RAIB Report 06/2012 March 2012

At approximately 10:13 hrs on Sunday 25 September 2011, the 10:10 hrs service from Kings Lynn to Ely operated by First Capital Connect struck a tractor on White House Farm User Worked Crossing (UWC).

The impact between the train and the tractor caused the front of the tractor to be separated from the driving cab. The tractor driver remained in the cab of the tractor, but suffered a broken collarbone, lacerations and bruising.

The tractor moved onto the crossing when the train was no more than 100 metres away and travelling at 70 mph (113 km/h). The train driver sounded the train's horn and applied the emergency brake, but was unable to prevent the collision. The second wheelset on the train derailed after the collision occurred, but the train remained upright and in line while stopping. The train driver suffered a chest injury and shock in the accident. No-one else on the train was injured. Evacuation of passengers took place after three hours because equipment providing electrical power to trains had become dislodged and was hanging close to the track.

At the time of the accident, there were frequent movements of tractors and trailers over the crossing because of activity associated with the harvesting of sugar beet in an adjacent field. The tractor driver was telephoning the signaller at Kings Lynn to ask for permission to cross on each occasion. This was not the normal method of working; usually, crossing users would check that it was safe to cross before doing so and the signaller at Kings Lynn would not be aware that the crossing was being used.

The accident occurred because the signaller gave the tractor driver permission to cross before seeking confirmation that the train had passed. The tractor driver did not check for approaching trains because he considered that the signaller's permission to cross was sufficient guarantee that it was safe to do so.

The Rail Accident Investigation Branch has made no recommendations. However, three learning points directly relevant to the causes or consequences of this accident have been identified:

• signallers need to be made aware of the need to ensure that safety-critical messages are delivered in the right way;
• when non-standard methods are to be applied for operating a UWC, it is important that all parties involved jointly review the proposed method of working, which should then be documented and confirmed in order that misunderstandings can be avoided;
• and the availability of staff for earthing overhead line equipment at remote locations.

The RAIB has identified a further four learning points related to matters observed during its investigation, but not directly relevant to its cause or consequences. They cover:

the measurement of sighting distances as part of the assessment of safety at level crossings;

engagement between Network Rail and authorised users when assessing risk at UWCs so that the way in which the crossing is used can be considered as part of the exercise;

checks on telephones and the accuracy of signs at level crossings; and

keeping information on authorised users current.

RAIB Report 05/2012 March 2012

On Wednesday 6 April 2011, an assistant track section manager (ATSM) employed by Network Rail discovered a structure (Bridge 94, on the main line between Birmingham and Gloucester) supporting the track which he believed to be collapsing. He was on site to check a hole in the ballast under sleepers on the down main line, first identified during a routine track inspection eight days previously, which had reappeared despite being filled with clean ballast.

The ATSM arranged for track maintenance staff to attend site during the evening to monitor the track. They discovered that ballast was falling into a watercourse under each passing train, and reported the failure to Network Rail's fault control. Staff on site arranged an emergency speed restriction, followed by the diversion of trains onto other lines to bypass the failing structure. There were no injuries, but severe disruption continued until after emergency repairs were complete 36 hours later.

Nobody had inspected the part of the structure where the failure occurred since 2001 because neither Railtrack/Network Rail nor their structures examination contractor recognised the need for staff who were trained and equipped to enter a confined space to examine this structure. Consequently the condition of the part of the structure supporting the track was unknown.

The RAIB has identified one learning point from this incident: the importance of undertaking reconnaissance visits as an integral part of the planning process for detailed examinations.

The RAIB has also made recommendations to Network Rail that focus on improving the awareness of structures which are not easily visible from track level, and improving the structures examination regime.

RAIB Report 25 (Part3)/2006 January 2007

The immediate cause of the SPAD incidents that occurred at Esher on 25 November 2005 and Lewes on 30 November 2005 (which are the subject of Parts 1 and 2 of this investigation report) was poor adhesion between wheel and rail. Both trains involved had failed to stop within normally expected distances, despite the systems on the train performing in accordance with their specifications and the drivers correctly implementing the professional driving policy prevailing within the relevant Train Operating Company (TOC) at the time. Both trains had travelled a distance of approximately 3km from

the time that the driver had first applied the brake. Stopping distances under normal circumstances would have been less than 2km.

