A ‘Modern Railways' investigation by Roger Ford
It has been calculated that the 11,500 drivers on the Railtrack network collectively see in excess of 10million red signals during the course of a year. In the year to 31 March 2000 , the total number of Signals Passed At Danger where the driver was responsible (Category A) fell to 595 – an all time low since records began in 1985.
Of this total only 30 were Categories 4-8 (Table 1) and of these only half occurred on passenger lines. But, as we all know, one of those 15 passenger line SPADs resulted in the Ladbroke Grove collision.
A failure rate of around one in 17,000 red signals observed, is an impressive demonstration of the reliability that can be achieved. Sir David Davies has calculated that statistically a driver will cause one SPAD every 17 years, or perhaps twice in a career.
But such performance had a dangerous downside. If you study the history of railway signalling technology you will see a constant process of stable doors shutting as the signal engineers sought to prevent the signalmen from making mistakes. But this entire edifice of interlockings and fail safe relays balances on the perceived ability of a small group of men on the footplate to make the right decision every time.
Sadly, the human condition means that perfection will always elude us. One authority claims that airline pilots average two mistakes per flight.
Back in November 1988 that eminent signal engineer Tony Howker presented a paper to the Institution of Railway Signal Engineers (IRSE) with the title Have we forgotten the driver? The message of the paper was simple. ‘There is no doubt that the lot of the signalman has been improved, but it is suggested that the locomotive driver who relies upon the signalling system for his instructions and safety could well argue that signal engineers have not given the same consideration to his lot and well being'.
Tony Howker is an inveterate footplate rider and his paper considered signalling as seen from the cab. Discussing overlaps, flank protection and the modern predilection among civil engineers for single lead junctions, he wrote, ‘The simplification of so many layouts and the widespread introduction or reversible operation means that trains travelling in opposite directions are no longer segregated to the same degree. Opposing movements now cross paths and approach one another without comprehensive means of directing them apart during both normal and emergency operations'.
Thus, not only had the driver been forgotten, simplification of track layouts and bi-directional working had made the outcome of any error potentially more serious. Howker saw only one logical outcome from his analysis, the installation of Automatic Train Protection.
Yet, when I discussed his paper with senior railway managers, I met incomprehension. Where was the problem? All the driver had to do was obey the signals, a simple task. And railway management has tended to treat SPADs as sins of commission, rather than omission.
We see this in the media where reporters talk of train drivers ‘running' or ‘jumping' red signals, the terminology used when a car driver nips across the lights as amber turns to red. But anyone who has been on the footplate and experienced a Category B SPAD, when a signal turns against you at the last moment, will know what cold fear is. It is particularly chilling if the incident occurs on curving track and you cannot see whether death waits round the bend.
No one SPADs intentionally. The four classifications of error type are: disregard, iscommunication, misjudgement and misreading.
Table 2 shows the causes of SPADs in 1999/00, both for all events and those in Category 4-8. A comparison highlights the large number of minor SPADs which can be attributed to mistakes, rather than inattention or other faults. And, as this was being written there were two SPADs, at Filton Bank and Virginia Water, where trains were unable to stop at red.
Such differentiation may seem contentious, but I would suggest that there is a difference between misjudged braking, or being caught out by unexpectedly low adhesion, which sees a train slide past the red signal by a few yards, and gross error where a signal is disregarded. Table 3 supports this view, and in several of the September major SPADs four drivers over-ran by over half a mile before, apparently, realising that they had SPADed or being stopped.
French Railways use just such a categorisation. A ‘mistake' may result in refresher training for the driver, or more frequent monitoring of his performance. A ‘fault' leads to disciplinary action and perhaps withdrawal from driving.
At which point readers should note that in July 2000, Her Majesty's Railway Inspectorate modified the definitions for SPADs (Table 2).
