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Learning from Operational Experience Annual Report 2013/14
Greg Morse D.Phil Operational Feedback RSSB Block 2, Angel Square 1 Torrens Street London EC1V 1NY 020 3142 5400 [email protected] The report may be downloaded from the RSSB website: www.rssb.co.uk.
Rail Safety and Standards Board 2014
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Contents
Report summary 5
1 Introduction 7
1.1 Purpose 7
1.2 Scope and structure 7
2 How do we learn? 9
3 What can help us learn? 11
3.1 Measuring safety performance 11
3.2 Investigations 13
3.2.1 Incident Factor Classification System 13
3.3 CIRAS 15
3.4 Right Track 15
3.5 Close Call 16
4 Investigations – lessons learnt in 2013/14 17
4.1 RSSB analysis of key RAIB recommendation themes 20
4.2 Incident Factor Classification System 24
5 CIRAS – lessons learnt in 2013/14 27
5.1 Who reports to CIRAS? 27
5.2 Why do people report to CIRAS? 28
5.3 Key issues of concern in CIRAS reports during 2013/14 29
5.4 Positive outcomes from CIRAS reports 30
6 Right Track – lessons taught in 2013/14 31
7 Lessons learnt in 2013/14 – train accidents 33
7.1 Statistical overview 33
7.2 Overseas accidents 33
7.3 Derailments 36
7.3.1 Lac-Mégantic and its implications 36
7.3.2 Freight train derailment at Shrewsbury, 7 July 2012 (pub. 07/13) 39
7.3.3 Freight train derailment at Castle Donington, 21 January 2013 (pub. 01/14) 40
7.3.4 Freight train derailment near Barrow upon Soar, 27 December 2012 (pub. 12/13) 41
7.3.5 Locomotive derailment at Ordsall Lane Junction, Salford, 23 January 2013 (pub. 03/14) 43
7.4 Signals passed at danger 44
7.4.1 Light locomotive SPAD at Stafford, 26 April 2012 (pub. 09/13) 46
7.4.2 SPAD at Norton-on-Tees West, 16 January 2013 – BULLETIN (pub. 05/13) 47
7.4.3 SPAD mitigation 48
7.4.4 Train Protection and Warning System 49
7.4.5 TPWS – ‘reset & continue’ 50
7.4.6 Dispatch against red 51
7.5 Animals on the line 51
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8 Lessons learned in 2013/14 – passengers 57
8.1 Statistical overview 57
8.2 Platform-train interface 57
8.2.1 Fall between train and platform at London Charing Cross, 24 November 2012 (pub. 07/13) 58
8.2.2 Ongoing investigations 59
9 Lessons learnt in 2013/14 – workforce 63
9.1 Statistical overview 63
9.2 Road vehicle driving 63
9.3 Track working 65
9.3.1 Track worker fatality at Saxilby, 4 December 2012 (pub. 08/12) 67
10 Lessons learnt in 2013/14 – members of the public 71
10.1 Statistical overview 71
10.2 Level crossings 71
10.2.1 Fatal collision at Beech Hill level crossing, 4 December 2012 (pub. 09/13) 72
10.2.2 Fatal collision at Motts Lane level crossing, 24 January 2013 (pub. 01/14) 73
10.2.3 Fatal collision at Athelney AHB, near Taunton, 21 March 2013 (pub.02/14) 74
10.2.4 Collision at Buttington Hall UWC, 16 July 2013 (pub.03/14) 76
10.2.5 Other level crossing initiatives 77
11 Lessons learnt – beyond the boundary fence 81
11.1 Case studies 81
11.1.1 Swedish nuclear industry 81
11.1.2 Climbing Mount Everest 82
11.1.3 Industrial radiography 83
11.2 RSSB Operational Feedback summaries 84
12 Learning activities and initiatives 85
Appendix 1. Progress against RAIB recommendations 92
Appendix 2. Glossary 99
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Report summary
If you’ve read our Annual Safety Performance Report, you’ll know the GB rail network has
continued to meet the Railway Safety Directive requirement to maintain safety and improve it
where reasonably practicable. One of the main contributors to this is the learning that flows
from near misses and accidents.
But that doesn’t mean learning is easy – not when companies comprise a number of different
and disparate memories, which do not necessarily interface perfectly, and which are subject
to change as staff retire, move on, or move in from elsewhere. And when you expand the
idea to a complete industry like rail, it becomes even more complicated.
Arguably, the current era of railway safety began after the Clapham Junction multiple train
collision of 1988, the inquiry into which led to changes in signal testing procedures and
working hours for safety critical staff. However, even in the relatively short period since then,
we’ve seen a huge amount of organisational change, and a variety of different regimes and
techniques for capturing (or not capturing) appropriate knowledge and learning.
So where does RSSB fit in? The short answer is that – as both a listening and a learning
organisation – we can help the rail industry put things right when something goes wrong, and
helps it remember the route that led to the solution.
Through our research programme, periodic safety reports, strategic risk papers, publications
on incidents inside and outside the railway, facilitation of the RED DVD series, Right Track
magazine, and the analysis and support we provide to national stakeholder groups, we learn;
through the cross-industry groups, CIRAS and SMIS, we listen.
In addition, we play a part in the accident investigation process by providing statistics to help
the Rail Accident Investigation Branch (RAIB) set incidents into context, by offering RAIB
expert knowledge from staff with extensive industry experience, and by bringing cross-
industry groups together to tackle industry-wide issues.
We also produce this Learning from Operational Experience Annual Report (LOEAR) to look
at some of the tools available to facilitate learning, capture some of the lessons learnt in the
fiscal year and consider specific issues affecting rail users and employees.
Summary of key points arising during 2013/14
Train accidents
The Lessons learnt section of the report deals with the multi-fatality accidents seen across
the world in July 2013, considers the risk from dangerous goods traffic and looks at risks that
can arise from derailments, signals passed at danger and animals on the line.
With specific reference to derailments, investigations have highlighted the intersection
between track and wagons at the outer limits of compliance with standards, while the SPAD
at Stafford in April 2012 drew attention to aspects of driver competence and safety
management systems. Though analysis of animal incursions indicates that the safety risk
from animal strikes is generally low, incidents can still occur, can cause harm, and can
impact on the operational and commercial aspect of the railway, in terms of delays, rolling
stock cleaning and line clearance.
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Passengers
The platform-train interface (PTI) continues to be a key area for industry risk management. A
number of recent events have highlighted areas for learning, including the dispatch
procedure itself, the role of the driver, the behaviour of passengers, and door design and
maintenance. The industry has focused on passenger risk at the PTI over the last two years,
via a dedicated task force.
Workforce
The two rail employee road vehicle-related deaths in 2013/14 highlight the continuing need
for focus on this area. A number of RAIB reports also raised issues for those managing and
working on infrastructure projects. Questions have been asked (inter alia) about worksite
length, the planning of safe systems of work, location knowledge and the competence of
agency staff.
Members of the public
The majority of the risk to members of the public arises from their own behaviour, although
this in no way negates the industry’s duty of care towards people using or interacting with its
environs.
Level crossings are key interfaces between the public and the railway. They represent low
risk to passengers and workforce, but higher risk to members of the public, who are largely
responsible for their own movements, taking account of warning signs and other controls.
The industry has a duty to ensure both that the signs and controls are fit for purpose and that
its operations allow the users to understand and follow them.
Investigations and recommendations
During 2013/14, RAIB published 26 reports, 22 of which involved incidents on the mainline
railway. These 22 led to 88 recommendations (compared to 82 recommendations from 19
RAIB investigations in 2012/13). The area of infrastructure asset management received the
most focus. However, when the causes are analysed along with a set of formal
investigations, safety critical communications rises to the surface.
CIRAS
CIRAS received 978 contacts from rail employees on a diverse range of topics in 2013/14, of
which 216 (22%) became reports after the screening process. Positive results included
(among other things) amendments to a non-compliant coach-lifting procedure, a review of
shunting operations in a large depot and improvements to station dispatch arrangements.
Beyond the railway
The industry is also mindful of the need to look beyond its own operations for insights or
initiatives, and knows that the key to success is not only about sharing lessons, but also best
practice and ideas.
This section of the report therefore presents a number of case studies where this has been
achieved, and links to RSSB’s summaries of some of the major non-rail accident public
inquiries, which can also offer suggestions for how your own learning procedures might be
finessed.
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Hyperlinks (underlined blue text) have been used throughout this document to aid navigation and access to relevant documents and websites. Grey boxes like this one have been provided to aid navigation. Green boxes have been provided to highlight learning points and extra information that readers might like to consider.
1 Introduction
The rail industry learns from operational experience by
investigating specific events and through the regular
monitoring of trends. RSSB is here to help with that process:
This Learning from Operational Experience Annual Report (LOEAR) contributes by summarising some of the learning points arising from investigations and other sources of information;
RSSB’s Annual Safety Performance Report (ASPR) – the ‘sister’ publication to the LOEAR – contributes by providing decision-makers with wide-ranging analyses of safety performance data on the mainline railway.
1.1 Purpose
The primary purpose of LOEAR is to provide learning information to decision makers in
RSSB member organisations. However, like the ASPR, it is also intended to inform rail
employees, passengers, the government and the public at large.
Since 2009, RSSB has worked with industry groups to shape the definition and objectives of
Learning from Operational Experience (LOE) to meet industry requirements. This report
describes the LOE processes and their evolution, while retaining the RSSB
recommendations tracking function of previous documents.
1.2 Scope and structure
The LOEAR considers a range of learning sources – like CIRAS, RAIB and Right Track
magazine – and identifies the key issues that have arisen between 1 April 2013 and 31
March 2014 in the following areas:
Derailments
Signals passed at danger
Animals on the line
The platform-train interface
Road vehicle driving
Track working
Level crossings
LOE also takes a look ‘beyond the boundary fence’ and Chapter 11 considers lessons that
have arisen from non-railway events, like the Fukushima nuclear accident, which came in the
wake of the Great East Japan Earthquake of 2011.
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2 How do we learn?
The railway and its regulatory bodies have been learning
lessons from accidents since William Huskisson MP was struck
and killed by Rocket at the opening of the Liverpool &
Manchester Railway in 1830.
Early incidents like this led to the first Railway Regulation Act
(1840), which required all injurious accidents to be reported to
the Board of Trade. Within 50 years, block signalling,
interlocking and continuous braking on passenger trains had
been made mandatory. The twentieth century saw further
advancements, ranging from continuous welded rails and multi-
aspect signalling, through to automatic train protection
systems.
The cycle of safety planning and performance reporting has become essential to ensuring
that this development continues, but much learning also comes from investigations into
accidents that have occurred, near miss data and reports to the industry’s Confidential
Incident Reporting and Analysis System (CIRAS).
In this report, LOE is defined as the process by which knowledge from the operation of
systems is gained, exchanged and used, leading to continuous improvement and the
development of a positive safety culture.
LOE is discharged through the rail industry’s national stakeholder groups, all of which have
been established by the RSSB Board. During
2013/14, a new meeting structure was introduced
progressively. The System Safety Risk Group
reports to the Board and looks at 100% of the
system safety risk. It is supported by four risk
groups looking at specific elements of the risk.
These are the Level Crossing Strategy Group
(LCSG), the National Suicide Prevention Steering
Group (NSPSG), the People on Trains and in
Stations Risk Group (PTSRG) and the Train
Operations Risk Group (TORG). The first two are
evolutions of existing groups and will become fully
operational in their enhanced role in 2014/15. The
latter two replace earlier groups including the
Community Safety Steering Group, the Rail
Personal Security Group, the Station Safety Group and the Operations Focus Group. In
addition the new Data and Risk Strategy Group looks at the industry’s mechanisms for
capturing and processing risk information.
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National stakeholder groups review the outputs from a number of RSSB activities, including:
Safety performance reporting – information on the latest trends, updated on a regular basis
Operational Feedback – learning from rail and other industry accidents
CIRAS – the rail industry’s Confidential Incident Reporting and Analysis System
Human Factors
Safety Management Systems programme
R&D – RSSB’s management of research and development on behalf of government and the railway industry
RED 37
RED 37 – released October 2013 – builds on the dramatization covered in RED 28.
See Opsweb for details.
An example of this learning loop in action may be seen
in the work the industry has done on reducing the risk at
the platform-train interface.
Since 2007, RSSB has used data from the Safety
Management Information System (SMIS) to provide the
(former) cross-industry Operations Focus Group (OFG)
with regular updates on risk and safety performance. In
2010, this exposed a rise in risk at the platform-train
interface. This prompted RED 28 to feature a poignant
dramatisation on the subject and led OFG to develop a
Station Safety Improvement Programme (SSIP), which
strives to identify and share the many good practice
initiatives that exist within the station operator
community.
At the end of January 2012, RSSB also held the first Station Safety Improvement Workshop.
The purpose of the event was to provide an update on operational risk management
initiatives, promote sharing, encourage good practice and obtain the views of front-line staff
on the issues associated with the management of operational risk at stations.
Though OFG has now been replaced by other bodies, work to improve station safety goes
on. More information on it and the risk at the platform-train interface may be found later in
this report.
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3 What can help us learn?
Just as businesses have to work as one to make a profit, and football teams play as one to
win championships, the rail industry needs to think and act as a cohesive unit to maintain
acceptable levels of safety and performance. This section describes five tools and methods
which will help you benefit from the loop of learning described in the previous section:
Measuring safety performance
Investigations (including the Incident Factor Classification System)
CIRAS
Right Track magazine
Close Call
3.1 Measuring safety performance
If you’re on a diet, you might
measure how much exercise you
do and check your weight. The
exercise is an activity, or an
input to your diet, whilst your
change in weight is an outcome
of dieting.
Transporting the same principle
to safety management, the
activities or resources that we
devote to improve safety are just
as important as the outcomes –
whether or not there are
accidents or operational
incidents.
Focusing on outcomes means
that responses only come after something has gone wrong. If the balance is shifted towards
measuring inputs to safety management, accidents can be pre-empted and avoided.
During 2013/14, RSSB concluded research project T953 Enhancing and Promoting the use
of Safety Performance Indicators. This is the culmination of four years’ work, in which we
sought out best practice from around the world and interpreted it for application in the GB
railway environment. To ensure that it was a good fit, we supported a number of
stakeholders in trialling the resulting guidance document, Measuring Safety Performance.
VolkerRail was one of the stakeholders we worked with in developing safety performance
indicators (SPIs) to support a new initiative: Right First Time (RFT). VolkerRail is a railway
contractor engaged in major infrastructure projects, often working in restricted hours when
trains are not running.
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The aim of RFT is to avoid accidents and disruption through doing a job once, at the right
time, in the right place with the right people and the right equipment. At the heart of this is
planning the works so that when, at site, everything runs smoothly.
By following the process set out in Measuring Safety Performance, VolkerRail quickly
identified potential activity and outcome indicators. The outcome of not achieving RFT was
problems during weekend works; this was recorded using a simple tick list, which was in turn
used as an outcome indicator.
To achieve RFT the team identified work and task planning as a key activity, which was
measured through a ‘readiness review’, an existing process that was not consistently
employed. Therefore an activity indicator was set around the use of readiness reviews; a
series of questions regarding key milestones before going to site. A readiness review score
for a weekends’ work was based around the total score at final completion, taking into
account scores at earlier milestones.
During the pilot stages, a clear correlation was evident between readiness review scores and
RFT scores. The higher the readiness review score the more likely RFT was achieved.
A recent presentation to the Project teams within VolkerRail covered three projects called
‘the Good, the Bad and the Ugly’.
The Good followed the readiness review process and had detailed set-up, delivery and
management of the work resulting in high RFT scores.
The Bad started out without any structure, briefing and roles and responsibilities etc. Through
a robust re-vamp and briefing session the Project Manager turned the project around and
started applying the readiness review process. As a result, the RFT scores for the project
went from a 50-60% success rate to over 90% each weekend.
The Ugly project team arrived on site unable to deliver the work as key assets/engineers
were not available to do it. On reflection, it was stated that if the project team had used the
readiness review process then they would have clearly been able to make informed
decisions weeks before and achieved RFT.
The process is now being incorporated into a company procedure to complement the new
Project Managers’ System.
An output of T953 is a number of supporting resources that have been made available to the
industry in the Measuring Safety Performance toolkit. This includes further details on the
approach that VolkerRail took, written as a supporting case study.
For more information, contact [email protected] or [email protected].
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3.2 Investigations
Though the cycle of safety planning and performance reporting is essential to ensuring that
safety continues to improve, much of the industry’s learning comes from investigations into
accidents and incidents.
The principal investigation of any safety event is conducted by the party immediately
responsible for the activity. To facilitate this, railway companies have their own arrangements
for carrying out internal formal and local investigations, as defined in Railway Group
Standard GO/RT3119 (Accident and incident investigation) and its associated Guidance
Note, GO/GN3519. The outputs are managed by the companies concerned, with actions
being picked up by their own tracking systems. The results of duty holder-led formal
investigations are also summarised in SMIS to give others the opportunity to learn from the
information.
The more significant accidents (involving loss of life or potentially significant consequences)
are investigated by the Office of Rail Regulation (ORR) as safety authority, and the Rail
Accident Investigation Branch (RAIB). RAIB was set up following a recommendation made
by Lord Cullen’s inquiry into the 1999 accident at Ladbroke Grove (a subsequent European
Directive on rail accident investigation also required Member States to create such bodies).
RAIB was fully established in 2005, after which RSSB ceased its accident investigation role.
If an accident involves a derailment or collision which results in, or could result in, the death
of at least one person, serious injury to five or more people or extensive damage to rolling
stock, the infrastructure or the environment, then RAIB will lead an investigation, draw
conclusions and make recommendations.1
RAIB investigates incidents on UK railway infrastructure without apportioning blame or
liability. It is independent of the rail industry and the ORR, with the Chief Inspector of Rail
Accidents reporting directly to the Secretary of State for Transport. RAIB’s recommendations
on the rail industry are addressed to the ORR2, which must then ensure that they are
considered and that, where appropriate, action is taken.
3.2.1 Incident Factor Classification System
As mandated under GO/RT3119, RSSB receives investigation reports from all GB railway
organisations. Currently, around 4,500 are stored, dating back to the late 1990s. The
conclusions therein carry a great deal of valuable information about event causes.
The trouble is, once their recommendations have been acted upon, there’s a danger that
some of their learning points will be lost or will not reach other parties who could benefit from
them.
What to do?
RAIB’s investigation into the Shap rollback incident of 2010 demonstrates why a new way of
capturing how accidents and incidents happen had to be devised.
1 RAIB may also investigate other incidents that have implications for railway safety, including those which, under slightly different circumstances, may have resulted in an accident. 2 RAIB can also address recommendations to other safety authorities and other public bodies, such as the police, the Department for Transport and so on.
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In short, Shap was caused by driver fatigue, but it was not mandatory to flag this factor up in
SMIS. This meant that there was little accurate, tangible evidence available to show the
magnitude of the issue. Clearly, some way of capturing this sort of information was going to
be vital if we, as an industry, were to get to real grips with common themes below the root
causes.
RAIB recommended that RSSB improve rail industry information on fatigue-related accidents
and incidents, although the project to address this – and more – was already under way.
What we did
In 2009, we developed a means to analyse accident reports through an Incident Causal
Classification System (ICCS), using a taxonomy developed by the Rail Accident Investigation
Branch (RAIB), to help us understand (inter alia) what makes operators do certain things at
certain times and what makes certain equipment fail under certain conditions.
Previous editions of the LOEAR featured analysis using the ICCS. More recently, however,
RSSB and Network Rail have worked together with industry to combine the ICCS, human
error and violation taxonomies and the Network Rail ‘10 incident factors’ within SMIS, some
of which are shown graphically, below.
Software for a single module – the Incident Factor Classification System (IFCS) – was
commissioned in November 2012.3 Between January 2013 and March 2014, it was
populated with data by a team of specialists at RSSB to enable:
Cross-Industry learning Causal trends are being identified for all in the industry using a consistent classification for key incidents. The information within the IFCS is heavily used by RSSB and Network Rail learning from operational experience functions in their central reporting and analysis.
3 As part of research project T994: Development of an incident factor classification system module for SMIS
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Incident investigation The IFCS is being used by incident investigators to identify past incidents with similar causes, which not only aids analysis, but also helps prevent previous recommendations being duplicated or contradicted.
In time, the IFCS module will contain causal classifications for all RAIB reports and Formal
Investigations. The risk-based sample also includes causal classifications for some local
investigations (eg for high-risk irregular working incidents). As with the ICCS, the IFCS
module will also include non-GB rail and non-rail investigation reports, in order to ascertain
how other industries learn from safety events which may have parallels with our own.
By February 2014, 235 incidents had been reviewed and classified. The outputs of our initial
analysis may be found here.
3.3 CIRAS
As the focus of Measuring Safety Performance suggests, learning does
not only occur after an event; many valuable lessons are revealed by
what might be termed ‘accidents waiting to happen’.
Reports to the industry’s Confidential Incident Reporting and Analysis
System (CIRAS) focus mainly on such ‘near miss’ events or perceived
deficiencies in safety systems and arrangements, a better
understanding of which provides a solid foundation for shared learning
across different industry sectors.
By capturing this knowledge, which comes from workforce members who have daily
operational contact with the railway, it is possible to identify issues before they cause injury.
Maintaining confidentiality is a key aspect of CIRAS. It is recognised that this may otherwise
restrict the information that can be disclosed. However, the advantage is that reporters may
be able to state their real concerns and describe underlying causes more openly than they
might to their line manager. This gives CIRAS the potential to provide unique insights into
safety issues.
Lessons learnt via CIRAS during 2013-14 may be found here.
3.4 Right Track
In 2012, RSSB launched Right Track, a quarterly magazine aimed at
front-line personnel to capture, share and promote safety learning and
initiatives in a down-to-earth way.
This year, the magazine has focused on station safety, suicide
prevention, SPADs, track worker safety, train dispatch and autumn
adhesion, among many other subjects relevant to drivers, guards, on-
train staff, station staff, dispatchers, signallers, shunters, depot workers
and track workers.
Right Track is available to all RSSB members, London Underground, and other companies
and bodies who have a role in supporting railway operations.
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It is available as a pdf and in paper form. Hard copies are distributed in bulk by arrangement
with individual companies.
A summary of the main themes covered by Right Track during 2013/14 may be found here.
3.5 Close Call
At the request of Network Rail and its contractors, RSSB has developed a new internet-
based Close Call System (CCS) that allows the industry to record and analyse ‘close call
incidents’ centrally.4
A ‘close call’ is defined as ‘an event that had the potential
to cause injury or damage’, like leaving a cable troughing
cover where someone might trip over it, but not a near
miss with a train or on-track plant, both of which will
continue to be reported into SMIS.
Network Rail’s mandate that all principal contractors (PCs) should ‘register’ with CCS has
resulted in a four-fold reporting increase. Of course the dataset is still limited, but this rise
has highlighted the following points:
‘Site welfare and housekeeping’ issues dominates every month, the monthly report showing them to represent more than a third of all records;
The vast majority of risks are categorised as ‘medium’ or ‘low’ risk;
Though all PCs are required to register on the CCS, not all are currently reporting; and
Differing reporting profiles are evident between projects, and the phasing of projects.
4 This was managed as research project T1015: Revision of the close call system.
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4 Investigations – lessons learnt in 2013/14
RAIB published 26 reports between 6 April 2013 and 5 April 2014, covering the following
categories:
Heavy rail – on Network Rail managed infrastructure (NRMI) (22)
Northern Ireland Railways (1)
Metro (2)
Tram (1).
Table 1 (overleaf) lists each of these investigation reports (with links to the reports in
question). Note that:
88 recommendations were issued from 22 RAIB investigations involving incidents on NRMI. This compares to:
82 recommendations from 19 RAIB investigations in 2012/13;
90 recommendations from 23 RAIB investigations in 2011/12;
76 recommendations from 15 RAIB investigations in 2010;
167 recommendations from 27 RAIB investigation reports in 2009;
127 recommendations from 18 RAIB investigation reports in 2008; and
158 recommendations from 22 RAIB investigation reports in 2007.
Tables 1 to 4 contain hyperlinks to aid navigation to RAIB’s investigation reports and bulletins.
