Description of Ladbroke Grove Rail Crash - Case Study Example

ACCIDENTS AND PREVENTION Name Institution Date Description of Ladbroke Grove Rail Crash The Ladbroke Grove rail crash is termed as one the worst rail accidents that have ever occurred in Britain (Kletz. 2002). The accident occurred on the 5th of March in 1999 at the Ladbroke Grove. On this day, 5th of March 1999, at exactly 08:06 British Summer Time, a Thames Trains service departed from Paddington station, platform nine and veered off to Bedwyn railway station in Wiltshire. The Thames Train (whose headcode was 1K20) was the type of a 3-car turbo class fitted with 165 diesel unit. The driver of this train was Michael Hodder (Kletz. 2002). The distance between Paddington station and Ladbroke grove junction is about two miles west of the point of departure. Between the junction and the station there are about six lines (bi-directional) which can be used to run into or out of the station. In addition to the bi-directional, there are series of crossovers to enable trains be routed from one route to the next. At the junction itself, Ladbroke Junction, there existed interconnections between the lines. Stretching to the West of this junction, were four lines on which trains could run over. These were named; Up lines, Down lines, Main lines and Up and Down Relief lines. The movement of trains on the bi-directional lines by the various trains was controlled by signals. Before any train could enter the lines it was imperative to confirm that that line was clear from any train. In presence of a train on a line the signal could show red meaning danger and upon absolute clearance the given line could be termed clear for entrance of another train. Upon departure of Turbo, on platform nine it took circuit DL and passed through SN17.It’s request for the route SN009 was successful.So at the junction the Turbo occupied the fourth line. However, this route was not set for the distance beyond SN109 (a zone that managed access to the Down Relief and Down line). This meant that any other train that had made a signal to occupy SN109 could land at the Down Main via point’s 8057 and consequently 8060 (Kletz. 2002). A minute after its departure, Michael Hodder was comfortably driving the Turbo on Circuit CZ via SN43 on the third gantry which was then indicating green .The crash between the Turbo and Train at High Speed occurred thirty three minutes after Turbo crossed SN109, went through 8063B which caused an impact between the Turbo and HST.At this time the speed of the Turbo was 51mph .Just before the impact , Michael Hodder attempted to apply brakes.The first brake was for service while the other was an emergency break at 30.75 seconds (Kletz. 2002). When the accident occurred, the driver of the HST, Brian Cooper died on the spot. The diesel that the train had, spilled out in the course of the collision and consequently provoked a tremendous fire. There were, in total, 31 fatalities, 24 of them occupants of the Turbo while the other six from the HST- due to the impact. One person passed on as result of the fire. A total of 227 people were admitted in hospital and an additional 296 sustained minor injuries. The latter were treated at the scene of the accident and discharged. Investigators of the accidents termed this crash as the worst that has ever happened in Britain. Immediate Technical Recommendations to Avoid Triggering the Accident As per the witnesses the immediate cause of the accident was the driver of the Turbo, Hodder.He,Hodder, failed to halt upon being given the signal at SN109 (Whittingham, 2004). Neither did he try to stop up the crash. Investigations revealed that there were only two brakes applied, one a service one while the other one was an emergency at 30.75 seconds, way before the crash was suspected. In accordance to Kyle Kletz, this can be termed as a violation since the driver of the coach omitted to do what he was supposed to do thus putting the lives of the passengers at risk (Whittingham, 2004). Two possible causes of violations are deliberate intention to omit doing what one is obliged to do or poor motivation. A preventative remedy for such violations would have been motivation of the drivers by incentives, better remuneration and working conditions. Given such an environment, the driver’s morale would be high and the seriousness with which the driver would have taken their work would have been out of question in this regard. Michael Hodder, may his soul rest in peace, had just graduated from driving school. He had very little experience with regard to coach driving. It is partly his fault to have accepted a task he was less prepared to handle but largely the firm’s mistake to have entrusted him to transport safely all on board without any support. As a preventative measure Michael needed an assistant or be given adequate orientation on the route before being left to work on his own. Otherwise such a task ought to have been given an experienced driver who would have known what to in order to avoid the accident. An experienced driver could have known that the area around SN 109 had caused serious threats before and thus take the signs seriously as preventive actions to avert the imminent crash. This particular accident could have been avoided if the coach had an experienced driver. The other potential cause of the accident was attributed to lack of a protection system for train that would permit application of brakes to