'The Toss of a Coin', Chapter 10 / 3

Chief Operating Manager, Crewe (cont'd)

Much of my time as Chief Operating Manager, later renamed Regional Operating Manager, at Crewe was taken up with coping with various organisational changes, an obsession of BR management since the early 1960s. Gone were the days when Philip Rees, the WR Chief Civil Engineer, could say to the 14th Minister of Transport since nationalisation that he was the 14th Chief Civil Engineer of the Great Western Railway and its successor since Mr Brunel. In the last chapter I referred to the proposed elimination of the Regions’ Divisional set-ups from a Board point of view. Now I had to implement it.

One essential if we were to lose this ‘middle’ tier of management was to strengthen the ground level by ensuring that the Areas had the right people running them. We were reviewing their boundaries and trying to find an optimum size, which would justify the sort of manager we needed for the future. Between 1982 and 1984 I was appointing men like Jan Glasscock, Gordon Ford, Sam Reed, Adrian Shooter, John Mummery, Iain King, Colin Hamer and Mostyn Goodwin to Area Management positions and setting up direct lines of responsibility between me and them, cutting out the Divisional structure.

In the initial stages, I needed some support in the former Divisional geographical areas - to be my eyes and ears, not to have any sort of administrative life. I therefore retained three Operating Superintendents, Alec Wise at Preston, Brian Scott succeeded by Bob Owen at Birmingham and David McKeever on the Midland. Their role was to ensure safety and train performance and assist me in the day to day dealings with the Area Managers. We set up regular Area Managers’ conferences to tackle some of the key issues and then I turned my attention to the Divisional Control offices, which had been retained for a temporary period after the demise of the Divisional Managers’ organisations.

Much of my Headquarters Control in Crewe had outdated equipment due for renewal and we seized the opportunity to go for the latest touch screen technology with the opportunity in future to hold so much more data required for decision-making by controllers on line instead of the myriad booklets and bits of paper that traditionally littered Control Office desks. I appointed a brilliant S&T specialist, Richard Stokes, to lead the small team, a man whose eccentric sense of humour (he told jokes in Latin on one occasion) and intellectual capability did not easily fit into the robust and forthright culture of day to day Operators. There was a lot of scepticism about whether our high tech vision for the new HQ Crewe Control would work, but we persevered and I held the doubters at bay and the transition was implemented remarkably smoothly in 1985.

I remember the large consultation meeting with representatives from around seven of the Controls being displaced. One member of the Manchester Control was especially vociferous and foretold chaos if their organisation did not remain to sort out the daily failures and DMU manipulations they had to resort to, to keep the trains running in the Manchester, Preston, Liverpool and Chester area networks. My experience at Cardiff came back to me and I realised that by their manoeuvrings the Manchester Control was prolonging a bad plan by covering up its deficiencies.

When I investigated their claims, I found the situation even worse than I thought when the degree of unit failures that they had been trying to cover was way outside any standards held by the M&EE function. When Douglas Power studied my concerns he found a major problem at Newton Heath depot. Thus Manchester Control, in what the individual controllers thought was the best interest of the customer, had managed to prolong the problem which could have been addressed much earlier had the root cause been identified.

During my tenure of office, there was concern that management of the Midland Main Line as well as the West Coast was too much for any one individual and there were suggestions that the Midland might be transferred to another Region. I was horrified - the Midland was no trouble - indeed its punctuality record kept the average of the LM Region punctuality statistics up the Regional InterCity table! Once I had a strong Area Management team at Derby, Nottingham, Leicester, Toton and St Pancras, I told David McKeever and the Area Managers to get on with running the Midland patch without interference from my Crewe Headquarters and they did just that revelling in the authority they had been given.

We went one further - Roger Williams, my Eastern Region opposite number, and I with support from Assistant General Manager Ivor Warburton and Freight Manager, John Edmonds, enlarged the Toton Freight Area to include both LMR and ER territory and made the Area Manager virtually self-sufficient. Whilst technically responsible to me - I still did his annual appraisal - to all intents and purposes he reported to the Freight Business thus anticipating the full introduction of Business Management, which was the next major organisational upheaval on the horizon.