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Table 1. RAIB investigations published in 2013/145
Publication Date
Report Title Infrastructure
Owner
REPORTS PUBLISHED IN 2014
02/04/2014 Class investigation into landslips affecting Network Rail infrastructure between June 2012 and February 2013
NRMI
31/03/2014 Locomotive derailment at Ordsall Lane Junction, Salford NRMI
27/03/2014 Collision at Buttington Hall user worked crossing, Welshpool NRMI
06/03/2014 Tram running with doors open on London Tramlink, Croydon London Tramlink
24/02/2014 Fatal accident at Athelney level crossing, near Taunton, Somerset NRMI
13/02/2014 Penetration and obstruction of a tunnel between Old Street and Essex Road stations, London
NRMI
16/01/2014 Derailment at Castle Donington, Leicestershire NRMI
14/01/2014 Fatal accident at Motts Lane level crossing, Witham, Essex NRMI
REPORTS PUBLISHED in 2013
11/12/2013 Derailment of a freight train at Barrow upon Soar, Leicestershire NRMI
29/10/2013 Fatal accident involving a track worker at Saxilby NRMI
03/10/2013 Track worker struck by a train at Bulwell, Nottingham NRMI
26/09/2013 Fatal accident at Bayles and Wylies footpath crossing, Bestwood, Nottingham Metro
25/09/2013 Train fire at South Gosforth
Tyne & Wear Metro
24/09/2013 Collision between a train and a car at Beech Hill level crossing, near Finningley NRMI
16/09/2013 Signal passed at danger at Stafford NRMI
12/09/2013 Dangerous occurrence involving an engineering train at Blatchbridge Junction, near Frome NRMI
02/09/2013 Train ran onto a washed-out embankment near Knockmore, Northern Ireland
Northern Ireland Railways
15/08/2013 Partial failure of a structure inside Balcombe Tunnel, West Sussex NRMI
08/08/2013 Collision between a stoneblower and ballast regulator near Arley, Warwickshire NRMI
29/07/2013 Dangerous occurrence at Lindridge Farm user worked crossing NRMI
25/07/2013 Accident at Charing Cross station NRMI
24/07/2013 Collision of a road-rail vehicle with a buffer stop at Bradford Interchange station NRMI
22/07/2013 Derailment of a freight train at Shrewsbury station NRMI
27/06/2013 Dangerous occurrence involving track workers, near Roydon station, Essex NRMI
20/05/2013 Accident involving a pantograph and the overhead line near Littleport, Cambridge NRMI
25/04/2013 Dangerous occurrence involving engineering possession, near Dunblane, Scotland NRMI
Key:
Off NRMI
5 Source: RAIB website.
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Ongoing RAIB investigations
There were a further 23 events that were still under investigation by RAIB at the end of
March 2014, three of which (shaded) are off-NRMI:
Table 2. Ongoing RAIB investigations (at 5 April 2014)
Incident date RAIB investigation
20/03/2014 Signals passed at danger at Greenford
03/02/2014 Passenger dragged a short distance by a train at Holborn station
22/01/2014 Fatal accident involving a track worker, near Newark Northgate station
16/01/2014 Serious near-miss involving a welding gang at Bridgeway user worked crossing, near Shrewsbury
12/01/2014 Engineering train collision at Kitchen Hill, near Penrith
23/11/2013 Locomotive failure near Winchfield, Hampshire
20/11/2013 Buffer stop collision at Chester station
26/10/2013 Fatal accident at Barratt's Lane No.2 footpath crossing, Attenborough, Nottinghamshire
26/10/2013 Road vehicle incursion onto the railway at Aspatria, Cumbria
15/10/2013 Derailment of a freight train at Camden Road, North London
15/10/2013 Derailment of a freight train at Gloucester
28/08/2013 Wheeled transport rolling off platforms at Southend and Whyteleafe stations
27/08/2013 Derailment of freight train at Stoke Lane level crossing, near Nottingham
25/08/2013 Uncontrolled evacuation of a train at Holland Park station (London Underground)
01/08/2013 Dangerous occurrence at Denmark Hill station, London
14/07/2013 Accident at Jetty Avenue no.18 user-worked level crossing near Woodbridge
25/06/2013 Incident at Butterswood level crossing, near Goxhill, Lincolnshire
06/06/2013 Near-miss at Llandovery level crossing, Carmarthenshire
05/06/2013 Passenger trapped in train doors and dragged a short distance at Newcastle Central station
31/05/2013 Accident at Balnamore level crossing, County Antrim, Northern Ireland
21/04/2013 Accident involving a runaway road-rail vehicle at Glasgow Queen Street High Level station
23/01/2013 Derailment at Liverpool Street station, London
14/09/2012 Broken rail incidents on the East Coast Main Line
Page 20 of 100
RAIB Bulletins
When RAIB’s preliminary examination of an incident suggests that a full investigation would
not lead to further significant safety lessons for the rail industry, in some cases it provides
related information or advice in the form of a short bulletin.
Between April 2013 and March 2014, RAIB issued four such bulletins:
Table 3. RAIB bulletins published in 2013/14
Publication Date
Title
21/11/2013 Track worker struck and seriously injured at West Drayton, 22 March 2013
14/11/2013 Member of staff struck by train near Poole, Dorset, 12 July 2013
30/05/2013 Signal passed at danger at Norton-on-Tees West, 16 January 2013
30/05/2013 Near miss at Southwark Bridge junction near Elephant and Castle station, 21 January 2013
4.1 RSSB analysis of key RAIB recommendation themes
Recommendations tend to reflect the nature of the incident from which they arise, but the
selection of incidents and the number of recommendations also indicate the weighting given
to the event by the investigating organisation. In other words, only the tip of the
accident/incident/unsafe act or condition ‘pyramid’ is represented by looking at
recommendations in detail.
It should be noted, therefore, that numeric analysis of recommendation trends has little
statistical validity. Indeed, a single report may generate multiple recommendations for one
category. In the interests of continuity, however, we have used the categorisation process
applied in previous years to RAIB recommendations. The results are presented overleaf.
Page 21 of 100
Table 4. SMIS recommendation categories
Distribution of RAIB recommendations (%) – 2013/14
Cat code Recs category Description
A Signalling system Lineside SPAD controls, signal sighting issues, train
planning and regulation, operation of the signalling
equipment.
B Competence management Training and development, driver management,
competence systems, briefing, assessment, staff
selection procedures, drugs and alcohol, fitness for
duty, fatigue.
C Rules, standards and instructions Modification /development of rules and predefined
standards for operation, standards/process change
management.
D Vehicle operation and integrity Train-borne safety equipment, fire protection, vehicle
maintenance, train data recorders, crashworthiness, in-
cab ergonomics.
E Infrastructure asset management Managing contractors, track/signalling maintenance
operations, work planning, technical specifications,
method statements.
F Event mgmt/investigation/ reporting SPAD management, public accident investigation, site
investigations, post-accident management, formal
investigations, formal inquiries, public inquiries, fault
reporting, emergency procedures.
G Monitoring and audit Monitoring activities, safety performance monitoring,
follow-up processes.
H Research and development Suggested research topics/specific areas of research.
J Safety communications Defining and communicating safety responsibilities,
general safety related communications, meetings,
techniques, methods and equipment.
K Culture Management commitment, organisational change.
Signalling system9%
Competence management
9%
Rules, standards & instructions
14%
Vehicle operation & integrity
2%
Infrastructure asset managment
37%
Event mgmt/investigation/ reporting
5%
Monitoring & audit13%
Research & development2%
Safety communications9%
Page 22 of 100
The ORR also keeps a record of the status of all RAIB recommendations. This is available on its website.
RSSB’s figures suggest that, in 2013/14, the largest recommendations component was
infrastructure asset management (37%). While a change from the emphasis on safety
communications seen last year, this is in line with the two previous reporting periods.
Recommendation categorisation – by year (%)
Comparing 2013/14 with 2012/13, reductions in the percentage of recommendations can be
seen for:
Vehicle operation and integrity;
Event management/investigation/reporting;
Safety communications; and
Culture.
However, there has been a rise in the percentage of recommendations which deal with:
Signalling system;
Competence management;
Rules, standards and instructions;
Infrastructure asset management;
Monitoring and audit; and
Research and development.
1
11
15
12
38
4 4 4
7
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7
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13
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30
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Recommendations category
Recommendations issued in:
2009/10
2010/11
2011/12
2012/13
2013/14
Page 23 of 100
The issue of infrastructure asset management is exemplified by RAIB’s report on the partial
structural failure within Balcombe Tunnel, which occurred early on 23 September 2011.
The crew of an engineering train saw that part of a large steel structure mounted in the roof
of the tunnel, spanning over both lines, was sagging down. An emergency inspection found
that on one side of the structure, three supports had become detached from the tunnel lining
leaving a 12-metre length only partially supported.
The structure, one of six within the tunnel, was intended to catch water dripping from the
tunnel roof. It was supported by anchor studs fixed with polyester resin into holes drilled in
the tunnel’s brick lining. Within the tunnel, 18 studs (5%) were found to be missing and a
further five studs were loose. RAIB’s investigation has found that this connection was
inadequate because the resin was not compatible with the tunnel brickwork and may have
been adversely affected by shrinkage and the damp conditions in the tunnel. It is probable
that the resin was selected using inadequate technical data and that insufficient resin was
placed around some studs.
Although some railway staff were aware that studs had fallen from the structure on more than
one occasion since 2008, this did not result in appropriate risk mitigation. This was because
of inadequacies in the reporting of these events and because there was insufficient support
for a member of railway staff who was managing some aspects of the tunnel maintenance
but had limited experience. Inadequate access for tunnel examinations due to conflicting
demands on the limited available access is considered to be an underlying factor.
RAIB has identified three learning points from this incident: the need to consider the
adequacy of information contained in manufacturers’ data sheets; the need to maintain
awareness of published information; and the benefit of marking significant tunnel defects
such that they are visible from track level.
What’s being done?
Network Rail arranged for temporary brackets to be fabricated and installed to support the
three detached beam-ends in their deflected positions before the tunnel was reopened to
traffic on 24 September 2011.
Further work included the provision of brackets to provide additional support to the
transverse beams remaining in the tunnel.
Immediately after the incident, Network Rail also undertook a review to determine whether
any other tunnels contained structures similar to those at Balcombe. In addition to tunnels
containing overhead line and signalling supports, five tunnels contained minor supporting or
reinforcing structures. Network Rail considered that none of these gave rise to significant
levels of risk.
In addition, Network Rail’s asset management function, which includes the structures
management engineers, has introduced a process to record and track actions requested as a
result of tunnel examinations.
Page 24 of 100
4.2 Incident Factor Classification System
As noted in section 3.2.1, RSSB and Network Rail have developed a SMIS-based Incident
Factor Classification System (IFCS) to capture the accident causes in RAIB reports and
Formal Investigations. Chart 3 shows the breakdown of the dataset by Network Rail’s ‘ten
incident factors’. Issues around equipment failures, practices and processes and supervision
and management feature most prominently.
IFCS dataset, by Network Rail’s ‘ten incident factors’
However, when we take a closer look – in Chart 4– at all the causes in the IFCS shown to
contribute to accidents, it becomes clear that communications is the dominant factor.
IFCS analysis, by causes and contributory factors
0%
5%
10%
15%
20%
25%
Ten incident factors
Communications31%
Equipment25%
Information5%
Knowledge, skills and experience
6%
Practices and processes16%
Supervision and management
12%
Work environment5% Communications
12%
Equipment22%
Information4%
Knowledge, skills and experience
13%
Personal6%
Practices and processes
16%
Supervision and management
18%
Teamwork3%
Work environment1%
Workload5%
Causal Contributory
Page 25 of 100
Chart 5 shows there to be a peak in all three industry sub-areas for communications, with
Signalling operations showing the most significant level, featuring (as causes) in almost 40%
of investigation reports classified. We will look at the area of communications in a little more
detail, but note that the IFCS allows each of the 10 factors to be unpacked and reviewed so
that we can identify how, for example, practices and processes or knowledge, skills and
experience can be better managed by the industry.
IFCS analysis, by industry area
0%
10%
20%
30%
40%
50%
Co
mm
un
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Eq
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Info
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Infrastructuremaintainence
0%
10%
20%
30%
40%
50%
Co
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Pe
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Signalling operations
0%
10%
20%
30%
40%
50%
Co
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Eq
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Info
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Kn
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Pe
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On-train operations
Page 26 of 100
Communications, by error type and workforce type
Chart 6 (above) shows that the reports currently classified show drivers and signallers to be
involved in the most protocol and content-related errors. This information is being used to
inform Network Rail’s communications strategy.
Note that the IFCS will be used to support RSSB’s forthcoming Human Factors research into
SPADs.
0%
10%
20%
30%
40%
50%
60%
70%
Sending information Communicationprotocols
Receivinginformation
Choice ofcommunication
method
Other/insufficientinformation
Driver
Signaller
Trackside staff
Other
Page 27 of 100
5 CIRAS – lessons learnt in 2013/14
During 2013/14, CIRAS began implementing a new business plan, focused on multi-level
industry engagement from managing director level right through to front-line staff.
The business plan aims to capture the reasons staff report to CIRAS more effectively. This
will help address the common misperception that staff use CIRAS as an alternative reporting
channel. In fact, evidence is growing that staff normally comply with the need to use internal
reporting channels first, but use CIRAS in a complementary manner where concerns remain
unresolved.
A key development in January 2014 was CIRAS’ selection by the Serco Group as the
external provider of confidential reporting to its staff in the marine and aviation sectors. A full
programme of visits has been organised to effectively launch the scheme, on a trial basis, for
this new business. This is in addition to the extensive, existing commitments CIRAS has to
its stakeholders in the rail industry. (Note, though, that the data in this section refers to the
rail industry only.)
5.1 Who reports to CIRAS?
Chart 7 shows the distribution of reports received in 2013/14, by reporter occupation.
Report distribution 2013/14 – by job category
Train drivers submitted the largest number of reports (79), a trend consistent with previous years.
79
34
14 13 12 11 108
6 6 6 5 53 2 2
0
10
20
30
40
50
60
70
80
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Page 28 of 100
It is, however, particularly positive to note that a diverse range of staff feel able to raise safety issues, including conductors, station staff, managers, signallers, as well as train crew.
5.2 Why do people report to CIRAS?
Of all issues reported to CIRAS in 2013/14, 22% came in because reporters found it difficult
to raise concerns with their managers. However, most (78%) had previously been taken
through internal company channels; this figure remains consistently high from year to year.
Chart 8 provides a picture of why those within the 78% then went on to contact CIRAS.
Reporters’ views of company response after issue raised internally
57% of reporters used CIRAS as they felt the response they had received from their company was inadequate;
28% believed the company response to be adequate, but they had not seen any changes or implementation at work, representing an increase of 7% on the previous year; and
13% claimed they had received no response whatsoever, a fall of 7% on last year’s figure.
It should be noted that concerns which get as far as CIRAS are likely to represent a small
proportion of all the issues that are pursued through a company’s internal processes.
Inadequate57%
Adequate but not implemented
28%
No response13%
Other2%
Page 29 of 100
5.3 Key issues of concern in CIRAS reports during 2013/14
In 2013/14, CIRAS received 978 contacts on a diverse range of topics. Of these, 216 (22%)
became reports after the screening process.
A breakdown of reports per industry risk category is shown in Chart 9.
Reporters predominantly focussed on the potential for accidents or incidents. The reports
therefore represent the perceived risks identified by reporters in the course of carrying out
their duties.
CIRAS reports against industry risk categories
Workforce safety62%
Passenger safety17%
Train accidents15%
Level crossings4%
Public safety2%
Page 30 of 100
5.4 Positive outcomes from CIRAS reports
CIRAS monitors the outcomes from the reporting process to ascertain the value and benefits
delivered to the rail industry. Positive outcomes from CIRAS reports, such as an
investigation, briefing, review or change, are recorded. Here are some of the best examples
of a CIRAS report ‘nudging’ management behaviour from 2013/14:
Several practices perceived as unsafe at a major contractor were highlighted. Communication was improved, and further training and briefings were provided.
Contradictory signage on a part of the West Coast Main Line was rectified following a full investigation. Other geographically adjacent areas were also checked for similar issues.
A non-compliant coach lifting procedure at a train operating company’s depot was addressed. The practice immediately ceased, and the correct process was implemented. Improved briefing was also introduced.
Shunting procedures in a large depot were reviewed by a train operating company, resulting in improved briefing being provided.
Station dispatch arrangements were reviewed comprehensively by a train operating company with a specially arranged site test. Improvements have been identified.
CIRAS also compiles statistics on the actions companies take as a result of its reports.
Companies are asked about the actions they have taken in relation to the confidential CIRAS
report they receive, and all response evaluation forms are analysed.
Page 31 of 100
6 Right Track – lessons taught in 2013/14
Starting with Issue 5, four issues of Right Track were published during 2013/14. Click on the
cover image to link to each on Opsweb.
Issue 5: ‘safety charter’, published May 2013
The cover feature of this issue dealt with the challenge of running
charter services, including handling passengers, dispatching trains
and coping with lengthy train paths. It also considered the ‘stop short’
phenomenon, and what one operator has done about it.
The regular RAIB report summary focused on the James Street fatality
and its aftermath, SPADtalk looked at the re-categorisation of SPADs
to align GB and European practice and the Moorgate buffer stop
collision of 1975 was remembered.
Issue 5 also included an article on the risk from road vehicle driving.
Issue 6: ‘pulp friction’, published July 2013
As the punning subtitle suggested, Issue 6 focused on the railway’s
preparation for autumn leaf fall, and some of the work that is being
done to combat it – like the trials of an ‘in service’ railhead treatment
train utilising equipment fitted to a Mark III Driving Van Trailer. The
chair of the Adhesion Working Group – First Great Western MD Mark
Hopwood – was also interviewed.
Temporary speed restrictions on lines adjacent to those closed for
engineering work were also discussed and track worker safety was
covered in a summary of RAIB’s report on the irregular working
incident at Dunblane on 28 October 2012.
Issue 7: ‘MOM’s the word’, published October 2013
The main feature in Issue 7 shed light on the role of the Mobile
Operations Manager (MOM), by comparing the issues that face those
working in an urban and a rural environment. There’s also an
interview with North Yorkshire Moors Railway operations manager
Norman Hugill about the challenges of running a safe, successful
heritage line.
The wider implications of fatigue – and what the industry is doing
about it – was covered, while the platform train interface was
considered in the summary of RAIB’s report on the fall between train
and platform incident at Charing Cross on 24 November 2012.
Issue 7 also included an article on TPWS ‘reset and continue’.
Page 32 of 100
Issue 8: ‘signalling change’, published February 2014 went wrong at
Issue 8’s main feature looked at the European Rail Traffic
Management System (ERTMS) in action on the Cambrian line, while
Network Rail’s new approach to ‘urban explorers’ was considered,
along with the role of the company’s Academy system in managing
competence.
There was also more information on the ‘in service treatment train’
referred to in Issue 6, while the RAIB report summary features the
track worker fatality at Saxilby on 4 December 2012. In light of the
Branch’s Stafford report, SPAD talk also considered the question of
light engine SPADs.
Page 33 of 100
7 Lessons learnt in 2013/14 – train accidents
7.1 Statistical overview
Version 8 of the Safety Risk Model (SRMv8) calculates the risk from train accidents to be 7.8
fatalities and weighted injuries (FWI)6 per annum, which is 5.4% of the total risk (excluding
suicide). Of this, fatality risk is 6.0 per year, which is around 9.1% of the total fatality risk.
There were no train accident passenger or workforce fatalities or major injuries during
2013/14. There have now been seven consecutive years without passenger or workforce
train accident fatalities (the last being the 2007 Grayrigg derailment, in which one passenger
died).
Train accident risk at a glance
Train accident risk in context (SRMv8)
Trends in train accident risk (PIM)
For more statistical analysis on train accidents, see Chapter 8 of the ASPR.
Topics covered in this section:
Overseas accidents
Derailments
Signals passed at danger
Animals on the line
7.2 Overseas accidents
July 2013 saw four major train accidents occur across the world: in Canada on the 6th (47
fatalities), France (12th, 6 fatalities), Spain (25th, 79 fatalities) and Switzerland (29th, 1 fatality).
An expanded consideration of the Canadian incident may be found later in this report, but in
September RSSB produced a paper to assess each of the ‘July four’ and measure them
6 Fatalities, injuries and shock and trauma are combined into a single figure, termed fatalities and weighted injuries (FWI). For more details on the injury classifications and their associated weightings, see the Annual Safety Performance Report.
Passengers 2.0%(2.8 FWI per year)
Public 2.8%(4.0 FWI per year)
Workforce 0.7%(1.0 FWI per year)
Train accident risk = 7.8 FWI per year (5.4% of total risk)
Other risk(not train accidents)
12.3
10.19.7
9.28.6
7.48.1
7.27.9 7.5
0
2
4
6
8
10
12
14
PIM
in
dic
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r
Page 34 of 100
against GB practices and safety mitigations. The paper may be downloaded from Opsweb,
but a summary of the main discussion points may be found in the table below:
Incident Key issues GB controls/considerations
Lac-Megantic, Quebec, 6 July 2013
RUNAWAY AND DERAILMENT
On 6 July 2013, a train carrying petroleum crude oil ran away on a line unprotected by signals and track circuits. It derailed in the town of Lac-Mégantic, Quebec, and a fire and explosions ensued. Forty-seven people were killed.
The train was planned to be left unattended on a publicly-accessible running line which had no runaway protection (such as trap points, catch points or derailers), despite there being a downhill gradient towards Lac-Mégantic.
Risks: tampering, vandalism, runaway.
The train had been secured using handbrakes and by keeping one of the locomotives running to keep the air brakes operative throughout the train.
Risks: handbrakes known to be inherently weak, unattended locomotive could have shut itself down at any time due to failure.
Loco shut down by the fire service due to a minor fire. Railway employee had been present. Railway control were aware.
Failing: locomotive not re-started after the fire
After about one hour the air brakes leaked off and the handbrake forces were not sufficient to hold the weight on the gradient
Failing: foreseeable consequence
In addition to the points raised above a report just issued from the Canadian Centre for Policy Alternatives7 suggests that ‘Changes to the Canada Transportation Act in the 1990s spurred a major restructuring of large carriers, resulting in a proliferation of smaller railways. One such line, the Montreal, Maine and Atlantic (MMA), which runs through Lac-Mégantic, embarked on a drastic cost-cutting exercise, laying off staff and cutting wages, in an effort to turn a profit.’
In this country, a train (of any kind) is unlikely to be stabled overnight unattended on a running line – said train would be scheduled to run to a specific destination, or at worst a siding or loop. Any stranded train would activate the track circuits, and the normal Rule Book controls would apply, ensuring that the signaller was informed, the train was protected in rear by signals, track circuit clips, detonators etc.
Trap and catch points are widely in use in the UK – particularly at the exit to sidings and the bottom of inclines.
It is especially unlikely that a train would be stabled on a slope on handbrakes only – at the very least, GB operators use wheel scotches on stabled locomotives and rolling stock – regardless of the lie of the land.
The issue of cost reduction pressures on the industry were explicitly considered in the board strategic risk review.2
Breitigny-sur-Orge, France,12 July 2013
DERAILMENT
On Friday 12 July 2013, a derailment occurred at Bretigny-sur-Orge, in which six people were killed and 30 were injured (eight seriously).
Incident highlighted fishplate manufacture and maintenance issues, akin to those found after the derailment at Southall East in 2002.
In GB, fishplates, not welds only, are used at 23 sites on 100mph lines to secure track to switches and crossovers. This allows the rail to expand and contract under prevalent temperature conditions.
This method is effective if well-maintained (including lubrication to ease movement). However, regular ultrasonic-testing is required to aid identification of the development of tiny flaws within steel. Regular rail-head grinding removes these flaws.
Fishplate breaks were a historic problem and have increased 30% over the last three years but reversed in 2012-13. Network Rail has a longer-term plan to remove bolted rail ends and use welded joints for rails and switches and crossings.
7 The Lac-Megantic Disaster ‘Where does the buck stop?’ Bruce Campbell, Canadian Centre for policy Alternatives, October 2013.
Page 35 of 100
Incident Key issues GB controls/considerations
Lessons from Southall East derailment learned.
Santiago de Compostela, Spain 25 July 2013 DERAILMENT
On 24 July 2013, a passenger train derailed at highspeed on a curve four kilometres from Santiago de Compostela, killing 79 people and injuring over 140.
• No high-to-conventional line-speed design control transition (only effective above 124mph; train passed at 121mph); the driver was the sole speed-transition risk control;
• Driver distraction: he had been on the telephone to the guard seconds before crash;
• Hybrid train-set stability and crashworthiness concerns: top-heavy front diesel generator car seen to topple first and derail set. Articulated mid/rear cars jack-knifed and one lost structural integrity causing fatalities; and
• Poor passenger survivability: 79-deaths; too high for non-head-on derailment/collision.
• Warning signs and TPWS reduce over-speeding approach control at higher risk curves. TPWS fitted to all PSRs were the linespeed is above 60 mph and the speed reduction is more than 1/3 of the linespeed. Trains considered to be able to take a PSR at 50% above the plated speed without derailing.
