Accident Investigators – 2019

In our project we’re used to looking at the reports produced by the accident investigators of 100 or so years ago (see this blog post, for example), and we’re keen to see how what they contain they might be useful today. But generally we’re dealing only with the printed reports of the investigation: what we know less about is the process of investigation, how cases were selected for enquiry, what happened behind the scenes, and so on.

When we were offered the opportunity to go into today’s accident investigators, to find out more about their work and to give an introduction to our project, we leapt at the chance. We were invited into the Rail Accident Investigation Branch (RAIB), the independent inspectors who look at many – though not all – accidents involving moving stock. So last month we headed to the Farnborough office for a look at the RAIB’s work.

The RAIB building; what you don’t see is that it’s next door to the Air Accident Investigation Branch, which has a huge hanger in which to work, and it’s right next door to Farnborough airport.

It was an excellent experience, and really helpful in getting more of a handle on the current industry, as well as helping us to think more about what the inspectors of our period might have encountered. I was one of a number of visitors being given the tour of the Branch’s work over a busy morning. We all appreciated the time we were given by the inspectors and their colleagues, including the introduction from the Chief Inspector, Simon French, which looked at the role of leadership.

There were three aspects we’d highlight from Simon’s talk as particularly pleasing to hear. Firstly, the evident trust he had in the ability of his team to work at the highest levels – sufficient that he was confident to let them handle the major investigations when they came. Secondly, the importance he placed on having time to reflect on past events and the need to learn from the past. Finally, Simon stressed that approaches which simply saw ‘human error’ as the major issue (as was often the case in our period) were far too simplistic, and that cases needed to be considered in the round. Very glad to hear this!

Over the rest of the morning we heard from Colin Ryan about the RAIB’s work in general and from Richard Brown, with a detailed discussion of the process and mechanics of investigating accidents, via the Sandilands Junction tram crash. This included a look at the tram itself, recovered from the crash location (a difficult task) and moved to the RAIB. This was a particularly solemn part of the day, given 7 passengers had been killed in the accident. It had clearly been a difficult investigation to carry out, and an extensive procedure, which has left its mark on the Branch – both as something the binds the team together and which has helped improve investigation techniques.

The help and support offered to the inspectors, especially those on site and who witnessed the scene first-hand, was also mentioned – something that was upgraded following the accident. Richard noted that inspectors generally developed coping mechanisms when dealing with incidents involving single individuals, but that was much more challenging for big cases like Sandilands Junction. No doubt this was very different to the period of our project, when it was unlikely that staff who witnessed the scene were offered much formal support. In addition, the sensitivity with which the families of the dead had been treated was clear, a testimony to the empathy and respect of the RAIB’s team.

Nick Bucknall introduced us to some of the more sophisticated aspects of today’s rail accident investigators, including computer modelling and the use of drones. Paul Tickner took us on a tour of the Incident Response Vehicle (in which I managed to locate the BR kit bag (a 25 year old survivor!) and the void gauge and Scottish void gauges – sadly more prosaic that the Scots having different voids!).

So far as the project is concerned, the session which had some of the strongest links between eras was given by Mark Young, a human factors specialist. Sadly the links were those which highlighted the sorts of things the project has seen: namely that in our period the key cause of accidents was found to be human error – but now there’s a much wider view of how accidents happen, placing the individual as one part of a bigger system. Mark reminded us that most of the time things go right, and that the accident is the uncommon event, but getting at the differences between work as imagined and work as it is done can be problematic. The examples that Mark gave were all really useful to help us think about these and other issues – the standout one being the Hest Bank 2014 near miss, in which a gang of track workers leapt out of the way of a 100mph train with around 2 seconds to spare. The footage from the forward-facing camera was terrifying, especially given we knew from a mile out what was about to happen.

I’d put this blog post together immediately after the visit – and only days before the tragic fatalities at Margam in South Wales on 3 July, in which two track workers, Michael Lewis and Gareth Delbridge, were killed. This was a stark reminder that some of the issues we see coming up in our project are not paper-based or confined to the past, but still very real challenges that the industry faces and doesn’t always meet. That this happened so soon after the visit to the RAIB gave me a much better appreciation of what they would be doing, and of the impact that the accident would have on all parts of the railway industry.

After the morning’s introduction to the RAIB’s work it was my turn. I was asked in as part of the RAIB’s Learning at Work week, on the suggestion of Paul Tickner and with the support of Colin Ryan. The intention was that our project might be able to give some longer-term perspective to help feed into the RAIB’s work today, and that we might be able to gain better insight into the work of today’s accident investigators. We outlined the place of worker safety in the nineteenth century and how it had largely been sidelined in popular and historical accounts, but from the late 1890s had left a big documentary trace which our excellent volunteers were working to make more accessible. Running through what we do and the ways in which we might think about history was certainly a useful exercise for us – hopefully it was also of use to those of the RAIB team who were able to join the session, in person and remotely from Derby. The questions and discussion after my talk were helpful in showing what might make our project data more useful to the RAIB, including focusing on accident causes and working on the comparability of data across time. Not necessarily easy to do, but important to try! The feedback from those present was very positive, and everyone was open to the possibilities that our project offered.

As a project we’re grateful for the invite and the day – it was very interesting all round and useful for us. Now to build upon that potential and see how we can feed in for the future!

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