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    Seminário de Análise e Prevenção de Descarrilamento PDF

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    Sergio Augusto

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    © All Rights Reserved
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    DERAILMENT MANAGEMENT & INVESTIGATION Session 1 — Development of Derailment Investigation - UK Mike McLoughlin eccraoens ior Dewea Marans 8 DERAILMENT INVESTIGATION OBJECTIVES OF DERAILMENT INVESTIGATION COURSE & SEMINARS ‘+ Make Brazilian Rail Companies safer BY * Help minimise exposure to derailment risk * Providing under-pinning knowledge about derailment factors + Learning from past deraiiments and pre-cursors = Understanding bath good and poor aspects of investigations '* Practising site investigation techniques x0 Rat UK SYLLABUS Introductions ‘Syndicate exercise — needs of participants Course Sessions Development of Deraliment lnvestigatian ~ UK Rail Network 2. Accident Theory & Human Factors ‘Rail Accident Site Monogement Deroilment Theory Main Line Deraiiments Deroilments in Yards & Sidings Derilment Management Policies Write on a Flip Chart ‘* What you want to learn from these sessions * Issues that need to be covered * Points to be discussed about particular railway accidents Development of Derailment Investigation -UK Major Influences ‘Over the last 40 years or so there have been seven distinct developments affecting derailment investigation in the UK; 1. Investigation methodology 2. Technical advances in wheel/rail interaction 3. Move to systemic investigations 4. Human Factors S. Reilway Privatisation 6. Development of industry Standards 7. Creation of independent investigating body These developments shaped the UK investigation process of today. Derailment investigation - Development Large scale modernisation of BR in 1950s/1960s led to increase in speeds and axle loads, replacement of steam traction by diesel and electric traction, and ‘hanged methods of track maintenance ‘Adverse side effect was incompatibility of major part of 2-axle freight vehicles ‘resulting in increased number of deraliments due to - * poor ride quality of wagons + consistent higher speeds + sensitive response to variety of track rregulaniies, 4 : Deraliment Investigation — Development Research/Sclentific ond Design departments relocated at Derby in 1964 Derailment investigation service to national network set up shortly afterwards in Research Division. Service funded by British Rail Board HO with objective to reduce deraiiments, Key components of investigation service were. Independent Investigations Development of site Investigation techniques Development of Track survey data processing ‘Access to Scientific/Technical/Design resources Development of derailment statistics database Investigation skills taught to front tine staff Creation of Independent investigating body “Oye ene XD Ra Lt. UK erg mere epesbremce tes Derailment Investigation — Development Independent investigations began in fate 1960s Development of site Investigation techniques + identity initial Point of Deraiiment ‘= Record and interpret deraiiment marks /+ Measurement survey of track Derailment Investigation — Development Independent Investigations, Development of ste investigation Derailment investigation — Development Development of Track Survey Data Processing + Standard format for measurement surveys * Charige from manual to computer processing « Development of anaiyss techniques Derailment Investigation — Development Derailment investigation — Development Derailment investigation — Development ‘Advances in Understanding Wheel/Rall Interaction ‘Theoretical studies of vehicle dynamics Quasi - static and dynamic testing of rolling stock Development of new wheel profiles and vehicle suspension systems, Development of vehicie dynamics modelling software ‘Vehicle Dynamic Modeling Package n a Railway Environment (VAMPIRE) Derailment Investigation — Development Move to Systemic Investigations Derailment investigation - Development Rall Privatisation 1994 rack Acces charges. + Penalty charges for delays caused by deraiments/alinckieos, + Competing investigations + Conflts of interest. + fist paral following mayor deraiments Privatisation of British Rall resuited in numerous companies contracted to run ‘rains, maintain train, and maintain infrastructure, + Standards necessary part of Railway Safety Cases, “+ Standards developed to sllow contractual obligations to be met. + Standards essential part of safety system. Derailment Investigation - Development Independent Investigating Body UK x0 Rea ts Ure = Derailmentinvestigation — Development Independent |nvestigating Body UK Formation of Rall Accident Investigation Branch (RAIB) * Scope of operation Types of occidents/ineidents to be investigated + Requirements to report + RAIB Primacy on site * Disclosure of information * Accredited agents x0 Ra i. UK a! ney ener se pe semrerin Sem = 10 Derailment Investigation — Development Current Developments; European Directive ‘Safety on the Community's Railways’ + Harmonising regulatory structures. * Developing Common Safety Torgets ond Safety Methods. + Independent national bodies for accident investigations. * Safety recommendations by investigation body not 1a create ‘blame or lability. End of Session 1 presentation Syndicate exercise — What are the two main derailment risks for Brazil Rail Network? Give reasons why. 1. DERAILMENT MANAGEMENT & INVESTIGATION Session 2 Parti- Accident Theory Part ii— Human Factors cha poser, AES | ACCIDENT THEORY ILC! ACCIDENT CAUSATION MODEL won |e ar ee eos lec |e EE |e Elle = le = women || Se « 7 A eS ee wiv ERE xo ot i UK ng ere Seana Meee tees Accident Theory Accident Causation Model Accident Theory ‘Accident Causation Model Accident Theory Common laments afanens j ‘ate ake pty Latent failures transmitted along functional or departmental pathways to the ‘sharp end’ of the system create conditions for unsafe acts. These find a gap in ‘the defences which may fall due to latent rather than active failures. x0 nel i. Ux i Derailment Causation Model Make alist of some ‘examples foreach stage ‘of the accident mode! ? ? - Saree Semone Derailment Causation Model fil! = nd i SN di Accident Theory ACCIDENT RATIO STUDIES ‘Major or aver 3-day lost trie injury Minor injuries Accident Theory ACCIDENT RATIO STUDIES Accident Theory DERAILMENTS Derailments with injury/forality, © Bxarcise ~ list typical precursors forthe bottom two levels of the: Pyramid for the various aspects of railways — a Accident Theory DERAILMENTS, Precunirs Deraitments with injury/fatolity, Derailments “ype preci of erent CLAPHAM =TURNING POHNT IN UKRAL ACCIDENT INVESTIGATION 35 fatale and 435 lyured Accident Theory ‘laphom Public Inquy Si Anthony Hidden QC Report in September 1989 contained 80 recommendations covering — + immediate Covses~ Wring erers/testng/nsrucionstainng ete * Underiying Causes within Management ~ ‘Organisation/management/monitoring et ‘= Improvements to BR Safety Culture ~ Total Quality/Cab Radios/protection/funding/procedures etc ‘+ Mitigation of Future Accidents ‘+ Improvements to Emergency Services + Improvements to BR Response ‘+ Rule Book amendments + Government funding of HM Ralway inspectorate x0 oi. UK [eeansreneege teen eee | Accident Theory Major Changes ‘+ Immediate and Underlying Causes * Human Factors seh ‘* Systemic Investigations ec Accident Theory ‘Types of Causes immediate Cause ‘* The reason why and when the derailment/accident happened at that location. ‘Substandard act or condition that triggered the derailment/accident. '* Usuaily the factor that can be put right most quickly, ‘Basic Couse * Underlying personal, job or organisational factors that created the conditions for the derailment/accident. ‘© The circumstances that could lead to atiather derailment/accident if not corrected. 