• Known TPWS weaknesses in relation to overspeed protection:
• Single point speed check • Possible to accelerate after going
over the TPWS OSS at a PSR • Differences for freight trains and
passenger trains
• There is a need for careful risk based consideration of the locations for future ERTMS-to-conventional line speed-transition sites.
• GB uses passive interior passenger survivability approach; this has been resisted in Europe, but supported by the ERA.
• Mobile phone use by drivers is banned in this country (Following the Chatsworth collision). However, cases of driver distraction remain a focus.
Granges-pres-Marnand, Switzerland, 29 July 2013 COLLISION
On 29 July, two passenger trains collided on the single line just outside Granges-près-Marnand station, killing the driver of the incoming train. The collision was caused by the driver of the departing train self-dispatching without waiting for the incoming train to pull into an adjacent loop. • The exit signal is a ‘common signal’, being
situated on the single line, beyond the conflict point. While at danger in this case, the train had not reached it prior to the collision, and in fact had built up some speed.
• The Swiss SIGNUM automatic train protection system is only partially effective at reducing SPAD risk, having only a warning/stop function, no over-speed supervision, and no departure-stop function when combined with a station passing loop. The system is designed to slow down a train passing a red signal, often fails to prevent it from reaching a potential conflict point.
• Confusion is also caused by the simplified station signal layout, which has only one departure signal for all lines.
• The investigation is on-going, but it is understood that SBB plans to accelerate ERTMS fitment.
• In GB, we do not have ‘common signals’. The Driver Reminder Appliance (DRA), which the driver must proactively reset before the train can move, helps prevent ‘dispatch against red incidents’.
• We also have TPWS, which is designed – where track and infrastructure layouts allows – to automatically stop trains within the safety overlaps and before it reaches a potential conflict point.
• However, TPWS does have some known weaknesses in the context of SASSPADs such as:
• Reset and continue
• Often short distances to the conflict point which can be a problem with short trains in a long platforms which can reach higher speeds when they pass the signal.
Page 36 of 100
7.3 Derailments
Derailments – specifically freight train derailments – received much media attention in
2013/14, initially because of the runaway, derailment and subsequent explosion of an oil train
in Lac-Mégantic, Quebec, on 6 July 2013. However, the incident was followed by a surprising
number of other, similar events, and led to a re-evaluation of how oil is transported across
the North American continent.
7.3.1 Lac-Mégantic and its implications
What happened?
On 6 July 2013, a train carrying petroleum crude oil operated by
the Montréal, Maine & Atlantic Railway (MMA) ran away on a
line unprotected by signals and track circuits. It derailed in the
town of Lac-Mégantic, Quebec, and a fire and explosions
ensued.
At around 23:00, the train stopped at the designated crew
change point near Nantes. The driver secured the train and
departed for the evening, leaving the leading locomotive
unlocked and the train unattended on a main line with a
descending grade of 1.2%.
At about 23:50, a local resident reported a fire on the
locomotive to the emergency services. The local fire brigade
responded, along with another MMA employee. Ten minutes
later, emergency shutdown procedures were initiated on the
locomotive and the fire was extinguished. The second MMA employee and the fire brigade
then left the site, leaving the train unattended once more.
Shortly before 01:00 on 6 July 2013, the train started to move and gathered speed as it rolled
uncontrolled down the grade and into Lac-Mégantic. While travelling well in excess of
linespeed, the train derailed near the centre of the town. The locomotives separated from the
wagons and came to a halt about half a mile east of the point of derailment.
Several of the derailed tank cars released product, resulting in multiple explosions and
subsequent fires causing 47 fatalities (42 confirmed), extensive damage to the town centre
and led to the evacuation of about 2,000 people from the surrounding area.
MMA, the lone driver in charge of the train, the company’s manager of train operations and
its rail traffic controller were charged with criminal negligence in May 2014.
Why did it happen?
In brief, the brake force applied to the train was not sufficient to hold it on the 1.2%
descending slope between Nantes and Lac-Mégantic. However, the Transportation Safety
Board of Canada has determined that MMA’s operating plan was to leave the train on the
main track, unattended, with an unlocked locomotive cab, parked alongside a public highway
where it was accessible to the general public, with no additional protection.
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Furthermore, says the TSBC, the accident has brought into question ‘the effectiveness of the
Transport Canada (TC)8 approved Canadian Rail Operating Rules (CROR)’, which – while
specifying the minimum number of handbrakes needed in general operating conditions – do
not always provide the number of hand brakes required under specific conditions. In many
cases, it is left to staff on the ground to determine the number of hand brakes to apply.
Sometimes, their own technique and physical capabilities can mean that the torque they
apply may not be proportional to the effective brake shoe force actually applied. In other
words, high torque does not necessarily generate a high braking force.
Accidents involving the rail transport of oil have become more common as oil production has
increased in North Dakota and Canada. Indeed, analysts expect up to 40 times more oil to
be transported by trains in North America over the next five years.
What’s being done?
To help combat the problem, the Association of American Railroads (AAR) proposed a
number of measures to bring older, sub-standard, tank wagons into line, including the fitment
of protective steel jackets and pressure relief valves.
The TSBC recommended that Transport Canada and the Pipeline and Hazardous Materials
Safety Administration (PHMSA) place tougher standards on all Class-111 tank wagons, the
Board having determined that older and unprotected Class-111s ruptured and released
crude during the Lac-Mégantic accident.
It also recommended that Transport Canada require rail companies to choose their routes
more carefully and require emergency response assistance plans along routes where large
volumes of liquid hydrocarbons are shipped.
After Lac-Mégantic, the US Department of Transportation (DoT) began its ‘Bakken Blitz’
initiative, which included spot oil train inspections in North Dakota. However, in January
2014, the National Transportation Safety Board (NTSB) issued the following advice to the
Federal Railroad Administration (FRA) and the PHMSA:
Hazardous materials route planning for rail companies should be expanded to avoid populated and other sensitive areas;
An audit programme should be developed to ensure rail companies that carry petroleum products have adequate response capabilities to address worst-case discharges of the entire quantity of product carried on a train; and
Rail companies and shippers should be audited to ensure they're properly classifying hazardous materials, and have adequate safety and security plans in place.
The US DoT then outlined new testing obligations, requiring hauliers to measure the
flashpoint and boiling point of the crude they are shipping (although they will not need to
measure other specifications, such as vapour pressure and corrosiveness, as long as they
are familiar with the characteristics of the oil). The tests will help determine how likely the fuel
is to ignite and will dictate what type of wagon can be used for shipments.
8 Transport Canada is the Canadian government department responsible for transport safety, rules governance, research, etc. For further details, click here.
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Learning points:
Is GB rail ready for an increase in oil traffic?
Unlike most hazardous materials, crude oil is not refined before being loaded onto trains. Its
properties can also vary greatly between shipments. According to the TBSC, the crude that
exploded in Lac-Mégantic had characteristics similar to unleaded petrol. It had been
incorrectly classified as ‘packing group III’ – the least dangerous option crude oil – but should
have been classified as a more dangerous flammable liquid. It had a high vapour pressure
and a low flashpoint, which – together – made it ‘readily ignitable’.
The Federal Railroad Administration (FRA) later announced plans to propose new rules
mandating two-person crews as well as new policies for securing stabled trains.
Immediately after Lac-Megantic, Canadian transportation officials issued an emergency order
prohibiting single-manning on trains hauling hazardous materials. Transportation officials in
the US had hoped that the cross-industry Rail Safety Working Group would come to a
consensus on the issue. The group agreed on other safety recommendations, but hit an
impasse on crew size.
In addition to two-person crews, the FRA plans to propose rules prohibiting freight trains –
including those transporting crude oil – from being left unattended on the main line as well as
in some yards. The proposed rules would also require locomotive cabs to be locked and their
reversers removed or secured.
The GB situation
In Britain, a service train is unlikely to be stabled overnight unattended on a running line –
said train would be scheduled to run to a specific destination, or at worst a siding or loop.
Any stranded train would activate the track circuits, and the normal Rule Book controls would
apply, ensuring that the signaller was informed, the train was protected in rear by signals,
track circuit clips, detonators etc.
Trap and catch points are also widely in use – particularly at the exit to sidings and the
bottom of inclines.
It is especially unlikely that a train would be stabled on a slope on handbrakes only – at the
very least, GB operators use wheel scotches on stabled locomotives and rolling stock –
regardless of the lie of the land.
However, as many of the North American shipments have resulted from a rise in shale oil
(‘fracking’), which poses questions for Britain, whose government is considering a number of
options to increase similar operations.
__________________________________________________________________________
In Great Britain, RAIB’s derailment reports have highlighted issues around:
Track and wagon maintenance;
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Earthworks inspection and maintenance; and
Standards.
The first point was demonstrated by the incidents at Shewsbury and Castle Donington.
7.3.2 Freight train derailment at Shrewsbury, 7 July 2012 (pub. 07/13)
At around 14:13 on 7 July 2012, the leading bogie of the 16th wagon of a freight derailed as
it passed over a set of points at the north end of Shrewsbury station. The bogie ran derailed
for 65 metres causing significant track damage in the process before the train was brought to
a stand. There were no reported injuries.
Causes
RAIB found the immediate cause of the derailment to be that the points were unsafe to
negotiate because of wear and damage. The degradation of the points since the last detailed
inspection had not been prevented by the maintenance regime, nor had it been identified by
the inspection regime.
The inspection regime in place at Shrewsbury at the time of the derailment was inconsistent
with the risk-based approach intended by Network Rail’s standard aimed at preventing
derailment on points.
Shrewsbury maintenance delivery unit misinterpreted the intent of this standard when it was
modified in 2008, and stopped regular detailed inspections of the points, relying instead on a
weekly visual inspection by a patroller and a 13-weekly visual inspection by a supervisor.
Neither of these inspections triggered the need for a detailed inspection which could have
revealed the degradation and the need for remedial actions.
What was done?
Since the derailment, the points have been replaced with vertical curved inset straightcut
switches. The alignment at the rail joint in front of the toe of the points has been reported as
improved. Network Rail expects that these actions will result in a lower wear rate being
experienced on these points and is monitoring these points accordingly. It is considering
making similar modifications to other points in the vicinity.
Network Rail also carried out a full review of rail lubrication in the Shrewsbury area and
agreed to procure new lubrication equipment, with a view to early installation.
The relevant standard has been re-issued and clarifies that the person undertaking the
supervisor’s visual inspection must be competent. The updated standard also clarifies that a
risk-based approach to the management of all track assets (including points) should be
embraced by local management teams.
In addition, the haulier (Freightliner) has improved its processes to monitor wagon
maintenance standards and the process to determine actions required if deficiencies are
identified.
RAIB has also recommended (inter alia):
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Cyclic top is also a causal factor in the derailment at Gloucester, which occurred at around 20:15 on 15 October 2013. The incident train was travelling at around 69 mph when the rear axle of the rear wagon derailed.
The driver was not aware of this and the train continued for some 3.8 miles until the derailed wagon struck a set of facing points. Both wheelsets were torn from the rear bogie and an empty container on the rear wagon was thrown off. The train then continued, causing further damage to the track and wagon, damaging two bridges and throwing debris to the road below. RAIB is seeking to identify the sequence of events leading to the derailment. It will consider how the track was maintained and why the train was permitted to run at a high speed over a section of track with cyclic top. It will also consider the design of the wagon and why the container fell off the wagon.
Identifying any maintenance delivery units that have not correctly adopted the risk-based approach to inspection of points intended by the relevant standard;
Removing inconsistencies between standards, and training and competence assessment materials;
Clarifying that a routine measurement to identify wear is mandatory;
Mandating that the routine measurement should be repeated for points in both normal and reverse positions; and
Ensuring that arrangements are in place to ensure that risks are adequately managed while any disparities identified between working practices and the requirements of the maintenance instructions are being resolved.
7.3.3 Freight train derailment at Castle Donington, 21 January 2013 (pub. 01/14)
At about 19:55 on 21 January 2013, a freight train derailed at Castle Donington. There was
extensive track damage, but no reported injuries.
Causes
RAIB found the immediate cause to be cyclic top
before the point of derailment, which excited the
suspension of the eighteenth wagon causing the left-
hand leading wheel to become unloaded and to
derail to the left. There had been a recurrence of
cyclic top in the vicinity of where the derailment
occurred, and the routine inspection and
maintenance had not kept the track in an acceptable
condition. In particular, planned stoneblowing on 20
November 2012, which should have included the
track through the point of derailment, stopped before
reaching it due to a shortage of time.
An underlying factor was that the ballast supporting
the track was fouled, causing the track to be
inadequately supported and leading to the recurrent
cyclic top. The need to renew the ballast had been
identified, but the work was not programmed to be
carried out until 2016/17.
Although not causal to the derailment, RAIB
observes that – had the signaller not shown vigilance
and returned a signal to danger on the adjacent line –
it is possible that an approaching train could have
collided with the derailed wagon of the incident train,
which was foul of the Down Chellaston line.
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Learning points:
Does your inspection and maintenance programme take a risk-based approach?
Are your standards, training materials and competence assessments consistent?
Do you check the track following the passage of trains, after lifting and packing work?
Is your safety information being communicated clearly so that it is fully understood?
What was done?
Two days after the derailment, Network Rail ran a track geometry recording train over the
Castle Donington route. It also brought forward the reballasting of the up Chellaston line in
the Back Lane area to 2013/14. This was completed on 19 August 2013.
Network Rail’s requirements relating to the competence of those required to raise speeds
have been implemented in the Trent section manager’s organisation.
RAIB also recommended:
Reviewing the planning of stoneblowing so that there is enough time allocated within the duration of a possession to complete the work planned to be carried out;
Reviewing the Rule Book requirements relating to the action taken after an abnormal brake application on a freight train, considering under what circumstances and how quickly the signaller should be contacted and the actions to be taken.
__________________________________________________________________________
The incident at Barrow upon Soar also highlighted problems with inspection and
maintenance, but this time with earthworks, not track and wagons.
7.3.4 Freight train derailment near Barrow upon Soar, 27 December 2012 (pub. 12/13)
At around 04:50 on 27 December 2012, a freight derailed about a mile north of Barrow upon
Soar. One of the rails had dipped because the supporting embankment had failed.
Causes
RAIB found that the embankment failed under the train’s weight as water within the earth had
become unstable and none of Network Rail’s processes had identified the problem. It noted
that an evaluation of the embankment might have identified the reduced stability, but the
circumstances for triggering an evaluation were unclear, and there was no defined process
for reporting ‘trigger events’.
RAIB also observed that the evaluation process did not make use of rainfall data, or data that
showed how the geometry of the track on the embankment was changing over time. An
additional inspection during flooding may have identified the issue, but none was required at
this location, as Network Rail did not consider how the embankment was constructed when
assessing the risk from an earthwork failure due to water. It is also possible that the
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embankment’s reduced stability could have been identified by a routine examination, but
none was due. A basic visual track inspection had been planned for three days before the
accident, but it was not completed.
What was done?
Network Rail investigated the cause of the embankment failure in order to understand what
had happened and to find out how it could be repaired. It duly repaired the embankment by
removing the ash material where it had slipped and by cutting steps into the clay. The
embankment was then rebuilt using stone. New drainage was also installed at its foot.
The Route geotechnical team within Network Rail’s East Midlands Route is continuing its
work using its Washout and Earthflow Risk Mapping system (WERM) to identify those
earthworks that are likely to be flooded and then assess the risk to each of these earthworks
from flooding. The output of this work will be used to populate the flood warning database for
the East Midlands Route.
Network Rail carried out a series of checks during February 2013, including track walks,
paperwork reviews, voice recording analysis and CCTV footage checks. No instances of
inspections not being done were found. Senior managers also carried out spot checks over a
two-week period and in each case found staff carrying out their track inspection activities
where they should be.
Network Rail has since undertaken further verification work and self-assurance checks. It is
satisfied that the track inspection regime for the Leicester area is compliant and has not
found any evidence of a widespread problem with missed inspections.
The company also issued a Safety Bulletin on 29 December 2012 about the actions to be
taken by maintenance staff after flooding at an embankment.
Once Network Rail became aware that some of the track faults found by the track geometry
recording run on 5 November 2012 had been missed, it checked that there were no other
such instances. Staff in the route asset management team responsible for track on the East
Midlands Route checked that all the track faults found by the last track geometry recording
runs over every line on the East Midlands Route had been signed off as repaired. No other
instances of track faults being missed were found. The section manager at Leicester
maintenance depot has since introduced local checks to prevent a recurrence.
RAIB also recommended:
Amending standards so that track maintenance staff are required to notify the Route Geotechnical Team if the foot of an embankment is saturated, flooded or has recently been flooded, and a track geometry defect or loss of ballast is found on top.
Amending processes so that, when assessing whether an embankment should be included in the flood warning database, the assessment should include additional factors relevant to its stability, such as how the embankment was constructed and the history of flooding or ponding at the foot of the embankment.
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Amending standards so that when an evaluation is carried out on an embankment, the evaluation considers how the geometry of the track on top of it has changed over time, using data recorded by Network Rail’s track geometry recording trains.
__________________________________________________________________________
Finally, the derailment at Ordsall Lane Junction gave further evidence of the need for holistic
thinking when dealing with the wheel-rail interface on curves.
7.3.5 Locomotive derailment at Ordsall Lane Junction, Salford, 23 January 2013 (pub. 03/14)
At 14:34 on 23 January 2013, a Class 47 diesel-electric locomotive derailed on a small
radius curve approaching Ordsall Lane Junction in Salford, and caught fire. The locomotive
was being hauled on the rear of an empty train, formed of another ‘47’ and five coaches.
Causes
The immediate cause of the accident was that the lateral forces acting at the wheel-rail
interface as 47500 negotiated the curve were sufficient to cause the flange of the leading
right-hand wheel to climb the outer rail.
RAIB found that the following factors had resulted in these forces being high enough to
initiate wheel climbing conditions:
The dry and clean state of the inside face of the outer rail on the curve that enabled high levels of wheel-rail contact friction to be established; recently-modified arrangements for lubricating the rails did not prevent this.
Machining work that had recently been undertaken to restore the wheel profiles on the locomotive; this removed any pre-existing lubricant and contaminant from the wheels that would otherwise have helped reduce wheel-rail contact friction levels.
The relatively low angle of contact between the wheel and rail associated with the newly-restored wheels on the locomotive; this reduced the locomotive’s ability to resist the climbing forces acting at the wheel-rail interface.
The wider than normal track gauge that had developed on the curve.
The above combined to generate the conditions necessary for derailment, but none of these
factors involved non-compliance with applicable standards.
RAIB noted that the causal factor was that a check rail had not been installed on this curve,
although its location radius met the criteria for fitment. Without a check rail there was nothing
to prevent the lateral wheel-rail forces tending to cause the right-hand wheel flanges to climb
the outer rail and into derailment.
Although it was found that the re-profiling of the wheels had left the wheel surface slightly
rougher than specified, RAIB decided not to investigate this any further. This was because
the surface was only marginally non-compliant and there is contradictory evidence about its
effect on wheel-rail friction.
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The basic approach to managing the risk of derailment on small radius curves on the national
network relies on vehicles and track complying with separate technical standards. However,
because these standards do not require consideration of the worst possible combination of
conditions, there remains a residual risk of derailment. It is generally recognised by the
railway industry that the level of this residual risk is reduced by certain traditional features,
such as check rails and trackside rail lubricators. Therefore, although not generally relied
upon, RAIB observed that any change in the provision of such features has the potential to
reduce the overall level of derailment safety.
What was done?
Network Rail fitted a check rail on the curve where the derailment occurred and also installed
additional rail lubricators in the area. It has also:
Issued a safety bulletin alerting its track engineers to the circumstances of the derailment and highlighting the importance of effective rail lubrication in reducing derailment risk;
Conducted a review of its rail lubricator assets in the Manchester area in order to identify any other associated deficiencies; and
Begun a review of curves on the London North Western (North) route.
Siemens made changes to its wheel re-profiling processes. Wheel lathe operatives are now
required to check every first wheelset that they re-profile on a shift in order to confirm and
record that the resulting surface finish and wheel profile geometry complies with the relevant
specification. It has also specified that operatives use a finer feed rate on the final cut.
RAIB also recommended:
Identifying all curves that are non-compliant with Railway Group Standard GC/RT5021 and Network Rail standard NR/L2/TRK/2102 in respect of the need to fit a check rail;
Reviewing the approach to managing changes that may affect the friction on small radius curves to understand whether any alterations to infrastructure and/or management arrangements have resulted in higher levels of friction;
Developing and implementing criteria for when it is necessary to formally assess the need to bring existing track assets in line with current design standards, and a process to record the findings of such assessments.
7.4 Signals passed at danger
In the aftermath of the high-profile SPAD accidents at Southall (1997) and Ladbroke Grove
(1999), the rail industry took a closer look at the causes of SPADs, the precursors to SPADs
and the risks that surround them. Groups were set up nationally and locally to monitor the
situation and implement various initiatives to bring the risk down. When this work began,
there were over 500 SPADs a year; now there are fewer than 300.
The professionalism of drivers, the relevance of driving policies and practices and the
success of the Train Protection and Warning System (TPWS) have combined to achieve a
situation where:
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Only one SPAD occurs for around every 50,000 red signals approached;
The vast majority of train journeys are SPAD-free; and
Only a small minority of drivers are ever involved in a SPAD.
However, we know that with complacency comes risk, so the SPAD situation continues to be
monitored closely. Indeed, Network Rail undertook a ‘deep dive’ review of the subject in
2013. Some of its findings are listed below:
A high-performance railway presents the fewest red signals to a driver, thus reducing exposure rates and the potential for error. However, there is currently no method to measure a driver’s exposure to red signals accurately;
TPWS has limitations in its effectiveness where train speeds are high, braking force is less than 12g or if railhead adhesion is poor;
Current industry understanding of SPADs suggests that the risk is unlikely to reduce significantly until the introduction of further technical solutions, such as the European Rail Traffic Management System (ERTMS);
Driver error is the single biggest cause of SPADs and it is considered that the limits of human performance are being reached;
There are indications that the rate of ‘avoided SPADs’ through TPWS intervention is increasing;
Light locomotives and empty coaching stock (ECS) moves are involved in a disproportionate number of SPADs – see the Stafford incident, below, for an example of the former;
Freight services in general have a higher number of SPAD incidents compared to passenger services (normalised);
A disproportionately high number of SPADs occur at position light signals (PLSs), linked with freight and ECS SPADs;
Vegetation management can reduce SPAD risk by providing a clear unobstructed view of signals, reduce the effects of low adhesion when braking and provide designed braking force in the event of TPWS intervention.
The picture in 2013/14
At 293, the number of SPADs occurring during 2013/14 was a 17% increase on the 250
occurring during 2012/13. At the end of 2013/14, the estimated level of risk from SPADs was
73% of the September 2006 baseline, compared with 60% at the end of 2011/12.
Measuring SPAD risk
The risk from each SPAD is measured in a consistent and objective way using the SPAD risk
ranking tool (SRRT). The risk ranking scores assigned to all SPADs are then combined to
track changes in the risk over time. The method is designed to assess whether the changes
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Learning points:
Are all your locomotives fit for main line service? This incident highlights that vehicle examination and maintenance regimes based on operating hours may not be appropriate for vehicles that spend a lot of time in sidings and depots.
are representative of any underlying change in risk, rather than just volatility in the data. This
makes the metric not overly vulnerable to one high-risk incident.
It is rare for a SPAD to be the subject of an RAIB investigation, but two reports were
published in the reporting period.
7.4.1 Light locomotive SPAD at Stafford, 26 April 2012 (pub. 09/13)
At about 13:35 on 26 April 2012, a light Class 47 en route from Washwood Heath to Crewe
passed SD4-81 signal at danger without authority. This signal is located on the Down Slow
line south of Stafford on the West Coast Main Line. It controls entry into the station and
protects any train movements traversing Stafford South Junction. The locomotive passed the
signal at a speed of about 30 mph and came to a stand approximately 94 metres beyond.
Although this SPAD was highlighted to the railway industry, it was not until September 2012
that RAIB was notified of the full circumstances behind it. By this time, the incident had
already been the subject of an investigation by an experienced railway professional, which
found that the driver had not responded correctly to the restrictive aspects on the signals
before SD4-81. As a consequence, the locomotive approached Stafford at too high a speed
and there was insufficient distance for it to stop before passing SD4-81.
Causes
RAIB found that the locomotive had been travelling at excessive speed as it approached the
Stafford area. The driver was probably aware that he had been exceeding the maximum
permitted speed for a locomotive running on its own, but he did not make a full brake
application as soon as he saw the double yellow ahead of the red.