These two incidents occurred against a backdrop of an increase in the number of adhesion- related SPAD incidents and a significant increase in the number of adhesion-related station overrun incidents on the national rail network during autumn 2005, as compared with autumn 2004.

The purpose of this investigation has been to establish the causes of this increase in adhesion-related incidents in autumn 2005 and by so doing, identify ways in which short, medium and long-term performance can be improved.

Risk from adhesion-related incidents

When viewed from a historical perspective, the risk from adhesion-related incidents can be characterised as high in frequency but low in consequence. There have been very

few accidents arising from low adhesion. The most significant adhesion-related accident occurred in November 1985, when two trains collided at Copyhold Junction in Sussex resulting in 40 people being injured, 11 of them seriously. Another low-adhesion accident occurred in November 1994 when a train ran into the buffer stops at Slough, causing the driver serious injuries.

However, the two near-miss incidents at Esher and Lewes in autumn 2005 demonstrate that the potential exists for a serious accident to result from low adhesion conditions. There were 6 incidents (including the Esher SPAD) where the length of the overrun exceeded 1000 metres and 18 incidents where the overrun was so severe that the driver continued to the next station rather than returning to the station that had been passed. There is scope for further action to address the risk arising from these severe incidents.

Based on historical experience, although adhesion-related incidents have rarely resulted in an accident, should an accident occur, the most probable outcome is a collision if a train fails to stop at a signal or derailment if a train runs through facing points at excessive speed or fails to stop at a signal where trap points are located immediately beyond. While modern rolling stock has a high standard of crashworthiness, a train collision has the potential for fatalities and injuries. Train derailments at low speed may not carry the same potential for fatality and injury, but they can also lead to collisions if the derailed train obstructs an adjacent line.

RAIB Report 25 (Part 2)/2006 January 2007

The RAIB investigation into the SPAD at Lewes on 30 November 2005 which resulted in a 'near miss' with another train has been undertaken in parallel with an investigation into the SPAD incident at Esher on 25 November 2005 and a general investigation into the causes of adhesion-related station overrun and SPAD incidents during autumn 2005. This report focuses on the results of the investigation into the Lewes incident alone.

At approximately 19:07 hrs on Wednesday 30 November 2005, train 2D45, the 18:54 hrs Southern Railway service from Brighton to Hastings passed signal LW9 at danger at platform 3 in Lewes station. Train 2D45 stopped over the crossover located to the east of Lewes station, passing signal LW9 by a distance of approximately 150 metres and running through 75 and 77 points. Signal LW9 was at danger to protect the movement of train 2F21, the 19:07 hrs service from Lewes to Seaford, which was departing from Platform 5 and routed through 76 and 77 points towards the down line.

The driver of train 2F21 heard train 2D45 approaching in parallel on the down line and realising that the two trains were on a converging path, stopped train 2F21 at the tips of 77 points, some 30 metres from the potential point of conflict. The vigilance and prompt action of the driver of train 2F21 is commended.

Nobody was injured in the incident and there was no damage to the rolling stock. Points 75 and 77 were damaged when train 2D45 ran through them. After a conversation between the signaller and the driver of train 2D45, the train was moved clear of 77 points and the driver relieved of duty as part of Southern Railway's standard response to serious incidents. The driver of train 2D45 had made no allegation against the brakes on the unit involved and a Southern Railway fitter confirmed that the unit was in a safe condition to move. After a brake test, the train was taken at a maximum speed of 30 mph (50 km/h) to Glynde where it terminated and passengers were conveyed to their destinations either by following trains or by road transport. The train was taken empty to Eastbourne sidings.

The driver of train 2D45 was driving in accordance with the professional driving policy in force at the time within Southern Railway. The actions of the driver were neither causal nor contributory to the SPAD.

Southern Railway's Class 377 fleet is equipped with a wheelslide prevention (WSP) system, which has the objective of minimising stopping distances under low adhesion conditions.

The Class 377 unit was also equipped with a sanding system, designed to work with the WSP system to improve levels of adhesion. Before autumn 2005, Southern Railway had recognised a weakness in the sanding characteristics of the Class 377 unit (sanding was available for a maximum of 10 seconds, irrespective of the duration of WSP activity) and had started a programme to extend sanding times to a maximum of 60 seconds (when the WSP system was active). The unit involved in the SPAD at Lewes had not been modified at the time of the incident.

