Network Rail and the Potters Bar Rail Crash - Assignment Example

Network Rаil аnd thе Pоttеrs Bаr rаil сrаsh By student’s name Course code+ name Professor’s name University name City, state Date of submission Introduction In the current globalized world, most organization are constantly facing competition, instability, and uncertainty. Disaster can befall any organization is it private or public, large or small at any time. Quite often, conventional risk and governance methods are not sufficient to detect and mitigate disasters (Kutsch and Turner 2015). Companies should concede to the fact that not all risks can be planned for. Some come at a time when the organization is unprepared and didn't anticipate the nature and magnitude of the disaster. Organizational resilience can, therefore, help by constantly expecting and changing to deep trends than permanently destroy the revenue generation of business. The British government in the footsteps of Japan and other countries announced in July 1992 that British Rail (BR) was to be privatized. Previously, Railtrack was the single organization in-charge of the national infrastructure of tracks and stations. Train operations were subsequently divided among 30 private companies, Network Rail being one of them. The privatization process started in 1994 and effectively completed in March 1997. During this time, many people predicted a decline in rail safety. It was claimed that the division of management, together with the resignation of several experienced supervisors, engineers and operators would lead to increased accidents. The forecast appeared to be true with just a few years of privatization. From the year privatization was complete, five fatal accidents have since occurred (Payne 2009). The 2002 Network Rаil аnd the Pоttеrs Bаr rаil сrаsh is the latest of them. This essay delves into the case, using theory and resilience concepts to help explain the incident. What went wrong and why The Health and Safety Executive (HSE) investigatory board was set up in May 2003 to investigate and present a report on the train derailment at Potters Bar which occurred on 10th May 2002. A train coming from London King Cross derailed at the Potters Bar when going over points 2182A. It caused the death of 7 people, while over 70 people were injured. After the board considering all the information, it was fully satisfied with the report. The following are the possible factors that could have caused the accident; i. Historical perspective Railtrack issued the Board with information about the background and basis behind the introduction of the railway points design involving stretcher bars that are adjustable. The adjustable bars came into existence in the 1990s majorly to overcome problems of a past design and the challenge of adjusting the flat plate stretcher bar to a satisfactory tolerance to acquire steadiness in putting in place the joints (Hollnagel and Leveson 2006). The development of the bars was achieved majorly by an experiential approach which involved tests on the network and improvements in the components' size until a versatile performance was achieved under the settings applicable during that period. A certain feature of the bars used on points 2182A is interesting in that once in place there were not meant to need adjustment after that and the intention of the design was that they should remain fit for purpose for several years after installation. The findings in the report by the investigative board put some doubt that the bars got this design intention. No evidence has been reported up to date by the report, recording or review of flaws that would have given information of the constant adequate operational performance of this certain important component of rail safety. After analysing the rail network, HM Railways Inspectorate (HMRI) have brought forward questions about the performance of the adjustable stretcher bars and the connected management and inspection arrangements. There's a possibility that the points are entering a period leading to the end of its life cycle, more so in the view of increased use, they had to deface over the last few years with the notable rise in rail traffic. Another possibility is that currently; they are performing outside their safety or design constraints. ii. Use of contractors The increased use of contactors in the maintenance of rail infrastructure is one of the major change that has happened since the use of the adjustable stretcher bar design started. The HSC has expressed the opinion that using contractors for maintenance does not lower the integrity of the infrastructure. Nevertheless, the change from internal technical proficiency and support to contractors must be carefully managed (Edson, 2012). The implications to safety need to be thoroughly assessed and robust assurance and monitoring systems placed. iii. Inspection practice Without a complete understanding of the safety and design flaws and the relevant operating and safety needs, an appropriate risk-based maintenance and inspection era can't be instituted. As noticed previously, the inspection and maintenance requirements for the adjustable bars before the derailment does not seem to have set in line with the design and safety flaws and the correct operating and safety guidelines understood fully. iv. The move to adjustable stretcher bars The modification in the number of stretcher bars used for a certain points system is a critical factor when making changes to the system, therefore, the need to have a good understanding of the safety measures. The board was informed that at the time of the design of the new adjustable stretcher bars, a dissimilar switch rail (UIC 54B) which had a higher stiffness than the existing rails (BS113A) was being used widely. Consequently, it let to fewer stretcher bars across the range points. For the points at Potter Bar, the implication is that two weight carrying stretcher bars were stated in the design for the turnout. This number is lesser than the formerly specified with the old type of stretcher bar for the