The driver probably did not have sufficient experience, competence or route knowledge for
the task he was performing and the operator – Devon & Cornwall Railways (DCR) – had not
followed its own process for managing the competence of drivers. The company also had
insufficient management controls to ensure compliance with its safety management system.
Furthermore, the ORR had not examined the implementation of DCR’s safety management
system following the issue of the company’s safety certificate nearly two years before this
incident.
RAIB also noted that the speedometer in the locomotive cab may have ‘partially misled’ the
driver.
What was done?
The ORR held a number of meetings with DCR to discuss the implementation of its safety
management system (SMS). It also carried out four site inspections of DCR’s operation.
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The ORR established a framework intended to deliver effective safety regulation in the period
between the issue of a new operator’s safety certificate and commencement of its
operations. The new process has been designed to meet the requirements of the common
safety method for supervision (defined in European Regulation No. 1077/2012). It includes
the provision for an ORR inspection of a new operator before issue of a safety certificate, the
capture of follow-up inspection activities into the ORR’s ‘five year inspection plan’ or the
possible refusal by ORR to issue a safety certificate.
The locomotive owner (RTL) clarified its maintenance requirements for locomotives which
are used infrequently on the main line. These include the requirement to confirm that safety
systems have been examined before locomotives are released for operational use.
British and American Railway Services (which owns DCR) brought in a new management
team, audited DCR’s compliance with its SMS and took steps to ensure the competence of
DCR’s own and hired-in drivers.
DCR submitted a new application for a safety certificate to the ORR on 10 July 2013, based
on a revised SMS. It also made changes to its organisation and some of its practices.
RTL temporarily withdrew its locomotives from main line operation while it made changes to
its policy and procedures. These include the introduction of a new hire procedure and
establishing annual reviews of vehicle maintenance issues. An annual speedometer test has
been included in the maintenance requirements for RTL’s locomotives.
The ORR has brought its teams of inspectors that are responsible for heritage and freight
operators together under one Principal Inspector.
RAIB also recommended (inter alia):
Implementing formal competence management processes for all safety-critical staff, taking account of best practice in the industry.
Implementing processes to confirm that locomotives, whether owned or hired-in, have been examined by competent persons and assessed as fit to run before their release for operational use.
Establishing a process for the periodic management review of its assessment of safety certificate applications and the resolution of outstanding issues through supervision.
Amending the rail industry standard for the management of route knowledge for drivers, train managers, guards and driver managers (RIS-3702-TOM) to require an assessment of the training needs of new staff. This should clarify how ‘transferred-in’ route and traction knowledge should be assessed by the new employer.
7.4.2 SPAD at Norton-on-Tees West, 16 January 2013 – BULLETIN (pub. 05/13)
Around 07:45 on 16 January 2013, a Sunderland–King’s Cross service passed NW36 signal
at danger at Norton-on-Tees West and passed over a level crossing adjacent to Norton-on-
Tees West signal box. The barriers were still raised and the crossing was open to road
traffic. The Norton-on-Tees West signaller saw that two cars, one in each direction, had
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stopped at the level crossing as the train was passing over it. The train should have stopped
at NW36. The driver was unaware that he had passed the signal at danger and the train
continued on its journey. It was not stopped until it reached Bowesfield, around 3.5 miles
beyond Norton-on-Tees West. There were no other trains in the area at the time of the
incident, so there was no risk of a collision between trains.
RAIB has noted the following:
Areas currently signalled with semaphores are being progressively converted to colour-light signalling, and drivers may thus be exposed to semaphore signals – and their operational characteristics – less often. This emphasises the need for train operating companies to review training and route assessments for drivers on semaphore signalling, and the need to maintain competence in that area.
Drivers need to be aware when they are approaching parts of a route when enhanced levels of concentration are necessary. A high standard of non-technical skills may assist drivers in improving their awareness of their current situation, and planning the appropriate actions necessary to ensure the continued safe working of the train.
Infrastructure managers need to take the necessary action to ensure they are aware of non-standard signalling practices and consider the potential hazards associated with their use to determine the benefits and the risk.
Simulation provides an opportunity for signallers to practise non-standard and emergency situations that they might encounter rarely, such as a train failing to stop after passing a semaphore stop signal which is on.
7.4.3 SPAD mitigation
Management of the ‘as is’ infrastructure
Managing the infrastructure can reduce the potential for SPADs by making sure signals
display clear, unambiguous aspects to drivers and by reducing the number of red signals
caused by infrastructure failures. There is a requirement to risk assess all signals to identify
those that may have a combination of characterises which makes them more vulnerable to
high-consequence SPAD event and the Signal Overrun Risk Assessment Tool (SORAT) has
been developed for this purpose.
Driver training and management
By far the biggest cause of SPADs is distraction and loss of concentration by the driver when
either approaching the ‘red’ or the sequence leading up to it.
Following its ‘deep dive’ described earlier, Network Rail asked RSSB to undertake a study to:
Improve industry understanding of the human factors issues associated with SPADs;
Draw together information on how industry manages human factors issues associated with SPADs; and
Identify good practices in managing the human factors associated with SPADs and possible areas for improvement.
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The project will achieve this by:
Analysing human factors associated with SPADs, using the IFCS and data from SMIS;
Reviewing the human factors elements of the SPAD investigation process using case studies at a sample of five railway companies; and
Working with industry to review the above with the aims of identifying best practices in the management of human factors SPAD risks and possible gaps in these processes.
The work aims to support the industry SPAD ten-year risk control strategy and is being
sponsored by TORG. The outputs are expected in early 2015.
Non-technical skills
Non-technical skills (NTS) are generic skills that underpin and enhance technical tasks. A
technical task – like train driving – requires a practical understanding of the relevant
techniques, procedures, roles and responsibilities, all of which are formally assessed to
ensure the person can carry out the safety-critical task.
But apart from that specialist, technical knowledge, safety-critical staff will also draw on a
range of NTS to carry out a task. These include the ability to take in information, focus, and
take decisions, and the way they communicate with others.
NTS play a vital role in safety by helping people to anticipate, identify and mitigate errors 0
including SPADs. For more information, click here.
7.4.4 Train Protection and Warning System
The Train Protection and Warning System (TPWS) was implemented in Great Britain as an
interim measure to reduce the consequences of SPADs, pending the implementation of full
protection through systems that monitor driver performance continuously.
It was envisaged that this higher level of protection would be delivered by the roll-out of the
European Rail Traffic Management System (ERTMS). In the intervening period, it has
become clear that this roll-out will take considerably longer than planned, leaving TPWS as
the primary means of mitigating SPAD risk for some time to come.
TPWS is installed on around 13,000 main aspect signals protecting junctions, 650 buffer
stops and 1150 permissible speed reductions, along with a number of other locations where
its fitment has been considered to be reasonably practicable.
Since the completion of installation at the junction signals in 2003, and in conjunction with
other risk reduction measures, SPAD risk has reduced by 90%. Over this period, TPWS has
proved to be a very reliable system, with the probability of it failing to operate on demand
after a SPAD (due to an undetected fault) being around 0.005% (or 1 in 2000 SPADs).
However, an incident in which a passenger train passed two consecutive signals at danger
near Greenford on 20 March 2014, reminds us that we should not be complacent.
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A freight had passed the junction at Greenford shortly before the passenger train was due.
Because this train was still occupying the line between Greenford and South Ruislip, the
signaller at Greenford kept the signal at the junction at danger. The passenger train,
travelling at about 20 mph, passed this signal and the next one, 142 yards further on, which
was also at danger. It passed over the junction and onto the single-track section towards
South Ruislip, which was still occupied by the freight train. The signaller at Greenford was
unable to send an emergency radio message to the driver, but contacted the signaller at
Marylebone signalling centre who was able to do so. The train was stopped after it had
travelled about 1.75 miles past Greenford.
RAIB’s preliminary examination found that the TPWS fitted to the train and the two signals
concerned did not intervene to stop the train. This was because the TPWS equipment had
self-isolated when the driver prepared the train for departure from Paddington. Although the
isolation of the equipment was indicated by a flashing light in the cab, the train was driven
with the TPWS isolated.
RAIB’s investigation will seek to understand why the TPWS self-isolated, why the driver did
not identify that the TPWS equipment was isolated and rectify the problem, and also why he
did not respond to the signals at danger at Greenford. It will consider Chiltern Railways’
arrangements for training, briefing and assessing the competence of drivers. The
investigation will also consider the operation of the signals at Greenford and the reasons why
the signaller could not radio the driver after the train had passed the signals at danger.
7.4.5 TPWS – ‘reset & continue’
A TPWS ‘reset & continue’ incident occurs when a train SPADs a signal, is stopped by
TPWS, but the driver then resets the TPWS and continues without the signaller’s authority.
When this happens, the protection which was provided by TPWS is reduced.
Since the installation of TPWS was completed in 2003, there have been 29 ‘reset & continue’
incidents. None have resulted in either a collision or a derailment, although in one instance
the SPAD train did run through a set of points.
What was done?
After the last ‘reset and continue’ incident (August 2013), RSSB
included an article on the phenomenon in the SPADtalk column of
Right Track 7, published October 2013.
More generally, in November 2009, the TPWS Strategy Group was set
up to help ensure the long-term viability of TPWS.
Part of the remit of the group is to monitor the reliability of the system
with a new programme of work being recently established to ensure
that the industry understands what the reliability requirements of
TPWS should be going forward and how it should monitor against the
requirements.
Completing and promoting the industry response to reset and continue has also been a key
part of the group’s work.
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Learning points:
‘Dispatch against red’ incidents highlight the need to adhere to the Rule Book (SS1, section 3.4), which clearly states that the dispatcher must check that any starter signal is showing a proceed aspect before giving the ‘right away’.
A TPWS strategy action plan may be found on Opsweb, but for more information, contact:
Colin Dennis, Technical Director, RSSB at [email protected].
7.4.6 Dispatch against red
Though cases of trains being dispatched against red signals regularly appear in the daily
control logs, the SMIS database shows only one such dispatch incident in 2012 resulted in a
start against signal (SAS) SPAD: at St Erth on 26 November 2012, when a St Ives service
passed SE63 (bay platform) signal at red by three feet, its driver having received the bell
code from the guard. Note that this incident features in the RED 36 safety DVD.
In this case, the level of risk was low because the track layout at St Erth is such that, had the
train continued beyond the overlap, it would have run down the branch, and not out onto the
main line.
Most ‘dispatch against red’ incidents result in the driver holding the train in the station or
stopping short of the signal. However, the more these ‘near misses’ occur, the more likely we
are to have another passenger service SASSPAD, the perils of which were demonstrated by
the fatal collision at Paisley Gilmour Street on 16 April 1979.
It should also be noted that – even for low risk ranking SPADs like St Erth – ‘dispatch against
reds’ can cause delays and reduce passenger satisfaction.
What was done?
RSSB featured ‘dispatch against red’ in the SPADtalk column of Right Track 4, published in
February 2013. The St Erth incident also features in RED 36.
7.5 Animals on the line
On 13 January 2012, a Hamburg-bound push-pull service running in ‘push mode’ struck a
herd of cattle and derailed. One passenger was killed; the driver and one further passenger
were injured.
For Deutsche Bahn, the accident raised questions about the fencing of main lines. For the
GB rail industry, the obvious question was ‘have we learned from Polmont?’ – Polmont being
the most recent fatal accident to have occurred in this country as the result of a collision
between a train and an animal.
The subsequent investigation centred not only on fencing, but also driving trailer
crashworthiness, radio communications and the rules governing the reporting of animal
sightings.
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Photo: Network Rail.
The pertinence of these lessons grew on 12 July 2012 when a passenger train struck cattle
on the line and derailed at Letterston Junction (see photo).
In response, RAIB produced a bulletin and RSSB produced two editions of a Special Topic
Report on ‘animal on the line’ incidents in Great Britain.
Polmont
On 30 July 1984, a passenger train – lightweight Driving
Brake Second Open (DBSO) leading – struck a cow at 85 mph and derailed. Thirteen people
were killed and 14 suffered major injuries, including the driver. The main lessons learnt were
as follows:
Fencing: the cow had accessed the line through a vandalised fence at an abandoned level crossing.
Rules: the driver of an earlier train had seen the cow on the bank inside the boundary fence. The rules in force at the time only required the reporting of groups of animals, or those actually on the line.
Communication: at the time, there was no way of contacting the driver to stop a train other than via the signalling systems.
DBSO: the vehicles had a light axle weight of 8.4 tonnes, and were not fitted with obstacle deflectors.
Action taken
The Scottish Region of British Rail (BR) used surplus funds to erect new fences along many of its routes. Where push-pull operation was to be introduced, BR also began to consider fencing as part of the route development plan.
A Rule Book change was made to make sure any large animal within the boundary fence was treated as an immediate danger to trains.
The National Radio Network (NRN) was introduced from 1986. (It is now being replaced by GSM-R, whose implementation is due for completion in 2014.)
Obstacle deflectors were fitted to DBSOs, while the carriage of passengers in driving trailers at speeds above 100 mph was banned (hence the Mk III and Mk IV driving van trailerss’ status as luggage vehicles). This was challenged by later designs like the Voyagers and Pendolinos.
DBSOs continued in Scottish front-line passenger service until displaced by new DMUs in the late 1980s. They were cascaded to the Great Eastern Main Line, where they worked until withdrawal in 2006, having been displaced by Mark III DVTs.
Mark III DVTs also remain in use on selected services from London Marylebone, while their Mark IV counterparts continue to be rostered on East Coast Main Line services. Since the late 1980s, however, the move has been towards unit train operation.
In the late 1980s/early 90s, BR fitted its Sprinter multiple units with snowploughs that also had the capability of deflecting minor obstacles on the track.
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Together, improvements in fencing, mobile communications, the rules and rolling stock
design since 1984 explain why the risk from post-animal strike derailment remains low.
Animal strike incidents accounts for an estimated 0.06 FWI/year, which represents 0.7% of all train accident risk (7.8 FWI/year). Around 60% of the risk from animal strikes is associated with the risk from derailment.
The risk is generally low because on-board injuries are rare (although the potential for harm remains when a train derails).
The average FWI level for the period between 2003 and 2014 is 0.03. Most of the harm from animal strikes takes the form of shock/trauma to the train driver. Drivers can also suffer minor injuries when the impact between train and animal breaks the windscreen.
There is also the potential for ill health exposure to employees dealing with the clean-up of cattle strikes. The RSSB Workforce Health & Wellbeing project is under way to help members understand and tackle such issues more effectively.
The total reported number of animal on the line incidents have fallen by 42% since 2003/04. However reported cases of animals being struck by trains have tripled over the same period. (When normalised by train kilometres, this is reduced to a doubling of the rate.)
Animal type
Deer
The report count for deer on the line is low compared to other animal types. However, the proportion of such cases leading to a strike is high (though the derailment consequences are considered to be lower than with cattle, horses and donkeys).9
Although there has been no clear trend in the number of reported cases of deer on the line, there has been a significant rise in the number of cases of deer being struck by trains since 2003/04.
Sheep
Reports of sheep on the line have fallen by 68%. This accounts for most of the overall reduction in ‘on the line’ incidents seen since 2003/04. However, while a large number of sheep are still reported to have accessed the line, fewer than 1% are struck by trains.
Cattle and horses
Reports of cattle, horses or donkeys on the line have fallen by 32% since 2003/04. Of all cattle and horses reported to have accessed the line, 6.9% are struck by trains.
Other10
There has also been a 13% increase in the number of other animals struck by trains since 2003/04. Most are birds, the next highest category being dogs.
Fencing
9 See Railtrack Great Western’s Formal Inquiry into the derailment of 1A91, the 15:30 Penzance–Paddington HST service following an animal strike at 15:52 on 17 August 1999 at Carn Brea (p.15, section 3.6). 10 Animals in the ‘Other’ category include badgers, birds, dogs and foxes.
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The recurring causal theme throughout the analysis is damaged fencing. Sometimes vandalism is to blame, sometimes maintenance.
In at least one case, poor reporting of damage exacerbated the problem; in another, flooding weakened the fence posts. This makes climate change a possible cause in the future.
The quest for food is the main motivator for cattle using holes in fences. However, two reports in SMIS noted herds that had stampeded the boundary fence after being unnerved by criminal activity.
Crime was also thought to be behind at least one horse-related incident.
Deer tend to bound across the railway between areas of natural habitat and grazing.
Train type
Most animal strike incidents involve passenger trains. The increase in incidents is due to a rise in the number of deer incidents since 2006/07.
The number of freight trains involved in strike incidents is reportedly around one-tenth of the number of passenger trains.
Route
Over the period as a whole, London North Western experienced the greatest number of animal strike incidents, with Scotland taking second place.
There was a 190% rise in incidents on the Scotland route in 2009/10, compared to 2008/09. Another peak occurred on the same route in 2012/13, which was 79% up on 2011/12.
Most of the incidents involving deer occur in the Scotland and South East routes, although London North Western has seen an increase since 2007/08. Most trains operating these routes are units (push-pull services now operate primarily on Anglia and London North East).
Cost
On average, 130,000 delay minutes are caused each year by trains striking animals or animals on the line. According to Network Rail, the associated cost of animal on the line incidents was around £4.9 million in 2012/13. In addition, the costs of fencing, clean-up and hidden costs such as passenger claims all have to be considered.
Given that trains striking animals accounts for an estimated 0.06 FWI/year, using the current value of preventing a fatality (VPF) 11 of £1,748,000 (per RSSB, June 2013), it would be justifiable to spend £95,500 per year if the safety risk could be eliminated.
It might therefore be justifiable to spend around £5m per year to eliminate this risk.
Closing remarks
11 Whilst the RSSB figure is considered to be a more up-to-date estimate of the VPF, it is based on
provisional estimates of economic performance and is therefore subject to some uncertainty that you should be kept in mind when evaluating any options. Guidance on how to incorporate the VPF into industry decision making processes can be found in the Taking Safe Decisions document, which RSSB published on behalf of the industry in 2008 and is currently being updated. Copies are available on the Taking Safe Decisions webpage.
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Clearly, many of the risks posed by cattle (and, by implication, other large-boned animals)
were addressed after the Polmont accident of 1984. While such animals can still access the
line, the chance of a derailment has been minimised by the subsequent upgrade, and later
withdrawal, of most lighter passenger driving trailers, along with the general improvement in
train crashworthiness exemplified by Classes 220, 221 and 390.
Regarding older multiple units in the Class 14x and 15x series, the former’s front aprons and
the latter’s snowplough/obstacle deflectors may have strength, but lack any real energy
absorbing capability. Nevertheless, their lower speeds help explain why the derailment risk
remains very low. It may get lower still as more of these designs are withdrawn.
As a result of more recent accidents like Letterston Junction, Network Rail has put standards
in place to mitigate the different types of fence-related risks evident at different locations. The
latest standard for the Management of fencing and other boundary measures will use the
likelihood of unauthorised access, the consequences of unauthorised access, adjacent land
use and the condition of existing boundary measures to determine the initial level of fencing
required and the subsequent level of inspection, repair or replacement needed.
Furthermore, animal incursions are a standing item at Network Rail’s regular boundary risk
management liaison meetings, and will also be covered by an ‘objects on the line’ deep dive
review, which is due to start in July and end in September 2014.
RSSB’s analysis shows that the cattle question has largely been replaced by a deer one. At
two million, the deer population is reportedly higher now than at any time in the last 1000
years. The reasons for this include milder winters, the planting of winter crops, increased
woodland cover and greater connectivity between green spaces in urban areas. Despite the
ability of these animals to jump fences of varying heights in order to access woodland
habitats and so on, the derailment risk is considered to be less than with a cow or horse.
According to the British Deer Society12, there are a number of diverse deterrents – ranging
from the bizarre and erratic (like the use of creosote and moth balls as barrier repellents) to
the bizarre and rather more effective (like spreading a concentrated extract of lion dung
along the perimeter).
However, as these solutions are ephemeral, the best way to deter deer remains ‘properly
erected and maintained deer fences’, although the recommended heights do depend on the
specific subspecies involved. A different approach to risk assessment is therefore advisable,
as these problems can be distinctly localised. RSSB’s work on geo-referenced risk modelling
(T972) may make this possible in the future. Based on the Safety Risk Model (SRM), this will
use the Wessex route as a pilot to demonstrate how comparisons could be drawn between
different locations in order to build up a clearer picture of how risk varies around the system.
Obviously, this will help the industry to focus resource where it is most needed. Network Rail
is already considering mapping the locations where wild deer access the line. Clearly these
two concepts fit together and may – in time – facilitate more targeted, risk-based fencing
programmes.
12 http://www.bds.org.uk/deer_deterrents.html
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It may also be that electrification – coming soon to the Great Western Main Line (inter alia) –
may see the erection of larger, eight-foot, fences, much as it did on the West Coast. This
may in turn see the risk fall yet further.
In summary, the industry can have a degree of confidence that risk from animal incursion has
been reduced by industry improvements in fence management, cab-to-shore
communications, the rules for reporting incidents and the robustness of trains to collision. But
while Network Rail will continue to monitor the situation, it is noted that the occasional
incident can still cause harm, and can impact on the commercial aspect of the railway, in
terms of delays, rolling stock cleaning and line clearance.
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8 Lessons learned in 2013/14 – passengers
8.1 Statistical overview
There were no train accident fatalities to passengers during 2013/14, but four passengers
were fatally injured in separate incidents in stations. In three cases, intoxication was
recorded as a potential contributory factor:
Two people were struck by trains, having fallen from the platform to the track;
One person died after falling backwards on to the line;
One person died from a heart attack, having been struck by a train.
The average level of harm to passengers over the last ten years has been 42.3 FWI per
year, of which 6.6 FWI relates to fatalities. As SMIS data does not contain complete
information on passenger assault, it is likely that the level of harm to passengers is
somewhat higher than this. The modelled risk from assault, as estimated by the SRM is 9.6
FWI, and is based on data obtained from BTP.
Note that research project T992: Safer stairs and escalators in public places has been
published. It was managed by the Construction Industry Research and Information
Association (CIRIA) and co-funded by RSSB and London Underground, among other
partners.
Passenger safety at a glance
Passenger risk in context (SRMv8) Trend in passenger harm
For more statistical analysis on passenger risk, see Chapter 5 of the ASPR.
Topics covered in this section:
The platform-train interface (PTI)
8.2 Platform-train interface
Over the past ten years, there has been an average of 5.4 FWI per year occurring to
passengers while boarding or alighting from trains.
41%(58.4 FWI per year)
Workforce
Public
45.2
42.3
43.4
38.6
38.4
38.8 42.9
42.6 47.4
43.1
0
10
20
30
40
50
60
70
80
20
04
/05
20
05/0
6
20
06/0
7
20
07/0
8
20
08/0
9
20
09/1
0
20
10/1
1
20
11/1
2
20
12/1
3
20
13
/14
FW
I
Weighted injuries
Fatalities
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RED 28
RED 28 – released November 2010 – covered the risks at the platform-train interface.
See Opsweb for details.
Over the same period, other accidents at the PTI (those not occurring during boarding or
alighting) have accounted for an average of 4.5 FWI per year, which is around 11% of the
total average harm to passengers over this period. However, they have accounted for an
average of 3.1 fatalities per year, which is nearly 50% of the average number of passenger
fatalities seen over the last decade.
There are many factors which affect the occurrence of accidents at the PTI. These factors
overlap, making up a complex list of criteria that contribute to the accident rate. The factors
include the age and gender of the passenger, whether or not they are intoxicated, and their
familiarity with rail travel.13 The accident rate varies throughout the year, with changes to the
passenger demographic (and the weather), and also changes according to the time of day or
week that the journey is taking place.
RAIB published one mainline PTI-related report in the year, covering the incident in which a
passenger fell between a train and the platform at London Charing Cross.
8.2.1 Fall between train and platform at London Charing Cross, 24 November 2012 (pub. 07/13)
At 22:26 on 24 November 2012, a member of the public fell between a train and the edge of
Platform 3 at London Charing Cross. The train began to move a few seconds after she fell;
she came into contact with the wheels and suffered life-changing injuries. The train stopped
after moving about 43 metres.
Causes
RAIB found that the person fell against the side of the
train and into the gap just before it started to move,
adding that the gap between the platform edge and the
train was large enough for the person to fall through.
The person’s serious injuries resulted from there being
no means for the customer service agent to stop the
train after the person fell and before it struck her.
The train had been dispatched by a member of staff on
the platform, who operated an indicator which told the
train driver when it was safe to start. The person
approached the train after this indicator had been
operated, and the dispatcher had no means of alerting
the driver to what had happened. The train was stopped
by a passenger on board, who operated the emergency
communication handle. The person who was injured fell into the gap between the platform
and the train at a point between sets of train doors.
RAIB made no recommendations, but provided the following learning point:
13 A commuter who is a more experienced rail user may be able to deal with hazards unique to rail travel better than a tourist who has little experience.
