Loss of Brake Control on a Sleeper Train Approaching Edinburgh 1 August 2019
Total Page：16
File Type：pdf, Size：1020Kb
Rail Accident Report Loss of brake control on a sleeper train approaching Edinburgh 1 August 2019 Report 05/2020 May 2020 This investigation was carried out in accordance with: l the Railway Safety Directive 2004/49/EC l the Railways and Transport Safety Act 2003 l the Railways (Accident Investigation and Reporting) Regulations 2005. © Crown copyright 2020 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.gov.uk/raib. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Website: www.gov.uk/raib Derby UK DE21 4BA This report is published by the Rail Accident Investigation Branch, Department for Transport. Cover image courtesy of Peter Fitton Preface Preface The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. RAIB’s findings are based on its own evaluation of the evidence that was available at the time of the investigation and are intended to explain what happened, and why, in a fair and unbiased manner. Where RAIB has described a factor as being linked to cause and the term is unqualified, this means that RAIB has satisfied itself that the evidence supports both the presence of the factor and its direct relevance to the causation of the accident or incident that is being investigated. However, where RAIB is less confident about the existence of a factor, or its role in the causation of the accident or incident, RAIB will qualify its findings by use of words such as ‘probable’ or ‘possible’, as appropriate. Where there is more than one potential explanation RAIB may describe one factor as being ‘more’ or ‘less’ likely than the other. In some cases factors are described as ‘underlying’. Such factors are also relevant to the causation of the accident or incident but are associated with the underlying management arrangements or organisational issues (such as working culture). Where necessary, words such as ‘probable’ or ‘possible’ can also be used to qualify ‘underlying factor’. Use of the word ‘probable’ means that, although it is considered highly likely that the factor applied, some small element of uncertainty remains. Use of the word ‘possible’ means that, although there is some evidence that supports this factor, there remains a more significant degree of uncertainty. An ‘observation’ is a safety issue discovered as part of the investigation that is not considered to be causal or underlying to the accident or incident being investigated, but does deserve scrutiny because of a perceived potential for safety learning. The above terms are intended to assist readers’ interpretation of the report, and to provide suitable explanations where uncertainty remains. The report should therefore be interpreted as the view of RAIB, expressed with the sole purpose of improving railway safety. Any information about casualties is based on figures provided to RAIB from various sources. Considerations of personal privacy may mean that not all of the actual effects of the event are recorded in the report. RAIB recognises that sudden unexpected events can have both short- and long-term consequences for the physical and/or mental health of people who were involved, both directly and indirectly, in what happened. RAIB’s investigation (including its scope, methods, conclusions and recommendations) is independent of any inquest or fatal accident inquiry, and all other investigations, including those carried out by the safety authority, police or railway industry. Report 05/2020 May 2020 Edinburgh This page is intentionally left blank Report 05/2020 4 May 2020 Edinburgh Loss of brake control on a sleeper train approaching Edinburgh, 1 August 2019 Contents Preface 3 Summary 7 Introduction 8 Definitions 8 The incident 9 Summary of the incident 9 Context 9 Background information 16 The sequence of events 18 Analysis 23 Identification of the immediate cause 23 Identification of causal factors 23 Identification of underlying factor 34 Factor affecting the severity of consequences 35 Observations 35 Summary of conclusions 37 Immediate cause 37 Causal factors 37 Underlying factor 37 Factor affecting the severity of consequences 37 Additional observations 38 Previous RAIB recommendations relevant to this investigation 39 Actions reported as already taken or in progress relevant to this report 40 Actions reported that address factors which otherwise would have resulted in a RAIB recommendation 40 Other reported actions 40 Recommendations and learning points 42 Recommendations 42 Learning points 43 Report 05/2020 5 May 2020 Edinburgh Appendices 44 Appendix A - Glossary of abbreviations and acronyms 44 Appendix B - Investigation details 45 Report 05/2020 6 May 2020 Edinburgh Summary Summary At about 07:25 hrs on Thursday 1 August 2019, the driver of the Edinburgh portion of the Lowlander sleeper service from London Euston was unable to control the train’s speed on the approach to Edinburgh. He was unable to comply with the maximum permitted speed at Haymarket East Junction, and would have been unable to stop the train before the junction if there had been a conflicting train movement.The driver was also unable to stop the train at Edinburgh Waverley station. The train came to a stop approximately 650 metres beyond its intended stopping point at Edinburgh Waverley platform 11, after the train manager operated an emergency button in a coach. The train crew subsequently identified that an air isolation cock between the locomotive and the coaches was closed when it should have been open. After identifying this and obtaining permission from the signaller, they reversed the train back into the platform where the passengers alighted. There were no injuries and no damage occurred. The driver was unable to stop the train because the brake pipe isolating cock on the leading end of the leading coach was closed. This prevented the brakes on all the coaches from operating when demanded by the driver, although the driver still had control of the brake systems on the locomotive. The isolating cock became closed during coupling operations when the Edinburgh train was split from the Glasgow train at Carstairs station; this happened after the mandated brake continuity test had been completed. The closure of the valve was therefore undetected prior to the train’s departure from Carstairs. The effectiveness of the brake systems on the locomotive also masked the absence of the coach brakes until the train was approaching Slateford, on the approach to Edinburgh. RAIB has made two recommendations. One is addressed to RSSB to change the wording of the railway rule book to make it clear that the brake continuity test should be undertaken after all coupling-related activities have been completed. The second is addressed to Caledonian Sleeper to review the vulnerability of the isolating cocks on its rolling stock, to prevent inadvertent operation by persons or objects. RAIB has also identified six learning points, relating to procedures for coupling and uncoupling trains, incorporating risk mitigations into operational procedures, risk assessing the running brake test, using the ‘train in distress’ signal, application of standards to rolling stock, and access to recorded train data. Report 05/2020 7 May 2020 Edinburgh Introduction Introduction Definitions 1 Metric units are used in this report, except when it is normal railway practice to give speeds and locations in imperial units. Where appropriate the equivalent metric value is also given. 2 The report contains abbreviations and acronyms explained in Appendix A. Sources of evidence used in the investigation are listed in Appendix B. Report 05/2020 8 May 2020 Edinburgh The incident Summary of the incident The incident 3 At about 07:25 hrs on Thursday 1 August 2019, the driver of the Edinburgh portion of the Lowlander sleeper service from London Euston, was unable to control the train’s speed on the approach to Edinburgh. The train exceeded the maximum permitted speed at Haymarket East Junction, and would have been unable to stop before the junction if there had been a conflicting train movement. The train failed to stop as scheduled at platform 11 at Edinburgh Waverley station, and was brought to a stand approximately 650 metres beyond its intended stopping point. 4 The train comprised eight Mark 5 coaches hauled by a Class 92 electric locomotive that had been attached at Carstairs. On the approach to Edinburgh the driver discovered that his train’s braking performance was well below normal. The driver had no control of the brakes on the coaches because a brake pipe isolating cock (BPIC) was in the closed position when the train left Carstairs station. This meant that the only effective brakes on the train as it approached Edinburgh were those on the locomotive, which were insufficient to maintain control of the train. The train manager brought the train to a stand by operating an emergency device in one of the coaches, which caused the coach brakes to apply. 5 There was no damage, nor any injuries, as a consequence of the incident. However, the outcome could potentially have been much worse, had it led to a collision with another train, either at Haymarket East Junction or at Edinburgh Waverley station.