Course Handout - Transportation Disasters
- Rail
Copyright Notice: This material was
written and published in Wales by Derek J. Smith (Chartered Engineer). It forms
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First published online 08:10 BST 9th May 2001,
Copyright Derek J. Smith (Chartered Engineer). This version [2.0 - copyright] 09:00 BST 4th July
2018.
Transportation Disasters
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Key to
Abbreviations: ATC = automatic
train control, a 1906 electro-mechanical SPAD warning and prevention system
[for further details, see the annotation of the Lewisham (1957) disaster]. ATP = automatic
train protection, a 1970s partly computerised SPAD warning and prevention
system [for further details, see the annotation of the Clapham (1989) and
Paddington (1999) disasters]. AWS = automatic
warning system, a cab visual and/or audio warning that a train has just
passed a signal at danger, which the driver then has to acknowledge in order
to cancel. DVT = driving van
trailer, the unpowered unit in a push-pull (see below) pair. ETCS = European
train control system, a state-of-the-art SPAD warning and prevention system
[for further details, see the annotation of the Clapham (1989) and Paddington
(1999) train disasters]. HSC = Health and
Safety Commission. HSE = Health and
Safety Executive. NTSB = National
Transportation Safety Board. push-pull = train with streamlined units at both ends - one
"blunt" or "hollow" (ie.
unpowered) - and therefore capable of operation in either direction without
being turned round. SPD/SPAD = signal
passed (at) danger. TPWS = train protection warning system, a 1990s SPAD warning and protection system [for further details, see the annotation of the Clapham (1989) and Paddington (1999) train disasters]. |
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The Rocket
Train Disaster, 1830: In this
incident on 15th September 1830 at the official opening of the 31-mile long
Liverpool and Manchester Railway, one of the VIPs was run over by George
Stephenson's Rocket. The VIP was the Liverpool MP William Huskisson,
one of the main proponents of the new railways. He had stepped from the
inaugural train - drawn by Northumbrian - while it was taking on
water, and was too "feeble in his legs" to get out of the way
quickly enough when Rocket - which according to one eye witness
"was parading up and down merely to show its speed" - passed by on
the adjacent track. George Stephenson then personally drove him the 12 miles
to Eccles, where a doctor was called, but he died from his injuries that
evening. [For fuller eye witness accounts, click here.]
What we have here, therefore, is an incident in which the first de facto
minister for railways was run over by the first locomotive having stepped
from the first train to run on the first all steam railway,
and not even the fastest ever medevac could save him. The Americans tried
hard to compete, however, opening their first railroad - the South Carolina
Canal and Rail Road Company - on Christmas Day 1830. Unfortunately, the
boiler on their first locomotive - Best Friend - had an irritating
habit of making hissing sounds from its safety valve, and on 17th June 1831 -
while its fireman was holding said safety valve shut - it blew itself (and
the fireman) to pieces. [Note the training issue - safety valves work by
hissing!] Preferring to ignore these portents, the next 30 years saw an explosion of railway building across the world; locomotives were simply "the most perfect of machines" (Scientific American, April 1851), regardless of how many people chose to fall in front of them or wilfully deviated from safe operating procedures. Depending on whose testimony you believe (other eye witnesses said that Rocket was not speeding), this might well be an early instance of a "show off" accident, such as the RMS Titanic in 1912 and the USS Greeneville in 2001. |
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Armagh Train Disaster, 1889: In this incident on 12th June 1889, the rear coaches of an overloaded seaside excursion train ran back down a steep hill and collided with the train behind. 80 people, mostly children, lost their lives. The incident is historically significant for two reasons, (a) because the subsequent public outcry forced the introduction of the (already invented) fail-safe braking system, that is to say, a braking arrangement where the brakes apply automatically in the event of power failure rather than go slack, and (b) because it forced the introduction of "block working" signalling, whereby a train cannot enter a given section, or "block", of track until the train in front is known to have cleared it. |
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Quintinshill
Train Disaster, 1915: In this
incident on 22nd May 1915, a fast 15-coach troop train was allowed by