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RED 37
RED 37 – released October 2013 – also covers the risks at the platform-train interface.
See Opsweb for details.
The investigation into Charing Cross has highlighted the risk associated with particular aspects of the train dispatch process, and RAIB believes that the following points should be addressed by the industry in its response to the James Street recommendations:
the possibility of providing a warning to people on the platform that a train is about to move;
a review of the standards relating to the clearance between trains and platforms;
the practicability of adding gap fillers at platforms used only by trains slowly;
the possibility of providing means for platform staff to remove the RA indication after it has been given, possibly also causing the signal at the end of the platform to revert to red, or giving some other indication of an emergency to the train driver; and
the potential for using enhanced radio systems (such as GSM-R) to provide a means for platform staff to send an ‘emergency stop’ message to drivers.
RAIB says it will be writing to the ORR ‘to draw its attention to these learning points as the
ORR is already monitoring the railway industry’s response to the recommendations made by
the RAIB in its James Street investigation’ (which featured in the 2012/13 LOEAR).
A research project to evaluate platform gap fillers is also in development.
8.2.2 Ongoing investigations
At the end of the year, there were also two ongoing RAIB investigations covering the PTI.
‘Trap and drag’
The first involves a passenger being trapped in train doors and dragged a short distance at
Newcastle Central. In common with a number of recent RAIB reports, this highlighted the
‘trap and drag’ phenomenon, which – like fall between train and platform incidents – can also
reveal flaws in the dispatch process (or execution) and the post-incident problem of stopping
moving trains.
In this case, which occurred on 5 June 2013, a passenger tried to board a train at Newcastle
Central as the doors were closing. She put her hand between the leaves expecting them to
re-open, but they closed around her wrist. The train then started to move, forcing her to jog
alongside.
The conductor could not see the trapped passenger due to the curvature of the platform.
Those on board saw what had happened and pulled the emergency door release. The
conductor then applied the emergency brake.
There is a parallel here with metro train operation – doors on much of the older London
Underground stock will re-open if a passenger puts an arm between the leaves. This is also
true of the units used on the Tyne & Wear Metro. On 12 April 2012, a passenger put her arm
in the closing doors of a train at Jarrow just before departure. Instead of re-opening as
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Learning points:
The RAIB reports and investigations discussed in this report raise the following issues:
The importance of fully checking train doors before trains depart;
The need for drivers to stop trains immediately if the passenger alarm is operated when any part of the train is within a station;
The need for the passenger alarm to be fully functioning;
The possibility of providing a warning to people on the platform that a train is about to move; and
The possibility of providing means for platform staff to remove the RA indication after it has been given.
expected, a malfunction meant they trapped her, forcing her to run alongside as the train
pulled out. A passenger on board activated the emergency door release, allowing the woman
to free herself.
RAIB investigated a similar event at King’s Cross on 10 October 2011. A passenger’s hand
became trapped when she tried to board a train as the doors were closing. The train started
to move before her fingers were released and she was dragged along the platform for around
20 metres. A member of platform staff had not fully checked the train doors before giving the
‘right away’. However, when the passenger alarm was operated, the train did not stop
immediately because the driver decided to continue to the next station. This decision had no
effect on the incident, but was contrary to the Rule Book and, in slightly different
circumstances, could have made it worse.
Wheeled transport rolling off platforms
RAIB is also investigating two similar incidents involving wheeled transport rolling off a
station platform and onto the track. In the first (Southend Central, 28 August 2013), the
elderly occupant of a wheelchair suffered a broken hip as a result of the fall. In the second
(Whyteleafe, 27 September 2013), a young child in a pushchair sustained minor injuries. No
trains were present in either case.
Historically, guidance on station design has indicated the desirability of gradients on
platforms falling away from the track. RAIB’s investigation will examine the circumstances
under which both of these platforms had gradients sloping towards the track, and the extent
to which the same situation occurs elsewhere on the railway network. It will also review the
extent to which this hazard is recognised by the railway industry and the steps taken to
manage the risk.
What’s being done?
In light of the fall between train and platform incident at Brentwood in January 2011 (also
featured in the 2012/13 LOEAR), RSSB amended Rail Industry Standard RIS-3703-TOM
(Monitoring the train during train departure) in March 2013 to emphasise that the train
dispatch task should include monitoring the door close process, and ‘should be designed to
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mitigate the risk of staff involved in train dispatch failing to observe a person falling between
the platform and the train or of observing potentially dangerous occurrences taking place.’
In June 2013, the Rule Book was also changed to require guards to stay at the door controls
until the train has completely left the station. This will allow the guard to respond to visual or
audible alarm signals from the platform (from dispatch staff or members of the public).
Dispatch staff must also position themselves on the platform so that they can see the whole
length of the train.
At the September 2013 meeting of the RSSB Board, a proposal for the development of a PTI
strategy for the GB mainline railway was approved. The Board also endorsed the creation of
a cross-industry PTI strategy group to support its production.
The core aim of the PTI strategy is to reduce safety risk and optimise operational
performance and availability of access in a manner that promotes the long-term best
interests of the mainline railway system. The strategy aims to identify both short and long
term deliverables for the mainline railway system as a whole for:
New railway developments/major renewals, and
Existing stations and rolling stock.
The strategy recognises the importance of undertaking detailed data analysis and research
in order to improve our understanding of factors affecting safety risk and operational
performance at the PTI. It has also been recognised that a number of theories identifying
causal factors to risk at the PTI exist across industry. To understand these and build
confidence in the causal factors, the following have been achieved:
Hypotheses to identify contributory factors affecting PTI risk have been developed;
Trials at a small number of stations to support the development of the hypotheses and test the workstream outputs have begun;
Good practice from around the industry is being collected with a view producing a new guidance document;
RSSB’s Special Topic Report on risk at the platform-train interface has been updated. The same data that formed the basis of this report was subject to a SMIS narrative coding exercise, which – along with a passenger behaviours workshop – recommend that the strategy focus upon the following behaviours:
Physical mistake (eg misjudges step, loses balance and illness or collapse leading to physical mistake)
Rushing behaviours
Lack of awareness
Too near the edge
Multiple trips on/off train for luggage
A series of workshops to identify contributing factors to PTI risk have been undertaken.
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A scoping exercise is also under way with a view to developing a media campaign. The latest
idea is to use social media to ‘sell’ safe behaviour and improve awareness amongst the
public of both risk and its mitigations.
A roadshow industry briefing will take place between July and September 2014.This will be a
key opportunity to gain industry buy-in and comment upon the first high-level outline of the
strategy. The presentations will be delivered by members of the strategy group and will
update industry on the key activities and outputs to date.
Research and development
‘T’ no. Title Link
T426 Minimisation of accidents at the platform-train interface – This research investigated PTI accidents, exploring their primary causes and the extent to which they can be reduced in number and severity. It examined public (and staff) behaviours and made recommendations on how minor changes to procedures or designs could make cost-effective improvements.
CLICK
T743 A review of passenger train dispatch from stations – This project reviewed passenger train dispatch arrangements in the light of current operations, taking risk and human factors principles into account.
CLICK
T866 Investigation of platform edge positions on the GB network – This project built on previous RSSB and Department for Transport research to improve the platform/train interface on the existing network, for the benefit of passenger accessibility and compliant stepping distances.
CLICK
T1029 Train dispatch tool. This project will provide a train dispatch risk tool that will be adopted by passenger train operators and widely utilised. Work is underway with Network Rail to establish whether completed risk assessments can be fed into a national database to establish an overview of total dispatch risk.
T1037 Train passenger footsteps investigation to support research into the reduction in passenger stepping distances and gauging constraints. This project examines the range of passenger footstep positions for vehicles in GB in order to inform options for how to best improve stepping distances in terms of infrastructure works, vehicle fleet deployment/cascade/modification and new vehicle design.
T1063 Platform recess. An investigation into whether the minimum recess of 300 mm for new or altered platforms is suitable for people to move into and be clear of a train.
RSSB’s station safety booklet covers slips, trips and falls, PTI risk and mitigation actions, and
related research into issues such as crowd management, tactile edges, wayfinding and
signs, and how to deal with winter conditions. A new edition is in preparation.
The current edition is available from RSSB, or can be downloaded here: LINK
For a ‘snapshot view’ of how passenger risk is being tackled, see Chapter 5 of the latest
ASPR.
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9 Lessons learnt in 2013/14 – workforce
9.1 Statistical overview
There were no workforce fatalities in train accidents during 2013/14, although there were
three workforce fatalities from other causes: two infrastructure workers died as a result of a
road traffic accident while on duty, while another was struck by a train and fatally injured.
When normalised by workforce hours, the rate of harm to the workforce increased by 8% in
2013/14, compared with 2012/13.
Slips, trips, and falls pose the greatest risk to the workforce as a whole. Around 26% of the
total FWI risk is from this source, although the contribution to the fatality risk is relatively low,
at around 1%.
The greatest source of fatality risk is being struck by a train, which accounts for 7% of the
overall workforce risk profile, but 41% of the fatality risk profile. Injuries from this cause have
a high likelihood of being fatal.
The greatest causes of workforce shock or trauma are assault and abuse, and witnessing
suicide and trespass fatalities.
Workforce safety at a glance
Workforce risk in context (SRMv8) Trend in workforce harm
For more statistical analysis on workforce risk, see Chapter 6 of the ASPR.
Topics covered in this section:
Road vehicle driving
Track working
9.2 Road vehicle driving
Many GB rail companies employ large road vehicle fleets to support their operations –
including incident response. Studies have shown that fatigue and accidents are subject to a
wide variety of factors, like irregular working hours, shiftwork, and so on.
Passengers
18%(26.0 FWI per year)
Public
36.8
31.4
25.3 26.2 26.3 25.223.3 24.4
22.825.2
0
5
10
15
20
25
30
35
40
45
20
04
/05
20
05
/06
2006/0
7
20
07
/08
20
08
/09
20
09
/10
20
10
/11
2011/1
2
20
12
/13
20
13
/14
FW
I
Weighted injuries
Fatalities
Page 64 of 100
The rail employee road vehicle-related deaths in 2011/12 and 2012/13 were joined by two
more on 19 June 2013, when two contracted Network Rail employees were fatally injured in
a car accident whilst on duty. Both had been welding at Langley Junction; on their way back
to the depot, their car is reported to have left the main carriageway and struck the rear of a
parked lorry near Claypole.
What’s being done?
As reported in Right Track 5, the rail industry is intent on tackling the
problem of road vehicle safety more effectively. Experience and
intelligence – including a recent study of CIRAS reports – is
revealing staff concern about the issue, especially where road
driving risk is made worse by journey times and fatigue.
In January 2012, the ORR published Managing rail staff fatigue, a
new guidance for employers, which covers all rail worker types and
includes a useful checklist. RSSB has also published a fatigue
management good practice guide to help industry stakeholders
comply with their obligations in this area.14
An industry steering group, including Network Rail, Balfour Beatty,
the ORR and the Health and Safety Executive, also commissioned
RSSB to undertake research to get a better understanding of the
subject. The project (T997 Managing occupational road risk
associated with road vehicle driver fatigue) has led to the
publication of rail industry-specific guidance documents to help staff
and managers identify the risk of fatigue when driving, how to
recognise the warning signs and cope with this issue. The
documents have been distributed to rail companies, along with
reminder sheets for staff to keep in the car and awareness-raising
posters to put up in canteens, foyers and mess rooms.
Managers will also be encouraged to ensure that the potential for road vehicle driver fatigue
is incorporated into job design, rostering, work risk assessments, and travel planning.
RED 35, issued in January 2013, used its usual format of a dramatic reconstruction to focus
the minds of people at briefings to the issues involved. The reality is that, although often a
‘grey area’, both company and individual have responsibilities to prevent such accidents.
By helping drivers and their managers identify risks and implement mitigations that are
practical and feasible in the rail environment, this project will help reduce fatigue-related road
vehicle accidents, the harm that arises from them, and their associated costs.
14 Namely, the Railways and Other Guided Transport Systems (Safety) Regulations 2006 (as
amended) (ROGS) – ‘Regulation 25 – Fatigue’.
Page 65 of 100
Learning points:
Do you know that RSSB has produced materials to support you in the fight against road vehicle driving risk?
More information on fatigue – and how to fight it – may be found in RSSB’s leaflet Fatigue
and Shiftwork and on www.opsweb.co.uk.
For a ‘snapshot view’ of how workforce risk is being tackled, see Chapter 12.
9.3 Track working
A number of RAIB reports published during 2013/14 have raised issues for those managing
and working on infrastructure projects. Two of these reports involve incidents with yellow
plant: the incident at Blatchbridge Junction on 19 March 2012 is a maintenance issue,
unheeded bolt fatigue causing a cab to detach in transit, damaging the cab itself and a foot
crossing; however, the other ‘yellow plant’ incident – the collision between a stoneblower and
a stationary ballast regulator at Arley on 10 August 2012 – is more operational in nature.
Overspeeding, long worksites, distraction
Though the stoneblower was being driven too fast due to possible (work-related) mobile
phone distraction, RAIB has determined the underlying cause to be the current tendency for
long worksites, which may encourage faster driving and therefore increase the risk from
collision.
Although not a factor in this accident, RAIB also observed that, for driving at night, the 40
mph maximum speed permitted in engineering worksites is not compatible with the braking
and headlight capabilities of the type of machine involved at Arley.
The Arley report observes a number of non-compliances with railway industry rules and
company procedures during the management of engineering work. Two reports published in
this reporting period highlight similar issues around planning safe systems of work (SSoW).
Page 66 of 100
The incident in which a signalling technician was struck by a train in Poole on 2 July 2013 highlighted the need for staff to be vigilant at all times when walking or working close to the line. It also highlighted the importance of using authorised access points to get on or off the railway (thus minimising the distance people need to walk alongside the line). Similarly, drivers should sound the train’s horn as it nears each group or individual, unless it is clear that all those on or near the line are aware of the approach. Infrastructure managers should note the importance of controlling vegetation close to the track which may obstruct the safe walking route along the cess.
Mobile phone distraction may also have been a factor in the incident where a lookout was struck by a train at West Drayton on 22 March 2013. The lookout had not anticipated undertaking safety critical duties that day and was transferred, with little warning, from an environment he perceived to be less hazardous in the yard. He said that, while in the yard, he had been using his phone to try and resolve some personal issues. He continued to think about these when deployed as a lookout. His phone was found on the trackside immediately after the accident in a position indicating it was probably in his hand when he was struck by the train. Telephone records show that the mobile phone sent and received a small amount of data during the time the lookout was on the track. Although it is possible that the lookout checked his mobile phone while on track, no other track workers recalled seeing him use his phone and the telephone records indicate little or no interaction with the device. While mobile phone use is likely to act as a distraction to users, RAIB nevertheless concluded that there was no definitive evidence that it was a significant factor in the incident.
SSoW – planning, knowledge of location, lack of experience, workload, safety
monitoring data
On 16 July 2012, a near miss occurred between a train and two track workers just north of
Roydon. At the time of the incident, the workers were working on a line open to traffic. They
were being protected by a system of work which relied on a lookout to warn of approaching
trains. If established correctly, this should have allowed them to reach a position of safety at
least 10 seconds before a train arrived. However, the lookout was unable to give the track
workers sufficiently early warning, because the controller of site safety (COSS) had
implemented a SSoW which was inappropriate,
given the nature of the task and the location in
which it was being undertaken.
The system of work implemented by the COSS
had been issued by a planner, who had selected
it as an appropriate system based on his
knowledge of the location and his previous
experience of working on the track. It is possible
that the incident could have been avoided had
the planner sought approval for the system from
a more senior person before it was issued, as
required by Network Rail’s standards.
The inexperience of the COSS and the group in
implementing this type of system of work was an
underlying factor in the accident. The short time-
frame in which the work was planned and the
experience of the planner were also possible underlying factors.
As a result of the investigation, RAIB identified two key learning points concerning the need
to keep the late planning of work to a minimum and for persons undertaking the duties of a
COSS to follow the requirements of Network Rail’s standards when issued with a system of
work on the same shift that a task is to be undertaken.
Page 67 of 100
The incident on 6 August 2012, in which an off-track inspector was struck by a train at
Bulwell was also caused in part by the adoption of a SSoW unsuitable for the location.
However, the off-track inspector did not realise that the system he was using was unsuitable,
probably because of the way it was implemented. He had also not realised it was unsuitable
when issued to him prior to the inspection; this was because the information provided to help
him check that it was appropriate did not effectively highlight why it was unsuitable.
This system of work was issued to the off-track inspector because the planner who had
prepared it was unfamiliar with the location. Information provided to support her decisions
about which type of system to use either did not effectively highlight its unsuitability or was
found by her to be impracticable to use given her workload.
In addition, it had become normal practice within the off-track section to plan and implement
the least protective type of system of work for undertaking vegetation inspections. This was,
in part, because the section only had a limited range of systems to choose from, but probably
also because there was an informal agreement within the section to adopt this practice,
which contravened the requirements of Network Rail’s standards. Senior managers were
unaware that this had occurred as they were provided with inaccurate safety monitoring data.
The increased workload of planners within off-track sections was also identified as a factor in
the accident.
__________________________________________________________________________
The fatality at Saxilby on 4 December 2012 was a slightly different case, in that there was a
total absence of a SSoW.
9.3.1 Track worker fatality at Saxilby, 4 December 2012 (pub. 08/12)
The incident occurred at 13:50, when a train travelling from Scunthorpe to Lincoln struck and
fatally injured a COSS working on one of the two lines at this location closed to rail traffic, but
standing close to the adjacent line, which was still open.
Causes
RAIB found that, being involved in the work, the COSS became distracted and stepped back
into the path of the train as it passed the site of work. The COSS had also failed to
implement a safe system of work for the task in hand. None of the other track workers on site
challenged it. They also failed to challenge the COSS for working within an unsafe area.
There were a number of factors which may have influenced the COSS in not requesting the
Protection Controller to seek a blockage of both lines:
His previous experience (before and on the day of the accident) was that it was difficult to obtain a line blockage of one line at this location and that there would be even less chance of getting a double line blockage;
He may have wanted to complete the task as soon as possible and the cold weather may have acted as an additional incentive;
The cold weather may also have affected the clarity of his decision-making processes;
Page 68 of 100
His familiarity with the location and the long sighting distance that was available for trains approaching on the Up line may have convinced him that he could provide adequate protection to anyone working in the six-foot.
RAIB also found that no effective action had been taken in response to the involvement of
the COSS in two other safety incidents in the two months preceding the accident. Moreover,
the COSS had not been subject to an effective formal performance review by the agency
(SkyBlue) that had hired him for COSS duties for the work taking place on 4 December 2012
and on other occasions. Deficiencies and omissions within SkyBlue’s management systems
had not been identified by its parent company (Carillion).
RAIB observed that the processes employed by the railway industry during its own
investigation into the accident at Saxilby may have taken insufficient account of the trauma
that some of the witnesses were suffering as a result of their proximity to the accident.
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What was done?
Carillion Construction Limited (encompassing Sky Blue) has introduced a requirement for a
manager to review all completed point of work risk assessment forms. The review is intended
to ensure supervisors understand their responsibility to complete the forms and to brief them
to all parties on site. A training programme is being implemented for all supervisors, which
explains the point of work risk assessment process.
Amey Colas has introduced a new procedure to specify how proposed restrictions on the
certification of employees and agency workers arising from investigations into incidents and
accidents should be dealt with.
Carillion Construction Limited has reported that it has:
Established a Competency, Compliance & Rail Training (CCRT) unit to control, monitor and manage compliance with its own procedures and rail industry standards. All requests for temporary suspensions of certification will be made to the CCRT. A programme has been established to ensure all SkyBlue workers are trained and mentored.
Re-briefed SkyBlue rail managers on their responsibilities to manage and develop agency workers to meet the required level.
Employed staff to undertake on-site safety critical observational assessments, mentoring and developing agency workers and support the implementation of safety training and initiatives in conjunction with Carillion’s customers.
Enhanced its incident database to provide an increased level of information relating to rail accidents and incidents involving external contractors.
Nominated a senior management team member as the responsible lead in the event of an incident, responsible for communications with the parties involved and deciding on the course of action to be taken.
Ensured that if an agency worker is involved in a safety critical incident, the worker’s certification will be temporarily limited to track worker level until the outcome of any investigations is known.
Stipulated that a designated manager will undertake a formal review of any findings from incident investigations to record appropriate actions to be taken and by whom.
Network Rail has:
Developed a system to enable all staff (including those who book onto the railway through a site access control point) to have their certification checked prior to working on or near the line;
Introduced the requirement for contractors and agencies to regularly monitor the performance, attitudes and behaviour of agency staff in order to ensure deficiencies are identified and addressed; and
Issued guidance to all contractors and agencies re applying the process for temporary suspension of the individual’s certification within the Sentinel system.
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Amey Colas has:
Re-briefed its investigation process to all safety managers.
Changed its incident logging and tracking database to ensure a nominated safety manager is appointed for an investigation.
Other initiatives
Network Rail has undertaken to achieve zero fatalities and zero life-changing accidents to
infrastructure workers by the end of CP5. This should also mean fewer incidents caused by
poor communications, poor planning, low competence and a lack of local knowledge.
One of the main workstreams to achieve this involves the introduction of a new safety-critical
role – the Safe Work Leader (SWL) – which will (inter alia) limit the role of COSS to Network
Rail and senior contractor staff only. This will give greater clarity on who is in charge, while
engendering improvements in planning and the management of task and operational risk.
Key issues raised by recent RAIB activity:
Overspeeding
Worksite length
Distraction while driving yellow plant
SSoW – planning, knowledge of location, lack of experience, workload, verity of safety
monitoring data
SSoW – absence of, failure to challenge absence of
Competence of agency staff
Compliance with rules and standards
Lookout sighting (vegetation)
Train noise (lack of)
Unfamiliarity with area
Use of authorised access points
Weather conditions and their effect on decision making
The need to remain focused while working on or near the line.
Page 71 of 100
10 Lessons learnt in 2013/14 – members of the public
10.1 Statistical overview
Excluding suicides and suspected suicides, there were 29 fatalities to members of the public
during 2013/14. When non-fatal injuries are taken into account, the total level of public harm
was 33.8 FWI, compared with a total of 46.7 FWI (42 fatalities) recorded last year.
Of the 29 fatalities, 21 occurred to trespassers and eight occurred at level crossings. In
2012/13, there were 32 trespass fatalities, nine level crossing fatalities, and one public
fatality not involving trespass or level crossings.
Trespass accounts for 76% of risk to members of the public. Accidents at level crossings
account for a further 11%. Of this, about two-thirds occurs to pedestrians struck by trains.
Most of the rest occurs to road vehicle occupants involved in collisions with trains. The small
remainder arises from slips, trips or falls, being hit by level crossing equipment, or being
involved in a road traffic accident at a level crossing.
Public safety at a glance (excluding suicides and suspected suicides)
Public risk in context (SRMv8) Trends in public harm
For more statistical analysis on public risk, see Chapter 7 of the ASPR.
Topics covered in this section:
Level crossings
10.2 Level crossings
Between 2004/05 and 2013/14, the average level of harm to members of the public at level
crossings was 9.2 FWI per year, and the average number of fatalities was 8.5.
At eight, the number of public fatalities at level crossings recorded in 2013/14 is close to the
ten-year average of 8.5, and one fewer than 2012/13. Six of the fatalities were pedestrians.
Passengers
Workforce
41%(59.0 FWIper year)
63.7
47
.5
61
.4
60
.2 65
.0
64
.9
68
.2
41
.1
63
.5
53
.9
0
20
40
60
80
100
20
03
/04
20
04
/05
20
05
/06
20
06
/07
20
07
/08
20
08
/09
20
09
/10
20
10
/11
20
11
/12
20
12
/13
FW
I
Weighted injuries
Fatalities
47
.5
61
.5
61
.2 66
.0
64
.9
64
.3
37
.1
51
.5
46
.7
33
.80
20
40
60
80
100
20
04/0
5
20
05/0
6
20
06/0
7
20
07/0
8
20
08/0
9
20
09/1
0
20
10/1
1
20
11/1
2
20
12/1
3
20
13/1
4
FW
I
Weighted injuries
Fatalities
Page 72 of 100
At around 07:38 on 22 March 2012, a motorist used the telephone at Lindridge Farm UWC to ask the signaller at the East Midlands Control Centre for authorisation to cross the railway. The signaller checked the indications on workstation, observed that a train had already passed over the crossing, and gave permission to cross. The motorist opened the near gate, crossed the railway line on foot, and while opening the far gate saw a train approaching. RAIB found that the signaller believed the train had already passed the crossing when he gave the motorist permission to cross because his workstation view showed the interface in the wrong place. This error had been present on the workstation view from the time it was commissioned as part of a project to transfer control of the railway from Leicester signal box to the East Midlands Control Centre. This project had redrawn a signalling plan for the Leicester area and introduced an error; a track circuit was incorrectly named. This was not noticed and was copied into a scheme plan, which was subsequently used to check the design of the signaller’s workstation views. During these design checks, the crossing was moved to the wrong track section on the view, so that it corresponded with the error on the scheme plan. The error was not identified during testing so the signaller’s workstation was commissioned with the crossing shown in the wrong place.
