We are delighted to announce that we have been appointed as a Value Added Partner by CGE Risk, the leading provider of barrier-based risk management solutions.

We have been using the bowtie methodology for several years with railway, metro, tram, fire & rescue and social care clients, so this appointment marks an important stage in how we help clients apply the technique.

Being a Value Added Partner for CGE Risk allows us to provide a complete solution for the bowtie risk assessment methodology; helping you to understand and apply the methodology and also provide and implement CGE’s specialist software for producing excellent bowties.
CGE Risk has verified that we have been trained in risk and incident analysis methods as well as the application of these in their software solutions.

If you are looking for consultancy (applying the bow tie technique to your business risks), training in the methodology and/or the software or advice on how to scope or purchase software then please contact us.
​

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.

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!

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.

We're now offering the bow tie method as part of our risk management services.
The bow tie method is a popular risk analysis tool that is used in many industries, especially those where there are significant safety risks. The bow tie itself is a diagram that helps you visualise the risk you are dealing with in one, easy to understand picture. The power of a bow tie diagram is that it gives you an overview of multiple plausible scenarios, in a single picture. In short, it provides a simple, visual explanation of a risk that would be much more difficult to explain otherwise.
​Contact us to find out more.

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.

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.