Systemic failure

Back in November 2010, a cement mixer crashed through the parapet of a bridge over the (branch) railway line between Guildford and Waterloo, close to Oxshott station in Surrey. The mixer fell onto a passing train. Miraculously, no-one was killed, although several people were injured, including the driver of the mixer, and a person sitting on the train directly under the point of impact, who was seriously injured.

The driver of the cement mixer, Petru Achim, played a large role in this incident. He crashed his lorry into the end of the parapet of the bridge, losing control, and then (in an attempt to avoid oncoming traffic) swerved it through the parapet itself and onto the railway, with serious consequences.

You may or may not be surprised to learn that Achim escaped relatively lightly in court. Charged with driving without due care and attention, he was fined £100, and given five points on his licence.

More significantly, because this crash happened on the railway, the Rail Accident Investigation Branch (RAIB) produced a full report on the incident. The background; how the collision occurred; how it unfolded; how it could be prevented. It’s 36 pages long, and you can read it here.

I stumbled across this incident a few days ago after re-reading Joe Dunckley’s brilliant post, 7 years, 4 months and 18 days, about the safety record of British railways, how that has been achieved, and the extraordinary difference with the safety record of Britain’s roads. As Joe writes,

The last time anybody died on a train that crashed in Britain was on the evening of 23 February 2007 when a Virgin Trains express to Glasgow derailed on mistakenly unmaintained track at Grayrigg in Cumbria

Perhaps the 2010 Oxshott incident was the closest someone has come to dying on a train since 2007.

It’s well worth reading the RAIB report, which produced five recommendations – two for Surrey County Council, two for the Department for Transport, and one for Network Rail – all with the intention of preventing such an incident ever occurring again.

The recommendations for Surrey County Council were that they should ensure the parapet ends of bridges in the county are visible and well-marked, and that they should review ways of protecting the ends of the parapet of this particular bridge in conjunction with Network Rail, and implement the best method for doing so.

The recommendations for the DfT were to issue guidance to highway authorities on how best to highlight the unprotected ends of bridge parapets, and also

to prepare guidance for highway authorities on identifying local safety hazards at bridges over railways which could be mitigated by measures such as signage, hazard marking, white lining or safety barriers, and include consideration of previous accident history and the causes of those accidents.

Finally, the recommendation for Network Rail was that it should

include, within its annual examination of rail overbridges, the requirement for the structures examiner to identify and record any highway features which may increase the risk to the railway such as absence, obscuration or poor condition of parapet end markers.

… and to improve its ways of reporting these issues to highway authorities.

The tone is neutral, without setting out blame. Essentially the approach is to recognise that human beings are fallible, and will fuck up, and sets out the ways to prevent that fucking up from causing injury or death.

I’m not at all familiar with how the Dutch investigate deaths on their roads, or whether they go into this amount of detail after collisions in an attempt to ensure that type of collision never occurs again, but there is a strong parallel here with the Dutch system of Sustainable Safety.

In typically Dutch language

Since humans make errors and since there is an even higher risk of fatal error being made if traffic rules set for road safety reasons are intentionally violated, it is of great importance that safety nets absorb these errors. Behold the Sustainable Safety approach in a nutshell! A type of approach that, incidentally, has been commonplace in other transport modes for a much longer time under the name of ‘inherently safe’. [my emphasis]

As this passage points out, Sustainable Safety is relatively new – it only started being applied in the Netherlands in 1997, much, much later than the air and rail industry began developing techniques to ensure that failures (either mechanical or human) did not snowball into death or injury – the techniques employed in the RAIB report described here.

It’s so new, in fact, that it obviously has not been applied everywhere in the Netherlands. Their crap, unforgiving road designs are still being removed and updated; their country lanes that carry too much motor traffic are still awaiting a systematic downgrading (or upgrading); bypasses to take through traffic away for the places that people live are still being built;  the process is ongoing.

A crap junction in Amsterdam

A crap junction in central Amsterdam

There are five strands to Sustainable Safety, but perhaps the two most important in this context are homogeneity and forgiving environments.

Homogeneity in essence boils down to not putting slow and fast things in the same space; and not putting light and heavy things in the same space. If you want motor traffic to go faster than bicycle traffic, then you should not put bicycle traffic in the same space. You should provide for it separately.

A textbook example - the main road into Utrecht from the east. Here it is acceptable for bicycle traffic to mix with motor traffic on the 30kph access road. But obviously not on the main road itself.

A textbook example – the main road into Utrecht from the east. Here it is acceptable for bicycle traffic to mix with small volumes of motor traffic on the 30kph access road (which is not a through-route for motor traffic). But obviously not acceptable to mix on the main road itself.