0 ma et ip of Causes Human Factors Session ii Human Factors People’s behaviour should be assumed to be rational (though possibly mistaken) from the point of view of their knowledge and mindset at the time ee if we can find out what factors guided people’s behaviour, we can see how Sidney Dekker (Professor of| ‘Human Factors) Accident Theory Accident Causation Model Human Performance Levels Human Performance Levels iw Errors and Violations v Adversarial Inquisitorial- team of experts, ora judge, hears and considers the eviéence then decides on causes and contributory factors. Inquistorial investigations - = Rail industry + National investigating Bodies ‘Adversaral- each party represented by legal counsel wing present the case 10 judge in a compete atmosphere. ‘Adversarial investigations — *» Low Courts * Arbitration © Public inquiries ‘System open to criticism in that the presentation of evidence can affect the Types of Investigations inquisitorial Qualities of Investigators '* Open minded. Qualities of Investigators ‘Human Factors. “Experience is the name everyone gives to their mistokes” Oscar Wilde Fallibility + Sliphopses/Mistoke Violations 23 Qualities of Investigators BUT....Investigators are human! Hence: ‘+ Company pressure/conflcts of interest. Peer pressure. Time pressure. Lock of resources. Qualities of Investigators Fallibility 14 Qualities of Investigators “Cy Bias - Predisposition/Prejudice Examples of bias or preconceptions + Anchoring the tendeney to rely too heavily on one piece of Information. ‘= Attentional bias - neglect of relevant dato wien making judgements of ‘association. * Bias blind spot - the tendency not to compensate for one's own cognitive biases. * Husory correlation - beliefs that inaccurotely suppose a relationship between @ certain type of action ond on effect. '* My-side bias - the tendency for people to fail to look for or to ignore evidence ‘against what they already favour. + Observer Expectancy effect -when oreseorcher/invesigator expects o giver resuk ond therefore unconsciously manipulates or msterprets Gotan order to fir poner aes fd Investigation Foundation Investigation Structure PRoGness + IMPLEMENTATION/MONTTORING + RECOMMENDATIONS + CONCLUSIONS * IDENTINCATON OF FACTORS oresire 4+ FORMALINQUIRVINVESTIGATIONS © TESTS, STUDIES, CALCULATIONS FURTHER EVIDENCE GATHERING FOUNDATIONS | © INVESTIGATION AND EVIDENCE a GATHERING 15 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group DERAILMENT MANAGEMENT & INVESTIGATION Session 3 — Rail Accident Site Management Mike McLoughlin x0 al Les UK taorginen Darire anager teas Rail Accident Site Management orKs UKLEGISLATION & STANDARDS SITE MANAGEMENT RECOVERY MANAGEMENT [RECOVERY RESOURCES &: TECHNIQUES EVIDENCE v WRECKAGE case sTuoy STORAGE OF EVIDENCE [20 Rad ic. Ue [geome se nemo vara t nee roe © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Rail Accident Site Management ‘UK RAIL GROUP STANDARDS: (GO/RT3118 Incident Response Planning & Management. “Statutory duty to ensure that accidents, incidents, near misses and other ‘dangerous occurrences are reported, investigated and analysed and that necessary preventative measures are taken.” GO/RT3119 Accident & Incident Investigation (GO/GN3518 Guidance on incident Response Planning & Management. {GO/GN3519 Guidance on Accident & Incident Investigation NOTE ‘+ Standards state what has to be done but net necessarily how to do it. * Guidance notes to the standards give advice and examples haw to mect Rail Accident Site Management ‘UK RAIL GROUP STANDARDS: GO/RT3119 Accident and incident tnvestigation ‘The requirements of this standard are based on the folowng principles: 8) Investigations determing the facts of an accident or incident. ts immediate and underying causes, and make recommendations ‘eliminate or minimise the risk from such events by addressing the frequency of occurrence and the consequences of the event ) The investigation processes mandated in the document are not intended a8 @ process for allocating blame or lability '©) The information included in a report of an investigabon carried out n ‘compliance with the document is not intended to ereate any © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Rail Accident Site Management x0 Rants. ux snes eo Rail Accident Site Management ‘SOME KEY ROLES — INCIDENT MANAGEMENT * Designated Local Person (DLP) * Evidence Co-ordinator * Infrastructure Engineer * Operations Manager * Person in charge of possession (PICOP) ‘Rail Incident Commander + Rail Incident Officer (RIO) * Recovery Engineer * Site Safety Manager * Train Operators’ Liaison Officer (TOLO) © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Rail Accident Site Management RAIL INCIDENT OFFICER RESPONS|BILITIES. + Lead the rail response. * Establish regular liaison with Control and Signaler. * Liaise with Emergency Services, Local Authorities, Investigating Bodies/Agencies. * Hold regular site meetings with parties involved. * Overall responsibility on rail issues. * Consider appointment of specialists. * Direct the actions of other rail organisations. * Ensure evidence is gathered/preserved. x0 Ras tes UK eg mine Dart anager enon Rail Accident Site Management PROTECTION 1, Fist priority sto protect the scene against hazards, Risks ~ collisions, electrocution, fire, dangerous goods et. ‘Sm a a Oe SS 2. Protect the ste for investigation, recovery and restoration. x0 ad te. UK © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Rail Accident Site Management What is the RAIB? tancoreneegean ee The independent railway accident investigation organisation for the UK Sole purpose to improve safety of railways and prevent further occurrences Does not apportion blame or liability, nor enforce laws or carry out prosecutions x0 Rad 1a ux [enone be rere eager tee Independent Investigating Body UK © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group RAIB’s key characteristics * Chief Inspector responsible to Secretary of State for Transport ~ part of the Department for Transport, but functionally independent (similar to Air Accident investigation Branch and ‘Marine Accident Investigation Branch ) * Lead Party ~ in rail accident investigations where there is no evidence that criminal action is the cause RAIB team at Derby. Carolyn Griffiths (Chief Inspector) in centre of group. Protos: Ras 2008 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group RAIB Investigators. Which railways are covered by the RAIB? * The RAIB