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Railway safety critical training

20/9/2017

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As part of our work to support Locomotive Services (TOC) Limited, we recently spent a day creating video footage of emergency situations that can forseeably occur when operating on the railway network. To create these sequences safely we carried out full risk assesments and safety briefings on the day to make sure that we kept everyone (and some very expensive camera equipment!) safe.
These clips will be used to support learning programmes that we are creating for drivers, firemen, guards, stewards, shunters, service personnel and traction inspectors. The learning programmes are part of the organisation's competence management system that we have developed and support the operational rules and procedures that we are working on.
The top photograph shows what happens when the locomotive suffers a 'blowback' (as happened on a charter train service at Wood Green in 2012). Blowbacks occur when combustion products from the fire are blown back into the cab - when a train passes into a tunnel or when there is a mechanical failure of some sort (as happened at Pickering on a heritage railway in 2006).
The second photograph shows the moment that a detonator (also known as fog signals) explodes under the wheel of a locomotive. Detonators are small metal devices containing a limited quantity of explosive. Detonators are placed on the running surface of a rail by the traincrew to protect approaching trains of a hazard (derailment, track maintenance work, or something fouling the line) - the wheels of a train will cause the detonator to explode and the sound will alert the driver to to stop the train immediately. As well as creating video footage of detonators being placed, and then exploding, we wanted to test how audible they would be from the footplate of steam locomotive under a range of conditions.
We are hugely grateful to the volunteers and staff at the Churnet Valley Railway for providing access to their railway, the locomotive and train, the crew for the day and for allowing us to do some very unusual things!
Steam locomotive blowback
Steam locomotive blowback
Locomotive wheels exploding a detaonator
Locomotive wheels exploding a detonator
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New charter train operating company

11/9/2017

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Our Managing Partner, John Baker, has been working with Locomotive Services (TOC) Limited to set up the organisation and to achieve safety certification from the Office of Rail and Road (ORR) so that it can run steam and diesel charter trains on the UK main line rail network. We have been working with a team of professionals to create a safety management system (SMS) and assess the risks of using 1930s on the 21st century railway network using the bow tie method. An important part of this has been analysing steam-era rules and instructions (mostly 1950s, but some dating from 1934) and turning these into suitable instructions using Plain English principles and current understanding of human factors.
On the 4th of August the ORR announced that it had granted a European Passenger Train Operating Licence to the company.
The next phase of our involvement will see us prepare for the first passenger services. This will include route risk mapping and creating training and competence management systems so that steam and diesel train drivers can be issued licences as required by the Train Driving Licences and Certificates Regulations 2010.

You can read more about the announcement on the Locomotive Services (TOC) Limited website, as well more about the locomotives it will operate.
Picture
Picture
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70 years since the world's biggest non-nuclear explosion - in Britain

19/11/2014

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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
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Road painting errors

10/6/2014

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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.

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Human error and narrow escapes in military training exercises

15/3/2014

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Royal Artillery firing 105mm Light Guns on exerciseFiring 105mm guns on exercise (image: MoD)
It's been a bad week in the news for the UK's military. Two human-related mishaps during training exercises could have had serious consequences. In the first incident, on Salisbury Plain, a 105mm round was fired towards the safe test firing area but because the wrong charge was used it went "much further" - 5 miles further. It exploded in a farmer's field, just 300m short of the main railway line. See the news story on the BBC website.
In the second incident, a torpedo was accidentally launched from HMS Argyll inside Devonport naval base. The torpedo was an unarmed version used for testing drills, so did not explode when it impacted a safety fence. See the news story here.
In both cases, the investigations have been launched to try to understand the causal factors.


See our pages on incident investigation and common causes of human error to see how we are helping organisations manage the 'human factor' in their business.

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Trams start running into Edinburgh city centre

21/2/2014

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Edinburgh Trams is a project we've been involved with for quite a while - great to see trams finally running into the city centre.
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Power engineer error leads to US firefighter electric shock

17/2/2014

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Electric shock warning
A fallen power cable caused a wildfire in the US state of Washington. Electrical power company engineers attending the incident believed that the other end of the power cable was also disconnected at the top of a pylon and so posed no danger to firefighters on the ground. However, the power cable was still live at 7.2kV and when a volunteer firefighter used a portable fire extinguisher on the fire he received an electric shock. Fortunately the firefighter was unharmed. For the full news story, see the Tri-City Herald report.

See our pages on procedures and documents, risk management and accident investigation for information about managing risk in an operational environment.

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Tragic error causes seven deaths on military training exercise

23/1/2014

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PictureA US Marine firing a 60mm mortar
In March 2013 seven US Marines were killed when a Marine double-loaded a 60mm mortar on a training exercise. Eight other Marines were injured by the explosion.
The investigation concluded that several common 'human factors' led to the accident: 
  • inadequate training and preparation;
  • communication (firing commands);
  • procedures; 
  • supervision, and;
  • task workload. 
See the full news story on the USA Today website.

Fortunately, in industry the outcome of human error is rarely this significant. For details on how we can help identify and manage human factor risks in industry, see our consultancy pages.

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