Silver Moor Consulting
  • Home
  • About
  • Consultancy
    • Barrier-based auditing
    • Task design
    • Training & competence
    • Procedures & documents
    • Accident & incident investigation
    • Decision support tools
    • Performance dashboards
    • Risk management >
      • Bowtie risk assessment
    • Operational readiness
    • Safety climate surveys
  • Training
    • Reducing maintenance error
    • Accident investigation training >
      • Accident investigator training
      • Senior accident investigator
      • Root cause analysis
      • On-Train Data Recorder (OTDR) analysis
    • Writing safety critical instructions
    • Bowtie risk methodology
    • Risk assessment
    • Trainer and coaching skills
    • Process mapping
    • Writing better reports
    • Creating a vision
  • Coaching
    • Accident investigator coaching
    • Consultant coaching
    • Manager coaching
  • Contact
  • News
  • Resources
    • Rail images
    • Tram images
    • Bus images
    • Human factors images
    • Event images
    • 1930s road safety advice
    • 1960s railway workshop safety
    • BR Training Manuals
  • Clients
  • Privacy

Norton Fitzwarren rail disasters, November 1890 and 1940

26/11/2018

1 Comment

 
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.
​
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.

1890 Norton Fitzwarren accident part 1
File Size: 1547 kb
File Type: pdf
Download File

1890 Norton Fitzwarren accident part 2
File Size: 1429 kb
File Type: pdf
Download File

1940 Norton Fitzwarren accident part 1
File Size: 1340 kb
File Type: pdf
Download File

1940 Norton Fitzwarren accident part 2
File Size: 1122 kb
File Type: pdf
Download File

How railway safety has changed
File Size: 1710 kb
File Type: pdf
Download File

Transport Heritage Site award from the Transport Trust
Transport Heritage Site award
Great Western Railway locomotives in the 1890 railway collision at Norton Fitzwarren
Locomotives in the 1890 accident
Great Western Railway coach badly damaged in the 1890 accident at Norton Fitzwarren
Damaged coach in the 1890 accident
Great Western Railway 'King' class locomotive 6028 'King George VI' after being recovered from Norton Fitzwarren in 1940
Locomotive after recovery in 1940
Railway accident site at Norton Fitzwarren in 1940
1940 accident site
Site of the 1940 railway accident at Norton Fitzwarren, taken in November 2018
Site of the 1940 accident
1 Comment

Accident report released on Sandilands tram derailment

7/12/2017

0 Comments

 
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.
Sandilands tram accident
Image: Rail Accident Investigation Branch
0 Comments

Bouncing back: New report on how business leaders overcame adversity

30/6/2016

0 Comments

 
The Chartered Management Institute has just released a report that gives insight into how managers cope with adversity. 
The findings of the report, and the recommendations that it makes, are in line with what we experience.
Understanding and managing risk (through tools such as Bowtie risk assessment) and building a culture where failures are seen as an opportunity to learn (through effective investigation) are at the core of what we do. 

The Chartered Management Institute (CMI) is the only chartered professional body for management and leadership, dedicated to improving managers’ skills and growing the number of qualified managers. 

Follow the CMI on Twitter at @cmi_managers: if you're based in the South West of England you can follow the regional branch at @CMISouthWest.
The CMI's recommendations for improving managerial resilience include:
  1. Make it OK to fail. Failure as a step on the way to success should be the new normal. 
  2. Develop risk tolerance – Build up risk tolerance through creating a culture geared towards accountability. 
  3. Encourage managers to accept, re-evaluate and face forward – Help managers to gain a sense of perspective by stepping outside the situation. 
  4. Foster a balanced mind-set and humility – Ensure a dose of realism and measured reactions by regularly reviewing best and worst case outcomes. 
  5. Offer mentors – Recognise the power of learning from mistakes.
  6. Build support networks – Strong personal networks can soften the blow of a crisis. 
0 Comments

70 years since the world's biggest non-nuclear explosion - in Britain

19/11/2014

1 Comment

 
On the 27th November 1944 3,500 tons of high explosives and an estimated 500 million rounds of rifle ammunition exploded underground at the RAF's munitions dump at Fauld in Staffordshire. 
The likely cause of the explosion was a spark from the brass chisel being used by an airman on a live bomb - a tool that was not permitted, but probably made the job easier. This spark set off a chain reaction amongst the live munitions. A nearby farm and lime works were completely destroyed and virtually every house in Hanbury village was seriously damaged. A 6 million gallon reservoir was breached, the flood waters causing severe damage. Seismographs across Europe registered the blast. Had the blast occurred above ground, the effect would have been similar to that of the nuclear explosions at Hiroshima and Nagasaki.
The official inquiry found that there were several systemic failings that had contributed to the accident: management of the site was poor, allowing dangerous work practices to exist. Suitable manpower had been in short supply, so Italian prisoners of war (200 of them) were being used to carry out menial tasks. Rescuers were met with confusion; no-one knew who was trapped underground because the required register wasn't maintained.
Approximately seventy eight people were killed, mostly civilians in the nearby plaster works and local people.