First, a surprising omission was rectified by identifying SPADs which kept within the overlap. Second, Severity 3 was amended to reflect the potential seriousness of over runs outside the overlap and longer than 200 yards, even if a collision did not ensue. If we take the new Level 3-8 Severity as the indicator of serious SPADs, the 30 events in 1999/00 mentioned above become 182.
If you study Table 1 you will see that a wide range of what might be called ‘driving and handling errors' each contributed small percentages of the total SPADs, for example 9% were down to misjudgements of train behaviour or environmental conditions. The two major causes were failure to check signal aspect and failure to react to a caution signal.
Now look at the same analysis for Category 4-8 SPADs. Failure to react to caution signal does not register – presumably because the danger signal was observed, a full brake application was made and the overlap contained the over run. This will be rectified with the new Severity 3-8 yardstick.
On the other hand 37% of Severity 4-8 SPADs were down to failure to check signal aspect, the causes of which could range from momentary inattention to distraction caused by a high cab workload.
|All SPADs Severity||4-8*|
|Anticipating signal clearance||5%||3%|
|Failure to check signal aspect||16%||37%|
|Failure to locate signal||7%||3%|
|Failure to react to caution signal||24%||0|
|Ignorance of rules/instructions||1%||0|
|Violation of rules/instructions||6%||10%|
|Wrong information given||1%||0|
|Ambiguous or incomplete information||2%||0|
|Correct information misunderstood||1%||0|
|Viewed wrong signal||5%||13%|
|Viewed correct signal/misread aspect||4%||0|
|Misread previous signal||1%||0|
|Misjudged train behaviour||4%||0|
|Misjudged environmental conditions||5%||0|
|None of the above||2%||0|
|Not yet categorised||18%||33%|
See Table 2 for definitions
A Definition applied to incidents up to 1999/2000
1. Overrun 0 - 25 yards, no damage.
2. Overrun 26 - 200 yards, no damage.
3. Overrun greater than 200 yards, no damage.
4. Track damage, no casualties.
5. Derailment, no collision, no casualties.
6. Collision (with or without derailment), no casualties.
7. Injuries to staff or passengers with no fatalities (including driver absence consequent upon trauma, without actual physical injury).
8. Fatalities to staff or passengers.
Revised definitions from July 2000
0 Not entered
1 Overrun 0 - 25 yards, overrun not exceeding overlap , and no damage, injuries or deaths.
2 Overrun 26 - 200 yards, overrun not exceeding overlap , and no damage, injuries or deaths.
3 Overrun greater than overlap plus all overruns greater than 200 yards and no damage, injuries or deaths.
4 Track damage only with no casualties.
5 Derailment with no collision and no casualties.
6 Collision (with or without derailment) and no casualties.
7 Injuries to staff or passengers with no fatalities.
8 Fatalities to staff or passengers.
Now the old guard managers insisted, and the media still believe, all the driver has to do is obey the signal. The trouble is two million years of evolution as hunter gatherers on the African veldt have not suited us genetically for recent tasks like driving trains.
Time for a personal interlude. We were driving back at night from an event in Surrey and had to navigate Guildford to get back onto the M25. Guildford 's road signing is not good and the ‘cockpit workload' was high.
At a left filter I was busily scanning for road signs. Then, as we drove up the desired motorway slip road Mrs Ford remarked, ‘didn't you see that red light?' No, I had been so focussed on navigating, that I had missed the red traffic light in the filter road and SPADed.
This may seem an oversimplification, but there are cases in aviation of pilots concentrating so hard on a problem that low fuel warnings were ignored until the engines stopped.
My Guildford ‘SPAD' occurred when I was alert and concentrating hard. How much easier for a driver whose shift breaks up normal sleeping patterns.
Take, for example, the SPAD at Old Oak Common in June 2000 which involved an overrun of approximately 1000 yards. The proximate cause was the failure of the driver of the Heathrow Express to locate the signal.
But the potential for an accident had been compounded by the failure of the driver to set up the cab secure radio (CSR) correctly. Thus the driver could not receive the emergency stop message from the signaller at Slough .
