In safe hands
PAUL STEPHEN meets RAIB inspector GRAHAM CLARK to find out how the Rail Accident Investigation Branch has been making our railways safer since 2005
F or as long as trains have been carrying passengers, there have been accidents. Indeed, we can go as far back as September 1830, when Liverpool MP William Huskisson became the world’s first railway fatality after being struck by George Stephenson’s locomotive Rocket, at the opening of the Liverpool & Manchester Railway.
It was a tragic demonstration of the dangers of standing on the tracks - from the very inception of this mode of transport.
If it had happened today, investigating the demise of Mr Huskisson would fall under the remit of the Rail Accident Investigation Branch (RAIB), which is a good deal younger than Stephenson’s pioneering train, having only become operational 11 years ago.
Prior to that, accidents were investigated by Her Majesty’s Railway Inspectorate, which later became part of the Health and Safety Executive. Now, those accidents are investigated by the nation’s railway regulator – the Office of Rail and Road.
The Cullen Report into the Ladbroke Grove rail crash of 1999 first mooted the idea of a new agency that was fully independent and complementary to the allied but much older Marine Accident Investigation Branch and Air Accident Investigation Branch.
RAIB’s task was to be properly objective, following justifiable criticism of the system it replaced, whereby the HSE – which had both regulatory and investigatory powers - could effectively investigate itself, in cases where it might be at fault for approving inadequate signalling or track layouts, for example.
The extent of RAIB's role is, therefore, to seek the truth and establish the facts. Crucially, however, it does not apportion blame or liability. Nor does it pursue criminal convictions. This caveat was deemed vital if investigators were to gather every possible piece of evidence. Witness anonymity was considered a necessary requirement to prevent key witnesses refusing to give evidence on the advice of legal representatives, for fear of incriminating themselves.
Under the legislation passed to create RAIB (the Railways and Transport Safety Act 2003), witness statements, names, addresses or even the fact they’ve been interviewed cannot be shared with third parties.
Although the ORR and British Transport Police are unable to access this information and must gather evidence from witnesses independently, all three parties co-operate heavily in other areas.
“You’ve got the industry itself, and health and safety law requires them to conduct investigations into accidents that affect their workforce at a basic level,” explains RAIB inspector Graham Clark.
“Then you’ve got the police, who must be involved if someone has broken the law, for example at a level crossing, where incidents often involve a violation of the law.
“You’ve also got the ORR, which will investigate when it thinks there has been a breach of health and safety legislation and may possibly bring charges. We are there for cases where there’s a lesson to be learned for public safety. We don’t carry out prosecutions (unlike ORR and BTP) - our aim is solely to prevent a reoccurrence, and not to apportion blame. If you think you have a claim against Network Rail for example, because you alone think there’s something wrong with a crossing, then it’s your responsibility to pursue the case.
“We have an understanding with ORR that we will work together. We will collect physical evidence and have primacy over that, but we will share that technical evidence with them. Typically, we’ll visit a level crossing and acquire data logger downloads, and the OTMR (On Train Monitoring Recorder) from the train and share all that information. We also have an understanding with the British Transport Police who usually get there before us and take photographs of the scene. We usually ask them to take photographs of certain things for us, and provide a really good set of images.”
Graham Clark is one of approximately 20 RAIB inspectors. The branch is headed by Chief Inspector Simon French, and is split over two sites at Farnborough and Derby. There are two principal inspectors at each site who each lead teams of four or five people. There is also a team of between two and four inspectors who are on call to respond to incidents at any time of the day or night, seven days a week.
The first point of contact is a duty co-ordinator, whose details are widely circulated to the industry. Typically, the first time RAIB will hear of an incident
is when Network Rail calls the duty co-ordinator from its national operations centre at Milton Keynes.
“When it comes to the team that goes on-site, the duty co-ordinator will decide what the response is going to be and who can get there quickest,” adds Clark.
“If it’s a long way away, or the railway needs to be re-opened quickly, then we can ask for an accredited agent to be present. These are people in the industry who we’ve trained. They’ll be identifiable by an RAIB armband and will know what to look for.
“They’ll go on-site first and will liaise with the duty co-ordinator, acting as our eyes and ears until we can get there. They’ll do stuff like secure the OTMR and make a note of weather conditions, and may even release areas of the site before we’ve even arrived.”