will investigate accidents and incidents on... © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group What type of accidents will be investigated? » The RAIB must by law investigate all serious rail accidents involving a derailment which result in or could result in... What type of accidents will be investigated? + The RAIB will not investigate... © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Other parallel investigations: The need for clear and sharing of evidence How does this work? RAIB leads the investigation unless: See © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group RAIB’s operation ‘Two operational centres Vehicles and workshops at both centres On call roster has staffin place at both RAIB mobilisation " © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Inspectors’ training + RAIB has established an extensive training scheme for its inspectors, which covers: x0 Rats UK Accredited Agents © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Current Accredited Agent status The Recommendation Process 14 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Notifications in the firstyear of operations ‘17 October 2005 17 Octaber 2008 60 RAIB led investigations (78 mobilisations) ~ 15 passenger trans derailed (minor injuries in one case only) ~ 9 freight trains derailed (no injuries) 2 collisions (minor injuries in two incidents) 2 train door incidents (1 serious injury) 20 level crossing accidents (5 fatal accidents, 2 serious injuries) 3 staff hit by train (3 fatalities), 2 near misses 4 run away incidents (2 PW trolley, 1 tramway and light engine) unsafe load 3 train defects (no injuries) 2 unauthorised train maverents 1 ral removed outside of possession limits 2 Category A SPADs (Includes trains running long way past signals) 1 Staff electrocuted (fatality) 2 Fire on rolling stock x Re Lia. UK onan rae Se sir Morag manip et ry REI tet What's on the RAIB website? www.raib.gov.uk 15 DERAILMENT MANAGEMENT & INVESTIGATION Session 4 Derailment Theory ‘Mike MeLoughin 0 ota. Uk eee Derailment.Theory Topics * Flange Climb Criteria © Resistance of Rall Vehicles to derailment and Roll-Over ~ Bogie Rotational Resistance ~ Torsional Stiffness = Dynamic Ride Tests ~ Vehicle Overturning + Vertical & Lateral Dynamic Forces Derailment.Theory Flange Climb Derailment ‘+ Whee! flange climes onto roll head ond deralis usually leaving a tel-tole ‘mark on the rail ada’ equation ia measure ofthe roby or Mange on “he expression pesuimstic hance roves steht agner waives of UV ea be tterates for snort aitance/teme Uc Ral Group standard species iets distance for duration of ting Derailment.Theory Vertical and lateral forces acting at flange/rail contact point Derailment.Theory (Coefficient of friction anc flange contact angle x0 lia ux te WORKED EXAMPLE OF L/V Where; Theoretical L/V = fan f\- “204 4+ tan B B=70° tan = tan 70° = 2.75 Then; 275-04 1+(04%275) - 2s = 235 = 235 = 1.119=1.1 1+(0.4x2.75) 114 24 FLANGE CLIMB RISK FRICTION AND FLANGE CONTACT ANGLE i ia... wal Derailment.Theory Resistance of rail vehicles to derailment Key elements Design characteristies and maintenance standards for; * Rolling stock * Infrastructure Safe operational speeds “ade Derailment Theory Rolling stock characteristics Dynamic Modes © Pitch * Bounce + Yaw (Nosing) + Lateral * Roll -_, 20 Rel aU sg eter Derailment.Theory. Resistance of rail vehicles to derailment and roll-over, Railway standards define vehicle characteristics and fimiting values of derailment criteria to minimise risk of derailment WEHICLE ACCEPTANCE TESTS. “L StaticTests 5, "Bogie Rotational Resistance + esses 2. Dynamic Tests 3. Computer Simulation (pet a rou ae OUT 48 Derailment,Theory Bogie rotational resistance Measured by fotating the bogie on an instrumented turntable. Nomaseihsjaag x° factor ised iy U.K. DerailmMent.Theory ‘Bogie rotational stifiness test Derailment.Theory Torsional stiffness Unit oro ioasing defined in Standard V = Nominal whee! load. AV = Relief of whee! load on track twist defined in Standard. UK lent 60% wheel offloading. x0 Ro itd. UF [sun tere =» ae supereiewtioncterence betwen ono pots ioaced SO metres i 8 sora curve. Warpage (warp sapareleaton ‘ference between 2 pomts sed 20 ‘eters at tangent or se the rcder curve as noted both the butting an ors depend on measures peretevatin taken at erent ples (10m o 20m) Depencing on the seerrnce found between these ressuemerse an sora geomet ae or be ered x0 Roti. UK " Derailment.Theory Derailment.Theory 13 Derailment.Theory Derailment Theor * Derailment.Theory | | Comparison of torsional stiffness test results Derailment.Theory * Prototype rolling stock subjected to dynamic ride tests. * Ride performance must meet standards. + Computer simulation can be used to predict ride performance. cenit ‘The computed ¥10 vain shal nowhere oxcaud 1.2 for whet profes with {ge ange eau ig gai Par SFr ws wah sa arge ‘angles the oparpriteInsing vale shall be determined onthe bass of [agats cotson (Delon, bulking nto account any prevous service ‘aporence ain ines a he angle teases apa a re poe ‘tora Bs hasbeen fuse tb th case foro former BF PS pre. Nadas ort indicates thatthe ting valve of YO sbowe when cersimaet willccur gwen By ie O° Teatmne lahore Crs the Mange ange and 21th eneticlent of whestral ction (in ths ease 0.22, a ccm ‘The simulation hal be capabe ef generating 2 ime history of YIA ratio athe ‘mot unaveurable wed The VIG ratio shall be computed using a shang ‘moan overs 2m length e ack 16 Vehicle/Track interaction Bogie hunting 20 Rol td. ux Manes oe Vehicle/Track Interaction Bogie and body hunting 2 Rl i Ux sg me Vehicle/Track Interaction Aerodynamic Effects Vehicle overturning due toeyctonic wind force x0 ho ia Ux sn Vehicle/Track Interaction Aerodynamic Effects. x0 iti. UK cag ear VEHICLE OVERTURNING Resistance to roll-over induced by over-speeding Vehicles to run round smooth curves at constant speed without rolling over at; * Not less than 26.5° cant deficiency for freight vehicles designed for max speed of 75 mph (120km/h). ‘= Not less than 21° cant deficiency forall other vehicies. ‘© Tobe demonstrated by theoretical methods. © UK max cont for CWA is 150mm = 6". (can be exceeded for specia! trains). ‘¢ Max cant deficiency is 159mm = 6° Ra Group Stands Derailment Theory Vertical forces 1. Static ‘+ Simple relationship between whee! load/diameter/profile and contact stress. + UK maximum vertical static contact stress at Wheel/rail interface = 1260 MN/m:. 2. P, Dynamic * Very high frequency stiffness component. 