All very unprofessional. But the investigation revealed that the driver had had very little sleep during the 48 hours preceding the SPAD. Also, the train been routed from the Traincare Depot via Reception Line 2, which contained the SPADed signal, rather than the usual route via Reception Line 1. Thus, tiredness was combined with a raised workload from travelling over a strange route.
There is a vast amount of human factors work being done on the performance of drivers, pilots and other people in jobs involving shifts and long hours. And there are no comforting solutions.
Our body clocks still tick away with the rising and setting of the sun and, as shown in the Old Oak SPAD, sleep depravation impairs the brain's performance. An Australian study has equated the effects of 22 hours of sustained wakefulness to a blood alcohol level of 0.08%, around the limit for road users. The DETR has proposed 20mg of alcohol per 100 ml of blood as the limit for civil aviation personnel
In the early hours of the morning, in particular, our clocks run down and several studies have shown the propensity for human error increasing in the hours after midnight . A US Federal Railroad Administration study showed that between 04.00 and 06.00 a driver was 15-16 times more likely to SPAD than between 18.00 and 19.00.
A study of road accidents in the UK showed similar results, with a peak around 02.00-03.00. Ships have a greater tendency to run aground at the same time of night
There is another factor that researchers have discovered. We are more likely to make mistakes between 2 and 4 hours into a shift.
An analysis of British Rail data for the years 1985-92 showed that the number of SPADs per million driver hours increased from around 10 at one hour into the shift to between 25 and 35 (depending on business sector) three hours into the shift, declining to 15-20 after five hours.
These are management and human factors issues which will have be covered another the time, since the focus of this investigation is the driver as a professional.
In the face of man's physiological unsuitability for the task of train driving on the 24 hour railway, an important defence is conscientiousness, or, as they call in aviation and the military, professionalism. If you are taught to do things properly as a matter of routine you are more likely to do the right thing when tired or under stress.
Over the years the task of the driver has been deskilled. The steam locomotive driver was also maintainer and the ‘engine management system', using the controls to optimise performance. There was also team work with the fireman to ensure there was adequate steam pressure at periods of high demand. It was a complex job.
With the arrival of diesel and electric traction, in Britain , at least, this expertise and the tendency among drivers for self improvement, was discarded by railway management. In the new boxes on wheels you had a lever for ‘go' another for ‘stop' and everything else was out of the driver's control.
When I took the late Cecil J Allen on a Deltic footplate for the first time, he was fascinated by the fact that maximum starting tractive effort was time limited, He wrote at length on this characteristic, even though I can't remember it having been an issue. For Cecil J, here was this mighty loco that needed a skilled driver to extract the best performance just like steam traction.
In pretty well every form of transport today the driver/pilot is an observer for much of the time, while clever computers and auto-pilots do it all for you. If I accelerate hard in my car on a wet road and the wheels spin, the torque is reduced automatically until the wheelspin stops and I move away as fast as the coefficient of friction allows.
This may, of course, be getting me into trouble faster than if I were controlling wheelspin directly. And as we have seen some of the new all electronic aeroplanes are very unforgiving when pilots take them into unexpected corners of the performance envelope.
Compounding the ‘stop/go lever' approach was the ‘driver as idiot' mentality among management. At English Electric in the 1960s we regularly received letters from drivers along the lines:
‘Dear Sir, we have recently taken delivery of your new locomotives at my depot. Management won't tell us anything about them, do you have a manual or users guide?
In fact, in 1963, British Rail published‘Diesel Traction, manual for enginemen' which was one of the best and most accessible general primers on the subject ever published. But it was sold for £1.50 at a time when I, as a Managing Director's dogsbody was earning £15 a week.
Another example of ‘Driver as idiot' came in the 1980s when IC125 power cars were overheating in the hot summers, boiling-off their coolant and blowing the cylinder head gaskets of their engines before the low water level protection device could operate.
