LEARNING FROM EXPERIENCE
Rail Accident Investigation Branch inspector ROWAN JOACHIM explains how the government agency works with preserved railways when things go wrong.
How the RAIB investigates accidents
All too often, the lessons learned from ‘near misses’ are not as widely known about or acted upon as those learnt from accidents.
The Rail Accident Investigation Branch (RAIB) investigates incidents and accidents and shares the lessons learnt as widely as possible so that other organisations can, hopefully, avoid similar events in the future. In a way, our overall goal is to do ourselves out of a job!
How does this work in practice? Duty holders have an obligation to notify us of various incidents and accidents, under the Railways (Accident Investigation and Reporting) Regulations 2005, and there is a guidance document (RAIB N3 quick reference guide) to help with deciding whether something is reportable or not.
The rule of thumb is: ‘if in doubt, report the incident’. Once we have been notified of an accident or incident, our duty coordinator decides whether to send out inspectors to conduct a preliminary examination. The duty coordinator will contact the railway by phone to explain what is going to happen. There
are some things the duty coordinator may ask to be captured prior to the arrival of the inspectors – things which might otherwise decay, be lost or destroyed, such as readings on pressure gauges, positions of regulators, driving/brake handles, reversers, dampers, firehole doors, gauge glass readings and so on. If the RAIB is sending inspectors, nothing at the scene of the accident should be moved or disturbed without the duty coordinator’s permission until they arrive.
Once on site, the lead inspector will determine a plan to collect all the information and evidence. Usually (depending on the scale of the incident or accident) two inspectors will attend the site, and photograph, measure, survey, collect CCTV or other recorded evidence (if there is any), conduct interviews, obtain training and competence records, any relevant documentation such as rule books, training manuals, work instructions, maintenance schedules and generally try and ensure they have as full a picture as possible of the events leading up to the accident or incident.
The results of this preliminary examination are collated and presented to the branch (usually the following Monday) when a decision is made on the action to be taken. There are four possible outcomes: investigate the incident, write a safety digest, ask for a copy of the organisation’s own investigation for our information or not take any further action.
MAKING RECOMMENDATIONS
If we decide to undertake a full investigation, a remit for the investigation will be set and the inspector assigned to lead the investigation will dig much deeper into the incident or accident. They may conduct more interviews, certainly ask for more evidence and get a better understanding of the organisation. Our investigations are, and must be, proportional to the accident or incident that occurred, but we do not stop at the most obvious cause; we will always look deeper to understand why things have gone wrong from an organisational, cultural and system level. The RAIB publishes a report at the end of every investigation to explain the circumstances of the accident or incident and to describe our findings. We make recommendations with the aim of minimising the likelihood of another similar event. We publish our reports
OUR INVESTIGATIONS ARE, AND MUST BE, PROPORTIONAL TO THE ACCIDENT OR INCIDENT THAT OCCURRED
on our website, with the intention that as wide an audience as possible will read them and transfer relevant lessons to their own organisations in order to try and prevent similar incidents occurring on their infrastructure.
If our preliminary examination concludes that the event was the result of non-compliance with established rules or standards, or we wish to reinforce existing good practice, we may decide to produce a safety digest. We may ask for clarification on certain things, or a few further details if necessary, to give us the required information. The aim of safety digests is to let people know what happened and reinforce learning that we have seen before, or show how it is applicable to this particular set of circumstances.
Accidents and incidents are usually the result of a number of things going wrong. Very rarely do accidents have a single cause.
We investigated an incident on the South Devon Railway (RAIB report 02/2018), in which a child nearly fell through a missing floor of a carriage toilet. The investigation uncovered problems in many areas of the organisation which contributed to the breakdown of both the internal and external reporting systems. One consequence of this was a delay in the railway recognising that a potentially serious incident had occurred.
The incident happened because the carriage was in service with no floor in the toilet compartment, and the child was able to open the toilet door, which had not been adequately secured. The train crew were not aware that the floor was missing, and the risk associated with this had not been sufficiently appreciated or adequately managed by the railway.
As with many accidents and incidents, if a risk is not fully identified, recognised and understood, it cannot be effectively assessed and mitigated. Processes and procedures should
“ACCIDENTS AND INCIDENTS ARE USUALLY THE RESULT OF
A NUMBER OF THINGS GOING WRONG ROWAN JOACHIM, RAIB
be available, clear and briefed to those who need to use them. So often they don’t exist for the circumstances people find themselves in; they are outdated, inappropriate or not understood by those having to use them.
It is really important that maintenance regimes for vehicles, plant, equipment or infrastructure, and any fitness to run or fitness for service paperwork, are appropriate for the system or equipment to which they apply, and are understood and used correctly by everyone who is a part of the process.
It is important that it is possible both physically and culturally for staff, whether paid or voluntary, to highlight any areas of concern or things they do not understand, so that any problems can be remedied. It is also vital that processes, procedures, training and competency requirements are reflected in the safety management system and its supporting documents, which themselves should be regularly reviewed and updated when required.