3. P, Dynamic * Impact Force affected by speed, track dip angle, and unsprung mass of whee! ‘+ Responsible for rail batter at joints, track dips, ond crossings. + UK maximurn P, force = 322 KN per wheel * Axles with high unsprung mass generate high P, forces. Derailment.Theory Lateral forces Gauge Spreading Force * Generated by inability of wheelsets to adopt radial position on sharp curves. * Leading wheels develop angle of attack. + Created by vertical wheel load and coefficient of friction (u). feck ; Derailment.Theory Gauge Spreading Force * Bogie vehicles with stiff primary suspensions and 2 Derailment Theory Lateral forces - Track Shifting Large lateral loads can be generated by; © Impacts at lateral kinks in the track. ‘+ Suspension bump stop contact caused by long wavelength Derailment. Theory Lateral Forces ‘Track Shifting - Prud” Homme Force + Formula defines limits for permissible lateral forces. Standards define limit when running at maximum speed ‘on curved track with maximum cant deficiency over a defined ramp to represent short wavelength misalignments in track profile. UK limit is 71 KN. UK use ‘average limit’ formula (= (/,+ 10)kN + Other railways use Prud’ Homme lower limit of L=O.BS(M/, + 10)kN Where {= lateral force and W = axe load in kN. Mel Pru Homme, A The Resstance cf Tack to Tranavers Force rom Moving Vacs. Reve Generale des Cremins e Fe amuary 1967 x0 mit ue 22 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group DERAILMENT MANAGEMENT & INVESTIGATION Session 5 Main Line Derailments Mike McLoughlin XD fa Ls UK tenga corran vanageret tamer MAIN LINE DERAILMENTS: TOPICS Derailment Risk Component Failures High Speed Derailments + Low Speed Derailments + Operations + Investigation Techniques & Technology + Evidence for Courts ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group “Trains struck By arge faling objects ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Chast 93. Trendin the mbes of PARTS © Mike McLoughlin. All rights reserved, Risk & Safety Consultancy Group al Report 201 4-15 Derailments by cause (2005/06-2014/15) Passenger Trains Chart 97. ‘Non-Passenger Trains alison cotision et th object agri runaway wth abject, Foting stock oting Envrcament stock Operations! Ineisent cevronment © Mike McLoughlin. All rights reserved Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Qgzil Train Acide! Tcdeates RespoornON Ge Va PET OETTE alti Acidentes Responsabilidede Operepbe © Mike McLoughtin. All rights reserved. Risk & Safety Consultancy Group Running line Geraiiments "a en ou unatnpingnesrtat cite seo ey Srtt Beane wesussesteees ele REREEPEREEEE ET ERE EEE ‘© Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Inln mwelngby asian and year, 2 2008 “ELELeLepereperetenel ‘© Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Pause for Questions? Pausa para perguntas? x0 Rad UK rey re wenger te Main Line Derailments Component Failures Rolling Stock * Ades + Bearings "= Suspensions Infrastructure © Rolls (© Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments KEY ISSUES. Component Failures © Design & Manufacture * Maintenance * Inspection * Investigation © Monitoring x0 Ratt. UK . "-E neg eer cere terapewet Vi il tee Main Line Derailments Component Failures Design & Manufacture * Characteristics - stress raisers, fatigue, handling. ‘© Materials ~ quality, consistency. ‘© Process of Change — vehicle design, dynamic behaviour, axle loads & speed. 10 © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Component Failures Maintenance * Techniques ~rail grinding, roller bearing strip-dewn, track re-ballasting. = Component life, + Resources. * Skills, training. x0 Rat tte UK Main Line Derailments Component Failures Inspection * Equipment —ultrasonic, magnetic particle erack detection, gouges. * Visual — training, skill & experience. = Periodicity — risk assessment, calculation, empirical. XD Rad Les. UK to " ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments re Baccl Component Failures * Problems identifying causes — lack of evidence, technical difficulties. Heat damage to ‘hot box’ components. Damage to fracture surfaces. Inadequate records and standards. ‘Pressure to restore operations. XD Rab iss. UK ting ae ret Mergers bent ie ati Main Line Derailments Component Failures Monitoring * lovestment imequipment, training. ‘+ Investment in new technology/research. + Revision of standards. Condition monitoring. 12 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Pause for Questions? Pausa para perguntas? 0 Rad tte UK Main Line Derailments High Speed Derailments * interaction Vehicle/Track + Excess Speed = Vehicle Ride Performance x0 Rabi UK [seangrege net arapere 8 oaetge cies Patti ‘© Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Main Line Derailments High Speed Derailments Interaction Vehicle/Track * Vehicle sensitivity to track irregularities. * Response to single irregularities. * Ovelic irregularities in top and line. x0 Ras tes UK ang eng ae reece terre Main Line Derailments High Speed Derailments Interaction Vehicle/Track + Poraile! dps atral joints or requlor spacing cause pltch er Bounce response. += Speed ond wee noture! frequency need to match aip spacing + Loaded vehicles have lower natural frequencies. x0 Rea te Ur 14 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments High Speed Derailments Interaction Vehicle/Track vem Ae + Stoggered rail jlnt result in twist fouls or eyelie cant leregutarities, ‘+ Hormenic rll can be generated between 30 ond 40 ker Main Line Derailments High Speed Derailments Interaction Vehicle/Track * Trains overturning on sharp curves * Increased dynamic response to track irregularities * Collisions due to increased braking distance + Flange climb derailments on points * Increased derailment damage © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments High Speed Derailments Interaction Vehicle/Tracl Vehicle Overturning “Treeederaects soe lation unto excess sped and overturn Maman Factors dominat ue Main Line Derailments High Speed Derailments (© Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments High Speed Derailments Interaction Vehicle/Track Pressure mark outer edge of right hand rail 15 sleepers prior to sleeper zero Pressure mark outer edge of right ‘hand rail 26 sleepers prior to sleeper 2er0 Morpeth 24 ne 1986 XD Rad 0. UK Main Line Derailments High Speed Derailments Interaction Vehicle/Track Excess speed results in increased derailment damage Ff) S’ 7 ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Low Speed Derailments Typical Locations and Causes - * Derailments on Switches and Crossings. * Track twiston curves. * Gauge spread on curves. x Rad it UR Main Line Derailments Low Speed Derailments MECHANISMS OF DERAILMENT Points and Crossings |. Flange climb on switchblade Split points Reversed points Crossing Vee bypassed wrongly Run-through (trailing move through points locked and set for opposite route) sae Ne © Mike McLoughlin, All rights reserved Risk & Safety Consultancy Group Main Line Derailments Low Speed Derailments ‘ ‘Simitar flexure turnouts present. greater angle of attack to leading whee! flanges. Excess speed can increase lateral simpact force significantly leading to flange climb derailment. Main Line Derailments Low Speed Derailments Interaction Vehicle/Track Per eye + Twist foults offlood wheels at high or low speed. # Speed restrictions not effective. x2 Rag Let Un ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Low Speed Derailments Main Line Derailments Operations Derailments MAIN CATEGORIES + Excess speed + Train handling ‘« Incorrect loading/ load shift * Signals Passed at Danger (SPAD) © Trap points ‘+ Communications error/foilure * Degraded operations XD Red te UK 20 (© Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Operations Derailments Uneven 1oad/shifted ioad/over load - ‘= Affects stability of ride, ‘+ Affects wheel loads = increased risk of flange climb, '* Damage to roller bearings etc. * increased damage to infrastructure. so Raates UK sewn Main Line Derailments Operations Derailments Signals Passed at Danger Human Factors * Technical couses * Environmental issues 2a © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Pause for Questions? 