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Post by FWOC on Jul 5, 2012 9:58:21 GMT
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Post by trt on Jul 5, 2012 12:31:00 GMT
A very interesting read.
So the obstacle detection system that reopens (I assume selectively) any door that has encountered an obstacle whilst closing is separate from the sensitive edge system, I take it?
Had the sensitive edge detection system also been able to automatically initiate a 25-75mm reopening, then the bag strap would probably have fallen away and would have resolved the situation. It is good that the investigation highlighted one or two discrepancies in the manual and the indicator light operation.
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Post by racka on Jul 6, 2012 0:16:13 GMT
A very interesting read. So the obstacle detection system that reopens (I assume selectively) any door that has encountered an obstacle whilst closing is separate from the sensitive edge system, I take it? Had the sensitive edge detection system also been able to automatically initiate a 25-75mm reopening, then the bag strap would probably have fallen away and would have resolved the situation. It is good that the investigation highlighted one or two discrepancies in the manual and the indicator light operation. Obstacle detect is automatic and selective, done based on motor currents. Stick your foot in a closing door and you will see what it does. You have pushback again now to allow the opening you speak of, don't know if all trains are fitted with it yet though. As regards the investigation, I consider the main cause to be the operator and levels of competency and training. At the end of the day, the door interlock cut out was operated incorrectly. If easily confused, there could have been any number of things that led to the operator switching the wrong switch. The Round Train was also cut out incorrectly, which could also have led to an incident. |
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Phil
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Post by Phil on Jul 6, 2012 8:19:10 GMT
As regards the investigation, I consider the main cause to be the operator and levels of competency and training. At the end of the day, the door interlock cut out was operated incorrectly. If easily confused, there could have been any number of things that led to the operator switching the wrong switch. The Round Train was also cut out incorrectly, which could also have led to an incident. It's too easy to judge - yes he was a person easily confused in a crisis *, but there again the modifications to the system changed the SE warning light so it would go out if the relevant button was pressed even if the fault was still there - - - - - and nobody thought it necessary to retrain the t/ops on the change. So there he is, he's got a sensitive edge fault. He goes through procedures and the warning light goes out. But he still can't get power and the book says nothing about the situation. No wonder he panicked if he was a nervy sort of guy. But it seems he was TOO conscientious, unlike most. Almost all other t/ops would have taken the train out of service there and then - but for the sake of the passengers (and the full platform after over 2 min dwell time) he decided to try to make it go with all the cutouts isolated - - "THAT WAY BE DRAGONS"  . The rest was virtually inevitable after this. Having been through the t/op technical selection process myself, I doubt he'd have a chance of passing the tests now - but you can't sack a guy who's passed all procedures at the time of his recruitment. Technology moves on apace - perhaps his brain is just not wired to. Despite all that, if the change in the warning light process had been passed on to drivers he would almost certainly have been able to follow procedures and get moving properly. I have a lot of sympathy for him.
* See below |
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Phil
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Post by Phil on Jul 6, 2012 8:38:40 GMT
This post is a digression to the main thread, but totally relevant to the person involved. Please ignore if not interested.
Note: this post is ANTI-discriminatory so please don't interpret it the wrong way round
I have worked with quite a few guys, mainly on the buses, who are 'thick'. They are without exception genuine nice friendly guys who' do anything to help you out and who everyone gets on well with, coz it's impossible not to. But some of them KNOW they're 'thick' and feel embarassed about it (even though the rest of the workforce don't care a jot). These guys always feel they have to PROVE they're up to the job in hand so often try extra hard - perhaps too hard - in difficult situations. In bus terms this meant keeping driving in really hazardous weather when all else had stopped; bringing home a bus with a potentially serious defect "so's not to let anyone down"; not claiming overitme when late and all sorts of thing trying to prove they were as good as the rest - - - when all the rest of us knew that anyway.