There was a simple solution, well simple to me. ‘Why not', I asked a BR engineer, ‘fit a temperature sensor in the header tank of each power car and fit temperature gauges in the cab. Then if there was overheating the power could be notched back'?
‘No, we couldn't let them do that', was the reply. The fact that the drivers' own cars had temperature gauges was not considered relevant.
Just to show that these attitudes are not outdated, there was a conference on the Train Protection & Warning System in March 2000. A speaker explained that in the case of freight trains eight braking rates are possible depending on the combination of traction and rolling stock.
Theoretically, the TPWS on board equipment could be set to match each of these braking rates. ‘But', we were told. ‘this depends on the driver so there will be just two settings'. This clearly has the effect of reducing line capacity, since one setting has to be the lowest braking rate.
Interestingly, later in the conference we were shown the cab display (Man/Machine Interface in newspeak) for ETCS with a range of warning signs and driver aids, including a ‘braking bar' which showed the optimum braking rate and changed colour if the driver was braking too hard.
It was irresistible. ‘On the one hand', I put to the panel, ‘we can't trust drivers to know what loco and rolling stock they are driving, on the other they are expected to be able to use this sophisticated display. Thick as a brick, then or really bright'? There was no answer and none had been expected.
But outwith the driving task, the driver retains responsibility for the technical performance of the traction in his charge. And in today's climate a train which ‘sits down' on the West coast Main Line or in Waterloo throat until fitters arrive will cost the operator dear.
At the same time, today's traction has unprecedented diagnostic facilities which, to a certain degree, get over the problem of remembering how to deal with a fault that you last encountered five years ago.
A driver in a Virgin Pendolino will be in charge of a £10million high tech train, with some interesting procedures to follow in the event of problems. This suggests that recruitment should be aiming for candidates at the right hand side of the intelligent bell curve.
At that same seminar, several people commented that setting up TPWS timers in general was difficult ‘because we don't know how drivers drive'. To which the obvious answer must be ‘the way they're taught'.
L487 – a case history
L487 is a signal on the Great Eastern's down electric line approaching Shenfield. Since November 1993 it has had had 16 SPADs.
Located on a tight left hand curve, the four aspect signal is approached on a rising gradient until 300 yards where the gradient changes to 1:151 falling. But an optical illusion gives the impression that the gradient continues to rise to the signal. Most trains stop at Brentwood and then accelerate towards L487 up the rising gradient.
With such a SPAD record a series of mitigating measures were taken. Remarkably, all the actions listed below had been implemented before the last SPAD at L487 in November 1999, although by only 3 yards.
L487 remedial measures
January – signal reminder sign
December Count down markers
February – Sectional Appendix –leaf fall risk area
– notified as multi-SPAD signal
June – Personal letter to all First Great Eastern drivers
September – Vegetation clearance
October – Briefing included in ‘Red Alert' SPAD newsletter
March - SSI data change
June AWS magnet painted yellow
October Chain link fence installed to collect leaves
October – mulch mat laid
November – gradient boards renewed
Signal head raised 5m
Banner repeater installed
Consecutive double yellow sequence removed.
Here we start to get into controversial territory because there seem to be a number of free spirits among the driving community who do it their way. Look for example at the saga of Signal L487 in the box and the growing list of remedial measures. Yet the train operator found it difficult to get drivers to accept that they had responsibility for not SPADing this signal
But, the same operator put all its driver managers through course on accident investigation and root cause analysis. This resulted in ‘a tremendous step forward'. Managers understood the factors that determined good driving and were able to identify what was needed to improve the performance of particular drivers.
From this work it emerged that some drivers, despite extra tuition could not be relied on to drive competently and suffered SPADs. Four drivers were dismissed as a result.
Since these drivers had presumably been through the BR developed aptitude tests and worked for a TOC that is noted for its professionalism, one wonders how they came to be passed driver in the first place. Or what message their lack of professionalism gave to younger drivers.