One of the issues I had to face was the relationship between the Operations Planning organisation and the increasing clout of the businesses. The Crewe Train Planning Office, especially the Train Timing Section, had developed a reputation for being inflexible and procedure-bound, unacceptable to the business management now beginning to flourish and flex its wings. There was a growing tension that I saw could easily cause a shift to the opposite extreme when the operating disciplines could be ignored with much grief as a result.

Therefore I made it my priority to understand the objectives and needs of the business sectors and try to wean my train planners to a more positive approach to see how things could be done rather than find the obstacles. At the same time I had to caution the businesses to consider the realities and not to assume that the tightest and cheapest solution without any contingency cover would work in practice.

We were being pushed hardest initially by the Freight business, then even more severely by the Provincial Services sector, which was under enormous pressure to reduce costs and saw the advent of new DMUs in the class 150 series as the ideal opportunity to achieve 100% availability and utilisation. The realism of planning the minimum maintenance required to the hours and locations when the sets were not actually in use was fine theoretically, but did not hold good in practice and some compromises had to be made on both sides. I like to think that we managed to avoid the extreme conflict, which had threatened at one stage.

During my time as Regional Operations Manager I had to think hard about our systems for managing safety and the culture surrounding it as we had a number of train accidents, some with serious potential, around 1984-5. I was becoming aware that BR’s traditional reliance on the ‘rules’ culture was inadequate and did not take into account often enough the context in which rules were applied or ignored, an issue to which I was to return in much greater depth after the Clapham Junction accident in December 1988.

This weakness was highlighted for me by an accident at Dorridge one Sunday to an express rerouted because of engineering work. A cross-country train hauled by a class 47 with Mark II coaches, was derailed and turned on its side when it ran through a cross-over at 60 mph instead of the permitted 20 mph. Luckily, despite the train being crowded, there were no fatalities or very serious injuries, but the inquiry identified a number of disturbing factors.

There had been confusion over which set of points was being used as part of the single-line working resulting in the driver not being properly instructed. I identified errors by seven different Operating staff which was bad enough, but the entire site was under the supervision of a comparatively young and keen Movements Supervisor who had prided himself in his ‘Rules & Regulations’ knowledge, had taken the R&R exams three years running, coming top of the Region and earning monetary rewards. The raft of mistakes stemmed initially from the inability of the man, who knew what should happen, to counter the culture of an experienced signalman who persuaded him ‘that we always do it this way, boss’. The result - modification of plans being implemented, confused briefing, poor communication.

I felt that knowledge of rules was too often tested ‘parrot fashion’, ie there was more emphasis on getting the words right than understanding the situations in which certain rules became vital or looking at the application of rules in problematical situations. Later, when I was evaluating BR’s safety management systems after the Clapham Junction accident, I spent time with James Reason, Professor at Manchester University who was an expert in understanding human error. He shared with me his belief from research he and others had carried out that decisions were routine, rule- based or problem-solving and made in normal or stressed environments and times. In each of these situations the percentage of errors could be anticipated.

I’d already been well aware of signals passed at danger (SPADs) as a key risk and whilst the ‘routine’ error level postulated by Professor Reason was only three errors per million decisions, what if a driver sees a million red signals in the 25 years of his driving career? For rule-based decisions the error rate was much higher - it was not just a matter of remembering the rule, but also which rule was appropriate in the circumstance at hand. If this decision was required in a stress situation the error rate doubled.

In the circumstances at Dorridge with out of course working, engineering and business pressures to complete on time on a Sunday afternoon and the confusion caused by the doubt over the crossings being used, there is no question but that this was a stressed situation and most of those involved made understandable errors - understandable that is from the academic point of view, but unacceptable if needing to run a safe railway.

I was also concerned about the increasing involvement of the civil police and their reaction of turning an incident site into a crime scene and the way in which this inhibited railway managers and staff uncovering the causes to learn, modify and implement revised safety measures.

