Long delay on the 11:00 Penzance to Paddington - 04 Aug 13

[whole diary]

[IndustryInsider]

Not taken long for Mr. Crow to jump on the bandwagon on this one:

http://www.morningstaronline.co.uk/news/content/view/full/136211

Despite the fact that it's not HSTs^▸ (High Speed Train) that are going in for refurbishment, which in any case doesn't include any changes to systems that might cause a train to fail.  Opportunistic nonsense from the RMT^▸ (National Union of Rail, Maritime & Transport Workers) yet again.  Though that doesn't mean that I hope Railcare at Wolverton is saved given that I spent a few months working there in my very early railway career.

[stuving]

Having read the RAIB^▸ (Rail Accident Investigation Branch) report posted by Worcester Passenger, I think the biggest problem with these incidents is 'hope' - the crew and staff all do their best, in what can quickly become very difficult circumstances, but by the time the operator realises it has a problem it is already too late to resolve it in an acceptable time. What seems to be lacking is a set of time-based triggers for escalation.

We should have the benefit of hindsight while these incidents are unfolding, because similar things have happened before and recommendations have been made.

I agree that there are enough previous incidents for the lessons to all be there for the learning. What struck me about the RAIB report was that all they can recommend is more reviews. So this time we will presumably get yet more reviews of plans, practices, communications between the various bits of NR^» (Network Rail - home page) and the TOCs^▸ (Train Operating Company) ... but will that prevent the same thing happening?

The details of faults, and the options for moving a failed train, vary a lot from case to case. One common point is that to evacuate passengers needs a lot of staff, and if they can't walk a short distance to a station is only half a solution - where else do they go? But to make sure passengers stay on a squalid overheated train also needs a lot of staff. Very good communications to the passengers might be a partial substitute, but if you can't even keep the PA^▸ (Public Address) working, how likely it that?

[insider]

Some facts regarding this incident from a source in ICC^▸ (Integrated Control Centre) Western.

15:26 Log Item created and control aware of 1A85 having suffered a loss of main res air

15:38 Both Driver & Train Manager have great difficulty with mobile phone reception. GSMR in both powercars is working perfectly and this being used as preferred method of communication,

Driver has made way to rear power car and isolated all normal things that cause problems, such as ATP^▸ (Automatic Train Protection), E70 brake control unit, driver returning to front power car to see if any effect. Walking route is along cess / ballast so this takes time.

A Riding Inspector (fitter) who is at Reading is requested to attend > further delayed as 1C86 14:57 Pad to Pnz which he was attempting to fix that failed at Reading. This was set swapped with an Up HST^▸ (High Speed Train), thusly departed RDG^‡(resolve) 45 mins late without the fitter on board.....as he was still on failed train,making it fit to go ECS^▸ (Empty Coaching Stock) to Old Oak.

Fitter actually travelled on 1C88 15:57 Pad to PNZ and was logged as on site at 18:01.

16:26  DBS^» (Deutsch Bahn Schenker - UK^▸ (United Kingdom) website) despatch resuce loco and TVSC^» (Thames Valley Signalling Centre - about) will hold in Woodborough Loop pending events.

Meanwhile Driver reports still unable to maintain air and now continues to fault find (locate air leak), this entails putting parking brake on front engine revving the engine and finding the air leak, by walking down the train. This process takes time and it didn't find the fault.

Also in this process the driver injured his ankle on the ballast....but still continued and eventually drove the train!!!

17:15 Traincrew reported as finding a fractured pipe. In process of isolating. But needed block on the Down Line. Again this line was open to traffic and being in the middle of auto section, process of getting a block, doing the work, going back to powercar using GSMR was taking a long long time!!!

Train Manager goes to lay protection at rear for 1Z99 . However loco will not help if air leak not found / isolated!!!

17:41 Set sill loosing air with pipe isolated.

18:00 Fitter on site

18:20 FGW^▸ (First Great Western) Manager on Site

18:42 1Z99 given permission to proceed to protecting signal

19:00 Fitter also unable to locate air leak...again all hampered with communication as only GSMR working.

19:49 After various fault finding and isolations fitters is confident faut is within rear powercar. Now isolating and detaching from formation.