I suspect that was the psychological profile of the t/op involved here. He (felt he) HAD to get the train home or his mates would have thought him stupid. By going too far and doing what he did, in fact he proved the very point he was trying to contradict.
No wonder I feel sorry for him.........Edit: I have now been told by someone who knows him well and has worked with him that the above profile is, in his words, "spot on"  .
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castlebar
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Post by castlebar on Jul 6, 2012 9:01:26 GMT
Well said Phil
He did what he THOUGHT was right, at the time, under pressure.
He put his pax first rather than take the train out of service as some would have done at the earliest opportunity, especially to report/blame a "sensitive edge" issue.
It's backfired on him, but all credit to him for trying to get the pax moving. He's now blamed for trying.
LT was full of people who never tried anything, and this applies to the higher grades as well as those who worked at pax level.
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Post by FWOC on Jul 6, 2012 9:12:52 GMT
Also well said Phill. For me the system of training let the driver down with ref to the warning light process and I hope that this is taken into account with the disapline process.
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Post by seaeagle on Jul 6, 2012 18:17:22 GMT
Also well said Phill. For me the system of training let the driver down with ref to the warning light process and I hope that this is taken into account with the disapline process. Without going into to much detail, the driver concerned is still working with LUL but now as a member of station staff. To be honest, the actions of cetain managers at the time left a lot to be desired with regard to the drivers discpline. |
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Post by racka on Jul 6, 2012 19:01:23 GMT
It's too easy to judge - yes he was a person easily confused in a crisis *, but there again the modifications to the system changed the SE warning light so it would go out if the relevant button was pressed even if the fault was still there - - - - - and nobody thought it necessary to retrain the t/ops on the change.
* See below My post was not solely a judgement of the operator in question, it was also intended to judge the fact that he was allowed to operate the train in the first place. As technology advances, trains are getting more complex with extra systems and controls, which although minimised where possible by design, introduce additional scope for confusion and error by humans. The competency requirements should be reassessed and increase accordingly. I also believe operators should be assessed more often and randomly - they are in charge of upto 1000-1200 people at a times safety. It is all well and good passing intial training, which does include fault handling straight after the training has taken place, but think back to when you were at school - you revise for exams, do them well, and have forgotten most of it a week or two later (that is the way it went for me anyway!). |
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Post by norbitonflyer on Jul 6, 2012 21:45:07 GMT
As technology advances, trains are getting more complex with extra systems and controls, which although minimised where possible by design, introduce additional scope for confusion and error by humans. It seems to be true, but it shouldn't be - progress should allow things to be designed to be easier to operate. How much experience did it take to really get the best out of a CSLR loco, or a steam loco? |
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Post by seaeagle on Jul 7, 2012 6:33:33 GMT
It's too easy to judge - yes he was a person easily confused in a crisis *, but there again the modifications to the system changed the SE warning light so it would go out if the relevant button was pressed even if the fault was still there - - - - - and nobody thought it necessary to retrain the t/ops on the change.
* See below I also believe operators should be assessed more often and randomly - they are in charge of upto 1000-1200 people at a times safety. It is all well and good passing intial training, which does include fault handling straight after the training has taken place, but think back to when you were at school - you revise for exams, do them well, and have forgotten most of it a week or two later (that is the way it went for me anyway!). You must be aware that operators have a refresher every year unlike the old days after you passed out as a driver at White City you were given nothing right through until the day you retired. To be honest, the original training given was rubbish in my opinion, I personally requested more and a lot of the questions I asked at the time couldn't be answered. Then to confuse things more, every week we got a handout called 'lessons learnt' which were then telling us to do things differently to the way we had been taught. |
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Post by tubeprune on Jul 7, 2012 6:45:09 GMT
I'm on the T/O's side on this. If you get a problem with a train in service, there's a huge amount of pressure on you to get it going again. Even with old trains without electronics, long delays due to drivers getting confused were not uncommon.