This came to a head after the Wembley accident in 1984 when an evening commuter train from Euston passed a signal at danger and collided with a freightliner train leaving Willesden Yard. The driver, wandering in a daze, admitted responsibility immediately and was then reported by the police and threatened with a court case, so that he was advised by his solicitors to say nothing at the BR internal inquiry or even at the one instigated by the Railway Inspectorate. It was only 18 months later after the prosecution case was dropped that we learned of omissions in the process of examining the driver after a serious fall at his home. This had failed to discover occasional mini black-outs that might have accounted for his lapse. Had we known this earlier we might have been able to plug a gap in procedures that could have led to other incidents.

Serious rail accidents are usually caused by multiple factors coming together, some bizarre as in the case of the collision at Eccles between a Liverpool – Newcastle express and a standing oil tank train and the ensuing fire. The bald facts were clear enough. The Liverpool train, hauled by a class 45 diesel with Mark II coaches, overran signals at danger and ran into the back of the tank train which itself was held at signals. We discovered that three weeks earlier the local authority had renewed a road bridge over the railway in red brick, thus spoiling the visibility of the red semaphore arm of the signal that was immediately in front of the bridge parapet. Attention was then focused on the sighting of the distant signal, which was clearly on. We learned at the inquiry that the distance from the signalbox controlling the distant signal was nearly a mile, the lever in the box was a very heavy pull and that one of the signalmen, a small man, was unable to clear the signal.

The regular drivers, faced with that distant signal ‘on’ would jump to the conclusion that ‘Joe’ was on duty and not take the aspect of the signal seriously as no train was ever normally brought to a stand at that location! In fact, on this occasion the oil train had stopped with a suspected hot box. No driver had ever thought to bring this to the attention of management – protecting the signalman presumably – and although drivers had grumbled about the difficulty in seeing the aspect of the home signal since the local authority bridge work, again no-one had told management. And local management had been too office-bound to get out and about and pick up the concerns or see the problems for themselves.

We had monthly Operations conferences chaired by Maurice Holmes, Director of Operations at the Board, which were held alternately at 222 Marylebone Road and at a Regional location organised by the relevant Regional Operations Manager. When my turn came I had arranged a visit to the new suburban network and control system in Dublin, courtesy of the CIE, and we had the GM’s saloon at the front of a Euston – Holyhead train to convey the participants. As we passed Rugby at speed I glanced out of the window and saw a train of hoppers in the process of derailing and tipping on their sides in a cloud of dust on the Up side. To this day Maurice accuses me of arranging this purposely to drive home the importance of the conference addressing some of my safety concerns!

My Southern colleague, Alec Bath, topped this a few conferences later by organising the meeting to see air traffic control and British Caledonian operations at Gatwick followed by a visit hosted by the SNCF in Paris to observe their new ticket barrier installations at the Gare du Nord. The trip was packed with useful things to see and learn, but Alec forgot to allow any time for the conference itself and we had to beg a small meeting room from the SNCF to squeeze in a quick discussion, and spend the time on the return ferry in conference instead of at the bar!

A major event during my tenure of office was the Crewe remodelling. Luckily we had succeeded in persuading the freight business, against their instinct, to retain the Crewe station avoiding lines, so we were able the close the station completely for a couple of months and route all through trains via the freight lines using Stafford as the railhead for the Crewe area.

There were teething problems of the revised arrangements in the first week. The first night of the closure was a disaster - the DMU taking the post office staff to Stafford failed on the remaining open single line for two hours and not all the post office staff turned out anyway. By the time adequate resources reached Stafford, trains were queued back and lateness of the night trains grew to hours. This was unacceptable and several of us spent some uncomfortable nights putting things right.

These issues, however, were resolved and the engineers completed the new layout, resignalling and rerouting all the overhead lines inside the allocated time. Unfortunately we then nearly spoilt the reopening. My Train Crew Manager, Bob Breakwell, had agreed with the relevant drivers’ LDCs that they would learn the new route and signalling through the station by observation of videos of the new layout. Three days before the reopening ASLEF officers at their HQ got to hear of this and stuck their oar in, fearing the precedent for future route learning and we were faced at the last minute with Crewe drivers and those from some other depots refusing to go through the route into the station without the traditional form of route learning – impossible in the timescale.