signalling failure to run at full speed into the back of a stationary local
train near Gretna Green, Scotland. The troop train was concertina'd
into about one third its original length, and wreckage thrown into the path
of another express going the other way, thereby causing a secondary
collision. The official death toll was 227 killed, including many who had survived
the first crash only to be mown down by the second, and many others who
survived both impacts only to be burnt alive in the fire which followed. The
Board of Trade enquiry listed five contributory factors (Muir, 1997):
For more on SPAD-type accidents, see under Lewisham (1957). |
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Harrow and Wealdstone Train Disaster, 1952: In this incident on 8th October 1952, a Perth to Euston express ran a red signal and collided with a stationary commuter train. The locomotive of the express was derailed into the path of a northbound express, causing a second collision. 122 passengers lost their lives. This is one of two high-profile incidents in the 1950s where signals were passed at danger, the other being Lewisham in 1957 ..... |
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Lewisham,
1957: In this incident on 4th
December 1957, a steam train passed signals at danger and ran into the rear
of a London suburban electric train. The locomotive destroyed the rear carriage
of the electric train, and in being derailed demolished the support column of
a railway bridge, bringing a thousand tons of steel down on top of the
wreckage. 90 people died. The problem of SPADs now became politically
sensitive enough to force the adoption of ATC. This system had been invented
as long before as 1906, but had not been compulsory due to the set-up
expense. However, the ATC is itself far from foolproof, and failed to prevent
the Clapham (1988), Southall (1997), and Paddington (1999) SPAD disasters. The pioneer
academic researcher into SPAD-type accidents was D. Russell Davis of the
University of Bristol. In one paper (Davis, 1966) he presented the results of
a comprehensive survey of 23 SPAD drivers aged over 55 on British Railway's
Eastern Region in the period 1960-1961. No one factor, medical or
psychological, emerged as critical, although there were significantly more
psychiatric and psychosomatic symptoms in the target group compared to an
age- and experience-matched control group. Momentary distraction was the
critical factor in only 3/23 events, and longer-term preoccupation in 4/23.
Case 10, for example, was in a hurry to get off shift because his daughter
was ill with measles and his wife needed to get the other children to school.
Indeed, so varied were the causes that Davis concluded that it would never be
possible to select and/or educate SPADs out of the system. "Signalling
systems," he wrote, "must therefore be designed to take account of
the kinds of errors that are likely to be made when the drivers' efficiency
has fallen off" (p220). References Davis, D.R. (1966). Railway signals passed at danger: The drivers, circumstances, and psychological processes. Ergonomics, 9(3):211-222. |
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Moorgate Train Disaster, 1975: In this incident on 28th February 1975, a London underground train failed to stop at a cul-de-sac platform and crashed at around 40mph into the buffers at the end of a 66 foot overrun tunnel. There was considerable damage to the first two coaches, and the driver and 42 passengers were killed. Rescue was slow and difficult due to access problems, and the final body was not retrieved until 4 days later. Subsequent investigations confirmed that there had been no problems with the braking system, and there was no evidence that the driver had been ill, suicidal, drunk, or under the influence of drugs. Indeed, witnesses on the platform had seen him in the normal position in his cab. The investigation was unable to rule on exactly what had happened, but the main theory was that the driver had lapsed into some sort of trance. |
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Clapham Train
Disaster, 1988: In this incident on
12th December 1988, a fully loaded commuter train into Waterloo passed a
defective signal and ran into the back of the train in front, derailing it into
the path of an empty train coming the other way. 35 people lost their lives,
and 69 were seriously injured. It emerged that a major signal modernisation
programme had been under way, and that a short in one of the circuits being
worked on had switched a red signal to green. In the resulting enquiry, a
number of contributory factors emerged, including the following:
RESEARCH
ISSUE: Why do humans
so willingly replace established patterns of work with "minimum
effort" regimes of their own devising? Is it poor education? Poor
training? Lack of supervision? Laziness? Personality factors? Sheer
perversity?