20:09 1Z99 at protecting signal, permission given to proceed. 1Z99 moving towards the rear of the train and will couple up and push up to allow the buckeye to be unhooked between the coach and the powercar

21:06 1A85 on the move!!!

1Z99 will drag powercar to Westbury

[insider]

Some questions I would like answered??

1) Why did it take 2 and half hours to get a fitter to site?

2) Why did it take so long even when rescue engine was on scene to detatch powercar and get moving (nearly an hour!)

3) At what point would they have evacuated?? 6 hours 7 hours......12 hours??

[Worcester_Passenger]

Insider - thank you for posting a factual log.

Though it does raise a lot of questions.

As ever, disasters involve a number of different events that all come together to make things worse : the lack of a mobile phone signal (did that also affect the passengers?), the duty fitter being busy on another train, the need for the rescue loco to uncouple the rear power car...

Pardon my ignorance, but trying to find a leaking air pipe by walking along outside the train sounds very nineteenth century - a bit like mending a puncture in a bicycle tyre. Presumably newer trains than the HSTs^▸ (High Speed Train) have all sorts of on-board diagnostic kit? Or am I hopelessly optimistic?

[ChrisB]

4) Why did the on-call Manager take over 3 hours to get on site? Where was he, PLY^» (Plymouth - next trains)?

All staff will be on the same mobile provider - my bet is that FGW^▸ (First Great Western) have one contract. Maybe there's reason to consider some being on a second different one?

[broadgage]

4) Why did the on-call Manager take over 3 hours to get on site? Where was he, PLY^» (Plymouth - next trains)?

All staff will be on the same mobile provider - my bet is that FGW^▸ (First Great Western) have one contract. Maybe there's reason to consider some being on a second different one?

It does sound as though limited cellphone coverage was a contributory factor.
Not being reliant on one network can help a bit.
I suspect though that no cellphone network would have worked well under the circumstances, in rural areas the network can only support a limited number of conversations or rate of data transfer. The operators try to provide a good service UNDER NORMAL CONDITIONS without spending too much on masts and towers (the erection of which is bitterly opposed)


I doubt that any mobile network would be able to cope with the extra traffic caused by this incident. About 500 persons on the train, and many of them useing cellphones or other mobile devices, on a network sized for the local population and the odd passer by.


For this reason I suggest that FGW should consider having satellite phones available in emergency, at least for senior management and perhaps for drivers and fitters.
These are totally immune to any congestion or overloading of cellphone networks, and are also immune to extreme weather that may topple cellphone masts or interupt the power to them.
Satelite phones are now available for about ^500, which would be money well spent considering the costs of delays.
The high cost of the calls is of little consequence in an emergency, IIRC^▸ (if I recall/remember/read correctly) it is about £1 a minute, so near continuall of a couple of sat phones for a couple of hours is only about £250.

http://evaq8.co.uk/Satellite-Phone-Emergency-Kit-Including-SIM-Card-And-Airtime.html

This is the sort of thing that I suggest, I have no connection with the supplier except as a customer.

[IndustryInsider]

If you were going to supply crew with another phone in the unlikely event of reception difficulties in such a situation, I'd have thought a portable GSM-R^▸ (Global System for Mobile communications - Railway.) handset would be the best idea.  Perhaps to be stored in the emergency equipment cabinet from this supplier:  http://www.selex-comms.co.uk/selex/pdf/gsmr_handheld.pdf

[Gordon the Blue Engine]

With all due respect to insider, I think some of the "facts" in the log may have got a bit confused in the manner/order they are stated. For example,

1.  HST^▸ (High Speed Train) Power Cars don't need "revving" to get air pressure.  Driver or Control wouldn't have said that. The compressors are electrically powered, not mechanically driven off the engine like Turbos etc.

2.  The traincrew (entirely logically) initially thought someone had pulled an emergency handle.  So that is why the Driver walked down the outside of the train, as the released air is designed to "whistle" audibly below the solebar to help locate the coach in which the emergency handle has ben pulled.  This item is shown as after 1626, and after the report that the Driver did the isolations in the rear Power car.  I suspect that in fact the Driver did the emergency handle check BEFORE he went into the rear Power car.