Or, take the simple, or so we thought, case of the Drivers Reminder Appliance which was intended to prevent drivers starting against signals after station stops. On stopping at the station with a red departure signal the driver pushes a red button which isolates traction power and is illuminated red. To start, the button has to be released.
But what happens? Thames Trains start training drivers to use it at single yellow signals on the mover. In parallel other drivers think that's a good idea too.
Other TOCs tell drivers to use it at all red signals, not just station stops. At one TOC the drivers started pressing the button as they braked for a red signal – which played merry hell with rheostatic braking, since this is cut out when the button isolates the traction.
Driver training and selection is currently the responsibility of individual TOCs, Virgin runs its Millennium Drivers training business. It seems clear that there needs to be a common approach to driver training.
Different operators have different requirements, from ‘round the houses' suburban , to 125 mile/h main line to heavy haul freight. But there must be a basic training period, with set subjects covered, including train handling, rudimentary traction knowledge and the rule book, operational procedures and communications.
This would lead to a test of competence by an independent examiner leading to the issue of a licence. If, as is likely, we get a National Rail Safety Board (NRSB), examining and licensing of drivers should be one of its first tasks
After all, if you learn to fly there is a common syllabus across Europe . For example, in exercise 4a the student is shown the effect of the flight controls and carries out the manoeuvres. Lesson 19 Part (iii) covers making turns on instruments and so on.
All this is in a manual you can buy and there are companion volumes of use of radio, navigation and the technicalities of aircraft. There is even a book of ‘patter' for instructors which gives the approved form of words and actions to be used for each lesson in the air.
So by the time someone has their flying licence, with a minimum of 45 hours flying time, there is every likelihood that they have been taught properly and can fly on their own.
Being taught properly is very important because bad habits will return to bite you in moments of stress. It is called ‘reversion'. Hence the need for syllabus and the patter, which means that those who instruct drivers must themselves be assessed after undergoing a course on what and how to teach.
Thus, the basic licence would allow a driver to take out, say, commuter and regional services or freight up to a certain tonnage, subject to route knowledge and detailed traction handling and fault finding. The basic licence could be endorsed for InterCity or Heavy Haul, Eurostar or Tilting trains subject to more training and a further exam.
Currently, simulators are being promoted as the ‘new thing' in driver training. But their main role should be in fault finding and rectification, route familiarisation and periodic checks of competence – something else the NRSB should introduce - rather than learning to drive as such.
For example, a simulator is the ideal way to refresh drivers on little used routes out of busy stations, allowing instructors to highlight signals with minimum sighting times. There is one caveat, the procedures followed, including taking over the ‘train' must accurately reflect real life if the driver is not to get into bad habits and start driving 400 tonnes of train like a computer game.
Professionalism is a two way process and currently, there is a tendency to give the driver the ‘right away' after which it is simply a case of following the path the signaller has set while looking out for signals.
At complex station layouts drivers should be notified of which path they will be taking for arrivals and departures. One of the hairiest arrivals in civil aviation was the old Hong Kong airport with its dog leg approach low over the city. But it was safe because the pilots recognised it was hairy, airlines had strict rules for experience and training before pilots could fly in, and cockpit crew were hyper alert.
Ladbroke Grove revealed among other things, that there were no recently issued track diagrams of Paddington station's complex approaches and that train crew passed around their own sketches which, one railway manager claimed, might be preferable to printed sheets since if you drew it yourself you probably understood it better.
This is the antithesis of professionalism. Drivers should carry a set of plastic covered track diagrams for the major stations on the routes for which they are passed. This could have down one side a list of the arrivals and departure routes than can be set, suitably coded.
Then, when the route was set before departure, the signaller could call the driver, specify the route and identify any potential problems. With the driver knowing where he was going, the cab workload (see my Guildford SPAD) would be much lower. Such illustrated diagrams for complete routes have been used on American railroads for some time.