give turnout. Such a step changes the redundancy level present if a single stretcher bar fails and the consequent impact of weight sharing between the bars still working properly (Edson , 2012). No evidence was found that such impacts as the alteration in the configuration of points were factored in when thinking of the change in the 1990s. v. Inspection and maintenance roles and responsibilities Two apparent dual inspection and maintenance administrations pointed out by HMRI’s investigation for points 2182A was an issue of notable concern to the board. The board believes that the different involvement of both the permanent way and signaling staff may have caused confusion and therefore, affected a structured, well-defined approach to inspecting and maintain points 2182A in a condition that is safe. The board also noted that in 1993 recommendations were sent to the then British Rail Track Design Committee that the installation of the stretcher bars should become the duty of signaling engineers. The recommendations were, nevertheless not implemented. The board could not ascertain whether such a change if applied would have also impelled Railtrack to shift absolute mandate of inspections and maintaining of the railway points to the signaling engineers. Were there any weak signals that might have been spotted? Like any accident, there exists areas or factors that led to the accident that could have been spotted and corrected to prevent it from happening. i. The design of the adjustable stretcher bar points. To begin with, after inspecting the points across the network, HMRI has raised queries about the performance of the adjustable stretcher bars and the related inspections and maintenance procedures. The same is also the circumstance for the analysis carried out by HSL in the area approaching Potters Bar moments after the accident, which discovered variable standards of circumstances of adjustable stretcher bar points systems across the rail network. The investigations revealed difference is the tightness of locking bolts and signs e.g. ‘pop marks.' With the increased use of the points over the recent past coupled with the subsequent rise in rail traffic, the company would have taken into consideration the reviews of the design or safety analysis. This would have ensured that points 2182A remain fit-for-use in line with the needed safety standards for critical components (Kutsch and Turner, 2015). Another interesting factor captured by the investigators about the adjustable stretcher bars is that once installed; they didn't require adjustment. The design intention was to have them fit for purpose for several years. The investigations however raised concerns as to whether the bars have achieved this design idea ii. The inspection practice. The team being used in the inspection and maintenance requirements for adjustable stretcher bars of the rail network seemed to have inadequate knowledge, expertise, and understanding of the design and safety limitation and the correct operating and safety requirements. The inspection and maintenance requirements for adjustable bars before the accident doesn’t seem to be in line with the design or safety shortcomings. For instance, a process suggested as having been used for inspecting the ability of the adjustable bars to satisfy their safety-related responsibility was meant for an operation to kick each stretcher bar as the technician walked along the rail. This guideline of inspection would have detected the failure mechanism of the ancient plate of stretcher bar or fracture (Comfort and Demchack, 2010). Having a proper inspection guideline on the design and safety requirements being followed by the company would have, therefore, helped avert the accident. iii. The dual inspection and maintenance administrations The investigative board believed that the separate participation of both signaling staff and permanent way might have caused confusion and hence worked against a framework of clearly stipulated approach to inspecting and maintaining points 2182A in a safe environment. There was the need to have a central inspection and maintenance administration for easy coordination (Sheffi, 2005). Some recommendations to the then British Rail Track Design Committee that the signaling engineers should be solely responsible for fitting if stretching bars were not implemented. In the judgment of the board, the division in the inspection and maintenance managements may have contributed to the situation of the points preceding the derailment. iv. Positioning of railway points During the accident, a woman died after a perimeter wall feels over her. The positioning points were close to a bridge led to the death of Agnes Quinlivan who was killed by materials falling from the bridge above Darkes Lane. If the points were positioned away from bridge or station, no or fewer fatalities could occur because of falling debris or structures (Välikangas, 2010). Were there any cultural factors that prevented the problem being reported or tackled earlier? The discussion above has also highlighted the safety culture displayed by the infrastructure controller since the accident occurred. A safety culture is important to guaranteeing the safety of industrial systems. An upright culture is one in which the staff in a company recognize the importance of safety matters and in which such recognition is exhibited in their attitudes, conduct, and sense of responsibility. There has been a culture of backwardness and inward-looking methodology that has refused to embrace how things are performed elsewhere. This has led to some of the recommendations for change to avert crisis not being implemented. A static attitude grounded on past railway engineering practices and philosophy of maintenance is acted as a stumbling block to tackling some of the problems that may have caused the accident. The slowness by the administrations to be more proactive towards problems related to safety using basic safety principles is also another cultural factor that affected reporting or tackling of problems that