protect against signals indicated at Danger. This is a mistake on the part of the engineers who designed this train, the management and control team of the train. Either of the officers in the control panel would have identified such a fault and report to the relevant authorities for further action. What such a mistake translated to is that ,the safety of all the individuals on the Turbo was solely in the hands of the driver who was endowed with the prerogative of all observation and vigilance needed to keep all and sundry safe. In this regard therefore, designers ought to have equipped the coach with this protection system. Another preventive action that would have been taken was to put in place an effective signal management team. The signal men failed to make a radio call and signal all the oncoming trains that there was danger caused by the Turbo. This might have been a violation or mistake due the poor training. A response team should be well-equipped and highly trained so as to help avert hazards like this one. The Multiple SPADs ought to have been maintained and their visibility reviewed from time to time to ensure that they give accurate observations.The SPADS at Paddington had last been reviewed in 1994.This is a very long times and any flaws would have been present. The sighting problems attributed to these gadgets was the ultimate subsidiary causes of the accidents Lessons Learnt from Ladbroke Accident 1999 and Recommendations There are several things that one can learnt from this accident. One of them is that hazards or accidents are preventable.Particularly, mistakes, violations and other contributory factors can be eliminated through careful forecasting of the potential hazards right from the time a machine is designed. Any designer should anticipate a long list of hazards and incorporate preventive measures in the design that go a long way in averting danger. For instance, in Ladbroke accident, it is the designer’s fault that the trains were not equipped with a brake protection system.Similarly, failure of the designer to design clearer visibility gadgets was a large contributory factor to the occurrence of the accident. The other lesson learnt is that once the designer has completed making the design, there is need for maintenance of the products (Mattias 2004). Such maintenance includes regular check-ups to verify if the equipments are working as intended and that any faults arising in the process of usage are rectified in due time. Flaws and faults are expected if an item is used over time. Making a machine for a user is not a guarantee that the machine will not cause an accident even if it is wrongly used. If the user instructions are not adhered to as expected serious hazards are inevitable (Mattias, 2004). The accidents also provoked serious thoughts on the value that proper training has on minimising hazards. Part of the cause of the accident at Paddington was defective training of driver Michael Hodder. According to research done by Mattias (2004), Michael had little experience on the route at his age of 31. This is probably the reason he would not tell what to do to save the lives of the passengers. Michael Hodder’s “defective training”, as termed by some investigators, raises questions on the threshold put on anyone intending to join driving of coaches. The regulatory bodies ought to raise the threshold put in place so that whoever is entrusted with the responsibility of saving the lives of such a magnitude passes through rigorous training before getting the certificate (Mattias, 2004). The other aspect to look at is management strategies employed by firms. Ineffective managers often overlook the needs of the workers and consequently subject them to conditions that make their lives at work miserable. Others poorly remunerate their workers. The two coupled together degenerate to poor morale and motivation. The latter as discussed earlier is a cause of violations in hazard analysis. As Frederic Herzberg advocates in his two-factor theory, hygienic factor such poor working conditions are contributory factors causing poor motivation of employees. Frederick Herzberg praises a conducive working environment as a factor that is poised to increase motivation of the workers. In this respect therefore, any organisation should not overlook the individual needs of the workers as these are contributory factors to violations and negligence while on duty. After the crash there are a number of lessons picked. Lack of hammer in the coach and escape paths in HST posed great difficulties in evacuating the victims. Such an issue raised concerns on how designers have catered for rescue and evacuating procedures in case of an accident. It should be accepted and that accidents are real and that can occur at any given time. This justifies the need to prepare adequately in case of any eventuality. Any design must ensure protection of the victims in the course of the accident as well provide for easy and smooth evacuation procedures. References Top of Form KLETZ. (2002). Accident Investigation - Missed Opportunities. Process Safety & Environmental Protection. 80, 3-8. Top of Form MATTIAS HOLMGREN. (2005). Maintenance-related losses at the Swedish Rail. Journal of Quality in Maintenance Engineering. 11, 5-18. Bottom of Form Bottom of Form Top of Form WHITTINGHAM, R. B. (2004). The blame machine why human error causes accidents. Amsterdam, Elsevier Butterworth-Heinemann. Bottom of Form Read More