Likewise if your road or street is going to carry heavy traffic as well as bicycle traffic, then something has to give – either that bicycle traffic should be separated, or heavy traffic simply shouldn’t be allowed on that road or street.

Screen Shot 2015-04-09 at 21.53.02

This hasn’t been achieved everywhere in the Netherlands yet, but it is being aimed at, everywhere. And this principle, even in isolation, ensures that Dutch roads and streets are considerably safer than British roads and streets, where we think nothing of mixing bicycle traffic with heavy motor traffic, or fast motor traffic (and usually both).

It is – appallingly – pervasive and normal.

Scenes like this in Dutch towns and cities are being eliminated.

A typical British urban cycling environment in Epsom, Surrey.

The principle of forgiving environments corresponds to the approach to rail safety. It recognises that human beings are fallible, incompetent, or inattentive, and attempts to ensure that the environment people are travelling can cushion those mistakes.

A typical British example of unforgivingness is the failure of a lorry driver to look in his mirror, at a particular moment, as he sets off from some traffic signals, just at the same time as someone cycling travels down a cycle lane on their inside.

Screen Shot 2015-04-09 at 22.30.59

A failure to spot someone travelling down the inside of a vehicle at a particular moment, in a mirror, coupled with a failure to appreciate the danger of using a cycle lane, should not result in death or serious injury. This is an unforgiving environment.

By contrast a forgiving environment separates movements, and/or ensures good intervisibility, and time to appreciate what the other party might be doing. It also allows rules to be broken (willingly, or unwittingly) without serious consequences. Because that’s what humans do – we break rules.

Screen Shot 2015-04-09 at 22.33.42

We don’t appear to have anything like Sustainable Safety in Britain. We therefore shouldn’t be surprised that collisions happen, again and again, in the same way, to the same types of people, involving the same kinds of vehicles, even at the same junctions, over and over again, and nothing appears to be learnt.

Screen Shot 2015-04-09 at 22.51.33

Over and over again.

We blame individuals for their failures – their failure to look in a mirror; their failure to appreciate that some types of cycle provision should be treated with extreme caution; their failure to not react quickly enough – without apparently ever stopping to realise that it’s the broken system that should be fixed, not the fallible human beings who are using it.

Maybe it’s because life is cheap in Britain – but that’s too simplistic. Life is selectively cheap in Britain. As the investigation that features at the start of this post shows, we take life very seriously when it is at risk on the railways, or in the air, and develop rational policies to structurally eliminate deaths and injuries from occurring in the future.

Yet on the roads, that concern for life apparently evaporates. Death and injury almost seems to be taken as an inevitable characteristic of our roads themselves; that they are innately dangerous.

The most telling manifestation of this assumption is the continual grumbling about the lack of personal protective equipment on the part of (a particular) vulnerable road user.

A fairly typical example – with equally typical responses

This kind of grumbling goes hand-in-hand with a blinkered view of Britain’s road environment as almost naturally hazardous – that our roads present spontaneous danger, to which the proper response is to don protective equipment before venturing into it, without even questioning the effectiveness of that equipment, or more pertinently whether our public space should even present such danger in the first place.

Other transport systems are designed in such a way that protective equipment is not needed, and make allowances for stupidity, incompetence, or inattention. Yet the British road network remains an inhospitable jungle, where mistakes mean death or serious injury for vulnerable users (and indeed even for those protected within motor vehicles).

The Dutch have appreciated this difference, and moved to put road design and road safety on the same footing as other modes of transport. Why haven’t we?

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15 Responses to Systemic failure

  1. abradypus says:

    Reblogged this on abradypus and commented:
    This. Making a mistake should not be fatal.

  2. Joe says:

    Why haven’t we? Simple. The English elect cretins like Johnson & Cameron. Until they elect somebody that cares, it will always be the same. There’s an election in May, I wonder if the English will make the same mistake for about the twentieth time? I know the answer.

    • Ian says:

      Given that in 1997 we elected the only alternative party available to us, with no discernible effect on road safety, I doubt that is the explanation. Do you reaally believe electing Milliband would make a difference to this? Surely it’s more to do with the stories we tell ourselves about cars as a tool of ‘freedom’.

      • Joe says:

        Milliband won’t give a toss either. The English don’t need another pseudo tory party but ‘people-based’ politics. And if they vote for business as usual expect another 5 years of blogs like this, ad nausum. Read the history of Groningen to see the alternative.

    • Bill says:

      Boris deserves some credit for pushing thru’ some segregation on the not so super highways. They could be better, he’s pushing them too late in his tenure as mayor but at least he’s done something.
      I use the segregated path on Tavistock most days and it would have been twice as wide had Frank Dobson not opposed it on behalf of the LTDA and their ilk.