could have prevented the train derailing. The outcome of the Rough rider report also highlighted some cultural factors that could have hindered problems from being brought to light or solved earlier (Casson, 2009). The report indicates that the people hired to respond to report of problems were always asking a question whenever an issue was brought to them. This could have inhibited the issue from being reported and appropriate action is taken to prevent the disaster from happening. Was the emergence of the incident an inevitability? The postulations and or findings in the investigative boards’ report pointed to a calamity in waiting. When the points 2182A was analyzed for the very first time, several factors were obvious. The lock stretcher bar, probably due to fatigue had a fracture. This led to its breaking which made the coaches detach hence leading to the derailment. Some components were also discovered to have been missing from the left-hand end of the front stretch bar. The unavailability of these important components further increased the probability of the accident occurring. Tests on several sets of points also indicated that nearly a fifth of the nuts was not completely close-fitting. A further review of the data collected during the exercise shows that flaws were detected in other three points and this led to the conclusion that there was inadequate understanding of the proper functions of the back drive on adjustable points of the type 2182A. The investigative board up to the time of compiling the report had not observed signs of existing framework for the reporting, capturing and or evaluation of safety-related shortcomings like lack of adjustable stretcher bars in important points such as the 2182A. The reporting system would have provided information on any consideration of continuous sufficient operational performance of the specific safety important component in the current day environment of operation. More over contractors conducting maintenance on points of the type 2182A didn't seem to possess available relevant comprehensive guidance formed from sufficient know-how of the design and safety needs of the network, inspection, and maintenance of the said types of points. This inefficiency by the contactors could be a possible cause of the derailment of the train. Another factor that indicates that the emergence of the incidence was unavoidable is the inspection practice. The lack of a sufficient knowledge of the design and safety shortcomings and the relevant operating and safety guidelines for points 2182A meant that an appropriate risk-based examination framework could not be instituted (Weick and Sutcliffe, 2007). Not having this regime in place to check on the inspection practice lead to overlooking key issues that may have resulted in the accident. Another factor that could have made the accident an inevitability is the move to start using adjustable stretcher bars. This move combined the use of fewer weight-bearing stretchers in the points of configuration without an evaluation being carried out on the effect of sharing the load on the remaining points in the situation a stretcher bar fails. The report further indicates that they're some bolts and nuts which were not tight at the time the accident was happening. The negligence towards the flaws discovered in points and design of the rail network is yet another possibility of the cause of the accident. The use of both the permanent way and signaling staff may have led to a scenario where duties and responsibilities were not clear (Lewicka, 2010). This may have affected the formation of a structured and definite approach needed to maintain the points. The use of dual inspection and maintenance officer could, therefore, be another possible factor that led to the incident. The Rough ride report pointed out that the people assigned to respond to cases of problems related to the safety crucial elements lacked relevant training, expertise and an attitude of questioning everything. Conclusion In as much as organizations are constantly working towards detecting and dealing with accidents before they occur, there's need to recognize that not everything can be planned. Some accidents just seem to happen irrespective of the safety and maintenance policies in place. From the report presented by the Health and Safety Executive, there’s a lot that could have been done to prevent the Pоttеrs Bаr rаil сrаsh. Organizations need to develop a culture of stressing on proactive measures and determination when facing unexpected cases. Companies also need to empower employees to act at their various stations. Furthermore, there's need to come up with the capability to detect, understand and prepare for accidents. Adapting to change is not just during times of disaster, it is a gradual process of embracing or adapting to change. References Payne, K., 2009. Learning from a Train Derailment. Constituents of Modern System-safety Thinking, pp.79–92. Edson, M.C., 2012. A Complex Adaptive Systems View of Resilience in a Project Team. Systems Research and Behavioral Science, 29(5), pp.499–516. Comfort, L. Boin, A. and Demchack, C. (eds.)., 2010 Designing resilience: Preparing for extreme events. Penn, PA: University of Pittsburgh Press. Hollnagel, E., Woods, D. and Leveson, N. ,2006 Resilience Engineering: Concepts and precepts. Burlington, VT: Ashgate Kutsch, E. Hall, M. and Turner, N. ,2015. Project Resilience: the art of noticing, interpreting, preparing, containing and recovery. Farnham: Gower Sheffi, Y. ,2005. The resilient enterprise. Cambridge, MA: MIT Press. Välikangas, L. ,2010. The Resilient Organization. New York, NY: McGraw-Hill Weick, K. and K. Sutcliffe.,2007. Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco, CA: Jossey-Bass. Casson, M., 2009. The world's first railway system: enterprise, competition, and regulation on the railway network in Victorian Britain, Oxford: Oxford University Press. Lewicka, D., 2010. Organisation management: competitiveness, social responsibility, human capital, Kraków: Wydawnictwa AGH. Read More