How to learn from the past

Today, quite by accident, I came across a paper published by the Institution of Civil Engineers in 2006, "The importance of learning from past experience" by Dr. Trevor Asher Kletz. It seems to me to be so relevant to the railway industry that I offer a summary of some of his advice below. The first one I've selected is so important I think it should be written into the rule book:

• "Never remove equipment or abandon procedures before it is discovered why they were introduced". This is so obvious and so often neglected that no further comment from me is necessary. 

• "Include a note on the reason why for every instruction, code and standard..." Although he doesn't say so, I'm sure he expects that the note should be part of the standard, not separated off in the dreaded "guidance notes". 

• For each process, there should be a folder of reports on past accidents, and that these should be compulsory reading for new recruits. 

Dr Kletz goes on to say that past major incidents should be included in the training of undergraduates and company employees. "The training," he says, "should start with accounts of accidents that demonstrate the need for codes, standards or instructions."
There is more, some of which is obvious, but the paper is worth reading in its own right. It can be found here:  Proceedings of the Institution of Civil Engineers – Civil Engineering, 2006, 161, No. CE6.

Train Refurbishment

If you are thinking about refurbishing your rolling stock, here some valuable lessons, learned through bitter experience:

• Always have a clear and fixed remit agreed with the operators before going ahead with the design;
• Never assume new stuff will fit into all the old trains. Even if it is specially designed, it probably won’t;
• Avoid messing with wiring unless you strip it all out and replace it;
• Every train/vehicle should be jointly tested and surveyed before acceptance by the contractor. All defects to be noted and agreed by both parties for inclusion in the work (or not) as required;
• Always assume you will find things you didn’t expect when you strip – you will, sometimes even when you're getting near the end of the job;
• Always expect things that are not supposed to be touched will be and will get damaged as a result;
• Always allow a long learning curve for the first few trains;
• Avoid changes in design or requirements mid-contract. It will be very expensive;
• Have some your own experienced staff working with the contractor’s team, on site, for the full duration of the contract, including the design phase. They can offer valuable help, build up a rapport with the contractor and keep an eye on things;
• Upon completion, jointly check and test every vehicle and then couple into a train and test again before acceptance;
• Always expect it to cost more than you estimated;
• Always expect it to take longer than you estimated;
• Don’t go for the lowest bid because it’s the lowest. It will cost more in the end;
• Work with your contractor rather than against him. Openness and co-operation will be cheaper for both of you.

There are certainly more lessons I could add but these are the most pertinent. I offer these because, almost 20 years after I was first involved in train refurbishment, these mistakes are still being made. I heard recently that, a year into a 2010 train refurbishment project, all the above lessons had been ignored, the contractor was forced into bankruptcy and the operator was left with a huge bill and a partly refurbished fleet that he now has to re-tender for, so he can get it all working again.

A Wrong Turn

A lady driver, aged 85, took a wrong turn at a level crossing at Basingstoke in England on January 26th  2012, when she drove onto the railway track and drove for 80 metres before she realised something wasn't quite right. She had a 20 year old male in the car with her. Apparently she was looking for the station car parking area. She's lucky she and the car didn't light up the area by touching the electric conductor rail that the line has.

One has to wonder how someone who can do that kind of thing has survived to that age. And as for her passenger, where was his brain.  Perhaps it was a family member....

Of course the railway was shut down for two hours and thousands of passengers had their journeys disrupted while the mess was sorted out.  I hope she will be prosecuted for endangering the lives of railway passengers.