18 April 2024 – An overview of the RAIB by Nick Bucknall – Inspector of Rail Accidents

Nick introduced himself and began by saying that the presentation would be in three parts each allowing for questions and answers, before moving on to the next part.

 

Part I – the RAIB (Rail Accident Investigation Branch)

This was set up in 2005 based in Dukes Court, Woking – which was well known to many members at Surrey Branch.  Nick, a Chartered Civil Engineer, joined the same year having already worked with BR and on HS1.  In 2012 the Woking base moved to accommodation shared with the AAIB at Farnborough.

He explained the origins of the RAIB and how it was set up after the very serious Ladbroke Grove accident in October 1999, as a result of the Public Enquiry.  The recommendation was that it should work in a similar way to the AAIB (Air Accident Investigation Branch) to study what happened and the safety lessons to be learned.  Although it is part of the DfT, it is independent and operationally separate, and an example provided here was of the Salisbury accident in 2021 where 2 trains converged at the tunnel entrance.

The RAIB has a set of statutory duties and powers granted under the Railways and Transport Safety Act of 2003 and the Railway Regulations of 2005.  It publishes investigation reports and safety digests, makes recommendations to relevant end-implementers and urgent safety advice may be published where this cannot wait for the final report.  Nick’s first major investigation was at Grayrigg in February 2007 and other examples of incidents he has worked on were also mentioned.

There are two bases, at Farnborough and Derby, to cover the whole country with on-call staff at both operational centres available 24/7 with the expectation that they should be able to deploy within 30 minutes.  What types of accident are investigated?  Mandatory accidents are those where there has been a derailment or collision or a serious, or potentially serious incident.  Then there are discretionary incidents where safety lessons could be learned.  It is not just mainline railways that are covered but also metro systems and tramways – most recently Edinburgh.  RAIB also covers a lot of heritage railways and Nick clarified the definition that determines whether or not the RAIB should be involved, with photographs to illustrate.  The other area covered is the Channel Tunnel up to the half-way mark.

The RAIB have quite a lean operation comprising a chief and deputy, 4 chief inspectors, 20 inspectors and 17 support staff.  Many of the inspectors are ex-railway but also from the police, Health & Safety Executive, ORR(Office of Road and Rail), and other organisations, sharing a wide variety of experience between them.  Extensive training is provided including evidence gathering to PACE standards – of a sufficiently high standard in case of later prosecution; interviewing witnesses and family liaison (very important); inspectors are provided with a warrant card – essential to enable access through police cordons.  Each inspector has their own speciality but an understanding of other fields too.

Nick outlined RAIB powers, duties and guiding principles, such as unrestricted access to any accident site and railway property, access to evidence and witnesses, as well as protecting witnesses and confidentiality so that witnesses feel able to talk more freely about what has happened without fear of recrimination.  Confidentiality, proper evidence based analysis and recommendations are also key.  There is a complicated relationship with the ORR and the Police and Crown Prosecution Service but it appears to be working well.  The benefits of an independent investigation were briefly detailed.

The formal investigation process begins with a preliminary examination and Nick explained how this works, what sort of things are taken into consideration.  It is only after the preliminary checks that an informed decision can be made as to whether or not to investigate.  Then a remit is developed and kept under review during the investigation; the sorts of evidence required from physical evidence to reconstructions.  This is a formally structured approach and Nick showed a number of examples to illustrate.  Eventually, there is a final analysis with a review of the investigation, findings, conclusions and areas of recommendation, before formal consultation and publication of the final report.

 

The RAIB has now been in operation for over 18 years and in that time has published over 500 reports.  Recommendations have produced safety improvements and it is encouraging to see a willingness to learn from mistakes.  Approximately 90% of recommendations are accepted with a corresponding risk if recommendations are not taken up.  The aim is to get the railway open again after an incident as soon as possible and having a good process helps to achieve this.

Questions and answers on this section of the presentation included the very recent example of a train derailment locally at Walton on Thames after completion of engineering works; signalling issues; lineside vegetation and railway landscapes adversely affected by climate change.

 

Part II – Stonehaven

Nick described the serious incident near Stonehaven in August 2020 with details of the investigation and the subsequent report well illustrated with photographs.  This included the weather in the run up to the accident culminating in a severe storm.  The drainage had been designed to cope with this but the investigation showed subsequent problems where some of the geotextile lining from part of the area of washout was missing and a bund had been built which diverted water exactly where it should not have gone.  These were major contributory factors to the landslip and, at the time of the presentation, it is still not known who built the bund.  The site was very unstable so drones were key to gaining a proper overview, and computer modelling was used to assimilate evidence and help work out exactly what had happened and the sequence of events.  This was shown to the families where they wished to know more of what had gone wrong and used in evidence at the fatal accident enquiry.  The details provided an enlightening insight into what had gone wrong.

 

Part III Signalling and Points

Two contrasting examples were given here – one from London Waterloo (2017) and the other from Dalwhinnie (2021); both involved signalling and points incorrectly set, highlighting the importance of correctly wiring up signalling and points systems and testing properly after any works have been completed.  In each case small things were not done properly leading to both incidents, and highlighting the depth of understanding required for signal designers, installers and testers, as well as the attitudes of all interested parties involved in such work.  Final safety checks and testing may seem to be tedious and time consuming but they are crucial.  Both incidents could be linked back in a way to the causes of the Clapham disaster again highlighting the importance of learning, understanding and following procedures correctly.

 

There was a comment from a signal maintenance person in the audience at this point that the mistakes made in the two examples were absolutely shocking emphasising how important it is to make sure that everything is functioning properly once a job has been completed.  Other comments showed that memories of previous disasters can fade and previous knowledge can be forgotten as illustrated by the example of a recent conversation with a railwayman who did not know about the Clapham disaster.

The vote of thanks described the presentation as amazing and enthralling with the recommendation to read the RAIB reports which are readily available on their website.

(www.gov.uk/government/organisations/rail-accident-investigation-branch)