3  As I said earlier, you don't need a loco to uncouple the rear Power Car, so the wording of the item at 2009 doesn't look right (and Control wouldn't use a phrase like "allow the buckeye to be unhooked").

Seems to me that Driver and traincrew did a pretty good job on the fault-finding front.  

The simple way of course to determine if there's an air leak in a Power car is to isolate the main and brake pipes by turning off the cocks on the jumpers between the Power Car and first Trailer and then see if the rest of the train holds air.  

[phile]

Some questions I would like answered??

1) Why did it take 2 and half hours to get a fitter to site?

2) Why did it take so long even when rescue engine was on scene to detatch powercar and get moving (nearly an hour!)

3) At what point would they have evacuated?? 6 hours 7 hours......12 hours??

To answer (1), the fitter was at Reading attending to another failure at the time.

[Super Guard]

A point on the mobile reception:  O2, Three & Vodafone have poor coverage in this area.  One is FGW^▸ (First Great Western)'s provider, one is my personal phone and third is my wife's personal phone, and pretty much from just past Westbury until Newbury (with the odd exception such as Hungerford), there is very little reception along that route, and certainly just short of Pewsey, it's practically "No Service" all round.

[Umberleigh]

Interesting there are no FGW^▸ (First Great Western) Thunderbird locos unlike Virgin. I think with an increasing number of HST^▸ (High Speed Train), which aren't getting any younger,  brake failures FGW will have to consider employing Thunderbirds

The train was attended to by a rescue loco, but it took a while to get there. A Class 59 ran up from Westbury, the rear power car was detached and the 59 hauled it back to Westbury. The front power car then continued with the train alone to Paddington. The other power car was then recovered today by a Class 57 and hauled to Laira. The delay in the 59 running to the train was probably because the first action taken by FGW is to attempt to rectify the fault, rather than dragging the train straight away.

Saw the 57 hauling the power car nose first over the Exe bridge just south of Exeter St David's.

[57604]

With all due respect to insider, I think some of the "facts" in the log may have got a bit confused in the manner/order they are stated. For example,

1.  HST^▸ (High Speed Train) Power Cars don't need "revving" to get air pressure.  Driver or Control wouldn't have said that. The compressors are electrically powered, not mechanically driven off the engine like Turbos etc.

True, they are electrically powered, but revving the engine increases the voltage of the 3 phase supply off the auxiliary alternator so the compressor runs faster so you create more air to help find the pulled pass com or leak. HST compressors are quite poor and the air capacity quite low, so it entirely feasible that by the time you get down the train looking for your leak that the air has dropped enough to bring in the low main reservoir protection so the power car stops feeding the train.
Revving the engines gives you more time to find your leak.

[fatcontroller]

Some questions I would like answered??

1) Why did it take 2 and half hours to get a fitter to site?

2) Why did it take so long even when rescue engine was on scene to detatch powercar and get moving (nearly an hour!)

3) At what point would they have evacuated?? 6 hours 7 hours......12 hours??

1) As already mentioned - Reading

2) Surely an hour was quite good - considering "on scene" is where? Unless it's immediately behind the train close enough to be coupled although I suspect it was actually at the signal in rear which would then have to come in slowly, couple up, detach powercar, affix tail lamp, ensure all personnel are clear of the line as well as communicate updates to the Signaller and Control then an hour sounds rather good.

3) Where were the 500 passengers going to be evacuated to? The train is not on fire, they are perfectly safe onboard. Note that the Driver injured himself walking on the ballast with his safety shoes on. How many other injuries would you have if the passengers had to walk on the ballast with their inappropriate shoes on??

6 hours is a long time to be sat on a failed train but realistically what else could have been done?

[Red Squirrel]

6 hours is a long time to be sat on a failed train but realistically what else could have been done?

The answer to that has to be 'a lot'.

Even if you accept (which I certainly do not) that it was necessary to keep people 'sat' on the train - I think 'trapped' is a more accurate word - it is clear to me that resources (staff, refreshments, facilities, entertainment even) should have been brought on site within two hours. There does not appear to be an adequate escalation plan; essentially it looks like no-one was empowered to 'own' the problem.