annual occupational health railway conference 2008 the work of the raib; emerging safety themes...
Post on 20-Jan-2016
216 Views
Preview:
TRANSCRIPT
Annual Occupational Health Railway Conference 2008
The Work of the RAIB; emerging safety themes
Carolyn Griffiths
Chief Inspector
Rail Accident investigation Branch UK
Part 1:What is the Rail Accident Investigation Branch UK?
Why was the RAIB established? How was it established? Organisation The investigation process
Part 2: The story so far
Some case history
What is the RAIB?
The independent railway accident investigation organisation for the UK
Reports to Secretary of State for Transport
Sole purpose to improve safety of railways and prevent further occurrences. Does not apportion blame or liability, nor enforce law or carry out prosecutions
Lead Party in rail accident investigations where there is no evidence that serious
criminal action is the cause
Operational for two and a half years
What is the RAIB?
Scope of responsibility Geography Types of railway Types of Accidents and Incidents
RAIB’s geographical area
Which railways are covered by the RAIB?
The RAIB will investigate accidents and incidents on…
Mainline
All operations by passenger and freight train operating companies
Metros
Including London Underground, Tyne and Wear Metro, Docklands Light Railway, Strathclyde Metropolitan Railway
Tramways
in England, Wales and Northern Ireland
Heritage Railways
with a gauge above 350mm
Cable-hauled Systems
of 1km or longer
Derailments or collisions which result in or could result in…
The death of at least one person
Serious injury to five or more people
Extensive damage to rolling stock, infrastructure or the environment
Or any other accident which, under slightly different circumstances, could have the same consequence
Discretion, to investigate other accidents or near misses based on: How serious the incident is; and The likely safety lessons to be learned
What type of accidents will be investigated?
What type of accidents will be investigated?
The RAIB will not investigate…
Worker accidents
/near misses unless involving train movements
Trespass or suicide
Why was the RAIB established?
Why was the RAIB established?
Major accident (Ladbroke Grove) 1999 ; 31 fatalities, 400 injured
• Public Inquiry recommended establishment of national rail accident organisation, independent of:
Government Safety Regulators Prosecutors incl. police All industry parties
Then…in 2004 European Rail Safety Directive Required Member states to establish an independent accident investigation by April 2006
Organisation design, recruitment and training
Dukes Court, Woking, Surrey The Wharf, Derby
How we investigate: Working with other parties
Other parallel investigations:The need for clear and sharing of evidence
RAIB
Safety Investigation
HMRI, DRDNI, Duty Holder
Enforcement of safety legislation
Police
Criminal Prosecution & Sudden Death Investigation
RAIB leads the investigation unless:
How does this work?
There is evidence that a criminal act caused the accident/incident
Criminal investigation normally will take precedence (eg terrorist incident or vandalism)
Police and the RAIB are required to agree if the Police investigation is to take precedence
The RAIB will still have access to the site and evidence, and may still conduct a safety investigation
RAIB recommendations formulated with industry input
RAIB is advised by the Safety Authority of industry parties intent
The industry parties notify the Safety
Authority their intent to
implement.
The Railway Industry has a
duty to consider the recommendations
Safety Authority ensures ALL relevant industry
parties are informed of the recommendations.
RAIB publishes report, sends to those involved
How do RAIB’s recommendations affect the industry?
Experience so far…..
Largest investigation so far
86 Completed; 33 Current Investigations
37 % : Train Derailments
13.25 %: Level Crossings
13.25 %: collision (with a train/or other object)
10.25 %: staff hit by trains/near misses
5.75 % involve runaway incidents
4.25 % unauthorised train movement
4% train door incidents
3.5 % involve Spads
2.5 % fire on Rolling stock
2.5 % train defects
2.25 % involve Unsafe loads
0.75 % involve Possession Issues
0.75 % electrocution
So why DO accidents happen? Examples….
Brentingby, 09.02.06: Driver fatigue
Runaway trolleys/road rail vehicle
Brentingby: 09.02.06
Brentingby: 09.02.06.
Cause: Driver had microsleep(s) and passed signal at danger
2 early shifts (shortened sleep?); rest day ( consumed 5-6 pints of beer) ; night shift- accident after 22 hrs awake.
Main task in 2nd half of shift Arrived early for work No check for fitness on signing on Briefing on fatigue did not deal with first night shift
issues
Brentingby: 09.02.06.
Recommendations: Operator to consider planned napping +facilities- if shift
pattern requires Research most effective sleep pattern when changing from
day to night shift. (Aware of research carried out in the USA)
Investigate feasibility of screening for sleep disorders Guidance for drivers on lifestyle to suit shift working
incl .preparation for first night shift. Include families where possible
Review checking for fitness for duty when ‘signing on’
Larkhall
Brakes - Larkhall
Notting Hill Gate
Notting Hill Gate
Brentwood
Risks…….
Trolleys are not wheel barrows – can carry 2T of rail Incident of one laden trolley runaway onto running rail- by luck operated track circuits and stopped approaching
trains
Road rail vehicles can present risk even though they should operate at slow speed (walking pace in possession) One road rail ran 7 miles, 3miles out of possession,
Runaway trolleys/road rail vehicles
Lack of gradient information in risk assessing the work 2 trolley incidents, 2 road rail incidents
Loss of adhesion due to contamination 1 Trolley incident 1 road rail incident
No adequate on-site functional test 2 trolley incidents
Speed of operation 1 trolley incident 1 road rail incident
Unauthorised alterations brake blocks - Larkhall brake linkage Notting Hill Gate tyre pressure- 2 road rail incidents
Approvals process All road rail and trolley incidents?
Are we making a difference?….
120 investigations; 86 published 83 investigations on Mainline network (2 in the Channel Tunnel) 16 on LRT/trams 14 on Heritage systems 7 on Metro Systems
497 recommendations Circa 95% acceptance
How do we measure up?Survey of stakeholders incl.: those we investigate and those we might investigate
@ senior level @ working level
unions other investigators such as the police and safety regulator
Positive outcome Quality of investigations and reports Interface with industry Highly rated organisation w.r.t. selected similar organisations in UK
But we are constantly trying to develop our capability further………
What’s on the RAIB website?www.raib.gov.uk
Accident NotificationWhat to notify: How to notify: Forms and Guidance
About UsHistory: Formation: Organisation: Powers: Contact
PublicationsInvestigations register: Reports: Safety Advice
NewsMedia notices released by the RAIB: Media contact details
LibraryDownloadable leaflets and information on legal framework
‘People need to know that accidents have been thoroughly investigated and that actions have been take so they don’t happen again
That’s what we do…’
Thank you
top related