This was not strictly a SPAD-type disaster, because the driver of the following train had seen a green light. Nevertheless it raised questions why trains were not more adequately protected by automatic braking systems when advancing into track blocks at risk. For a technical analysis of the error sequence (cognitive and otherwise) click here, and for an introduction to the technicalities of the ATP concept click here. |
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Fox River
Grove Train Disaster, 1995: In this
incident on 25th October 1995, a train sliced the back off a school bus stuck
on a level crossing due to a red traffic signal. Seven children died. The
subsequent NTSB investigation judged that this was due to an intermittent
fault with the traffic signal control unit, and that following seven earlier
near misses it had been checked repeatedly. This is an interesting incident
because it shows what can go wrong with split responsibility. Highway
engineers had confirmed that there was nothing detectably wrong with the road
signals, and railroad engineers had confirmed that there was nothing wrong
with the track signalling. Both had a "my box" mentality which on
this occasion - when the two systems interacted and became a superordinate
system - proved fatal. Here are some of the key factors [See abstract of Final NTSB Report]:
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Southall Train Disaster, 1997: In this incident on 19th September 1997, a Great Western Intercity express passed a signal at danger and collided with an empty freight train. Seven people lost their lives. The HSC official enquiry published its report in February 2000 and noted that the express had been sent out despite having its AWS out of order. It also criticised the fact that the ATP system which had been recommended in the aftermatch of the Clapham disaster in 1989 had still not been implemented. Great Western were fined £1.5 million for having no system to prevent trains operating with the AWS isolated and no alternative in place. |
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Eschede Train
Disaster, 1998: In this incident on
3rd June 1998, one of Germany's state-of-the-art Inter City Expresses, en route
from Munich to Hamburg, derailed at 124 mph and crashed into the supports of
a bridge over, killing 101 passengers. In the subsequent investigation, it
transpired that the proximate cause of the derailment was a wheel cracking
due to metal fatigue. The wheels in question had a steel hub and a steel
running surface, but the two were separated and cushioned by rubber bushes.
This design, known as the "duoblock"
wheel, was introduced to counter vibration problems in the restaurant car,
and relied on the integrity of the outer steel tyre. As with the Challenger disaster in 1986, there were underlying errors as well. There had, for example, been some friction between the manufacturer of the wheels and the railway operator, Deutsche Bahn (DB). The manufacturer regarded the design as insufficiently tested for the proposed high speed exposure. However, DB had gone ahead with their implementation regardless, because they had been getting a bad press on the issue of vibration. Then in January 1997, a technical report on duoblock wheel failures on the Hannover tram service was forwarded to DB but not acted upon. This incident is thus one of many where warnings had been given prior to the event, but substantially ignored. |
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Paddington
(Ladbroke Grove) Train Disaster, 1999:
In this incident on 5th October 1999, a commuter service heading west out of
Paddington failed to stop at a red signal, and crossed the path of an
Intercity express from South Wales. 31 people lost their lives, including the
driver of the commuter train. In the subsequent Railway Inspectorate
investigation, it transpired that the signal in question - signal 109 - had
in fact been passed at red eight times in the preceding six years (International Railway Journal, November 1999). Indeed on the network as a whole there are a
total of 22 signals which have been passed at danger on seven or more
occasions. There are a number of reasons for this, including poor siting and
sun glare. The official enquiry was headed by Lord Cullen and Professor John Uff. The ATP system
(see the Clapham disaster, 1988) was by now obsolete, and though it had been
requested by the Clapham enquiry it had not been widely implemented. Its
successor, TPWS, would have prevented this tragedy by automatically stopping
the commuter train. This system is currently being rolled out at an estimated
cost of £450 million, and should be in place by 2003. However, it is far from
the perfect solution because it is only intended for speeds up to 75 mph. For
higher speeds, it will be "barely half as effective" (The Daily
Telegraph, 30th March 2001). Even safer still is the European train
protection system, ETCS, but this is more expensive again, and could not be
in place until around 2015. In other words, not only did Britain introduce
its 100mph-plus service in the 1960s without a servicable
SPAD system, but has little chance of having one more than half a century
later. Here are some of
the important issues:
STOP
PRESS: It is worth
noting that responding to a traffic signal is not always a single perceptual
act. In December 2000 another train went through Signal 109. The driver
reported seeing and noting it, but then had to look away momentarily; it was
only when he looked back up and re-checked the signal - by then
occluded by overhead equipment - that the error occurred and he wrongly
marked it as having cleared. The psychological processes controlling the sort
of visuospatial working memory required by "second glance" eye
movements such as this are far from fully understood (see the neural circuit
in Smith, 1997; Figure 4.6, if unconvinced). In response to this latest
