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RSSB A4 Template with Numbered Headings A Better, Safer Railway Train Operations 2019/20 A summary of health and safety performance, operational learning and risk reduction activities on Britain’s railway. 1 Introduction Most of the time the railway runs well, everything goes to plan, and everyone gets to where they should be at the time they need to be there. Sometimes, though, things don’t run so well. Trains are delayed because of problems with the train itself, the traction supply, a trespasser, a broken rail, signal failure, human error and a whole host of other issues in between. Fatal derailments, collisions and buffer stop collisions have become increasingly rare over the last 60 years, thanks to improvements in the integrity of our equipment, but also in the training, process and safety management system improvements that come about as we continue to learn from past incidents and present precursors. However, the refreshed LHSBR has highlighted a number of strategic challenges, noting (among other things) that there is still inconsistency across the industry in how signal passed at danger (SPAD) events are managed, and calling for an increased understanding of where they are most likely to occur. As well as stopping trains ‘going too far’, though, there is also a growing need to understand why trains sometimes ‘go too fast’. The challenges identified in this document will help us direct resources to improve operational safety in the future. Headlines 2019/20 • On 31 March 2020, the annual moving total number of SPADs was 362.1 This is the highest such figure since March 2005. • At the end of January 2020, the indication of underlying SPAD risk reached 91% of the September 2006 baseline. This is the highest value since June 2011. • There were 277 fewer recorded signaller errors in 2019/20 than in 2018/19. Most of the errors involved wrong-routing. • The Red Aspect Approaches to Signals (RAATS) Toolkit was launched in October 2019. RSSB is setting up a RAATS user group to share best practice and drive further development and implementation. • Network Rail is looking at ways to improve safety critical communications. The Train Accident Risk Group (TARG) supports the development of a national strategy and will be working on this with the industry, taking initiatives already under way into account. 1 For more information on this and all the other data in this report, please see the Data transparency document. 2 • Work to understand the hazard of ‘going too fast’ is under way. The next phase involves creating an overspeeding risk bowtie through a workshop and industry collaboration and a potential R&D project to understand future mitigations. • This year the recorded number of major injuries to passengers on trains has fallen, but is still higher than the preceding years. As well as the on-train conditions seen before, analysis has found sudden braking and intoxication to be causal to a number of incidents. 2 Train accidents 2.1 Safety overview This section presents the wider picture of safety per the Safety Management Intelligence System (SMIS). 2.1.1 Precursor indicator model Figure 1 Twenty-year trend in the passenger PIM The passenger precursor indicator model (PIM) shows the PIM indication of potentially higher-risk train accidents (PHRTAs) risk to passengers broken down by theme (figure 1).2 2 The PIM indication of PHRTA risk to members of the public and workforce is shown at an aggregated level. 3 The overall PIM has a large component which indicates the risk of level crossing usage to members of the public, this is discussed in the Level crossing report. The passenger part is a better indication of trends in train operations risk. At the start of 2000/01 the PIM indicator of passenger PHRTA risk stood at 9.6 FWI; at the end of 2019/20 it was at 3.3 FWI. This represents a decrease of 6.3 FWI (65%) over 20 years. Much of this can be explained by changes to the SPAD risk indication in the first six years, during which time TPWS was being rolled out. As a result, between 1 April 2000 and 1 April 2006, the figure fell by 3.5 FWI. At the start of 2000/01, the PIM indicated the greatest PHRTA risk to passengers to be from SPADs. By the end of 2019/20, this had changed to infrastructure failures. From 31 March 2019 to 31 March 2020 the indicator of infrastructure asset PHRTA risk to passengers has increased by 0.68 FWI, or 83%. This is explored further in the Infrastructure asset integrity report. 