22 ‘© Mike McLoughiin, Al rights reserved. Risk & Safely Consultancy Group Main Line Derailments Investigation Techniques & Technology onsite OFF site + Initial objectives. + Depot tests/examinations. * Locations of evidence. * Dato Processing & Analysis. ‘Types of ewidence & priorities... * Laboratory analysis. '* Derailed running evidence. '* Vehicle/Train dynamics simulation, + Evidence colletion. + Train performance calculations. + Investigation equipment. '» Reconstruction modelling. + Evidence collection techniques. '* Analytical toots. + Evidence for Courts Main Line Derailments Investigation Techniques & Technology Site Investigation STARTING POINT OF INVESTIGATION, Accidents/incidents will have an origin of location where the event took place. “This is: : . The starting int for the investigation. __ © Areference position. + The place likely to contain evidence of the immediate cause or yield valuable elves. 23 ‘© Mike McLoughiin, All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Investigation Techniques & Technology Site investigation INITIAL OBJECTIVES ON SITE. In the case of a derailment these are to: ‘© Establish the initial point of derailment. * Identify the first vehicle/wheelset to derail, * Establish the course of events from initial derailment until the train stopped. x0 Rar uss. UK feng mere Dent at Morag Main Line Derailments investigation Techniques & Technology zee Site Investigation DERAILMENT INVESTIGATION 24 ‘© Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Locations of evidence + CASH SCENE og Pleas of ebies + ACODENTHINGIDENT NBTATION 67 Poet of Berasimen (PO) INTERMEDIATE eg erated running between POD ad Pinel rash xen ‘+ APPRONCHTOTHE SITE Wp tack condtion preceding PD + AMEAD OF THESETE ep Smet, + ADINCENT TO THE SITE 4901 roswey property ‘REMOTE LOCATIONS eg Carte Room Main Line Derailments Evidence - Key Points + Needed but can be obtained later e.g. line gradient, fxed installations, maintenance records, trock history. ‘+ Lowest priority. + Con be recovered or obtained ot a later stage. * Quickly record ‘perishable’ aspects e.g. temperature, position. + Important to record or label the evidence. ‘+ Top priority and must be recorded / recovered quickly ‘© Moy be lost or destroyed during recovery or repairs. ‘+ May be lost due to passage of time, changes in temperature, chemical change, memory loss, ete x0 atts. UK 26 © Mike McLoughlin. All rights reserved. Main Line Derailments pcReae > eee Pall: Evidence Main Line Derailments Evidence - Key Points Perishable evidence is mainly lost due t TIME Pressures Temperatures. Chemical change e.g drugs & alcohol, corrosion. Recordings e.g. video, tapes may over-record. Data retrieval may over-write or have limited fe. Environment. Weather e.g. rail/road surface, lighting, visibility. Witnesses e.g. loss of contact. Memory. Risk & Safety Consultancy Group © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Evidence - Key Points Perishable evidence is also lost due to: CHANGE OF CONDITION (RECOVERY, REPAIRS) Main Line Derailments Investigation Techniques & Technology Site investigation - Assigning roles *» Prepare a plan for on-site and off-site evidence collection * Liaise with Site Contrallér and other agencies + Agree who collects and what '* Conform to protocols for removal of evidence ** Split the team and assign tasks * Co-opt helpers ‘+ Target accessible areas and perishable evidence * Keep Site Controller informed as to progress * Advise Site Controller on completion x0 Ras Um ar ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Evidence.- Key Points DERAILED RUNNING Follow the signs, pursue the quarry. Siena Derailments leave a trail of evidence. iaonateeenes e Main Line Derailments Evidence - Key Points a domage oe left Derailed Running Evidence Important to correlate vehicle ond infrastructure damage and recover evidence such as detached components. 28 © Mike McLoughiin. ll rights reserved. Risk & Safety Consultancy Group Main Line Derailments Evidence - Key Points: DERAILMENT MARKS [Deraiiment marks are key evidence. resent when wheel(s) left the rail 29 (© Mike McLoughiin, All rights reserved, Risk & Safety Consultancy Group Waiipe, Deraimens _DERAILMENT MARKS IMPORTANT TO RECORD - * Length. * Number of marks. * Position relative to signals, platforms, aoe ee * Nature e.g. heavy, light, irregular. * Secondary marks after initial derailment. * Attempted derailment marks. * Position of tread corner marks relative to flange marks. '* Marks on rails before derailment and into the : Use a logical: ‘dentiyifrostroctare Jnacotedrection ond convention e9 Le left rail, R = right rail in direction of troves ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Evidence - Key Points MAPPING THE SITE METHODS * Pacing out + Counting sleeper/raiis Tape rules! ‘+ Measuring wheels «Electronic distance ‘measurement * Loser ‘+ Toto! Stations survey + GPs Relate debris to fistures or datum x0 Feast UK Main Line Derailments Pause for Questions? Pausa para perguntas? LO Ral is UK an ‘© Mike McLoughlin. All ights reserved Risk & Safety Consultancy Group Main Line Derailments Investigation Techniques & Technology Investigation equipment Main Line Derailment: Investigation equipment + Resources to measure, record and preserve evidence + Safety and personal protective rquipmest. 32 © Mike McLoughlin. All rights reserved, Risk & Safety Consultancy Group Main Line Derailments co Investigation equipment Main Line Derailments Investigation equipment 33 © Mike McLoughlin, All rights reserved Risk & Safety Consultancy Group Main Line Derailments Investigation equipment ‘MiriProf cipal call and whee! profile recording Main Line Derailments Investigation equipment (© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Main Line Derailments Investigation equipment = r Abtus Trock Recording Trolley x0 Ras tes UK Main Line Derailments | Investigation equipment RAIL SIDE WEAR GAUGES UK Jaw Stepped Wedge Gauge 35 © Mike McLoughlin. All rights reserved. Main Line Derailments Investigation equipment VOIOMETERS Instruments Yo Measure Deflection OF Rai ‘When Vehicle Land Applied x0 Rat Les Um 36 Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Voidmeters a7 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Table 1 tolerance lis twisting and warping according to the VMA posignone wera Fomgiona ve Foto 1 Mouagens de aavana esque Photo 2 Left fever assembly. ‘hota 2- Right lever assembly. 2 Ra int UK 38 ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Foros —Nowage do ahpostes Fove = Mouagen do dsp, Com 0 dispositive devidamente montado, a grade comeca a ser ‘monitorada em seu desiocamento vertical. Com a passagem de trens. 