The other two fatalities where occupants of the same road vehicle, which was involved in a
collision with a train.
Most accidents at level crossings are caused by user behaviour – whether by error or
deliberate violation. However, a small proportion of the risk is due to workforce error or
equipment failure.
10.2.1 Fatal collision at Beech Hill level crossing, 4 December 2012 (pub. 09/13)
At 12:31, a passenger train struck a car at
Beech Hill level crossing, near Finningley.
One of the occupants of the car, a young
child, was seriously injured in the collision
and later died in hospital.
The crossing was fitted with a data logger
which showed that the crossing was
operating normally at the time of the accident,
with the barriers down as the car approached.
The car driver stated that she did not see that
the wig-wags were flashing as she
approached and only noticed the lights and
barriers when she was very close to the
crossing. The weather was sunny at the time
of the collision but there had been rain
showers earlier and the road surface was
wet, leading to glare from the low winter sun.
Causes
RAIB arranged for the wig-wags to be tested
in an optical laboratory. It was found that they
were fitted with 36 W lamps and an obsolete
design of red lens unit. Their light output was
measured to be well below the specification
for lights of this type. Network Rail had no
plans in place to replace the light units with
brighter ones and had no process to identify
that such replacement was necessary.
RAIB also listed the following causal factors:
The visibility of the wig-wags and barriers was poor, because of the following:
The environmental conditions,
The light output from the red wig-wag light units was lower than specified and was hard to see against the bright sunlight,
Page 73 of 100
The light output of the lamps was lower than specified and the red lenses fitted to the wig-wags were of an obsolete design that did not meet their specification,
The level crossing barrier was not conspicuous against the background when viewed from the north side of the crossing
Network Rail did not have a process for checking that existing wig-wag lamps and lenses met their specification.
Network Rail’s level crossing management process did not adequately recognise and deal with the effect of sunlight on the visibility of crossing equipment; and
Network Rail had no ongoing plan to replace 36 W wig-wag units.
What was done?
Network Rail replaced the 36 W wig-wag units at Beech Hill with LED units on 16/17
December 2012. It also issued guidance to its signalling maintenance staff and level crossing
inspector maintainers on the risk from wig-wag signals being affected by sunlight. The notice
described how the sun could affect a road user’s ability to see the red lights when shining
from behind the wig-wags or from behind the observer. The remedial action suggested was
to fit longer hoods to the lamp units. However, RAIB notes that this would only be an
effective remedy in situations where the sun is shining from behind the observer.
RAIB also recommended:
Determining which level crossings are fitted with 36 W wig-wag units and draw up a time bound plan so that their replacement with LED units is done as soon as possible;
Putting in place a method of identifying locations where there is a significant risk from sunlight impairing the visibility of level crossing wig-wags and barriers;
Developing and installing a new type of wig-wag with higher luminous intensity than the existing LED units for use at crossings where high background luminance and sunlight glare is a particular problem; and
Enhancing the inspection and maintenance process for wig-wag lamps to provide assurance that they continue to meet their specified performance standard.
10.2.2 Fatal collision at Motts Lane level crossing, 24 January 2013 (pub. 01/14)
At 17:37 – during darkness – on 24 January 2013, a cyclist was struck and fatally injured at
Motts Lane level crossing by a passenger train travelling close to 100 mph. The crossing’s
warning lights were showing red, and the audible warning was sounding. The cyclist was
unaware that the train was so close, probably because it was difficult to pick out the train’s
headlight amongst the lights of Witham station, about 700 metres away.
RAIB says that it is not possible to say why he rode into the path of the train against the red
lights, although it may have been because he was used to seeing the lights at red for long
periods before trains arrived at the crossing, and decided that it was safe to cross.
Page 74 of 100
Causes
The lights showed red for long periods because there were deficiencies in the design of the
area’s railway signalling system, which was not being used as designed. The cyclist may
also have misjudged the train’s speed and position.
RAIB added that a causal factor was that Motts Lane crossing had not been replaced by a
bridge, despite previous plans to build one. It also observed that Motts Lane crossing is
heavily used, but Network Rail’s figures did not accurately reflect this.
What was done?
The day after the accident, Network Rail instructed the signallers at Liverpool Street IECC to
use the appropriate stopping or non-stopping signalling setting for all trains passing through
Witham. Although this will not fully resolve the extended warning time issue, it will improved
the situation until a bridge is provided.
Network Rail has appointed staff with suitable qualifications to its Liability Negotiation team,
and has changed its internal guidance on level crossing closure processes to address the
problems that were encountered with the initial application to extinguish the bridleway rights
at Motts Lane.
Network Rail plans to close Motts Lane crossing and replace it with a bridleway bridge.
RAIB also recommended:
Reviewing all automatic level crossings to identify locations where complex track and signalling layouts, nearby stations and/or railway operations may lead to the red road/pedestrian lights showing for an excessively long time;
Determining, in the light of the risk that arose from the indiscriminate use of the non-stopping setting at Liverpool Street IECC, whether there are any other locations where local instructions/practices may be at risk of introducing unnecessarily long waiting times at automatic crossings, and taking appropriate action to correct the situation;
Review its processes for designing and implementing Automatic Route Setting where it interacts with level crossing controls, and amending or enhancing them as necessary to produce assurance that the design will result in the crossing operating in accordance with relevant standards and guidance;
Establishing appropriate maximum time(s) for red lights to be designed to be shown at MSL crossings, and acceptable levels of variability for this time, and stopping patterns), in view of the risk that users may become intolerant of extended waiting times.
10.2.3 Fatal collision at Athelney AHB, near Taunton, 21 March 2013 (pub.02/14)
At around 06:23 on Thursday 21 March 2013, a car drove around the barriers of Athelney
AHB crossing, near Taunton. This took the car into the path of a train that was approaching
at high speed. The motorist was killed in the resulting collision.
Page 75 of 100
Causes
The motorist drove around the barriers without waiting for a train to pass and the barriers to
re-open. The level crossing was closed to road traffic for longer than normal before the
arrival of the train, because of earlier engineering work that had affected its automatic
operation. The motorist may have believed that the crossing had failed with the barriers in
the closed position, or that the approaching train had been delayed. He did not contact the
signaller by telephone before he drove around the barriers
Although not causal to the accident on 21 March 2013, RAIB observes that:
The road markings are not consistent with Network Rail’s ground plan for Athelney level crossing or the ORR’s level crossing guidance.
The emergency call to the signaller, made by the driver of the train after the collision, was incorrectly routed by the GSM-R radio system.
There was no data logging facility at Athelney level crossing or Exeter signal box; this would have facilitated the investigation into the accident and could have provided operational benefits.
What was done?
Network Rail’s internal investigation into the accident has recommended that its Western
Route should consider modifying the strike-in treadles at affected crossings to prevent
crossing controls from becoming ‘out of synchronisation’. Western Route advised in June
2013 that it was in the process of fitting directional strike-in treadles to the eight AHBs within
its area that have independent treadle and track circuit operation.
Network Rail Telecoms also has reconfigured the GSM-R system so that emergency calls
from Athelney are routed to Exeter and Westbury signal boxes.
Network Rail’s Western Route has issued instructions to signallers at Exeter and Gloucester
signal boxes on how to reset crossing controls which have become ‘out of synchronisation’.
This requires the signaller not to clear routes over an AHB until:
A train has been occupying the approach track circuit for 30 seconds; or
The signaller has sent the ‘contact signaller’ message using the GSM-R system and the driver has responded; or
The signaller has received ‘train waiting at signal’ from the protecting signal.
Network Rail’s Western Route has clarified its policy such that all crossings with signalling
equipment controlling them should be equipped with event loggers. Where there is either no
logger or one that is not fully functioning, the Route has provided funding to do this.
RAIB also recommended (inter alia):
Introducing measures to reduce the risk from extended operating times of automatic crossings caused by operation of a strike-in treadle by a train travelling away from the level crossing;
Page 76 of 100
Reviewing past and current research into level crossing signage and emergency communication with signallers and consider means of improving the presentation of public emergency telephones for non-emergency use at automatic level crossings;
Modifying the location of the pedestrian stop lines at Athelney level crossing as required to make these conform to the current guidance published by the ORR.
10.2.4 Collision at Buttington Hall UWC, 16 July 2013 (pub.03/14)
At 11:44 on 16 July 2013, a collision occurred between a passenger train and a farm trailer at
Buttington Hall farm crossing near Welshpool on the line between Shrewsbury and
Machynlleth. The tractor driver and two other people nearby sustained minor injuries; two
passengers on the train taken to hospital, but were discharged later the same day.
The train was operated by Arriva Trains Wales and consisted of two 2-car units. It was
travelling at 75 mph at the time of the collision. There were 140 passengers and two crew
members on board. On the day of the accident, the farm crossing was being used by tractors
bringing in a harvest from fields on the opposite side of the line. The farmer had appointed a
contractor to do the work, and an attendant had been provided at the crossing to telephone
the signaller and operate the gates.
Causes
The accident occurred because the system of work in use at the crossing was inherently
unsafe, leading to ineffective control of road vehicle movements over the crossing and
frequent use of the crossing without the signaller being contacted. This system broke down.
There were also underlying management factors:
The harvest contractor did not implement an effective safe system of work at the crossing;
Network Rail’s process for risk assessment of these types of crossing did not adequately deal with periods of intensive use; and
Network Rail’s instructions to users of these crossings did not cover periods of intensive use.
The accident occurred due to a combination of the following causal factors:
The system of work in use at the crossing was inherently unsafe. This resulted in:
Ineffective control of road vehicle movements over the crossing; and
Use of the crossing without the signaller being contacted.
The system of work broke down.
The following underlying management factors were also identified:
The farmer did not establish an effective safe system of work at the crossing.
The output of a risk assessment using the ALCRM is based on an estimate of the road traffic, averaged over the whole year. This does not separately identify the risk at times of intensive use, such as at harvest time.
Page 77 of 100
Network Rail’s instructions to authorised users on the safe use of UWCs did not cover periods of intensive use.
RAIB also noted that the signaller’s method of work did not involve asking the crossing
attendant to confirm that the crossing was clear after a series of crossings by tractors.
Although not linked to the cause of the accident on 16 July, RAIB has observed that the
prolonged closure to road traffic of the nearby Buttington AHB crossing on the A458 road
may have led many road users to ignore the wig-wags and barriers. Finally, RAIB has
identified the following key learning point:
It is important that infrastructure managers, in conjunction with the police, ensure that, when
an automatic crossing is closed across the road for an extended period due to a mishap,
suitable measures are promptly taken to manage the traffic, reopen the road and discourage
road users from passing the illuminated wig-wags without proper authorisation.
What was done?
Network Rail staff at Machynlleth have defined a method of working for use when a UWC is
to be intensively used in their area. They have applied this to a UWC which is being used by
civil engineering contractors working at a sewage works and have also written to the
authorised user of another UWC which has a history of misuse to ask that it be used.
The method of working is based on that given in Rule Book module TS9, but also requires
the crossing user to post an attendant at the crossing to call the signaller for permission to
cross. The signaller then gives a call back time by which the attendant must call the signaller
to confirm that they are clear of the crossing and the gates have been closed. The signaller
applies reminders to the block markers each side of the crossing during the time between
granting permission and receiving the call back.
RAIB also recommended:
Review and improving processes for assessing the risk at user worked crossings so that the increased risk during periods of intensive use is properly taken into account;
Defining one or more safe and practical methods of working that may be adopted at user worked crossings during periods of intensive use; and providing clear information to staff and authorised users on how and when they should be applied; and
Reviewing measures in the level crossing risk management toolkit designed to mitigate the risk at UWCs during times of intensive use.
10.2.5 Other level crossing initiatives
RSSB has published project T984: Research into the causes of pedestrian accidents at level
crossings and potential solutions on behalf of the industry. An early output was advice on
decision points, which has also been published by RSSB: LINK
Network Rail has put a level crossing risk reduction programme in place, and has met the
targeted reduction in level crossing risk of 25% over the course of CP4. A further substantial
Page 78 of 100
safety improvement in is planned for Control Period 5 (CP5), which runs from April 2014 to
March 2019.
Recruitment has been completed for the 100+ dedicated Level Crossing Managers and
Route Level Crossing Managers. This will support the continued improvement of asset
inspections, as well as data collection for risk assessment and modelling. The role includes
building relationships with authorised users and across the wider community to help improve
rail industry understanding of local risks.
High-risk footpath crossings are also being replaced by footbridges, in line with a policy
decision to remove the need for pedestrians to cross high-speed main lines unprotected by
barriers. Two new modular footbridges were erected to close crossings and detailed plans
have been developed to complete 33 more similar schemes in 2013/14.
Sighting and warning times are being improved at passive level crossings, which has
resulted in enhancements to more than 1,100 crossings since 2010.
Work has continued for the development of red light safety cameras with number plate
recognition technology. Three systems are currently undergoing Home Office Type Approval,
with a view to roll them out at 150 AHB or AOCL crossings during 2013/14.
Thirteen mobile safety vehicles were deployed during 2012/13, covering every route on the
network. The vehicles – which are staffed by British Transport Police – have detected and
prosecuted more than 1,000 motorists responsible for red light violations since 2012.
Audible warning devices have been developed to provide a spoken warning to advise
pedestrians when another train is approaching. These are now being introduced at around
150 station level crossings to help make sure pedestrians understand that it is not safe to
cross when the crossing sequence continues after a first train has entered, or passed
through, the station.
A form of approach locking (barrier inhibition) is being installed at more than 70 high risk
manual crossings to remove the risk from the crossing being opened to road traffic while a
train is approaching (but the signals set to danger behind it).
Network Rail is continuing with two major initiatives to educate level crossing users:
On national television, radio and online during October 2012, the See Track / Think Train campaign delivered the message ‘Distractions can cost you your life, take care at crossings’. The campaign ran again in May 2013 to coincide with spring/summer peak usage and the International Level Crossing Awareness Day (ILCAD).
Rail Life, a primary and secondary school initiative for young people launched in May 2012, continues to support railway safety awareness within schools. A September 2012 digital campaign on Spotify, YouTube and Twitter (featuring rapper Professor Green) highlighted the dangers that distractions like headphones can bring, the key message being ‘Lose your headphones, not your life’.
Page 79 of 100
Research and development
Road-Rail interface research is conducted in nine main areas:
Understanding the risk at level crossings to enable prioritisation of remedial actions;
Identifying and sharing good practice in Britain and overseas to facilitate the adoption of appropriate solutions;
Identifying new technical and operational solutions to prevent errors and misuse of crossings;
Understanding the costs of level crossings and the benefits of adopting alternatives to optimise societal benefits;
Working in collaboration with highway and planning authorities to design out safety risk and reduce the overall cost to society;
Understanding the needs of vulnerable users at level crossings to facilitate social inclusion;
Review and overhaul of the legislative framework for level crossings to identify legal requirements and consolidate disparate regulations;
Research into bridge strikes and vehicle incursions; and
Research to support inquiry recommendations, government and regulatory policies, proposed and new legislation.
RSSB’s Road-rail interface safety guide pulls together summaries of this research in one
document to provide a useful resource to assist industry with accessing relevant information.
A new edition is in preparation.
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Page 81 of 100
Did you know?
The Federal Aviation Administration runs a website devoted to the lessons learned from aircraft accidents across the world. Accidents can be selected according to three ‘perspectives’: airplane life cycle, accident threat categories, and accident common themes. Follow this link for details.
11 Lessons learnt – beyond the boundary fence
Our industry does not exist in a vacuum. Clearly, there
will be accidents and incidents in other sectors that carry
lessons from which we can all benefit.
It is widely recognised that the Baker Panel review into
the BP Texas City oil refinery disaster of 2005 and the
Haddon-Cave report on the Nimrod accident of 2006
contain lessons from which the rail industry could benefit.
Indeed, as we saw in section 3.2, the Baker review led
our industry to take a closer look at safety performance
indicators and the proactive management of risk.
However, learning is a line signalled for bi-directional
running, as the Buncefield Oil Depot explosion of
December 2005 demonstrated. Included among the investigation report’s recommendations
was a proposal that the oil industry ‘develop incident databases that can be shared across
the entire sector, subject to data protection and other legal requirements’. It added that
examples ‘exist of effective voluntary systems that could provide suitable models’, naming
RSSB’s National Incident Reporting System, NIR-Online, as a worthy model.
This shows both how rail learned from oil and oil learned from rail. It’s something that other
industries would do well to consider. Had the Environment Agency (EA) been aware of the
Hatfield derailment of October 2000, it might have understood the implications that
‘maintenance holidays’ can have on infrastructure. Railtrack stepped back on track repairs
and gauge corner cracking was the result; the EA failed to dredge the Rivers Parret and
Tone and flooding was the result during the storms of early 2014.
Yet the key to success is not only about sharing lessons, but also best practice and ideas –
that is, we need to learn just as much from what we do right as what we’ve done wrong. This
section therefore presents a number of case studies where this has been achieved, and
highlights the occasional summaries of some of the major non-rail accident public inquiries
produced by RSSB which can also offer suggestions for how your own learning procedures
might be finessed.
The industry is also mindful of the need to look beyond its own operations for insights or
initiatives.
11.1 Case studies
11.1.1 Swedish nuclear industry
A study of accident investigation in the Swedish nuclear industry was published in 2011.15 It
is primarily concerned with the application of the MTO concept (man-technology-
organisation) introduced to Swedish nuclear operations in 1979.
15 C Rollenhagen, Event investigations at nuclear power plants in Sweden: reflections about a method and some associated practices (Safety Science, 2011).
Page 82 of 100
One of the features of MTO was a greater emphasis on event investigations. Of particular
interest is how this new focus affected learning from accidents. This process is described in
the paper as advancing from problem identification to problem solving, and is described as
‘one of the most difficult issues associated with experience feedback’. The paper suggests
that organisations often find that similar events reoccur because recommended actions have
not been implemented or have been ineffective. Many of the recommendations, it notes, are
‘more of the same’, rather than innovative solutions to well-known problems.
This leads to a discussion of the contradiction inherent in the ‘culture of safety’ and ‘the
culture of innovation’. In effect, increasing risk is a factor that supports innovation –
something which has been evident in our own industry, from the application of absolute block
signalling and interlocking, to the development of train protection systems like AWS, TPWS
and ERTMS.
Nevertheless, the paper suggests that some steps have begun to emerge that encourage
processes for finding better solutions. One of these steps has been the creation of ‘system
groups’ that include representatives of the whole system in question. This approach has
shown some success in strengthening the way that plant outages are managed. Again,
parallels may be drawn with our own industry, with the creation of the safety co-operation
groups, systems interface committees and indeed with the existence of RSSB itself.
11.1.2 Climbing Mount Everest
A rather different type of disaster was the subject of a paper by D. Christopher Kayes
published in 2004.16 This examined the underlying reasons for the deaths of eight climbers
who were part of an expedition to climb Mount Everest in 1996. The author was interested in
organisational learning and how this could break down in the face of an organisational
problem.
By 1996, climbing Everest had ceased to be the exclusive domain of adventurous
mountaineers willing to take calculated risks to achieve their goals; in fact, it had become
part of the tourist industry, with companies offering members of the public the opportunity to
ascend the mountain under the guidance of experienced leaders and with the help of teams
of Sherpas. Hazards had not been eliminated, but it was widely believed that they could be
controlled: the route up the mountain was well-established, timings (a critical factor in
reaching the summit and returning safely) were well understood, accurate weather
predictions could be made, and the equipment used was the latest and most sophisticated.
However, for those who attempted the climb from the highest camp to the summit on 10 May
1996, a number of things went wrong. At two points, safety ropes had not been fixed as they
should have been, creating a bottleneck as several teams of climbers had to wait while the
work was completed. Ideally, climbers should reach the summit by 13:00 and start back
down again so as to reach camp before nightfall; in fact, some of the climbers that day did
not reach the summit until 17:00 – far too late for a safe descent. As a result, with a
snowstorm setting in and climbers running out of oxygen supplies, several individuals
became stranded – disorientated or too exhausted to continue – and suffered fatal frostbite in
the severe temperatures.
16 http://www.sagepub.com/isw6/articles/ch9kayes.pdf
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The immediate causes of the disaster were easy to establish. Although an agreement had
been reached between the teams as to what time they should leave camp, at least one team
ignored this. There had been inadequate preparation of the route, with unfixed ropes, and a
series of decisions to continue to the summit long after the time when the attempt should
have been abandoned.
However, the paper explores the underlying causes in detail and is particularly concerned
with the team dynamics. Strong leadership had limited the ability of team members to
respond to changing circumstances – this became critical when the leaders themselves were
incapacitated. Some of the leaders displayed an inappropriate bravado while others, as it
became clear after the event, considered teamwork relatively unimportant. The narrowness
of purpose (the need to reach the summit) was also a factor driving the teams on when they
should have abandoned the attempt – a more broadly defined purpose would have
recognised the necessary contingency of returning down the mountain. Kayes also notes that
the teams faced an ‘ill-defined problem’, one that cannot be answered with current
knowledge. Unfortunately, they did not recognise their problem as ill-defined depending
instead on the knowledge that previous expeditions had enjoyed a 100% success rate.
The general lessons drawn out in the article about how teams operate and organisational
disaster have a relevance to many industrial situations far beyond the extreme environment
of high altitude mountaineering – including (for example) track working and shunting.
11.1.3 Industrial radiography
A paper prepared for the International Atomic Energy Agency examined the lessons from
major radiation accidents; one of the practices considered was industrial radiography.17 The
authors analysed statistics relating to the accidental exposure of industrial radiographers and
found that there was one case of death due to leukaemia caused by chronic excessive
radiation exposure; in about 15% of cases excessive whole body doses caused three
radiographers to suffer acute radiation syndrome, and in about 30% of cases local radiation
doses caused various medical procedures to be necessary for radiographers including
amputation and skin grafts.
A review of these accidents identified a range of causes including a failure to follow
procedures, insufficient training, insufficient regulatory control, inadequate maintenance, and
equipment malfunction. Occasionally there was a deliberate violation of the rules.
However, in virtually all these accidents the radiographer failed to use a survey meter to
confirm that the radiation source was shielded and in some cases switched off their personal
alarm or ignored the signal. The paper notes that radiographers often see safety precautions
as a burden that is not necessary to produce a radiograph and, because radiography is a
competitive business, cutting costs is a matter of survival for some companies.
In the light of this, the following measures were identified as management actions to
implement the lessons learned:
17 P. Ortiz, M. Oresegun and J. Wheatley, Lessons from major radiation accidents (International Atomic Energy Agency).
Page 84 of 100
Managers need to actively encourage and foster a safety culture. Safe work should be praised and unsafe shortcuts discouraged.
Managers should be aware of the potential for accidents and the consequences for the individual and the company. Training should provide a full knowledge of the consequences of accidents illustrated with pictures of the effects of radiation.
Managers should implement a radiation protection programme ensuring that radiography work is only carried out by fully qualified staff, procedures are followed, supervision is provided, emergency equipment is available, personal monitors and survey meters are used appropriately, and all equipment is correctly maintained and tested regularly.
Appropriate resources should be provided and internal audits/inspections carried out.
11.2 RSSB Operational Feedback summaries
Occasionally, RSSB will produce an ad hoc report to highlight issues raised by inquiries into
non-rail events with a view to promoting pan-industry learning. All maybe found on the LOE
resources page of the RSSB website.
Page 85 of 100
12 Learning activities and initiatives
During 2013/14, the RSSB Board considered a number of strategic papers and presentations
on the main elements of system risk.18 This chapter presents ‘snapshots’ of that risk – and
some of the initiatives our industry has been working on to help mitigate it – in the following
key areas:
Passenger
Workforce
Public
Chart 10 summarises the system safety risk, and shows that the Board considered 100% of
the modelled residual risk on the mainline railway, as defined by SRMv8.
Each of the risk papers focussed on particular areas of risk within the category under
discussion represented by the darker shades. Risk areas represented by lighter shades
were covered in the main paper or appendices, which showed all of the risk from the SRM,
including summaries of how industry and RSSB address all risk areas. The public risk paper
also addressed suicides (inter alia). Together this shows how the industry is managing all
safety risk.
Annual review of total system risk profile (2013 example).