2.1.2 SPADs Figure 2 Trend in SPADs and SPAD risk On 31 March 2020, the annual total of SPADs was 362—the highest since March CIRAS 2005. By the end of January 2020, the A breakdown of CIRAS reports over the last indication of underlying SPAD risk had three fiscal years shows that 20%-24% of reached 91% of the September 2006 incidents cited had the potential to lead to a baseline. This is the highest value since June SPAD, collision or derailment. 2011. By March 2020, however, the underlying risk indication had fallen to 71%. 4 2.1.2.1 SPAD causes To identify any consistent causes or underlying causes related to the increase, RSSB risk and human factors practitioners analysed over 150 SPAD investigation reports from 2018 and 2019. The results were compared to a study of underlying causes of SPADs from 2016 and 2017. Figure 3 Proportions of identified factors leading to SPADs in 2016-2017 and 2018-2019 The analysis uses the ten incident factor classification system and was conducted on subsets of SPADs from each set of years. The subsets were selected to represent the overall distribution of SPADs over operator type and time of year. As there was less detail in the available investigation reports for the 2018 and 2019 SPADs, a lower number of factors was identified. That said, the distribution of factors over factor type appears similar for both datasets. The rise in the proportion of environment and infrastructure, vehicles and equipment were investigated further, but neither was found to be a strong candidate for explaining the overall rise in SPAD frequency. Indeed, the analysis did not identify any single, strong candidate to explain it. A further ‘deep dive’ is therefore being conducted for more clarity. 5 2.1.2.2 Approaches to red aspect signals Figure 4 Estimated stopping approaches to red signals in 88 train describer areas Figure 4 shows the estimated number of stopping approaches (approaches to red aspects that did not clear before the train reached the signal) for 88 train describer areas (see Appendix A for a list). There is no noticeable trend, but note that the estimate is taken from the Red Aspect Approaches to Signals (RAATS) Tool. RAATS is a relatively new tool and further work is needed to validate and understand its outputs. The underlying SPAD risk metric is calculated by aggregating systematic risk rankings assigned to each SPAD. The underlying SPAD risk metric is comprised of the number of SPADs in the previous year, how close each SPAD train came to a location at which an accident would be possible, and how severe the most likely accident at each location would be. Most signals on the rail network can be passed by a certain distance before there is any possibility of an accident. This means the risk implications of each SPAD, and therefore how much each SPAD contributes to the underlying SPAD risk metric, vary greatly. A freight train passing a stop board by a metre or two at walking pace is significantly different from a fully loaded passenger train passing a signal at danger and coming to a stand on a junction with a route set for another train. This means a small set of a certain type of SPAD can have a very large effect on the underlying SPAD risk metric. The SPADs with the greatest effect on the underlying risk metric are those that pass a signal at danger and reach a location where an accident involving a passenger train is possible. 6 2.1.2.3 Trends in SPAD risk Figure 5 Trends in SPAD risk explained Figure 5 shows the underlying SPAD risk alongside the annual moving total number of SPADs where a train reached a location with potential for a collision involving a passenger train. The patterns of the two series are closely aligned, illustrating that the underlying risk estimate has been driven by a small subset of the total number of SPADs.3 On 23 March 2020, the UK government issued a nationwide lockdown in response to the Covid-19 pandemic. This led to steep reduction in rail travel and the number of train journeys. The reduction in rail traffic has coincided with reduced SPAD numbers and risk. From the end of 2019/20 to the end of May 2020, the SPAD annual moving total reduced from 362 to 330 and the underlying SPAD risk reduced from 71% to 58%. A ‘deep dive’ is being conducted to better understand the safety impact of Covid-19. As part of this, RSSB will be looking at the relationship between trains run, red aspects approached and numbers of SPADs during the lockdown period. 3 One such SPAD occurred on 25 May 2019, when an empty coaching formation passed ground position light signal EK5145 by 632 metres, stopping in Ramsgate’s Platform 4. At the time, a route had been set into the same platform for a passenger train. The passenger train was brought to a stand by a TPWS intervention when the signal it was approaching reverted.
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