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CSRE Limited Railway Safety in the UK Lessons Learned from Disasters in UK Rail 3 rd China Urban Rail Development Summit by David Shipley, CSRE Limited 22 nd September 2011, Tianjin, PRC

Lessons Learned from Disasters in UK Rail

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Page 1: Lessons Learned from Disasters in UK Rail

CSRE Limited

Railway Safetyin the UK

Lessons Learnedfrom Disasters in UK Rail

3rd China Urban Rail Development Summitby David Shipley, CSRE Limited

22nd September 2011, Tianjin, PRC

Page 2: Lessons Learned from Disasters in UK Rail

CSRE Limited

1. INTRODUCTION

Page 3: Lessons Learned from Disasters in UK Rail

CSRE Limited

Introduction – David Shipley

• Background in design of safety systems for oil & gas and nuclear industries, prior to railways;

• Advised UK Department for Transport on train safety issues;

• Assisted in the development of rolling stock standards, raising safety levels in passenger trains.

Page 4: Lessons Learned from Disasters in UK Rail

CSRE Limited

2. SUMMARY OFHISTORIC DISASTERS

Page 5: Lessons Learned from Disasters in UK Rail

CSRE Limited

Disaster Timeline, 1830 - present

• Since the birth of passenger railways in 1830, disasters have plagued the general safety record

• Railways are, and have always been far safer than road travel, however, public service responsibility gets in the way and distorts the facts

• Presentation will show that whilst the number of accidents has remained pretty constant, the number of deaths has dropped substantially

Page 6: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d15th September 1830First Passenger serviceFirst fatal accident!

Page 7: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1840s to 1860sRailwaymania!Rapid growth, but little or no signalling or safety in general

Page 8: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1870s to 1900sContinued growthInvention of fixed signalling with interlocking

Page 9: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1914 to 1919First World WarMassive troop movements by rail, shortage of trained staff

Page 10: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1920s and 1930sTechnical advances in train designReplacement of wooden bodied cars with steel bodied cars

Page 11: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1940s and 1950sSecond World War bomb damagePost war austerity, plus shortage of trained staff

Page 12: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1960s and 1970sFurther technical advancesDevelopments in safety systems, improved car body strength

Page 13: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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d1980s to presentImproved crash worthinessMovement towards risk-based Safety Management Systems

Page 14: Lessons Learned from Disasters in UK Rail

CSRE Limited

3. THE TREND TOWARDSA SAFER RAILWAY

Page 15: Lessons Learned from Disasters in UK Rail

CSRE Limited

Statement.

Improvements in safety are usually the result of a

catastrophe.

Discuss.

Page 16: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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Shipton-on-Cherwell, 1874

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Page 17: Lessons Learned from Disasters in UK Rail

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Shipton-on-Cherwell• Train derailed, carriages fell from bridge;• Railway Inspectorate inquiry held, finding: -

– Old design of cast iron wheel, fractured;– Poor brake system design, the engine only

braking with the weight of the rear coaches crushing the front ones;

• Led to: -– New design of wheels, much more durable;– Through train braking on all passenger trains.

Page 18: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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Quintinshill, 1915226

Page 19: Lessons Learned from Disasters in UK Rail

CSRE Limited

Quintinshill

• Three trains collided and burst into flames;• Board of Trade inquiry held, which found: -

– Old wooden carriages used because of shortages;– Signaller, who had worked long hours changed shift;– Signallers (2) sent to prison for manslaughter.

Page 20: Lessons Learned from Disasters in UK Rail

CSRE Limited

UK Train Accidents – 1830 to 2010

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Harrow & Wealdstone, 1952112

Page 21: Lessons Learned from Disasters in UK Rail

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Harrow & Wealdstone• Three trains collided, many cars crushed;• Railway Inspectorate inquiry held, finding: -

– Signals passed at danger (SPAD - reasons unknown, both driver and fireman killed);

• Led to: -– Introduction of Automatic Warning System

(AWS), preventing uncontrolled SPADs

Page 22: Lessons Learned from Disasters in UK Rail

CSRE Limited

So, the answer is yes!

• Accidents, and the detailed post accident investigations led to: -– Through train braking being introduced;– Cast iron wheels being replaced;– Wooden carriage bodies being phased

out;– Automatic Warning System (AWS) being

developed and introduced.

Page 23: Lessons Learned from Disasters in UK Rail

CSRE Limited

4. RAIL PRIVATISATION –LOSS OF CONTROL

Page 24: Lessons Learned from Disasters in UK Rail

CSRE Limited

Rail Privatisation – Loss of Control

• UK railway system privatised in 1993/4;• British Railways replaced by: -

– Twenty five passenger operators;– Four freight operators;– One infrastructure controller;– Three train leasing companies;– A mass of services companies.