Clark is the most deployed of RAIB’s current crop of investigators, having attended 63 accident sites since he was recruited in October 2005. Like most of RAIB’s investigators, he worked for British Rail until the mid-1990s before continuing to work on the railways after privatisation.
He says that the number of accident investigations taking place at any one time isn’t consistent, but that the general trend has been a falling number of incidents in the 11 years since the formation of RAIB.
However, he’s quick to point out that his workload isn’t getting any smaller, as the initial site visit forms only a very small part of a far more comprehensive and detailed process of investigation.
“The output (of accidents) was seven or eight per year in the early days, but that’s down to one or two now and some people have gone for more than a year without going to an incident. I think we’ve become much safer - it was once quite common to be working on two or three investigations at the same time, but as rates have declined we’ve tended to work on them one at a time.
“You get an initial rush over the first couple of weeks when you’re collecting data and building a picture of what an investigation’s going to be like. You formulate your plan and then try to piece together a timeline of events. And it might be a lengthy timeline, spanning from when a particular bit of track was renewed or a train was built, to a much shorter one for the days leading up to an accident.
“You follow on from that into cause and analysis using recognised techniques that we’ve all learned on a three-year accident investigator course at Cranfield University. We follow that up using our own cause and analysis software that might throw up new lines of inquiry.
“You interview witnesses and other people as you find them and work your way up the tree – you start at the bottom, with the guys on the ground, and end up with the managers and some quite senior people.
“Generally, after three or four months we’ve got a pretty good picture of what caused it and how to stop it in future. Then we hold a final analysis review and get on with writing the report.”
Each RAIB report then goes through an exhaustive programme of review and refinement prior to publication. The first step is to present findings and recommendations to industry and key stakeholders for peer review and to gauge initial reaction.
Then the draft version of the report must go to ORR as the first stage of formal consultation.
“The report goes backwards and forwards quite a lot. ORR will look to see if the recommendations are ones it can enforce or not, so we might end up re-wording them. Then the draft can be distributed to everybody else involved, which includes what the regulations state as ‘anyone whose reputation may be impugned’. Typically, for a level crossing, that would be the train driver, car driver, crossing operator and NR and the TOC corporately – and they all get two weeks to comment on the report.
“Then we’d get the relatives (of the deceased or injured) in and give them a presentation and a copy of the report to take
away which, at this stage, is still marked as confidential.
“Finally, we address every individual comment and answer it. There’s an internal review process covering how much we’ve changed the report and only when that’s done can we approve the final version for publication.
“Regulations say this should ideally be done within a year, but we’ve been looking to push that down.”
Clark is currently assigned to the RAIB investigation into an injury sustained by a trackside worker on the Midland Main Line in Leicestershire in February, when a train struck equipment used for loading raw materials at Mountsorrel Quarry.
He says that the report is due to go out to consultation later this month, and should be published in October after a span of just eight months.
Looking back at all the investigations that RAIB has been involved in, Clark highlights two in particular – Grayrigg and Beech Hill.
The high-speed derailment on the West Coast Main Line at Grayrigg in Cumbria in February 2007 remains the only accident leading to the death of a passenger on a train since RAIB became operational, while the death of a car passenger at a level crossing at Beech Hill on the Doncaster-Gainsborough line in December 2014 led to some of RAIB’s most far-reaching recommendations.
He adds: “Grayrigg was the last fatal accident involving a passenger, but we’ve had some since with the public at level crossings and trackside workers. And we continue to investigate some frightening near-misses involving track workers.
“Beech Hill was the level crossing where we recommended getting rid of old lamps and replacing them with more modern LEDs. That has affected all of Network Rail’s level crossings as hundreds of them still used the old 36W bulbs. Replacing them with new and brighter LED units will bring improvements to crossing safety, because a lot of level crossing incidents were being attributed to drivers ignoring the warning lights. But the investigation at Beech Hill concluded that the driver approached the crossing at a certain time of day, when the sun was right in the person’s eyes, compounded by the fact that they couldn’t see the lights because they were too dim in the daylight.
“That report has therefore undoubtedly saved lives and led to a big change.”
In 2015 alone, RAIB attended the scenes of 32 incidents, published 20 reports and made 74 recommendations. Now in his eleventh year as an investigator, is there anything that still has the capacity to surprise Clark? “Yes,” he concludes. “The human factor.
“I can’t think of a single case where we’ve not been able to work out what happened - but sometimes it’s difficult to work out why a person took a certain course of action, and we have to propose two or three possibilities.
“People will always be an unpredictable factor.”