The crater is 90 feet deep and covers 12 acres.
Despite the scale of the disaster, few people have heard of it. You can read more about the explosion at this local history website, and more images are available here.
RAF Fauld today - unexploded munitions
Unexploded munitions remain buried at the site. Image: Frank Smith
1944 aerial photograph showing crater
Aerial photo from 1944 showing the huge crater and debris field
1 Comment

Norton Fitzwarren rail accident, Nov 4th 1940

4/11/2014

12 Comments

 
Today marks the anniversary of a serious accident on the Great Western Railway at Norton Fitzwarren in 1940. 27 people were killed, and a further 75 were injured when their express sleeper train from London (carrying over 900 people) passed two signals at danger, derailed and overturned. The accident occurred at about 3.45 a.m. on a very dark, wet and windy night. 
The train had been routed from the main line to a relief line at Taunton, to allow another train (carrying newspapers) to pass. However, the driver was under the impression that he was still on the main line and continued to accelerate until he realised his error. By that time it was too late to bring the train to a halt. The train went through a set of catch points at about 45 mph (there to protect the main line). The locomotive tipped onto its side and the first six coaches telescoped into each other, blocking all four tracks. Luckily, the newspaper train had just passed the express - had the two trains collided the casualties would have been far greater. 
The causes of the accident still feature in rail accidents today. The driver, with over 40 years' experience, was probably operating on 'auto-pilot' - his experience worked against him as his actions became subconscious; including cancelling two warnings from the automatic signalling system. He had also lost his 'situational awareness', being unaware of which line he was running on; he had never before been diverted onto this line and the signals that applied to him were on the opposite side of the track from normal practice. Fatigue and other psychological factors were also likely to be present; the train was working during wartime blackout conditions, during the night and his home in London had recently been damaged by bombing.
You can read the accident report on the Railways Archive website, and the story is told in detail in this contemporary newspaper report.
Norton Fitzwarren rail crash scene, 1940
Rescuers at the crash scene
Wrecked coaches, Norton Fitzwarren rail crash 1940
Wrecked coaches
12 Comments

Road painting errors

10/6/2014

0 Comments

 
PicturePhoto: KentOnline
Human errors often have humorous rather than safety critical consequences. The two examples here illustrate system failures which caused embarrassment for the organisations involved, but probably nothing more.
In the top example, a sub-contractor working on street repairs after gas main works made the road marking error. Instead of marking the temporary space as 'DISABLED', a rather different marking was made. The operator was probably doing the best they could - the real failure is in the system that allowed the error to occur. See the KentOnline news report for the full story.

PicturePhoto: BT.com
In this second example, road painters repeated a spelling error that was first introduced on the section of road two years previously. Here, 'MINUTES' was replaced with 'MINUITES'. Again, the error lies in the system somewhere, not with the individual carrying out the marking. For the full story, see BT.com.

0 Comments

Organisational deficiencies lead to human error in nuclear sector

7/2/2014

0 Comments

 
Nuclear power plant
Research by the International Atomic Energy Authority (IAEA) published in December 2013 showed that 80% of significant events at nuclear power plants can be attributed to human error, while only 20% can be attributed to equipment failure. 
For many years the belief has been that human error is an individual-focused phenomenon or motivational issue. However, it has recently been identified that approximately 70% of these errors are down to weaknesses in organisational processes and cultural values. These organisational deficiencies are often hidden in management processes, structures and values and can create workplace conditions that lead to a human error or reduce the effectiveness of risk control barriers. The full report can be viewed here.

See our pages on how we help organisations manage the conditions that can lead to errors and our accident investigation pages.

0 Comments

    Archives

    November 2020
    November 2019
    June 2019
    April 2019
    March 2019
    November 2018
    June 2018
    May 2018
    December 2017
    September 2017
    March 2017
    February 2017
    January 2017
    November 2016
    September 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    November 2015
    October 2015
    May 2015
    March 2015
    February 2015
    January 2015
    November 2014
    October 2014
    September 2014
    June 2014
    March 2014
    February 2014
    January 2014
    December 2013

    Categories

    All
    Accident
    Awards
    Business Skills
    Chartered Management Institute
    Coaching
    Communication
    Construction
    Cranes
    Design
    Distraction
    Events
    Fatigue
    Handover
    Heritage Railways
    Human Error
    Investigation
    Leadership
    Light Rail
    Maintenance Error
    Management
    Medical
    Mentoring
    Metro
    Military
    Mindfulness
    Networking
    Nuclear
    Organisational Failures
    Procedures
    Rail
    Resilience
    Risk
    Rule Compliance
    Social Care
    Strategy
    Supervision
    Task Workload
    Training And Competence
    Tram

    RSS Feed


Silver Moor Business Consulting LLP is registered in England and Wales. Registered Number: OC389666. VAT Registration No. GB 178 0758 72 
Registered Office: Coombe Wood House, Winscombe Hill, Winscombe, North Somerset, BS25 1DH, United Kingdom.

© Silver Moor Business Consulting LLP 2023. All rights reserved.