82 companiesin total!

Page 25: Lessons Learned from Disasters in UK Rail

CSRE Limited

Fatal accidents – 1980 to present

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Privatisation

Polmont, 1984

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Page 26: Lessons Learned from Disasters in UK Rail

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Polmont• Train derailed after hitting cows on line;• Independent public inquiry held, finding: -

– Low axle load on leading vehicle in push-pull train caused derailment;

– Driver could not see an adequate distance in front of the train.

• Led to: -– Minimum axle load limits on leading vehicles;– Mandatory high intensity headlights.

Page 27: Lessons Learned from Disasters in UK Rail

CSRE Limited

Fatal accidents – 1980 to present

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Clapham Junction, 1988

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Page 28: Lessons Learned from Disasters in UK Rail

CSRE Limited

Clapham Junction• Three trains collided, many cars crushed;• Independent public inquiry held, finding: -

– Defective signalling following maintenance the root cause of accident;

– Poor crashworthiness in cars led to many deaths.

• Led to: -– Improved crashworthiness in new designs and

ultimately replacement of more than 1000 cars.

Page 29: Lessons Learned from Disasters in UK Rail

CSRE Limited

Fatal accidents – 1980 to present

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Ladbroke Grove, 1999 31

Page 30: Lessons Learned from Disasters in UK Rail

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Ladbroke Grove• Two trains collided at junction;• Independent public inquiry held, finding: -

– Inexperienced driver, passed signal at danger;– Serious procedural failures on the part of

operators, infrastructure controller and safety authority.

• Led to: -– Complete revamp of railway safety management,

establishing current working systems.

Page 31: Lessons Learned from Disasters in UK Rail

CSRE Limited

5. CULLEN –REGAINING CONTROL

Page 32: Lessons Learned from Disasters in UK Rail

CSRE Limited

Cullen – Regaining Control

• Following a series of serious accidents in late 1990s;• UK Government ordered public inquiry;• Lord Cullen appointed as chair;• Report from inquiry made important recommendations

relating to safety management, most of which were implemented;

• Present safety management regime resulted, with an outcome of very low levels of fatal train accidents.

Page 33: Lessons Learned from Disasters in UK Rail

CSRE Limited

The Present – Stable Structure

• UK rail system remains privatised, with many players;• Safety management regime is stable and well

understood;• Checks and balances in the various organisations

ensure openness when an incident occurs;• Very few deaths now occur in UK railway system as a

result of train related accidents.

Page 34: Lessons Learned from Disasters in UK Rail

CSRE Limited

The Present – Stable Structure

Sets standard

s

Ensures complian

ce

Investigates

accidents

Page 35: Lessons Learned from Disasters in UK Rail

CSRE Limited

7. CONTINUOUSIMPROVEMENT

Page 36: Lessons Learned from Disasters in UK Rail

CSRE Limited

The Present – Stable Structure

Page 37: Lessons Learned from Disasters in UK Rail

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Fatal accidents – 1980 to present

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Ufton Nervet, 2004

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Page 38: Lessons Learned from Disasters in UK Rail

CSRE Limited

Ufton Nervet• Car driver decided to suicide at level crossing,

causing derailment at 200 km/hr;• RAIB investigation held, finding: -

– Car driver maliciously caused derailment, which was unavoidable.

• Led to: -– Most deaths and serious injuries caused by

people being ejected through broken windows. RAIB recommendation that all new trains have laminated glass in all passenger windows.

Page 39: Lessons Learned from Disasters in UK Rail

CSRE Limited

Fatal accidents – 1980 to present

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Page 40: Lessons Learned from Disasters in UK Rail

CSRE Limited

Grayrigg• Pendolino derailed at 155 km/hr, some

vehicles rolling down embankment;• RAIB investigation held, finding: -

– Defective points were root cause of derailment, due to poor maintenance.

• Led to: -– Only one fatality, in an extremely serious crash,

as a result of all recommendations previously made having been implemented, including laminated glass, which saved many lives.

Page 41: Lessons Learned from Disasters in UK Rail

CSRE Limited

8. SUMMARY

Page 42: Lessons Learned from Disasters in UK Rail

CSRE Limited

Summary

• Accidents have always happened from time to time, and probably always will;

• The best we can hope for is to learn from an accident and feed what we learn into future engineering designs and working procedures;

• An open approach, involving independent organisations that work in partnership with common goals has drastically reduced the number of deaths as a result of train accidents.

Page 43: Lessons Learned from Disasters in UK Rail

CSRE Limited

THANK YOU!Questions & Answers