. The Service Control Manager’s report states that the SC received the authority from the Service Manager, but this conflicts with the voice recordings. The message phoned through from service control to the NOC stated that there had been a SPaD and that correct procedures had been followed, whereas they had not.

South Kensington/Gloucester Rd 17/03/09; points failure. I have seen the report written by the SO. The SC wanted to organise two safety critical moves. The SC contacted the SO and told him that the DMT would call the SO to obtain his authority for train D013 to pass signal EF266 at danger. This did not happen. Train D013 passed signal EF266 at danger without the correct authority - as observed on the control room line diagram by the SO. Next the SC told the SO that he would be contacted by the Station Supervisor at Sloane Square to obtain authority for train C207 to pass the signal EFX 768 at danger. The SO was not contacted by any member of staff at Sloane Square. He noticed the train pass the signal on his diagram shortly afterwards. SM daily review stated that train 13 had applied the correct procedure.

These are not isolated occurrences - I am aware of other similar incidents.

My concern is that LU has clear rules for carrying out safety-critical procedures but these rules are not being followed. I appreciate that there will be situations where following the rules will create delays that increase the overall risk of harm to passengers, for example from heat stress. LU has a procedure for authorising deviations from the rule book, via the RDO, but again this is not always followed.

LU has based its ROGS submission for its Safety Certificate partly on the procedures laid out in the rule book. If these rules are not followed this will seriously undermine ORR’s confidence that LU is operating in the manner set out in its submission. LU should ensure that its rules are followed at all times. If those rules prove unworkable LU should consider revising them.

I would appreciate a response to this letter, with time-bound proposals to address these issues, by 15 September 2009. I will then consider the adequacy of the response and decide what action to take next. Given the potential risks and previous correspondence, an improvement notice will be considered. Section 28(8) of the Health & Safety at Work etc. Act 1974 requires me to give to your employees information concerning their health and safety. Copies of this letter have been sent to the Trains Safety Council and the Service Control Safety Council.

Yours sincerely Quentin Cole HM Inspector of Railways - TfL