      • Joe says:

        There you have it in a nutshell – the famous ‘British sense of fair play’. “Well, we must give him some credit….”
        Rubbish! It’s a token effort to keep you quiet. That is why you won’t get anything in England because you won’t stand up and shout at the top of your voice. You’d rather have a quiet moan & a chin-wag. Don’t want to embarrass anybody.

        Vote for what you want, or always be subservient to what you’re given. (easy for me to say because I’m not english & can’t vote in your election).

  3. Well put as usual. I hope people who can change this, get to read this blog. “Look at those train passengers/air travellers, dark coat, iPod on #deathwish”.

  4. Andy R says:

    You might be interested in the report linked below ‘TRANSPORT SAFETY COMMISSION – UK TRANSPORT SAFETY: WHO IS RESPONSIBLE?’, particularly page 44.

    Click to access TSC-Responsibility-report-Prepub-March-2015.compressed.pdf

  5. It would be interesting to apply the usual ‘road casualty reduction’ approach, based heavily on KSI stats, to the railways.
    Clearly (a highways engineer might say) if nobody has been killed or seriously injured, there is no safety problem to address. If there are no casualties to reduce, then we can be relaxed about enforcing speed limits for trains. Why shouldn’t they be allowed to go a bit faster?
    Of course, not all local authorities take this blinkered approach based on KSI targets, but many do. The quickest way to reduce road KSIs for cyclists to zero would be to ban all cycling; ditto for elderly pedestrian casualties; and child casualties could be eliminated by insisting that all children must go to school by vehicle, which would ‘meet the target’ and solve the problem.

  6. Whilst I agree with a lot of this – I disagree that individuals are not responsible.
    In this case it is very clear that Martin Low, Director of Transport for Westminster City Council who blocked TfL’s modest proposals to make this dangerous junction safer.
    He should resign and be subject to manslaughter investigation.

  7. paulc says:

    another photograph has emerged of the roundabout tragedy, the victim’s bicycle is slap bang in the middle of the lane, the tipper truck is astride both lanes…

  8. Andrea says:

    One of the main reasons the rail industry has adopted #VisionZero, and the road engineers haven’t is the nature of crashes. Rail crashes are multi-fatality, headline-grabbing events that demand a reaction. Contrast that with the drip drip of one-fatality collisions that hardly get mentioned in local papers. In the first quarter of 2015, eighteen pedestrians have been killed in London (same number as killed by Islamists in Paris), but hardly anyone knows:

    Indeed, the rail industry became serious about Vision Zero only after the dual Southall – Ladbroke Grove disasters. And one can argue that London is getting protected cycle tracks partly because of the prominence given to cycling fatalities (compared to, say, pedestrian fatalities, which are 4-5 times as numerous)

  9. Jitensha Oni says:

    As I sit here typing through a miasma of NOx and saharan dust with streaming eyes and sore throat, I feel the answer to “why haven’t we” probably goes back to well before the Dutch named and codified sustainable safety, and the answer will be complex. Didn’t the name sustainable safety just make explicit and codify what they had already discovered as best practice, and had been using for a couple of decades, during the time UK had reached rock bottom as far as bike use was concerned? An historian may be able to fill in the details – some are beginning to emerge on the Dutch side for English speakers, and I look forward to learning more. I suspect different attitudes to childhood freedom may be a factor (search David Hembrow’s blog for posts on “children”). More importantly, now, 42 years on, there are 3-4 generations of UK people who haven’t had much experience of cycling. Many of those that Oakley found the need to comment on are probably in that category, as may be herself, many drivers, and most(?) government officials. At least I’m now seeing more families out and about cycling in the SW London parks on shared use paths at weekends, so at least the art of cycling considerately in crowds is being learned.

    On a sourer note. “the British road network remains an inhospitable jungle, where mistakes mean death or serious injury for vulnerable users”. None more so than one of my local roads as featured here – the A244 through Oxshott. This has AADF of motors about 25000 – similar to Albion Way in Horsham, but on a road that is 8-12 m wide. AADF for bicycles? About 70*. The chance of making a life-threatening mistake is probably what keeps most local people off their bikes here (note: lots of roadies buzz through at the weekend on their way to the Box Hill MAMIL shrine, and may actually be skewing the AADF figure to a higher value, but it’s ball-park correct, i.e <<1%). It is highly ironic that one of the best examples of transmission of sustainable safety procedure (by RAIB) to a highway setting took place on this road.

    * a "hilly" excuse is belied by the variable demographic of the few local riders that I do see, and the well patronized bike rack at the rail station.

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