The biggest problem is that for 364 days a year you sit in the cab and everything works fine and one day follows another in the same boring sequence until you are lulled into a false sense of security. You come to work, do the duty, go home. Then day 365 comes along and throws a whole big pile of sh*t at you.
The first thing that should kick in with an incident is the training, but it's always been a couple of years at least since you had any training in this particular incident and in the meantime someone's been messing about with the train and changed the software. So, you're already starting with one hand tied behind your back.
As you go through the procedure, you can feel the pressure building. As each second passes by, the pressure increases, added to by unhelpful interruptions from passengers, station staff and controllers. And the damn train still won't start. Now what? I think you get the drift by now.
Another problem is that trains are now very complex and most of this complexity is hidden by complex software. Despite 40 years of electronics on trains, the TCMS, alarms, indications etc. there's still no easy way of helping the driver to get out of every problem he or she is likely to meet and the software can even defeat the engineers. I spent some time yesterday with an engineer wrestling with the software on a Class 70 (an Ugly Betty). It defeated him.
There is also a recruitment aspect to this. Most T/Os come from station staff these days. Station staff are recruited for their inter-personal skills, their ability to deal with people, face to face every day, with lots of questions, directions, assistance and people skills, not their technical skills. Then the same people are put in a cab, in the dark, alone, with almost no face to face action all day, lots of complex technology and even more complex rules and procedures. I'm not convinced that many of them make the transition very well. I think the T/O selection system needs to be improved.
And finally, not many drivers really know much about the technology they are sitting on. The driver of the Class 70 I was on yesterday knew very little about the loco. He knew how to make it stop and go and that was basically it. If anything goes wrong, he relies totally on the software to get him out of trouble. So it's not just an LU issue.
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Ben
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Post by Ben on Jul 7, 2012 8:16:01 GMT
Paragraph 73 is a rather sad comment on modern mentality.
"The RAIB has been unable to establish why the train operator was so determined
to keep the train in service; a likely reason is that he wished to minimise the delay
to following services"
As others have suggested above, the reason he had determination should be blindingly obvious!
Is it any wonder he was confused if the system gave him unexpected and buggy indications??
At least he tried his hardest. And if people knew that they'd surely respect him for it.
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Post by racka on Jul 7, 2012 9:48:35 GMT
You must be aware that operators have a refresher every year unlike the old days after you passed out as a driver at White City you were given nothing right through until the day you retired. To be honest, the original training given was rubbish in my opinion, I personally requested more and a lot of the questions I asked at the time couldn't be answered. Then to confuse things more, every week we got a handout called 'lessons learnt' which were then telling us to do things differently to the way we had been taught. I knew there were refreshers but wasn't sure of the durations. The simulators at Northumberland Park are quite good, and can replicate a wide range of scenarios (I'm not convinced the training as it is makes best use of them). If I were in charge of the driver training/management, I would be wanting to make best use of them, possibly getting drivers in once every month or two, just for a couple of hours, to throw quite random sets of scenarios at them, and putting them under pressure to resolve quickly. It is human nature that the more times that you are put into crisis situations, that you will react more calmly the next time you are in a similar crisis situation. |
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londonstuff
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Post by londonstuff on Jul 7, 2012 11:37:13 GMT
Well said, TubePrune, this sums up the situation perfectly - reading the report I could almost feel the pressure building: an evening peak at Oxford Circus and the train, to him/her, wasn't working like it should, trains stacking up behind and the platform being absolutely crowded. A relatively new stock, much more complicated technology which wasn't/isn't 100% reliable, has known faults and procedures being changed since the last training course. It just sounds like a recipe for disaster.
I felt very, very sorry for him/her reading this and doubt I would have reacted much differently myself.
From what others have said it seems disciplinary action has taken place which has led to them no longer being a train op. Sounds like the powers that be have used this is an excuse to get them off the train when actually, given the circumstances, they should be looking at themselves.
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