Saturday, 25 May 2013

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Tiredness was cause of near disaster on rail line near Tebay

It began as a routine overnight journey. The freight train – a class 92 locomotive pulling 13 twin container wagons – was travelling from a terminal in Birmingham to Mossend in Glasgow on the night of August 17 last year.

Like so many in his industry, the driver was working at night while most of the working population slept.

It’s an exacting job, in which the safety of the driver and the public alike depend on the rigorous observation of tried and tested safety procedures.

On every train journey, the most important safety factor is the ability – and the alertness – the driver.

On this particular night, as the train trundled northwards on the West Coast Main Line through the dark Cumbrian countryside, a tragedy was only narrowly averted.

It was just after 2am and the 498 metre long train was pulling its load of 663 tons up the hill between Tebay and Shap Summit.

At 2.04, the train slowed to a stop and – invisibly as far as the driver was concerned – began rolling backwards.

It continued gathering speed as it headed back towards Tebay, reaching a maximum speed of 51mph before the driver – no doubt horrified at what he now realised was happening – applied the brake.

When the train came to a halt, its backwards journey had lasted four and a half minutes and covered 2.2 miles. The rearmost wagon was just 800 metres from the turning into Tebay sidings.

Luckily, nobody was injured in the incident. It happened only a short distance from the scene of the Tebay rail disaster of 2004, in which four track maintenance workers were killed by a runaway wagon.

The investigation into last year’s incident was carried out by the Rail Accident Investigation Branch (RAIB).

It says that had the driver not braked when he did, the freight train would probably have smashed into the sidings within a minute at around 64 mph and derailed. So what was the cause?

The detailed 35 page report pulls no punches in its conclusion: “The investigation found that DB Schenker’s train driver, who was working the first in a series of night shifts, was probably fatigued and not sufficiently alert at the time of the incident.”

The driver had been exposed to a work pattern likely to induce “high levels of fatigue”, even though his employer had planned shift patterns using a recommended industry model.

The incident has prompted one rail union boss to claim that job losses across the rail industry are creating work pressures with potentially serious safety implications.

RAIB investigators looked in detail at the incident in August last year.

They examined the driver’s work pattern in the days before the incident.

It emerged that on Monday, August 9, eight days before the “run back” incident, the driver began a series of six early shifts, leaving home at 6.30am for his first shift.

On the Saturday, he left home at 2.30am to start work at 3.15am after being able to sleep for only three hours the night before. He had Sunday off, but on Monday, August 16, he worked the first of five consecutive night shifts, reporting for duty at 6.34pm.

The driver was scheduled to finish work at around 5.45am the following day.

The driver was experienced with an unblemished safety record dating back to 1976, and was considered among the best working for DB Schenker, says the report.

It continues: “The immediate cause of the incident was that driver did not demand enough power for the train to climb the gradient, and then did not apply the brakes to stop it from running back...”

Explaining why the driver took so long to become aware that the train was running backwards, the report adds: “He was probably fatigued; his journey was monotonous; he was in a dark and comfortable environment; and there was little in his field of view to attract his attention.”

When interviewed, the driver, who returned to normal duties in April, said he did not feel the train slow to a stop, and only became aware it was running backwards when he saw a green signal light receding in his cab window.

He accepted being disorientated. The report continues: “He had been continuously awake for over 18 hours.

“He stated that he was tired but could not sleep in the day before the first night shift so instead carried out light duties around the home.

“He was driving his train at 2.04am, a time of day when his alertness and performance levels were at their lowest; and he possibly had some sleep loss due to progressively earlier shift start times from Thursday August 12 to Saturday, August 14.”

Investigators found that freight train drivers said they found it most difficult to remain alert on the first of their night shifts.

The report also highlights the driver’s cab – warm, dark, comfortable and quiet – as a possible factor in reducing his alertness.

Furthermore, the train’s headlights illuminated a relatively small and unchanging scene as it travelled through the darkness and rain.

Commenting on the driver’s transition from early shifts to night shifts, the report says: “The driver had one day off work before his first night shift, which is not unusual for freight train drivers who routinely work five or six consecutive before a day off. He stated he was tired but could not sleep on the day before his first night shift.

“(He also tried but could not sleep ahead of the shift that started at 3.15am on Saturday August 14).

“This is understandable because the driver had been awake and at his most alert at those times in the days before his early and night shifts.”

In its conclusions, the RAIB report urges DB Schenker to reduce the number of shifts which cause fatigue, pointing out that the same should apply to other freight train operating companies.

The report also urges the Office of Rail Regulation to provide updated guidance on shifts which cause high levels of fatigue, with advice on how to improve them.

Not everybody has been reassured by the report’s findings. The RMT’s Carlisle-based organiser in the north, Craig Johnston, said he fears many fatigue-related incidents in the industry go unreported.

He said: “Many other workers in the rail industry work similar shift patterns to that driver and some employees who do safety critical jobs work even worse shifts.

“There are people doing night shift on Saturday, then 2pm to 10pm on a Sunday and then starting work again at 6am on the Monday.

“There are people working excessive shifts and excessive hours. The bottom line is that we have a 24 hour railway, but there are fewer and fewer people to run it.”

Mr Johnston hit out at a recent report by the Government’s rail industry advisor Sir Roy McNulty, who said operating costs should be cut, saying: “The bottom line is that it has become all about money and how much shareholders can rip out of it.

“But you can’t expect fewer people to do the same or more work. I don’t believe any of the safety lessons from earlier accidents such as Tebay have been learned so, sadly, there could be another tragedy.”

A DB Schenker spokesperson said: “We have cooperated fully with the RAIB during their investigation and will work with all relevant bodies on the recommendation they have made.”

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