0 dispositive registra todos 08 movimentos conforme as imagens de um video regitradas abaixo: With property mounted device , the grid begins to be monitored ints vertical displacement. With the passage of trains the device records all movements 3s Images from a video recorded below. xo Ras ta. UR eect Serer waragerer tem Photo 5- Video images ofthe device ta operation 39 © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Toes Ness Sane antes Det oa asafomasie de esau dsm da det de er bjt 40 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group a © Mike McLoughlin. Ail rights reserved. Risk & Safety Consultancy Group. Grifico 3 —Resultado dos clleules de torgio. © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group ‘Geifcs 1 Rasalinds dos divides de enpeno disco 43 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Logo, fica constatado que com 9 hata dindmico, 0 problerna nfo verfcado em condigtes estiticas fea muito mais grave e representa risco a cireulacHo. A informacdo gerada pelo teste diskmico comprovou sua efcicia uma vex que nBo foram [encontrades anomalias no vag evolvide no descarniamento nem na condugso do maquinista este trem. Foi veriicado no loealque 0 vagho sofreu um grande alvio de roda, provocaco por Jum deteito geométrico invisivel em condigBes e:ticas. Therefore, t's found that with the dynamic effect, the problem unverified static [conditions is much more serious and poses a risk to the movement The inform ation ]generated by the dynamic test proved its effectiveness since anomalies were found in the car involved in the derailment or the driver's driving'ths train. it was verified on the spot that the car suffered a big wheel of relief, caused by an invisible geometric detect Main Line Derailments investigation equipment, © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group 6, DERAILMENTS IN YARDS AND SIDINGS Derailments in Yards & Sidings Topics + Principal differences to Main Line derailments. + Main categories of derailments. + Operations derailments + Underlying causes. + Gauge spread. + Flange climb derailment risk + Derailments at Points & Crossings. + Handbrakes. * Catch paints. © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group, Derailments in Yards & Sidings Principal Differences to Main Line Derailments + Low speeds, * Tight curves, * More Points & Crossings. * Points not locked and detected. * Lower track maintenance standards. * Lower investment = poor quality track, + Reliance on communications to control movements. * Safety Culture/Human Factors feature strongly. Derailments in Yards & Sidings Main Categories of Derailments + Obstructions. '* Obstructed wheels at load-outs. + Gauge Spread. '* Split or reversed points. *+ Flange climb at points. * Collisions. '* Flange climb on twisted track. * Traction and Braking shocks (Buff & Draft forces). © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings ‘OPERATIONS DERAILMENTS + Obstructions such as scotches. + Failure to check points. + De-roilers not removed. Route set incorrectly. ‘+ Collisions with buffer stops/ other roil vehicles. + Runaway vehicles. ‘+ Premature release of spring points. ‘Insecure doors on vehicles striking point levers. ‘+ Dragging equipment such as chains. + Hondbrakes left on (causes deroilments/rail failure on main lines) = Vandalism. x0 Rad Lis UK anges eet waragenes krvemern ron tre pene Derailments in Yards & Sidings Precursors for Derailments Underlying/Basic Causes of Most Derailments. * Rules or procedures not followed. * Inadequate inspection. * Inadequate maintenance. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Human Factors Violations ~ people deliberately not complying with rules & procedures. WHY people commit violations Behavioural Modifiers * Poor perception of risk + Low chance of detection + Ineffective disciplinary procedures * Lack of reward for safe proctice ‘+ Poor accountability * Poor supervisory style = ‘+ Complacency (coused by occident free environment) ‘+ Inadequate management attitude x0 raw ues ure Derailments in Yards & Sidings Blame Cycle rot + reoson x Rat Lr © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Operations Derailments Communications error/failure © Safety culture * Working practices * Technical factors Derailments iin Yards & Sidings Operations Derailments Wheel scotches left in position and run over. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group + Tight curves * Loose/missing rail fastenings. + Timber sieeper foilure. * "Poor track support. Derailmentsin Yards & Sidings Flange climb derailment csk + The carves + Node fous. | Poor track support. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Points & Crossings Some 40 to'S0% of deraiiments oceur at points. x0 Rad tt OK ae ore rn Derailments in Yards & Sidings Derailments at Points CHECKING POINTS ~ Shunter only checks unreliable points. (CATCH22 if points made more reliable then Shunter won't, bother to check! PROBLEM ~ Hand points are inherently unreliabiel © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Points & Crossings Types of points- Derailmentsin Yards & Sidings Points & Crossings ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Points & Crossings Derailments in Yards & Sidings Points & Crossings © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Poss pee Marks on check ral incicate wheel Range go:0g wrong side of crossing nose. Lie check rai resuts is wheel fange contact ‘with crossing nove and increased sk of deraiiment. x Rad tet UK Derailments in Yards & Sidings Maintenance & Standards Lower maintenance standards. Different standards for private sidings ond industrial premises. '* Materials cascaded from main lines. * Infrequent inspections. ‘* Operations damage to infrastructure. * Inadequate resources (people/materials). 10 ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidj Hand Brakes Hand brakes left on- * Result in whee! fats. + Wheel flats can damage/frocture rails ‘= Result in ‘fos flanges’ and derail ot points xo Ros tit UK Derailments in Yards & Sidings Hand Brakes " © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailments in Yards & Sidings Catch Points Derailments. © Run-aways. * Trains rolling back. Derailments in Yards & Sidings Oerailment investigation Problems- Under-reporting of derailments. Sub-standard investigations. Lack of expertise. Conflicts of interest. Safety culture problems. Commercial pressure. Reports contain ‘causes of convenience’ © Mike McLoughlin. All rights reserved. Risk & Safety Consultaney Group 13 © Mike MoLoughlin. All rights reserved. x0 Ra te UK XD Rad Lies UR DERAILMENT MANAGEMENT & INVESTIGATION Session 7 DERAILMENT MANAGEMENT POLICIES Mike McLoughlin Derailment Management Policies 1. Cost of Deraitments Deraiiment investigation Committee Working Group Deraiment Statistics Setting goaistargots Priorities ‘Communications Academic Research ‘Safety Culture/Human Factors ‘What probiem? 