incident, the HSE has written to Railtrack demanding urgent action to improve
visibility at this signal. (The Railway Magazine, May 2001.) Reference Smith, D.J. (1997). Human Information Processing. Cardiff: UWIC. [ISBN: 1900666081] |
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Hatfield
Train Disaster, 2000: In this incident
on 17th October 2000, a northbound GNER express fouled a broken rail near
Hatfield, and crashed, killing 4 passengers. This incident achieved a deal of
notoriety because it revealed the true extent of cost cutting and
deterioration of the rail network - inspectors had detected the cracks in
January, but the repair work was not due to begin until November (The
Times, 19th October 2000) - and was followed by "the Great
Repair" of Winter 2000/2001. The HSE report is due to be published in
July 2001. Virgin Trains' CEO Chris Green said in a speech to the Institute of Logistics and Transport on 13th February 2001 that three things had gone wrong with Britain's railways since they had been privatised in 1994. To start with, the new owners had underestimated the complexity of railway operation. Secondly, they had got rid of too many junior and middle managers in ill-considered cost-cutting initiatives. And thirdly, they had lost sight of their core assets in the rush to contract work out. They forgot, in other words, how to run a railway (The Railway Magazine, April 2001)! |
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Kaprun Train
Disaster, 2000: In this incident on
11th November 2000, a fire broke out in the funicular railway leading from
Kaprun in the Austrian Alps up to the Kitzsteinhorn
Glacier. It totally destroyed the two-coach train, and killed 159 people. The
fire broke out in the lower carriage when the train was 600 metres into the
3200 metre tunnel, and, once alight, it simply turned the 45º tunnel into a
gigantic flue. The few passengers who survived did so by breaking windows and
making their way down rather than up. Here are some of the factors under
investigation:
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Selby Train Disaster, 2001: In this incident on 28th February 2001, an express train passing under a road bridge struck wreckage from a road accident above. The impact derailed the front of the train into the path of a 1600-ton coal train coming the other way at around 50mph, and in the resulting head-on collision 10 people lost their lives. The accident was fundamentally a sad combination of coincidences (a 67 billion-to-one freak accident, according to The Railway Magazine, April 2001), but there is nevertheless room to criticise the adequacy of the crash barriers separating the road and rail traffic at such crossing points, and there is also some suggestion of a fundamental concept fault in the push-pull arrangement of modern high speed trains. The problem is that only one of the two cab units is powered, and therefore the two units - whilst superficially identical - do not weigh the same. Unless the train is loop-turned at both ends of its journey, therefore, every other trip is with the heavy unit pushing rather than pulling the rest of the train. The driver, of course, sits in whichever happens to be the leading unit, so there is no problem unless and until there is a derailment, whereupon it is considerably more stable to have the heavy unit in front of the passengers than behind them. That is to say, it is considerably easier to derail the Class 91 DVT (at 45 tons) than the matching locomotive (at 84 tons). This has been common knowledge within the railway industry since an earlier accident at Polmont in Scotland in 1984, when nothing more substantial than a cow derailed a similar configuration train, killing 13 passengers. The HSE have since announced that there were 35 incidents in the last two years involving motor vehicles on tracks (excluding level crossing events), so there is a distinct base level of risk (The Railway Magazine, May 2001). |
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Hither Green
Train Near-Disaster, 2001: In this
incident on 12th March 2001, two commuter trains collided just outside Hither
Green station, in South London. Damage was comparatively light thanks to last
moment braking by one of the trains. Investigations are still under way, but
preliminary reports indicate that the SPAD was committed by a driver with
only 12 weeks' experience. The technical press has already suggested that
inadequate training for route familiarisation purposes led to the driver
misjudging which of several signals applied to him (The Railway Magazine,
May 2001). The Managing Director of the network, Olivier Brousse,
put his finger on it when he remarked in an interview: "Safety is not a
perfect science" (The Daily Mail, 13th March 2001). STOP
PRESS (1): London
Underground drivers were guilty of 658 SPAD-type events in 2000, compared
with 340 in 1994. Monthly returns on the national system as a whole revealed
33 SPADs in January 2001 and 42 in February 2001 (The Railway Magazine,
May 2001). STOP
PRESS (2): On 18th
April 2001 Virgin Trains unveiled £2 million's worth of new driving cab
simulators at its Driver Training Centre at Crewe. Virgin Train's CEO, Chris
Green, said: "This is the first major use of driver simulators in the UK
and it really is time that rail joined the air industry in using these
high-tech safety aids" (Rail, April 18th 2001). STOP PRESS (3): Class 66 locomotives are fitted with the Westinghouse Datacard 6100 data recorder. The software for this railway equivalent of an aircraft's "black box" is currently being updated to allow it to record from up to 60 sensors ten times a second. This data will eventually be routinely analysed to detect individual locomotives developing faults and/or individual drivers developing poor habits (The Railway Magazine, May 2001). The HSC is proposing to make black box recorders legal requirements by the end of 2005. |
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