18 Covering safety, performance and efficiency. Data source: ORR for historical data; SMIS for recent statistics.
14%
6%
39%
3%
28%
11%
19%
61%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jul 2013 - Workforce Sep 2013 - Public Nov 2013 - Passenger
Cu
mu
lative
pro
po
rtio
n o
f to
tal syste
m r
isk, e
xclu
din
g s
uic
ide
a
nd
su
sp
ecte
d s
uic
ide
Passenger risk (also covered)
Passenger risk (highlighted in paper)
Public risk (also covered)
Public risk (highlighted in paper)
Workforce risk (also covered)
Worforce risk (highlighted in paper)
Assault and abuseRoad traffic accidentsSlips, trips and fallsStruck/crushed by trainTrain accidents
TrespassLevel crossingsVandalism
Platform train interfaceSlips, trips and fallsTrain accidents
Page 86 of 100
Passenger risk
Risk from Type of event Fatalities
per yr FWI
per yr RSSB R&D projects to support industry Industry co-operative actions Duty holder actions
Passenger
behavio
ur
In stations
Burns; Manual handling; Slips, trips and falls; Platform-train interface accidents
4.64 23.08
T157 on slips etc and falls updated by T829 (published) T426 (published) on platform/train interface. T749 (published) Protection from aerodynamic effects of passing trains T759 (published) Improving the methods used to provide access to and from trains for wheelchair users- good practice guide in preparation T866 published Investigation of platform edge positions on the GB network T978 Development of new ‘Suburban’ passenger vehicle standard gauge T992 on Safer Stairs (published) and escalators (in progress) T1037 (underway) Train passenger footsteps investigation to support research into the reduction in passenger stepping distances and gauging constraints
Under the Modernisation of Safety Cooperation (MoSC) project, the System Safety Risk Group (SSRG) has been created to facilitate and manage 100% of industry system safety risk. Station safety falls within SSRG’s remit and will be reviewed and considered by a sub group moving forward; sub groups are expected to have completed their first meetings by March 2014, and work is currently underway to set up the groups and manage the short term risks. A coherent GB strategy on PTI is being developed by RSSB with the aim of coordinating PTI-related activities towards common industry goals that will improve operational performance, as well as reducing safety risk.
Programme of stairnose marking, increased use of the slip, trip and fall toolkit, passenger safety awareness campaigns. Improved emergency preparedness training of staff, improved winter preparedness, increased CCTV coverage, improved passenger communications..
On trains
Falls from train in running; Slips, trips and falls; Struck against objects
0.17 2.84
T605 (published) crowding covered on-train accidents to some extent. T358 (published) Risk from on-board accidents T052 a/b, T246, T422 (all published) passenger signage T686 (published), T769 (Published) – Guidance on SDO T910 published) Review of interiors crashworthiness research 1989 – 2009 SK&P analysis of injuries associated with internal doors in response to request form VV SIC/Passenger Focus.
A train dispatch risk assessment template and improved guidance on the factors that affect station safety risk has been developed and added to RIS-3703-TOM. Work undertaken with Charter Operators, Network Rail (NR) and TOCs to improve management of passenger risk associated with Heritage Operations. Furthermore, guidance for Station Managers produced to assist duty holders improve the way passenger risk is managed at stations – this includes development of station safety plans, risk identification, target setting and performance measurement techniques.
Passenger safety awareness campaigns, further installation of CCTV , improved emergency preparedness training of staff, enhanced luggage storage space, review of internal door operation, maintaining secure station accreditation and review of processes for ensuring passenger welfare during service disruption
Work
forc
e b
ehavio
ur
Station staff Train despatch; Station management
0.91 14.24
T743 & T132 (published) train despatch/ train despatch risk tool: being updated by T1029 T248 & T425 (published) relating to train slipstream effects on platforms. Station safety issues all covered in station safety research guide (as T828) T881 Evaluating wayfinding systems for blind and partially sighted customers at stations (published)
RIS for Passenger Train Dispatch and Platform Safety Measures (RIS-3703) approved and issued. This standard provides information on factors that should be considered when conducting train dispatch risk assessment and methods by which positive safety behaviours can be engendered in both staff and members of public. The Station Safety Improvement Project has delivered a range of tactical solutions that positively shape workforce behaviour – including development of behavioural markers and guidance on professional behaviours for train dispatch staff.
Hazard awareness and accident prevention campaigns for staff, review of train despatch arrangements, improve safety culture and development of a Station Managers Safety management training programme..
Train crew Evacuation; SPADs; Train despatch
0.59 1.62
Evacuation covered in T626 (published) – for high temperatures only. SPADs covered in some 20+ projects, all published. See RSSB website and Operations safety research guide (published as T838. Fatigue and obstructive sleep apnoea studied in several projects eg T059, T299 (published) and T699 (published) Train despatch – as above. T512 (published) Buffer stops. Crashworthiness and Vehicle Interior research, T118, T189, T310, T424
TPWS initiatives related to fitment of TPWS at PSRs and in-cab modifications are being considered by the TPWS Strategy Group set up in 2009 by the RSSB Board to determine the way forward for TPWS as part of a long term Train Protection Strategy. The latest outputs are a draft handbook on the use of AWS and TPWS and an update to the TPWS Strategy Group’s action plan. Proposals to change GO/RT3119 and to propose a review of the Standard.
Increased use of driving simulators, improved rostering to reduce fatigue, unobtrusive monitoring of driver performance, development of a competency standard for on board hospitality staff, personal development plans for drivers and review of SPADS to ensure all lessons learnt
Signaller 0.25 0.31 Review of Rule Book. NR communication initiatives
Track worker Maintenance work/error; Errors in possessions
0.10 0.13 Detecting rail flaws T060a (published) Maintained by TOM Delivery Unit. ISLG are addressing Occupational Health issues as a programme of wok for 2012/13
Improved briefing and training, increased use of lookout operated warning systems, Improved possession management systems and safety critical communication protocols.
Shunter 0.01 0.02 Shunting safety special topic report, published February 2008. OFG have sponsored the development of a generic shunter training course in DVD format which provides a standardised, modular, and interactive training package. This is now available to the industry.
Commitment to undertake shunting risk assessments.
Environm
ent
Weather Weather 0.09 0.14
T096, T173, T371, T643 (all published) – Weather, climate change, T112, T554 (published) - scour/flood T796 (published) Sanders, T797 (underway) Performance and installation criteria for sanding systems, T959 (underway) Onboard detection of low adhesion T925 TRaCCA (published). Next stage as T1009 (in progress). R573 on movement of trains through flood water in development
Sustainable Development Steering Group is looking at effects of environment on future rail industry. Project 11/005 New guidance on winterisation
Scour/flood and coastal infrastructure – action to take forward resides with NR
Adjacent property/land
Adjacent property/land 0.01 0.02 T360 (published) – management of structures & earthworks T679 (underway) – The effects of railway traffic on embankment stability
NR infrastructure management processes.
Engin
eerin
g f
ailu
res
Infrastructure
Bridges; Broken rail; Buckled rail; Drainage; Fire or explosion; Stations; Track twist; Points failure
0.86 1.64
T078, T207, T330, T357 (published) – derailment risk Station roof design and maintenance covered by CIRIA-managed project T038 Crashworthiness and Vehicle Interior research, T118, T189, T310, T424 T854 Reducing the number and impact of vehicle strikes on railway underline bridges (published) T988 (developing) Bridge design requirements
Input to RGS and TSIs.
Improved management processes for bridge strikes, mitigation of risk from buckled rails, improved management of sleepers to reduce risk from gauge spread, improved analysis and intervention from use of the New Measurement Train and improved signalling maintenance.
Rolling stock Bogie/suspension; Brakes; Electrical; Interior; Other
0.24 1.15
T209, T356, T550, T551, T607 (published); T774 (underway) – Human factors in axle inspection T201, T314, T424 (all published) Windows T118, T189, T310, T424 (all published) Crashworthiness ,Vehicle Interior research, T988 (developing) Bridge design requirements T860 (published) All electric braking T843 (published) / T1018 (underway) Fire standards T1024 (underway) Procedures for dealing with bodyside windows broken in service
RISAS accredits Approval Bodies (RISABs) who in turn assess and, where suitable, certify suppliers involved in train maintenance. This process is designed to encourage and promote the continuous improvement of products supplied. Following the publication of T883 which highlighted the potential for significant savings resulting from a review of major supplier approval systems. T908 initiated, to set up a framework to realise these savings. Input to RGS and TSIs.
Fitment of laminated windows, improved interior design and crashworthiness, consider further installation of CCTV and ongoing modifications to address specific risks and improving the man/machine interface of TPWS
Level X’ings 0.00 0.00 Covered by the Road Rail Interface Safety Group / Network Rail Level Crossing Strategy Group (successor body)
Covered by Network Rail Level Crossing Strategy Group
Public
behavio
ur
Crime Arson; Assault; Objects thrown at trains; Passenger trespass
1.74 8.49 Assaults, trespass and vandalism all covered in large number of published projects, mostly supported by RPSG and RDG Police and Security Steering Group. Covered by T846: A guide to RSSB research in community safety.
Crime topics are reviewed nationally, enabling industry organisations to consider local measures working in partnership with local authorities. SSRG sponsors the annual Community Safety forum to inform industry and share good practice. Good practice is also shared via the community safety resource centre website. Rail. A guide to the new anti-social behaviour (ASB) legislation has been produced. BTP launched Operation Avert to minimise the disruption due to trespass/suicide. Network Rail and TOCs work together at a local level to tackle railway crime. Initiatives often using diversionary activities such as football that are offered to youngsters alongside rail safety messages.
Rail enforcement officers (REOs) given direct access to BTP radio network. Improved conflict training for members of staff using SWeRVe. The industry is working hard to prevent cable theft. Scrap Metal Dealers Act 2013 was given Royal assent in February 2013. Network Rail has a series of initiatives running to tackle railway crime, including trespass. The latest ‘track test’ demonstrates that it is hard to predict which direction a train is coming from when trespassing on the track. Several TOCs have working groups to manage assault risk in their areas.
Page 87 of 100
RSSB workshop for TOCs/NR to learn and share good practice in implementing and enforcing an alcohol ban on trains, to counter assaults, ASB and STF.
RVs at LX Road users at level crossings
0.22 0.31 Large number of research projects published and eight in progress covering all areas of road /rail interface T757 on Public road level crossing signs and T984 on private road signs in progress
Covered by the RRISG including industry participation in the International Level Crossing Awareness Day (ILCAD) and the NR Don’t Run the Risk campaign. RSSB hosts an RR forum and European Level Crossing Forum.
NR appointed a Head of LX, produced a policy on management of LX to reduce train and accident risk by 25%, by the end of CP4. NR continuing with awareness campaigns and manages Road-Rail Partnership Groups with local authorities. BTP operate NR funded mobile camera fitted vans which have been operating in various areas which can issue Fixed Penalty Notice letters. BTP and CPS to produce guidance for prosecutors on careless/dangerous driving at LX.
Pedestrian Passengers on footpath crossings
0.64 0.66
T332 (published) on station crossings T652 (published) on another train coming warnings T730 (published) on Elsenham RAIB recommendations. T984The causes of pedestrian accidents at LX and potential solutions (in progress)
Covered by the RRISG including industry participation in the European Awareness day and the Network Rail Don’t Run the Risk campaign
NR is risk assessing all crossings and trying to educate users through signs, etc. The four highest risk/busiest station crossings have been or are due to be closed. A new awareness campaign will focus on distraction events.
Total 10.5 54.7
Page 88 of 100
Workforce risk
Key risk areas (risk from):
Main groups affected (risk to):
Main types of event relevant to workforce risk
Fatals FWI RSSB actions to support industry Industry co-operative actions Duty holder actions
Passr
actio
ns
At stations
Train drivers, station staff Attending to or witnessing passenger accidents.
0.00 0.04 Station Safety Improvement project
Specific research and topic reports.
Red 28 focussed on the platform-train interface using a fictional dramatisation.
A Rail Industry Standard (RIS) for passenger train dispatch and platform safety (RIS-3703-TOM) completed in June 2011.
Passenger safety awareness campaign for boarding/alighting trains. Improvements to customer display screens and public address systems to reduce crowding around signs and late rushes to trains. Review of incidents of passengers being taken ill on trains to establish common causes and develop plans to reduce the numbers of such incidents.
On trains 0.00 0.00
Work
forc
e b
ehavio
ur
Station staff Station staff Personal injuries. Accidents related to train despatch and station management.
0.13 1.95
RSSB facilitation of OFG and SSRG
Station Safety Improvement project
Specific research
Aerodynamics Project
Enhancement of train dispatch RIS
Continued use of the slips, trips and falls toolkit and the HSE’s ‘shattered lives' campaign, review workforce footwear and communication campaigns. Training needs analysis for conductor and train dispatch staff duties and use outputs to update training courses. Publicity campaign highlighting the hazards to station staff of doors, drawers and floors. Improve Driver Only Operation (DOO) dispatch equipment on stations. Provision of mobile panic attack alarms for use when staff open and close offices and stations.
Train crew Train crew Personal injuries. SPADs. Accidents related to train dispatch
0.58 5.61
Facilitation of OFG / SSRG
TPWS strategy support
Personal track safety of train crew
New approach to rules project
RED, Right Track and OPSWEB
Specific research e.g. T940 - Identifying, quantifying & managing the risk of musculoskeletal injuries & illness among train drivers
National Operators Risk Conference and workshops
New approach to route learning
TPWS risk management
Good practice share
ATOC Safety Forum
NR level crossing strategy
Station safety improvement project
Individual company injury prevention
Fatigue management
Signaller Signaller / crossing keepers
Personal injuries. Miscommunication; and the operation of level crossings
0.04 0.19 RSSB facilitation of CSSG and RPSG
SWeRVe II
BTP Annual Plan Objectives NR internal communication and line management
Infrastructure workers
Infrastructure workers, including OTP crew
Occupational hazards including electrocution and being struck by trains. Train accidents caused by maintenance errors. Road vehicle safety, working with plant and at height.
2.74 13.41
Facilitation of ISLG and OFG
Workforce health project
New approach to rules project
CIRAS
Road driving risk project
Specific research e.g. T997 - Managing occupational road risk associated with road vehicle driver fatigue
Network Rail PSLG
M & EE Group
Modernisation of Safety co-operation
New Close Call System
RED 35 – driving fatigue
Common Inductions
National Skills Academy
Ballast Dust Working Group
NR Vision and Strategy for ‘Transforming Safety and Well Being 2012-2024’
NR Life Saving Rules
NR RRV Improvement programmes
NR track safety strategy
Contractor culture and leadership programmes
Fatigue control improvements
Shunters Shunters Personal injuries (including crushed by trains). Coupling / train preparation errors.
0.03 0.04
RSSB facilitation of OFG
Shunter Interactive training DVD
National Freight Safety Group Developing and reviewing individual training plans and examining supervision and monitoring guidelines for shunters. Introduction of unobtrusive monitoring. Development of a manual handling brief. Improvement to loading and train preparation processes.
Environm
ent Weather
Train crew, track workers Train accidents due to effects of high winds, flooding, snow & ice etc.
0.01 0.04 Sustainable Rail Programme TSLG and technical strategy NR Asset Management plan
Improved drainage management
Operational client controls
Adjacent property/land
0.00 0.01
Engin
eerin
g f
ailu
res
Infrastructure Infrastructure workers, train crew
Problems with the track, signalling systems, or bridges, embankments, tunnels etc.
0.19 1.05
Specific research
Specific standards
Industry co-operative input to Railway Group Standards and Technical Specifications for Interoperability.
Strategic replacement of softwood sleepers. Application of latest technology to monitor and reduce track defects. Focussed risk assessment on track stressing & effects of weather on embankments and structures. Identification and remedy of ‘rough-ride’ sites. Bridge examination intervals based on risk.
Trains Train crew Faults with train interior (including seats and windows). Electrical faults. Brakes, bogies etc.
0.06 0.70
Specific research
Specific standards
RISAS
ATOC Engineering Council
ROSCO collaboration
Introduction of a digital reader to measure axle box temperatures and new rolling stock with improved interior design. Fit high intensity headlights to class 142 and 143 fleet to enable increased visibility to track workers and people working on or near the line. Improve cab environment of class 66 locomotives to minimise fatigue levels. Fitment of a second interlock switch to class 150 to reduced the risk of ‘wrong-side’ door interlock failure.
Public
behavio
ur Crime
Station staff, train crew, crossing keepers
Assaults. Arson, missiles thrown at trains, objects on the line and other acts of vandalism. Witnessing
0.07 3.52 SWeRVe II
Facilitation of CSSG and RPSG
Track off
NR trespass campaigns
General improvements made to CCTV systems across a number of stations. Rail enforcement officers given direct access to the BTP radio network. Improved conflict training for members of staff. Fencing priorities matched
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suicides and accidents to / near misses with trespassers.
Specific research e.g. T901 - Understanding guidance surrounding the personal security issues of lone working and T845 - Improving suicide prevention measures on the rail network in Great Britain
National Suicide Prevention Group
BTP Annual Plan
with trespass hotspots. Campaign run during school holidays to deter trespass and anti-social behaviour. Closure of access to unused platforms. Placing of Samaritans posters around stations and additional staff training to identify potentially suicidal people. Utilise SWeRVe v2.0 to educate staff on conflict avoidance and management.
Level crossings Crossing keepers, train crew, infrastructure workers
Accidents at level crossings. Road vehicle incursions. Bridge bashes.
0.07 0.17
RSSB facilitation of CSSG and RRISG
ALCR model
Specific research
Chair of European LX forum
DfT and ORR follow up to risk assessment
Participation in ILCAD
BTP Annual Police Plan Objectives
Continued development of NR’s ‘Don’t Run the Risk’ campaign with a new strapline ‘ lifesavers not time wasters’. NR risk assessment of crossings through the Level Crossing Risk Model. Cameras installed at all level crossings and deployment of enforcement vehicles. Strategy to upgrade AOCLs and close UWCs when possible.
General Train drivers, station staff Attending to or witnessing accidents similar to passenger accidents in stations
0.00 0.15
Specific research
Facilitation of CSSG
Annual Community Safety Forum
Station Safety Improvement project
T845 is also evaluating the Network Rail campaign with Samaritans which is raising awareness of the hazards of railways.
Individual company programmes
Station enhancement programmes
Total 3.93 26.9
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Public risk
Risk from Main types of event Fatal FWI RSSB actions to support industry Industry co-operative actions Actions by individual organisations
Public behaviour
Crime
Trespasser struck by train or electrocuted. Assaults, threats and verbal abuse
42.13 45.25
A large portfolio of previously published research on trespass issues is available from the RSSB website. More recently published: T704: The contribution of alcohol to personal safety and security risk on the railways (Including Good Practice Guide); T723: Making the most of data associated with railway crime; T943 Addressing crime and disorder through planning and design; T954 Evaluating measures to improve personal security and the value of their benefits. The Trackoff website supplies educational materials to teachers to enable them to warn their students of the dangers of inappropriate behaviour on the railway network. During 2009 a DVD was sent to more than 30,000 schools throughout the country. RSSB manages the annual Community Safety Forum, Newsletter and Resource Centre website to inform industry and share good practice.
Crime topics reviewed nationally by the System Safety Risk Group and regionally by Community Safety Partnership Groups, which enable industry organisations to consider local measures and work in partnership with local authorities. Operation Tornado is a BTP scheme involving scrap metal recyclers that is designed to crack down on metal theft. Following a successful pilot in the North East of England Operation Tornado is being rolled out across the UK
General improvements made to CCTV systems across a number of stations; general management and maintenance of systems also upgraded. Rail enforcement officers given direct access to the BTP radio network, enabling them to contact BTP immediately when necessary. TOCs, Network Rail and BTP use a variety of staffing measures including security guards, rail enforcement officers, special constables and police community support officers. BTP is the ACPO lead on metal theft. Use of mini-helicopters and regular visits to scrap dealers, to combat cable theft. Network Rail is working hard to prevent cable theft: Funding extra, dedicated British Transport Police officers around the country; using CCTV to detect people are on the network and to support the police; trialling methods of securing cables; using forensic marking agents; introducing cables which are harder to steal and easier to identify; setting up dedicated security teams. A new bill that legislates scrap metal dealers is now on the statute. Fencing priorities matched with trespass hotspots. Network Rail has a series of initiatives running to tackle railway crime, including trespass. Some examples are: Rail Life, a website aimed at teaching young people about the dangers of misusing the railway; media campaign with 400m hurdler Dai Greene – this showed that if an athlete at the peak of fitness cannot outrun a train, an average person will not stand a chance; Partnership with Streetgames – offering local kids the chance to engage in sport and not mess around on the tracks; Rail Reps – a mentoring relationship between school and BTP volunteers. Network Rail’s Partnership Awards recognize work by groups to encourage the public to act responsibly when using the railway.
Pedestrian Pedestrian struck by train at (footpath) level crossing
5.71 6.11
Published: T335, Improving road user and pedestrian behaviour at level crossings, T650 Improving safety and accessibility at level crossings T653, Safer European level crossing assessment and technology (SELCAT); and T730 Understanding human factors and developing risk reduction solutions for pedestrian crossings at railway stations. In progress T984 Research into the causes of pedestrian accidents at level crossings and potential solutions. In 2011, a new level crossing teaching package was added to the Trackoff website.
The Road-Rail Interface Safety Group (managed by RSSB, includes representation by ADEPT) has a broad remit, eg covering level crossings, incursions and bridge strikes. Supported at local level by Road Rail Partnership groups involving local authorities. Al railway organisations are working with BTP and CPS, providing evidence to prepare Impact Statements for courts. Network Rail, helped by BTP, has had several awareness days in support of ILCAD to inform the public of the need to act safely at level crossings. BTP are operating vans with ANPR cameras to detect red light running at level crossings, funded by Network Rail. RSSB hosted the 12th Global Level Crossing Symposium in October 2012, in partnership with Network Rail and the ORR.
Network Rail risk assessment of crossings through the Level Crossing Risk Model. Network Rail has developed a new communications plan to address the issue of pedestrian safety at crossings and a specific campaign targeting schoolchildren has been launched. Network Rail has engaged a theatre company to perform ‘off the level’ a play highlighting the dangers of misusing a level crossing. This initiative is being considered nationally. Network Rail has produced a new level crossing safety leaflet to hand out during awareness days to both pedestrians and road vehicle drivers. Offending drivers now given the option of attending a training course rather than points on their licence. Cameras installed at level crossing to identify incidents of road vehicle misuse. Network Rail has centralized level crossing management into a single system considered as a separate asset. There are programmes to the end of CP5 to reduce the risk. Opportunities to close private level crossings are pursued with landowners, leading to over 700 being closed in recent years. Network Rail manages the Bridge Strike Prevention Group (BSPG) working with the Road Haulage Association, Highways Agency, ADEPT, LUL and others to reduce the frequency of bridge strikes through information booklets, awareness/education events for lorry drivers, producing a database of low bridges for truckers’ atlases, correct signing of bridges and other initiatives. Network Rail is continuing to work with DfT and ORR, to implement the protocol of “Managing the accidental obstruction of the railway by road vehicles”.
Road vehicle
Train collision with road vehicle at level crossing; road vehicle incursion not at level crossing and bridge strikes
2.81 3.15
Published: T729: Further work on obstacle detection at level crossings; T737: Documenting the All Level Crossing Risk Model; T863: Updating the Level Crossing Risk Management Toolkit, T738: Trialling the national roll out of the level crossing cost model; and T854: Reducing the number and impact of road vehicle strikes on railway underline bridges. In progress: T756: Research into traffic signs at level crossings (second stage) and T983: Research into signs at private level crossings. RSSB chairs the European Level Crossing Forum, to share good practice and coordinate public awareness campaigns (ILCAD) and encourages the EU to hold workshops on managing risk at level crossings. RSSB holds an annual road-rail information forum to update public groups on safety at the road-rail interface.
General Non-trespass related slips, trips and falls at stations
0.64 1.28
Published research projects: T157a: The best flooring materials for stations; T157b: Safer surfaces to walk on - reducing the risk of slipping; T158: The use of tactile surfaces at rail stations; T532: An evaluation of frost, ice and snow precautions at stations; T829: Safer surfaces to walk on: an updated guide. T834 Reducing accidents through inclusive design: steps, stairs and ramps T749, Guidance on protecting people from the aerodynamic effects of passing trains in progress. . In progress: T992 Safer stairs and escalators in public places
Industry groups looking a similar risk to passengers, eg Operations Focus Group (OFG), will also address same risks to members of the public.
Covered by individual duty holder actions aimed at reducing passenger risk at stations.
Engineering
Level crossing LX equipment malfunctions
0.10 0.22 No research specifically addressing public risk. The work of systems interface committees and standards committees related to engineering issues.