We opened with the absurd anomaly of seeing Crewe drivers piloted through their own territory by drivers from Bescot or Saltley or other foreign depots! I can remember the reopening of Crewe station by our local renowned MP, Gwyneth Dunwoody, in which she proclaimed that she was now required to eat her hat as she, informed by some local railway trade union doubters, had expressed the view that we would never reopen on time. She was gracious enough to concede she’d been wrong, but it was a damn close thing and it was the Operators who nearly spoiled it after the superb work by the infrastructure engineers.

In 1985 I was contacted by Dr Alan Wickens, Director of Derby Technical Centre’s research facility. For sometime he’d believed that the Operating function had insufficient technical support in running its activities and that a lot of operating knowledge and decision-making processes should be amenable to IT modelling and assistance. We debated this at length, especially as at the time I was in the throes of the application of modern IT equipment to Control, and we agreed that this was an opportunity that should be explored further under Dr. Wickens’ ‘blue-sky’ budget as opposed to that set by the businesses and functions to overcome particular technical problems.

The railway timetable planning process was already computerised, but the day to day decisions around its implementation had myriads more perturbations and options than could be modelled under the conventional programming used. Dr Wickens thought that the application of heuristic methodology might provide a means of developing more useful decision-making assistance to Operators in the field and together we decided to recruit an academic to explore this in depth. A Research Fellow from the USA was duly recruited and briefed by the two of us, but Dr Wickens retired and his replacement cut the budget to exclude the more risky speculative research and the development of this particular opportunity disappeared.

Concern over reliability and punctuality of our train services continued to plague everyone. The General Manager in 1985, Malcolm Southgate, got fed up with the weekly bickering at his Monday morning conferences between the three chief engineers and operations over whom to blame for poor punctuality performance and asked me to sit down with them and thrash out the root causes of our problems. I found allies in Bob Brown, the Regional Civil Engineer and Ken Burrage, the Signal & Telecoms Engineer in particular and I started with the allegation that each engineer made, that they were achieving the targets for reliability that had been set them. I therefore decided to take them at their word and work out the implications of the achievement of such targets on train punctuality.

I started with Doug Power, the Chief Mechanical & Electrical Engineer who told me that the target mileage per casualty for the class 87 electric, the most reliable locomotive, was 36,000 miles, a casualty being defined as a delay of 10 minutes or more caused by a locomotive or rolling stock failure or defect. There happened, by chance, to be 36 locomotives of this type and crudely they were averaging nearly 1,000 miles per day when in traffic, so even a poor mathematician like me could calculate that we were accepting a failure every day. The much larger class of 86/2s was targeted at 24,000 miles per casualty, 85s and 47s at 10,000 miles and other lesser breeds even lower. I estimated that we were building at least a dozen engine failures into the train plan every day by accepting these targets.

By the time I added the targets in mean time between broken rails, structure failures, track circuit, points and signal failures, and the average daily occurrences of incidents over which we had little control (suicides, police incidents removing drunk or aggressive passengers, dealing with trespassers, animals on the line, etc) I calculated that if the Operator was perfect (!) we could achieve 62% absolute right time or around 85% within 10 minutes against the overall punctuality BR target of 70% right time and 90% within ten minutes. However, the more disruption and out of course running was caused by these failures, the greater the likelihood of operational delays caused by train conflictions and staff errors. We assessed the lost time from the various causes and using values developed by the InterCity business with Cranfield College, we could build an investment case to reduce some of the highest risk factors.

Shortly afterwards Malcolm went to Eurostar and Cyril Bleasdale moved from Intercity to GM LMR. After one particularly dreadful weekend when the overhead wires came down between Hest Bank and Carnforth on a particularly exposed stretch of line, we calculated that the delays incurred cost the business a potential half million pounds in lost revenue. Very quickly a £62,000 scheme to strengthen the overhead wiring on this stretch was approved. This gave the business a more positive tool for improving revenue through quality improvement.

I guess as a result of this study, I was sent for by David Kirby, Board Member for Operations and Engineering, and asked to accept the position of the Board’s first Quality & Reliability Manager. ‘Why me?’ I asked in some innocence, to receive the riposte, ‘Well as Operations Manager of the West Coast Main Line, you know more about failure than anyone else.’ I hoped he was joking.