10. Links with Other Railways/Organisations 11, Deraiiment Mitigation Cerne v een Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group. Derailment Management Policies Cost of Derailments ‘Most costs of industrial ‘accidents/derailments are not identified . For every 15 identified costs there can be $9 unidentified ‘+ Management time das ‘+ Delays/operational problems + Loss of business Across 2 range of industries estimates of uninsured costs lie between $8 and $36 for each $1 insured cost. f business profit margin is 5% then for; SAM cost of derailment - $20M from revenue 5% © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Management Policies Derailment investigation rdafsene:ie Raturelut'the probe * Establish Derollment investigation & Reporting Stondard/Procedures. ‘+ Troin investigators ‘+ Investigations resourced and equipped. Transparent investigations. ‘+ Accurate identification of immediate/Bosic/Root causes. ‘+ Robust recommendations thet: + Eliminate derailment. = Minimise the risk of recurrence. = Mitigate the consequences. Derailment Management Policies Committee/Working Group The train won't leave the st + Represent business groups/departments. * Co-opt independent specialist. ‘+ Include workforce representatives = Co-opt academics. + Alloeate ‘Champions’ to initiatives. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Management Policies - Derailment Statistics Investigation intelligence needs to be collated and analysed. + Design detailed report form. + Construct user-friendly database. + Analyse deraiments by causes. contributory factors, location, operations, engineering etc. + Normaiise data to get rates per X° . Problems with normalising data from Yards & Sicings. © ee iil Derailment Management Poli Setting Goals/Targets Goals/Targets need to be; * Realistic. + Achievable. * Backed up by investment/resources. + Given sensible timescales. Comporable to best rates achieved on other systems. = Setfort | -Main Lines © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Management Policies Priorities For Main Lines and Yards & Sidings concentrate on; '* High risk locations. * Clusters of causes. ‘+ Types of derailment with high potential for fatality/injury. Derailment Management Policies ‘Communications Involve workforce - set up local groups. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Management Policies Academic Research Invest in research projects + Problem solving. + Research alternative solutions. Derailment Management Poli Safety Culture/Human Factors Evaluate safety culture. Improve communications. Simplify rules/procedures. * ‘Cascade briefings from top down. + Improve training & personal development. Enlist Human Factor specialists. © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Derailment Management Poli Links with Other Railways/Organisations + National Railway Organisations. * National Railway Organisations — other countries. * International Union of Railways (UIC). + European Rail Research Institute (ERI). * European Association for Railway Interoperability (AEIF). XD Ral Ld UK End of Session 7. x0 Ral Ltd UK eecereeeness verge tenn © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group DERAILMENT MANAGEMENT & INVESTIGATION Session 8 Derailment Prevention Mite Metoughin Derailment Prevention 1. Condition Monitoring ~ Rolling Stock. 2. Condition Monitoring - infrastructure. 3. Monitoring & Maintenance problems 4. Track Engineering. ‘5. Trackside Equipment. 6. Operations. 7. Rules/Standards. 8, Safety Culture. 9. Derailment Mitigation © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Condition Monitoring Rolling Stock ‘© On-train transducers. © instrumented vehicles/portable ride recorders. '* End of train monitors. © Speed compliance systems eg ATP. ATC. Improved troin broking. Maintenance technology eg Ultrasonic. { x0 Rad te UK Lanegan cater eget emesis tetinatts_ | Derailment Prevention Condition Monitoring Infrastructure Track Recording Vehicles. Remote condition monitoring. Continuous Welded Rail (CWR) stress testing. Maintenance technology eg Ultrasonic. Automatic wheel load measurement. © Mike McLoughlin. All rights reserved. Derailment Prevention Monitoring & Maintenance Problems Lack of resources. Inadequate knowledge of assets and condition. © Commercial/Operations pressure, © Investment priorities. ‘+ Workforce competence. Inadequate Standards. '* Contractors— communications, control, hand-back. Emerging technical problems. x0 Rath OK Derailment Prevention Network Rail UK - New measurement train (NMT) ‘The NMT is a converted interlty 125 ful of vanced detection and recording equipment, including scanners, lasers and digital video: ‘cameras. It can instantaneously measure and report on the condition ofthe track and other components. Among other things + Counts every single sleeper and even individual ral clips + Takes crystal-clear digital images + Measures even bounce] and noise checks the 2s: ster ++ Collects data while’ jat 125 mph (200 km/h). ‘The NMT gives extremely accurate reports on the type and exact location of even very small maintenance requirements. Potential problems can be fowed before they affect train operations. ‘Around 94% of trains now arrive on time every year. x0 Rad td UK Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Ground Penetrating Radar & Ultrasonics sor © Mike McLoughlin. All rights reserved. xD Rad tha = Soft clay under chalk not, ‘supporting the track-bed Risk & Safety Consultancy Group Derailment Prevention Ground Penetrating Radar Example of Application of GPR Proposed area for Re-ballasting ‘Actual problem area Identified by GPR Derailment Prevention Ground Penetrating Radar © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Friction Management Solar powered friction management ‘equipment in Brisbane, Austra Derailment Prevention Trackside Equipment * Wheel impact detectors. * Hot axlebox detectors. ‘+ Hot/Cold wheel detectors. * Dragging equipment detectors. © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Track Engineering Sacrificial points protector Den Meragerert Derailment Prevention ‘Track Engineering ‘© Mike McLoughlin. All rights reserved. Derailment Prevention ‘Track Engineering xo Resta ux Protection rail at points on London Underground. eereneey mere eager ti pees Derailment Prevention ‘Track Engineering Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention a ring XD Ra Ls UK ‘track at vulnerable location. Derailment Prevention/Mitigation Track Engineering © Mike McLoughlin, All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Operations Defensive driving techniques. * Driver reminder devices, * Vigilance systems. '* On-train monitoring recorders. © Speed monitoring. Temporary Speed Restrictions. Derailment Prevention Speed v Derailment Risk Temporary Speed Restrictions (rs) ‘TSR PROBLEMS Braking heavy trains on failing gradients. * Ineffective for severe track twist on curves. ‘+ Risk of vehicle frequency/track irregularity wavelength coincidence. * Need for risk based guidance. Human Factors v Compliance. 10 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Speed v Derailment Risk Lateral Forces TSR Temporary Speed Restriction _ ‘Speed Why? cr Dependent? Derailment Prevention Speed v Derailment Risk Vertical Forces TSR = Temporary Speed Restriction seed | wm? Bie oftse | Dependent? a " © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention ® Speed v Derailment Risk Temporary Speed Restrictions (TSR) TSR PROBLEMS Ineffective for severe track twist on curves, T a TSR will; * Reduce dynamic effects and forces * Minimise damage should a derailment occur x0 Pad i UK Derailment Prevention Rules/Standards Rules/Standards/Procedures - * Need to be understood. * Require under-pinning knowledge. * Should be written in Plain Language. * Communicated by cascaded briefings. * Revised in the light of experience. * Be achievable by workforce using allocated resources. 