In any event, letting the driver get on with it between stations will no longer be tenable if the much vaunted ‘Japanese' operation is to be introduced. Passing times will have to be kept more accurately, which means individual schedules on the driver's desk and an accurate clock in each cab.
An evening spent at Welwyn North studying traffic flow through this ‘bottleneck' showed that the ‘top link' men of the GNER were running with notable precision, hitting their passing time to the half minute. Personal experience shows that WAGN drivers on suburban duties are less precise. Yet to get maximum capacity, every train in the timetable has to run like clockwork. Professionalism again.
Some drivers now complain that the job has become boring since privatisation created smaller TOCs and removed the variety of the daily turns. The prospect for promotion within the line of seniority has also gone and with it the top link man as role model. Perhaps one way to make the job more interesting is to make it more demanding from the point of view of timekeeping, as is the case on some European railways.
In its response to the Heathrow Express SPAD already mentioned, the HMRI required the operator to ensure that the CSR is set up ‘at the first available opportunity'.
This seems to be carrying attitudes to the low safety criticality of radio, already outdated in the 20 th Century, over into the 21 st . Unless the driver can set up the radio and establish contact with the signalling control centre, the train should not enter service.
With the European Train Control System depending on safety critical digital radio (GSM-R), a revolution in train radio communications is in sight. A major opportunity would be missed if this were restricted to trains running on the ETCS fitted high speed main lines.
While it is not suggested that drivers of round the houses suburban trains should report leaving every station, notification that the train was ready to leave at the start of a working and arrival at the end of the run should be encouraged. This would ensure that drivers were using radio and the correct procedures several times a day.
Nor can the industry afford to delay decisions on the future use of radio. While the first Network Management Centre (NMC) at Birmingham is running late, and Railtrack seems to have cooled on its original plan to concentrate control of the network within 11 NMC, emergency procedures should be under development now.
How, for example, will the NMC controller deal with a SPAD? With open channel and routes divided up by frequencies, an emergency code could be broadcast stopping all traffic.
If the driver is to be brought into the control ‘loop', railway communications must be transformed. Today's communications are based on the ‘driver as idiot' who cannot even be trusted to report the position of his train accurately.
Thus there is either the Signal Post Telephone, with its unambiguous location, or Cab Secure Radio which goes to extraordinary lengths to identify each train uniquely.
Meanwhile, airliners are flying into Heathrow at 90 second ‘headways' using open channel radio – that is, where anybody on the frequency can transmit and receive. But, just as each aircraft has a transponder that ‘squawks' an identification code, so each train has its unique running number stepped along the track berths on the signaller's panel by the train describer.
Open Channel radio is heresy in railway communications, and it has had a poor record. In the United States there were examples of radio assisted collisions when the system came in. But it works elsewhere.
Once again, it is lack of professionalism that is the problem. As Stanley Hall records in Hidden Dangers, the complexities of the National Radio Network was unable to cope with the derailment at Ais Gill and prevent a collision.
Quoting Hall, after the driver of the derailed train had pressed the emergency button on the NRM set in his cab, the conversation with the Control Office at Crewe went as follows.
Driver ‘Blea Moor to Carlisle , derailed blocking both road. Can you stop the job between Kirkby Stephen and Blea Moor'.
Control: We'll arrange all that, driver. Over and out'.
Note, no formal warning of an emergency, no standard ‘patter', no repeating of the message back and the railway colloquialism ‘stop the job'. Now you may think that I am being unkind, that here were two railway blokes unused to radio. But blokes can be trained to use correct R/T procedures and railwaymen have traditionally been good at ‘doing it by the book'.
For another example of poor R/T procedure we turn to the ‘mate' railway and the fatal accident at Glenbrook , New South Wales in December 1999. An electric multiple unit ran into the back of the Indian Pacific.
