John Baker, our Managing Partner, has researched two railway accidents that happened at the same Somerset village 50 years apart. This research has been in support of Norton Fitzwarren's bid to receive a 'red wheel' heritage plaque from the Transport Trust in recognition of the villagers' efforts to rescue the victims in both crashes. The leader of the project, Mary Hayward, had seen our news article on the 1940 accident and asked if we could help with her research. Of course, we were delighted to help especially since both accidents had a significant 'human factor' element.
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We have previously written a short article on the 1940 accident, but the accident of the 11th November 1890 was also blamed on 'human error'. In this accident the signaller, George Rice, forgot that he had left a goods train standing on the main line and allowed an approaching fast passenger train into the same section. The passenger train collided with the stationary goods engine, killing 10 passengers and seriously injuring many more.

John's research revealed several new facts about both accidents and also documented more about the victims and those involved. This research has been published on posters that will be displayed in Norton Fitzwarren Village Hall. Copies of the posters for download are included at the end of this article.

As part of the Red Wheel project, John was asked to give a radio interview to the BBC - this is now available on the BBC website.

​On the 17th November, the Transport Trust awarded Norton Fitzwarren with a 'Transport Heritage Site' award. We were delighted to attend to see the culmination of Mary Hayward's work to get the actions of the villagers recognised following these two tragic accidents.

On the 9 November 2016, a tram on the Croydon tramway network overturned at Sandilands. The tram had been travelling at 73 km/h when it entererd a curve that had a maximum speed limit of 20 km/h. The speed caused the tram to overturn as it passed through the curve, and resulted in passengers being thrown around inside the tram, with some being ejected through broken windows. Of the 69 passengers involved in the accident, seven died and 61 were injured; 19 seriously.
The Rail Accident Investigation Branch's report has been released today and makes some far-reaching recommendations for the way tram operations in the UK are regulated and managed. Sadly, many of the recommendations are made about things that are already known about (and managed) in the rail sector, but which were not applied to tramway operations - tramways are often regarded as being more akin to road operations than rail operations. The accident at Sandilands makes it clear that rail sector engineering standards and management systems (for example fatigue management) are highly relevant to tram operations.
The investigation report concludes that it is probable that the tram driver temporarily lost awareness on a section of route on which his workload was low. A possible explanation for this loss of awareness was that the driver had a microsleep, and that this was linked to fatigue. Exacerbating this was that there were few landmarks so that the driver was unable to quickly reorient himself.
The report makes 15 recommendations to improve tramway safety. Some apply to the operator of the Croydon tram network (First Group), but many apply across  all UK tram operations:

• creating a dedicated safety body for UK tramways 
  
• reviewing how UK tramways are regulated
  
• introducing automatic braking and driver vigilance systems to trams (some tramways already have vigilance systems)
• developing a better understanding of the risks of tramway operations, particularly when the tramway is not on a road
• improving the strength of tram doors and windows
• improving safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes
• improving the tram operator’s safety management arrangements.

Management-speak annoys us intensely here at Silver Moor. Far from making things clearer, it confuses and irritates employees. Management consultants are often blamed (usually with justification) for introducing these phrases. As a management consultancy practice (we ‘operate in the management consultancy space’) our clients are often very pleased (and surprised) by our plain speaking. This is because we see the effects of poor communication in high-risk industries when we investigate serious incidents and accidents.
The video on the right, produced by education charity Teach First, gives a great insight into how confusing management-speak can be. They asked primary age students to identify and translate some of the worst phrases used by management in workplaces.
The Plain English Campaign has a lot of free resources to help. We use these principles both in our work (for example writing operational procedures) and in our training – to help you improve your own skills.
Try our three ‘management speak’ games to see how you and your managers fare. 
Keep your communication short, keep it clear, keep it free from management-speak and jargon.

The 22nd May this year marks the centenary of the UK’s worst rail accident, at Quintinshill in 1915. This crash, near Gretna in Scotland claimed the lives of 224 people and injured a further 246. Of these, 216 of the dead and 205 of the injured were members of the 7th (Leith) Battalion The Royal Scots on their way to Gallipoli.

The Board of Inquiry found that the railway staff had made critical errors, the main one being that the signaller had forgotten a train left standing on the main line. The express troop train was then routed along the same line and collided with it at speed. The wreckage was then struck by another train passing in the opposite direction. Many of the causal factors reported by the Board of Inquiry are now recognised ‘human factors’ that are common to many accidents. These included fatigue, distraction, irregular handover between shifts and not following written rules. 


You can find out more about the disaster on Wikipedia. There is also a Facebook group commemorating those who lost their lives.

There's a BBC documentary about the disaster airing on BBC2 Scotland on Wednesday 20th May at 9pm.

We got great feedback for our new accident investigator training materials this week. One delegate said "This was really well-paced training, encouraging all to be actively involved through group exercises and realistic case studies." Our Investigator Handbook and materials for event and causal factor charting were particularly well-received.
All our accident investigation training is tailored to suit your industry; we will work with you to create relevant case studies and where possible we will use your accident reporting documentation (accident reports and investigation report templates or forms) during the training. 
See our accident investigation training and accident investigation consultancy pages for more information, or contact us to discuss how we might work with you.

Our popular accident investigator training has been enhanced by some new resources: an Investigators Handbook, new case studies and practical resources for delegates to use during the training.
The Investigator's Handbook provides practical tools and techniques that can be applied at all stages of an investigation. This will help investigators move beyond 'human error' and be able to identify the problems with systems within which the humans have to operate.
All our accident investigation training is tailored to suit your industry; we will work with you to create relevant case studies and where possible we will use your accident reporting documentation (accident reports and investigation report templates or forms) during the training. 
See our accident investigation training pages for more information, or contact us to discuss how we might work with you.