0 Rab tid UK 12 ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Preventio: Safety Culture f © Company policies. '* Training/Knowledge * Derailment risk knowledge. Hu Derailment Prevention Derailment Mitigation End of train monitors. Coptive Bogies. Dragging equipment detectors. ‘* Temporary speed restrictions = 13 © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Derailment Mitigation External steel or concrete up-stands to constrain derailed wheelsets. x0 Ras tid UK Derailment Prevention eel Derailment Mitigation Protective covers for vuinerable equipment. 14 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention Derailment Mitigation “Temporary speed restriction’ or domage liveation Railways get safer with; + Trained investigators. + Methodalogical investigations. * Resourced investigations. ‘Investigator initiative, innovation. + Accurate identification of derailment causa’ factors. + Investmentin derailment prevention/mitigation. © Corporate memory, refresher training. * Investment in Research. x2 Roa tes Un 15 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention/Mitigation Derailment Prevention/Mitigation ‘Training UK infrastructure managers in deraiiment isk. ‘Equipment demonstatons by supplier. Digital cross-tevel gauges, Opal Min’ aser, Laser rai profie recorder, Amber troley recorder x0 Ro i ur © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention/Mitigation “Training UK Senior Track Engineers in deraiment investigation & rok Derailment investigation Training MTR Hong Korg 2012 [<0 Rad Lk UK a 7 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group iment Prevention/Mitigation Tabletop training exercises uses MTRC software 0 Rad UK: Derailment Prevention/Mitigation Derailment Mitigation Tsing Ma bridge © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Tsing Ma suspension bridge to cirport on antau istond, Hong Kong xD Ras cx. UK Derailment Prevention/Mitigation Rail Safety Research in the U Ral Safety & Standards Board (RSSB) UK «+ Rail independent not-for-profit company iGwied and funded by major stakeholders ‘rail industry * RAD Government funded. ' Appr AS32m each year + Three main areas + Engineering ‘Results published wwwarssb.co.uk tn rept 19 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Derailment Prevention/Mitigation ‘Some RSSB Safety Research Projects ‘* Wind Overturning Study. * ‘identification and quantification of injuries In rail vebicles during accidents. ‘+ Mental workload assessment for train drivers. ‘+ Management and understanding Roling Contact Fatigue (RCF).. + Development of Anti- RCF wee! profile. = Whole train dynamic behaviour in collisions. ‘and improving crashworthiness. Train windows on passenger vehicles. Derailment Prevention/Mitigation Researching for Survival Principal hazards + Lass of survival space. Reduce risk of derailment. Masimise ability of vehicies to absorb impact. Ensure vehicle stays upright ‘and in line. Protect people against injury. Provide for escape and rescue. 20 © Mike McLoughiin. All rights reserved. Risk & Safety Consultancy Group 24 © Mike McLoughlin. All rights reserved. ention/Mitigation UK Research Evacuation & communications Passenger restraint Injury criteria ‘Windows + Prevent derailment Whole train + Absorb energy are, + Keep upright Retainbagie “Protect people ‘Signage ‘+ Faclitate escape Safe interiors. Seats and tables Energy absorbing. couplers Fuel tanks: Obstacle deflectors ape at apo Nd Life RUorES | Reports: werwersb co.uk End of Session 8. Syndicate exercise — * List three main controls that would reduce the risk of derailments or mitigate the consequences. * List pros and cons for each. 22 Risk & Safety Consultancy Group © Mike McLoughtin. All rights reserved. Risk & Safety Consultancy Group DERAILMENT MANAGEMENT & INVESTIGATION Session 9. CASE STUDIES x0 Raw txt UK CASE STUDIES ‘One or more of the foliowing case studies will be shown depending on time ‘available in the last session of the seminar. Additional sides will be shown to, provide more detail LFreight train derailment on points. + Lack of Standards. * Inadequate reporting. + Conflicts of interest. 2 Passenger train derailment on points. ‘+ Site investigation difficutties. ‘+ Technical problems. 3. Freight train deraiiment on modemised Main ine. '* Difficult technical investigation. ‘+ Comprehensive contro! actions. Rees Uk omen “ ‘© Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group CASE STUDY 1 Freight Train Derailment on Points Freight train derailment on points before privatisation of British Rail, * Diese! locomotive +15x102 tonne tanks loaded with petrol. * 3 tanks derailed; 7%, 8, and 9” at @ train speed approx. 24km/h. * Speed not excessive. ‘* Tanks owned and maintained by private company. * Track left-hand curve 764m radius, cant between 10mm and 20mm. * ©’ switch, straight planed, undercut blade made of manganese steel, * Local gradient 1:189 falling. XD Rat Lid UK Freight TrainiDerailment on Points ‘Genera ews of deraliment © Mike McLoughlin. All rights reserved, Risk & Safety Consultancy Group Freight Train/Derailment on Points Da aekead in d control and environmental damage Freight Train Derailment on Points Site after removal of wagons ‘Approach to No.40 points © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Freight Train Derailment on Points Condition of switch blade. XD Ral bk UK Freight TrainiDerailment on Points Recording swith sch es aon Le aa eS in) ‘© Mike McLoughlin. All rights reserved Risk & Safety Consultancy Group Freight Train Derailment on Points 20 Rate UK Freight Trein/Derailment on Points ‘Analysis of traci and vehicle damage Identified right leading wheel of leading derailed wagon te have eralied first © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Freight Train/Derailment on Points ‘Severe ridge/ip on right leadioe Left leading whee! flange shows whee! flange (derailed fist) neg e wear Freight TrainiDerailment on Points ints locking mechanism strained during the derailment: © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Freight Train Derailment on Points Evidence showed that the right leading wheel of the 7 wagon derailed by flange climb on the switch biade. The wheel flange had a ridge (toe radius build-up) outside maintenance limits which enabled it to engage and climb the switchblade. Discussion Points; Wheelset scrapped before case concluded Lack of Standards. Lack of equipment to gauge switch blade wear. Inadequate reporting. Conflicts of interest. Competing investigations. CASE STUDY 2 © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group © Mike McLoughlin. All rights reserved. Risk & Safety Consultancy Group Passenger irainiDerailment on Points tng eer Sere regrets ae a: ester Passenger Train Derailment on Points

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