At the inquiry it was stated that the EMU driver was told by the Controller that the signal in rear of the Indian Pacific was red ‘but it's on auto so trip past it'. When the driver called up again from a station and asked ‘I'm right to pass it am I', the signaller replied ‘Yeah Mate, you certainly are'. He wasn't, the Indian Pacific was still in section.
In his inquiry Justice McInery was critical of ‘the undisciplined and colloquial way important matters relating to rail safety were communicated'.
Railway Safety has begun a major work programme on safety critical communications (Safety Report October 2000). It is a massive task in an industry with no culture of ‘patter'. Note that small percentage of SPADs in Table 1 down to failure in the transmission of instructions.
And yet, it can be done, British drivers with Eurostar have been trained to use the French Railways formal radio procedures which use standard phrases (<ital>dialogues formats<ital). Each procedure is identified by a four letter code. For example PUMA (Poursuite marche ), POTO (Pousse du Train) and COVO (Contre Voie).
My favourite is BEST (Divagation Bestiaux Entre Points Designes) which goes as follows, losing something in translation.
Controller: Train 9176. This is Control St Denis Over.
Driver: Control St Denis. This is Train 9176. Over.
Control: Prepare for procedure BEST.
Driver: Ready for procedure BEST. Over
Control: Order is given to driver of Train 9176 to drive on sight (en marche prudente) from km 92.6 to Km 96.5 between Lessart and Beuvraignes and report.
Reason: straying animals.
Order given to driver of train 9176 to drive on sight from km 92.6 to Km 96.5 between Lessart and Beuvraignes and report.
Reason: straying animals.
Message Number 725.
Message Number 725.
Driver: Will report back.
No scope for ambiguity there, although the detail contrasts strongly with the abbreviated communications between flight deck and air traffic control which seems to work even in three dimensions.
All of which brings us back to the driver when I can do no better than quote Gerard Fiennes in I tried to run a railway. In 1967, the 10.00 of Kings Cross was racing across the Vale of York at 80mile/h when a cloud of dust billowed across the slow and main lines. Almost immediately, a derailed cement wagon lurched into their path.
Driver John Evans ‘threw out all the anchors', even remembering to apply sand. Second Man Dennis Evans reached down to his bag, took out three detonators, opened the offside door of the cab so that it could not jam shut and braced himself against the door post: if he survived the collision he was ready to run up the track to protect the up line.
At the last moment, Evans threw himself across the cab before the 100 tonne wagon ripped the drivers side out of DP2 followed by the first six coaches in which seven passengers died. Evans and Smith survived.
‘These events', commented Fiennes, ‘make up one of the many reasons why railways must above all else cherish the Men of the Front End. They must select, train, discipline and turn them into Evanses and Smiths. It is the Front End only which positively gets us there safely, speedily, punctually and comfortably. All others stand aside or actively prevent us getting there'.
Make that men and women of the front end and Fiennes has got it just right.
(This article is dedicated to the drivers and pilots who have allowed me to observe their work at first hand.)
When the driver over runs a signal at danger after observing and obeying the signalling sequence correctly, reacting appropriately and making every effort to stop.
When the driver passes a signal at danger having been conscious of a signal (not necessarily the correct one) but having formed a wrong appreciation of what is required of him or her. This category includes both:
1)Reading the wrong signal (the less restrictive aspect of an adjacent signal) or ‘reading through'.
2)Misreading the aspect of the correct signal (the wrong aspect is registered in the driver's mind)
When a driver passes as signal at danger due to:
1)Disregarding the signal physically
2)Disobeying the meaning despite reading it correctly. This includes the important sub-category where the driver proceeds regardless of a signal aspect on the expectation that it will very soon clear(eg at approach released signals). Otherwise contravention may be due to ignorance or conscious violation of the rules.
3)Failing to react to cautionary aspects on approach to the signal passed at danger.
When ineffective communication between people contributes directly to the SPAD.
A fifth category, None of these, is used when an event does not fit the above definitions but a driver or other staff is involved.