Obstacle detectors have been developed and trailed. Warnings on approach to level crossings have put into Garmin satellite navigation systems.
Rolling stock Third party injury from train accidents
0.21 0.25 Engineering research predominantly focused on rolling stock itself and passengers.
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Risk from Main types of event Fatal FWI RSSB actions to support industry Industry co-operative actions Actions by individual organisations
Infrastructure Third party injury from train accidents
0.28 0.35
T359: Management of stressed continuously welded track, T569: Development of risk based examination intervals for Network Rail bridges, T696: Appraisal of Eurocodes for Railway Loading, T683: Research to investigate and advise on optimisation of close- and long-range viewing of signals, T804: Automatic Warning System (AWS) Infrastructure Characterisation all completed;, and T808, AWS Testing - the way forward in progress.
RSSB has worked closely with Network Rail and appropriate European committees (CEN/UIC) to establish requirements that are relevant to the GB railway industry in the Structural Eurocodes.
In addition to internal studies and the development of standards and management processes, Network Rail have actively participated as a stakeholder representative on research project steering groups and the review of project outputs. Following the publication of T569, Network Rail has used the guidance provided to establish examination intervals for their bridge assets on the basis of risk. Work is also targeted at reducing the frequency and consequences of bridge strikes.
Workforce behaviour19
Station staff Non-trespass related slips, trips and falls at stations
0.03 0.42 Published: T743, Improving the arrangements for train dispatch from stations. T749, Guidance on protecting people from the aerodynamic effects of passing trains in progress.
Duty holder responsibilities and initiatives related to competence management and development that address the prevention of train accidents will be relevant here.
Train crew
Third party injury from train accident
0.13 0.16 No research specifically addressing public risk Initiatives such ATOC Driver Managers group.
Track worker 0.01 0.01 No research specifically addressing public risk
Signaller 0.25 0.27 No research specifically addressing public risk
52.4 57.7
Public behaviour
Suicide Suicide, suspected or attempted suicide
219.5 224.3 Project T845 Improving suicide prevention measures on the rail network in Great Britain, in progress
Working with Samaritans to train rail staff to recognise behaviour that might lead to suicide. Two courses are available: managing suicidal contacts and trauma support. Network Rail’s cross-industry National Suicide Prevention Steering Group and Working Group addresses suicide prevention.. Emotional Support Outside the Branch (ESOB) – All Network Rail priority locations are covered by local Samaritans branches. The Samaritans/Network Rail suicide reduction campaign was refreshed and re-launched in September 2012.
Closure of access to unused platforms. Placing of Samaritans posters around stations and additional staff training to identify potentially suicidal people. Network Rail are working as part of the European RESTRail project to tackle trespass and suicide prevention. Network Rail has produced a Drivers Guidance document outlining the behavioural impacts and strategies for recovery should a driver be involved in a suicide event. In addition they have also produce Memorials Guidance on how to deal with requests for memorials. BTP have launched a new fatality guidance document that has already had a positive impact on the delay impact of events. British Transport Police Referral Scheme – this is being piloted in the London North area but will be rolled out this year to all areas. BTP officers are able to refer individuals to the service through the Central London Samaritans branch.
19 Third party risk also has the potential to arise from workforce activity away from the mainline railway, for example road traffic accidents whilst driving between sites. This is not covered by the SRM.
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Appendix 1. Progress against RAIB recommendations
Table 5. RAIB recommendations (NRMI) closed out (all years) – per ORR
Incident date
Recs issued
RAIB investigation Total recs
Recs in progress
Recs closed
18/10/2005 14/07/2006 Freight train derailment at Hatherley, near Cheltenham Spa
5 0 5
19/10/2005 21/07/2006 Collision at Black Horse Drove Crossing, near Littleport, Cambridgeshire
4 0 4
26/10/2005 11/08/2006 Derailment near Liverpool Central 8 0 8
26/10/2005 25/08/2006 Track worker fatality at Trafford Park 9 0 9
28/10/2005 28/03/2006 Derailment at Watford Junction Yard 4 0 4
02/11/2005 02/11/2006 Runaway manually-propelled trolley between Larkhall and Barncluith Tunnel
16 0 16
04/11/2005 02/11/2006 Derailment at Oubeck North, near Lancaster 6 0 6
26/11/2005 29/11/2006 Derailment of a train at Moy 10 1 9
03/12/2005 11/12/2006 Investigation in station pedestrian crossings initiated by a fatality at Elsenham Station
10 0 10
05/01/2006 20/12/2006 Broken rails at Urchfont and Kennington after transit of freight train
6 0 6
11/01/2006 18/08/2006 Cutting of rail from a line that was still open to traffic, near Thirsk station
8 0 8
12/01/2006 20/07/2006 Station over-run at Haywards Heath 2 0 2
18/01/2006 14/11/2006 Derailment at York 4 0 4
27/01/2006 20/12/2006 Collision between train and buffer stops at Sudbury 2 0 2
06/02/2006 19/09/2006 Derailment of a Ballast Plough Brake Van at Carlisle 6 0 6
Recs issued 2006 Total 100 1 99
25/11/2005 08/01/2007 Autumn Adhesion incidents 2005 including Esher and Lewes. Reports 1, 2 and 3
25 2 23
14/01/2006 30/01/2007 Derailment incident at Edinburgh Haymarket 3 0 3
21/01/2006 30/01/2007 Derailment incident at Waterside, East Ayreshire 7 0 7
31/01/2006 23/01/2007 Derailment incident at Cricklewood 6 0 6
09/02/2006 23/01/2007 Derailment at Brentingby Junction, near Melton Mowbray
10 0 10
15/02/2006 30/04/2007 Train door incident at Huntingdon 6 0 6
21/02/2006 21/02/2007 Unsecure load incident at Basford Hall 5 0 5
19/03/2006 25/07/2007 Near miss involving track workers at Manor Park 3 0 3
07/04/2006 30/04/2007 SPAD incident at Camden Road 9 0 9
01/05/2006 29/05/2007 Near miss incidents at Crofton Old Station Level Crossing
6 0 6
22/05/2006 26/04/2007 Train collision with a road vehicle at Bratts Blackhouse Level Crossing
8 0 8
10/06/2006 30/08/2007 Power door incident at Desborough 9 0 9
28/06/2006 18/07/2007 Derailment at Maltby Colliery 4 0 4
17/07/2006 12/07/2007 Fatal accident to shunter at Dagenham Dock 7 0 7
29/07/2006 29/05/2007 Fatal accident at Deal 9 0 9
18/08/2006 08/08/2007 SPAD incident at Purley 5 0 5
27/08/2006 24/05/2007 Runaway incident at East Didsbury 8 1 7
08/09/2006 21/09/2007 Derailment at Washwood Heath 4 0 4
11/09/2006 18/12/2007 Derailment at London Waterloo 14 0 14
12/09/2006 13/09/2007 Derailment at Epsom 3 0 3
25/09/2006 05/09/2007 Collision at Copmanthorpe 2 0 2
31/10/2006 22/08/2007 Collision at Badminton 4 0 4
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17/03/2007 18/12/2007 Near miss at Tinsley Green 8 0 8
Recs issued 2007 Total 165 5 160
12/09/2006 13/05/2008 Derailment at Croxton Level Crossing 11 0 11
13/01/2007 28/02/2008 Derailments at Merstham, near Redhill and Kemble 9 0 9
28/02/2008 23/12/2008 Network Rail's management of existing earthworks / Kemble (15/01/2007)
6 0 6
15/01/2007 27/03/2008 Derailment of a passenger train near Kemble 2 0 2
28/01/2007 24/04/2008 Runaway wagon at Armathwaite 3 0 3
23/02/2007 23/10/2008 Derailment at Grayrigg in Cumbria 29 1 28
29/04/2007 28/02/2008 Fatal accident at Ruscombe 7 0 7
10/05/2007 31/01/2008 Derailment at King Edward Bridge, Newcastle Upon Tyne
4 1 3
01/08/2007 10/01/2008 Collision near Burton on Trent 4 0 4
10/08/2007 31/07/2008 Derailment at Duddeston Junction 8 0 8
22/08/2007 20/11/2008 Incident at Didcot North Junction 9 0 9
27/08/2007 11/06/2008 Incident at Aylesbury North 4 0 4
29/08/2007 30/10/2008 Incident at Ty Mawr 7 0 7
29/08/2007 23/10/2008 Accident at Leatherhead 6 0 6
29/11/2007 28/10/2008 Member of staff hit by a train at Reading East 5 0 5
01/02/2008 25/09/2008 Damaged footbridge at Barrow on Soar 4 0 4
20/01/2008 23/12/2008 Near miss at Bishop's Stortford 5 0 5
16/04/2008 23/12/2008 Fatal level crossing accident at Staines, Surrey 4 0 4
Recs issued 2008 Total 127 2 124
04/07/2009 19/11/2009 Collisions between container doors and passenger trains at Eden Valley
3 0 3
30/03/2009 19/11/2009 Track worker injury near Dalston Kingsland Station 3 0 3
19/12/2008 12/08/2009 Incident involving a container train at Basingstoke Station
3 0 3
18/12/2008 14/12/2009 Collision and derailment of a passenger train at North Rode
3 0 3
07/12/2008 27/08/2009 Workforce struck by a train at Stevenage 6 0 6
22/11/2008 19/11/2009 Fatality at Bayles and Wylies footpath crossing 8 1 7
10/11/2008 10/11/2009 Derailment at East Somerset Junction 11 0 11
03/11/2008 07/10/2009 Level crossing fatality at Wraysholme 5 0 5
21/10/2008 28/07/2009 Near miss at Llanbadarn Level Crossing 8 1 7
27/07/2008 24/06/2009 Incident at New Southgate 5 0 5
01/07/2008 11/06/2009 Incident at Poplar Farm level crossing 2 0 2
18/07/2008 29/10/2009 Collisions and runaways involving road-rail engineering machines / Whinhill (18/07/2008)
3 0 3
24/06/2008 18/06/2009 Collision at Acton West 8 3 5
19/06/2008 06/03/2009 Investigation into User Worked Crossings / Loover Barn Level Crossing (19/06/2008)
8 1 7
28/05/2008 20/08/2009 Incident at Bridge GE19 near London Liverpool Street station
7 1 6
23/05/2008 12/11/2009 Workforce hit by a train at Kennington Junction 3 0 3
26/04/2008 14/09/2009 Collision at Leigh on Sea 7 0 7
31/03/2008 30/03/2009 Level crossing fatality at Tackley station 6 0 6
25/03/2008 18/03/2009 Derailment of a freight train at Moor Street station 3 0 3
01/03/2008 29/05/2009 Two incidents at Cheddington and Hardendale 10 0 10
22/01/2008 20/01/2009 Level crossing fatality near Haltwhistle 4 0 4
25/01/2008 30/04/2009 Derailment at Scunthorpe 9 1 8
05/12/2007 25/02/2009 Collision at Glen Garry 7 0 7
13/11/2007 16/07/2009 Workforce struck by a train at London Victoria 9 0 9
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04/11/2007 27/05/2009 Runaway engineering machine at Romford, Essex 6 0 6
03/09/2007 12/02/2009 Derailment at Glasgow 4 0 4
22/06/2007 22/01/2009 Derailment at Ely 16 0 16
Recs issued 2009 Total 167 8 159
12/06/2008 14/01/2010 Derailment of a freight train at Marks Tey 7 0 7
27/01/2009 03/02/2010 Derailment of a freight train near Stewarton 12 0 12
22/03/2009 18/03/2010 Incident at Greenhill Upper Junction, near Falkirk 6 0 6
06/05/2009 12/05/2010 Fatal accident at Fairfield level crossing 3 0 3
01/06/2009 25/03/2010 Derailment of a passenger train near Cummersdale 5 0 5
25/08/2009 18/08/2010 Derailment at Wigan North Western station 4 1 3
23/09/2009 05/08/2010 Overhead line failure, St Pancras International 7 0 7
29/09/2009 23/09/2010 Fatal accident at Halkirk level crossing 6 0 6
11/10/2009 05/08/2010 Derailment at Windsor and Eton Riverside station 3 0 3
14/11/2009 23/09/2010 Failure of Bridge RDG1 48 (River Crane) between Whitton and Feltham 6 1 5
28/11/2009 28/10/2010 Derailment near Gillingham tunnel, Dorset 5 0 5
02/12/2009 02/09/2010 Fatal accident at Whitehall West Junction 2 0 2
19/12/2009 07/10/2010 Near-miss at Victory level crossing 4 0 4
04/01/2010 21/06/2010 Collision at Exeter St Davids station 1 0 1
14/02/2010 09/12/2010 Incident at Romford station 5 0 5
Recs issued in 2010 Total 76 2 74
23/03/2011 15/12/2011 Train passed over Lydney level crossing with crossing barriers raised 3 1 2
28/01/2011 28/11/2011 Passenger accident at Brentwood station 5 0 5
08/11/2010 17/11/2011 Station overrun at Stonegate, East Sussex 3 0 3
05/02/2011 20/10/2011 Derailment of a passenger train near Dryclough Junction, Halifax 5 0 5
28/12/2010 29/09/2011 Derailment in Summit tunnel, near Todmorden, West Yorkshire 5 1 4
17/08/2010 15/08/2011 Uncontrolled freight train run-back between Shap and Tebay Cumbria 4 3 1
17/08/2010 11/082011 Collision between an articulated tanker and a passenger train at Sewage Works Lane UWC 6 1 5
05/11/2010 04/08/2011 Bridge strike and road vehicle incursion onto the roof of a passing train near Oxshott station 5 2 3
29/09/2009 & 03/11/2008
28/07/2011 AOCL Class Investigation 4 1 3
06/06/2010 14/07/2011 Accident at Falls of Cruachan Argyll 6 0 6
20/07/2010 11/07/2011 Runaway and collision of a road-rail vehicle near Raigmore, Inverness 4 0 4
10/07/2010 07/042011 Collision between train 1C84 and a tree at Lavington, Wiltshire 4 0 4
04/05/2010 24/03/2011 Runaway and derailment of wagons at Ashburys 6 0 6
30/03/2010 23/03/2011 Track worker struck by a train at Cheshunt Junction 2 0 2
16/01/2010 28/02/2011 Fatal accident at Moreton-on-Lugg, near Hereford 4 3 1
04/01/2010 24/02/2011 Derailment of a freight train at Carrbridge, Badenoch and Strathspey 4 0 4
22/12/2009 31/01/2011 Near miss involving a freight train and two passenger trains, Carstairs
3 0 3
06/03/2010 24/01/2011 Passenger train struck by object at Washwood Heath 4 0 4
Recs issued 2011 Total 77 12 65
04/09/2011 20/12/2012 Near miss incident at Ufton automatic half barrier level crossing, Berkshire
7 6 1
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28/01/2012 13/12/2012 Fatal accident at a footpath crossing near Bishop’s Stortford
3 2 1
12/04/2012 03/12/2012 Person trapped in a train door and dragged at Jarrow station, Tyne and Wear Metro
5 4 1
30/11/2011 21/11/2012 Road vehicle incursion and subsequent collision with a train, at Stowmarket Road
9 7 2
03/02/2012 21/11/2012 Derailment at Bletchley Junction, Bletchley 3 1 2
22/10/2011 27/11/2012 Fatal accident at James Street station, Liverpool 3 1 2
19/12/2011 27/09/2012 Collision between a train and a lorry and trailer on Llanboidy automatic half barrier level crossing
6 2 4
26/08/2011 19/09/2012 Derailment at Bordesley Junction, Birmingham 4 4 0
27/07/2011 30/08/2012 Derailment at Princes Street Gardens, Edinburgh 5 5 0
18/07/2011 09/08/2012 Container train accident near Althorpe Park, Northamptonshire
4 3 1
12/06/2011 06/08/2012 Track worker struck by a train at Stoats Nest Junction
1 0 1
24/08/2011 18/07/2012 Fatal accident at Gipsy Lane footpath crossing, Needham Market, Suffolk
4 1 3
10/09/2011 12/07/2012 Incident involving a runaway track maintenance trolley near Haslemere, Surrey
6 2 4
10/04/2011 02/07/2012 Detachment of a cardan shaft at Durham Station 6 0 6
19/06/2011 27/06/2012 Incident at Llanbadarn Automatic Barrier Crossing (local monitored), near Aberystwyth
6 3 3
03/10/2011 21/06/2012 Fatal accident at Mexico footpath crossing (near Penzance)
5 1 4
10/10/2011 30/05/2012 Person trapped in doors and pulled along platform at King's Cross Station
1 1 0
26/05/2011 23/05/2012 Safety incident between Dock Junction and Kentish Town
3 1 2
25/09/2011 29/03/2012 Collision between a train and tractor at White House Farm User Worked Crossing 0 0 0
06/04/2011 22/03/2012 Partial failure of Bridge 94, near Bromsgrove 3 0 2
08/03/2011 27/02/2012 Two incidents involving track workers between Clapham Junction and Earlsfield 5 2 3
08/01/2011 15/02/2012 Tamper driver struck by a train at Torworth level crossing 1 0 1
20/02/2010 30/01/2012 Passenger train derailment near East Langton, Leicestershire 4 0 4
Recs issued 2012 Total 94 46 48
23/08/2011 15/08/2013 Partial structural failure in Balcombe Tunnel 9 0 9
20/08/2012 08/08/2013 Collision at Arley 3 0 3
22/03/2012 29/07/2013 Incident at Lindridge Farm UWC 5 1 4
25/03/2012 24/07/2013 Buffer stop collision at Bradford Interchange 5 0 5
07/07/2012 27/07/2013 Derailment at Shrewsbury 4 0 4
16/07/2012 27/06/2013 Dangerous incident at Roydon 2 0 2
05/01/2012 20/05/2013 Dewirement at Littleport 2 0 2
25/04/2013 28/10/2012 Dangerous occurrence involving engineering possession, near Dunblane 0 0 0
28/01/2012 28/01/2013 Freight train derailment at Reading West Junction 5 5 0
02/05/2012 14/01/2013 Fatal accident at Kings Mill No.1 level crossing, Mansfield 1 0 1
Recs issued 2013-14 Total 36 6 42
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Table 6. RAIB recommendations on RSSB to 30/04/14
Incident date
Published date
Type of report and location Rec. no.
Accepted by RSSB?
Action plan in
progress?
Closed in SMIS
Closure accepted by ORR
11/01/06 18/06/06 Cutting of rail on line still open to traffic near Thirsk
1 28/03/07 16/01/09
04/11/05 02/11/06 Derailment near Oubeck North, Lancaster
4 13/08/07 01/11/07
25/11/05 08/01/07 Autumn Adhesion
8 N/A 17/11/08 15/11/11
10 N/A 17/11/08 15/11/11
11 N/A 17/11/08 15/11/11
12 N/A 17/11/08 15/11/11
15 N/A 17/11/08 In progress
16 N/A 17/11/08 In progress
17 N/A 27/02/08 08/12/09
18 07/09/12 15/11/11
02/11/05 02/11/06 Trolley runaway, Larkhall
2 19/12/08 09/09/08
9 28/03/07 19/10/10
26/11/05 29/11/06 Derailment near Moy 10 13/08/07 16/01/09
09/02/06 23/01/07 Derailment near Brentingby, Melton Mowbray
3 13/01/09 30/04/08
4 02/06/08 30/04/08
7 02/06/08 30/04/08
14/01/06 30/01/07 Derailment at Haymarket, Edinburgh
1 28/03/07 19/10/10
16/04/06 30/01/07 Blowback of loco fire at Grosmont
9 15/11/08 16/06/10
15/02/06 30/04/07 Train door incident at Huntingdon 5
18/07/07 06/04/08
29/07/06 29/05/07 Fatal accident at Deal
1 25/07/08 09/11/09
4 19/03/08 09/11/09
5 11/03/08 09/11/09
8 25/07/08 09/11/09
18/08/06 08/08/07 SPAD at Purley 4 02/05/08 30/06/09
31/10/06 22/08/07 Collision at Badminton 1 07/07/08 06/11/08
3 N/A 03/11/07 01/10/10
10/06/06 30/08/07 Train door incident at Desborough
9 19/12/08 08/12/09
29/04/07 28/02/08 Track worker fatality at Ruscombe Junction
4 N/A 04/08/08 02/11/1220
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27/08/07 11/06/08 Two trains in the same section at Aylesbury
3 08/09/09 18/09/09
01/02/08 25/09/08 Collision of a train with a demolished footbridge, Barrow upon Soar
3 15/06/09 08/12/09
23/02/07 23/10/08 Derailment at Grayrigg
22 N/A 31/07/09 08/12/09
23 N/A 31/07/09 08/12/09
25a21 N/A 31/07/09 25/01/11
25b N/A 31/07/09 25/01/11
25c N/A 31/07/09 25/01/11
25d N/A 31/07/09 25/01/11
25e N/A 31/07/09 25/01/11
27/08/07 30/10/08 Train overspeeding through an emergency speed restriction at Ty Mawr Farm Crossing
1 N/A 14/01/09 13/11/08
22/08/07 20/11/08 Signal passed at danger and subsequent near miss at Didcot North junction
3 N/A 18/09/09 26/01/10
4 N/A 18/09/09 26/01/10
8 09/11/09 09/11/09
01/03/08 27/05/09 Detachment of containers from freight wagons near Cheddington and Hardendale
6 N/A 14/10/09 01/02/10
7 N/A 14/10/09 19/10/10
9 N/A 14/10/09 01/02/10
21/10/08 28/07/09 Near miss at Llanbadarn AOCL near Aberystwyth
3 05/10/09 05/05/10
26/04/08 14/09/09 Freight train collision at Leigh-on-Sea on 26 April 2008
6 N/A 08/02/10 22/01/10
7 N/A 08/02/10 22/01/10
22/11/08 19/11/09 Double fatality at Bayles & Wylies Crossing, Bestwood, Nottingham
7 In progress In progress
04/05/10 24/03/11 Runaway and derailment of wagons at Ashburys
4 27/05/2011 In progress
17/08/10 15/08/11 Uncontrolled freight train run-back between Shap and Tebay, Cumbria
4 In progress In progress
28/01/11 28/11/11 Passenger accident at Brentwood station
2 02/09/13 16/09/13
03/10/11 21/06/12
Fatal accident at Mexico footpath crossing (near Penzance), 3 October 2011
2 In progress In progress
19/06/11 27/06/12
Incident at Llanbadarn Automatic Barrier Crossing (Locally Monitored), near
6 02/07/13 In progress
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Aberystwyth, 19 June 2011
12/04/12 03/12/12
Person trapped in a train door and dragged at Jarrow station, Tyne and Wear Metro, 12 April 2012
5 02/07/13 In progress
22/10/11 27/09/12 Fatality at James Street, Liverpool, 22 October 2012
3 In progress
12/04/12 16/11/13 SPAD at Stafford, 12 April 2012 5 In progress
21/01/13 16/01/14 Derailment at Castle Donington 4
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Appendix 2. Glossary
For a full list of definitions, see the Annual Safety Performance Report.
Acronym Expansion
AHB automatic half-barrier crossing
ALARP as low as reasonably practicable
AOCL automatic open crossing, locally monitored
ASPR Annual Safety Performance Report
ATOC Association of Train Operating Companies
BTP British Transport Police
CCS Close call system
CCTV closed circuit television
CIRAS Confidential Incident Reporting and Analysis System
COSS controller of site safety
ECS empty coaching stock
ERA European Railway Agency
ERTMS European Rail Traffic Management System
FOC freight operating company
FWI fatalities and weighted injuries
GB Great Britain
GSM-R Global System for Mobile communications – Railway
HSE Health & Safety Executive
ICCS incident causal classification system
IFCS incident factor classification system
INES International Nuclear Event Scale
ISLG Infrastructure Safety Liaison Group
LOE Learning from operational experience
LUL London Underground Ltd
MOM mobile operations manager
NRMI Network Rail managed infrastructure
NRV national reference values
OFG Operations Focus Group
OHLE overhead line equipment
ORR Office of Rail Regulation
PHRTA potentially higher-risk train accident
PICOP person in charge of possession
PIM Precursor Indicator Model
PTI platform train interface
RAIB Rail Accident Investigation Branch
RGS Railway Group Standard
RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
ROGS Railway and Other Guided Transport Systems (Safety) Regulations 2006
RRISG Road Rail Interface Safety Group
RRV road–rail vehicle
RSSB Rail Safety and Standards Board
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Acronym Expansion
SMIS Safety Management Information System
SPAD Signal Passed At Danger (without authority)
SRM Safety Risk Model
TOC train operating company
TPWS train protection and warning system
UK United Kingdom of Great Britain and Northern Ireland
UWC user-worked crossing