Post-incident testing of the unit involved in the SPAD at Lewes by Bombardier (the manufacturer of the Class 377 fleet) indicated that the key systems on the train, braking, WSP and sanding had performed in accordance with the specification for those items of equipment. The standards that apply to the design and operation of these systems, the Train Operating Company's (TOC) involvement with their specification, their optimisation for low adhesion conditions and the way in which they are tested to demonstrate that they are fit for purpose are issues that have been considered in the Part 3 report.

The treatment of the railhead by Network Rail on the line where the incident occurred involved water jetting and applying a layer of Sandite using a Multi-Purpose Vehicle (MPV). Railhead treatment of Falmer bank had been undertaken approximately eight hours before the SPAD occurred. Treatment commenced at a point approximately 800 metres beyond the location where train 2D45 started experiencing adhesion problems. The effects of Sandite are gradually eroded with the passage of trains. The time lapse and traffic density between treatment and the incident would have limited, if not negated, the benefit obtained over those parts of the bank that had been treated by the time train 2D45 passed.

Railhead swabbing of the area where the incident had occurred (which was undertaken soon after the incident) found localised and limited evidence of contamination from vegetation and hydrocarbons. It is likely that the effect of the contaminant was exacerbated by light rain, which commenced as train 2D45 approached Falmer bank.

Data gathered from the On Train Monitoring and Recording (OTMR) equipment from the unit involved indicated that train 2D45 experienced severe low adhesion conditions for a distance of approximately 2,500 metres. It is likely that available levels of adhesion were less than 0.02 (see paragraph 8), whereas normal dry rail would offer at least 0.20. Severe low adhesion conditions are discussed in the Part 3 report.

The actions of the signaller involved in the Lewes incident were neither causal nor contributory to the SPAD. However, there are lessons to be learned with relevance to the training of signallers in handling emergency Cab Secure Radio (CSR) messages and the circumstances under which Network Rail performs routine drugs and alcohol testing. There are also lessons to be learned with regard to co-ordination between Network Rail and TOCs following near-miss incidents.

Three recommendations specific to the Lewes incident are made to improve safety, all of which relate to matters arising from the incident, as referred to in paragraph 19. The Part 3 report contains a number of recommendations relevant to the causal and contributory factors associated with the Lewes incident, but with broader application.

[Communications Aspects]

The signaller attempted to make an emergency call via the CSR to stop train 2F21 before it reached 76/77 crossover and crossed into the path of train 2D45. The CSR emergency stop facility has two buttons, one red and one yellow. If a signaller wishes to send an emergency stop message to a specific train, the red button is pressed. The system then asks for the signaller to input the train reporting number of the specified train and, once confirmed, the message is sent. If a signaller wishes to stop all trains within the area controlled by the signal box (or within a designated zone), the yellow button is pressed and, once confirmed, the emergency stop message is sent to all trains.

During the incident at Lewes, the signaller intended to send an 'all trains stop' message, but pressed the red button on the CSR equipment in error. Thinking that the 'all trains stop' message had been sent, the signaller took no further action to stop train 2F21. The emergency message had not been sent to (or received by) train 2F21 as the CSR system was waiting for a train reporting number to be keyed in by the signaller. Train 2F21 continued out of Platform 5 towards 76 and 77 points.

RAIB Report 25 (Part 1)/2006 January 2007

This report contains the findings of the RAIB investigation into the incident that occurred at Esher on 25 November 2005 when a train passed two successive signals at danger, overrunning the first signal by a distance of approximately 1050 metres. It is Part 1 of an investigation into adhesion-related incidents during autumn 2005.

On 30 November 2005, a signal passed at danger (SPAD) incident occurred at Lewes in circumstances that bore some similarity to the SPAD at Esher. The drivers of both trains had alleged that severe adhesion problems had been the cause of the overruns. The RAIB has also undertaken an investigation into the SPAD at Lewes (reported in Part 2 of the autumn adhesion investigation).

During the early stages of the investigation into the two SPAD incidents, it became apparent that there had been a higher number of adhesion-related SPADs and station overrun incidents in autumn 2005 than had occurred during autumn 2004. A separate report, Part 3 of the autumn adhesion investigation, has been prepared to address the causes of the high number of adhesion-related incidents in autumn 2005. Some of the issues identified in the investigation of the incident at Esher have much wider relevance than for that incident alone. Where appropriate, this Part 1 report into the incident at Esher contains references to the analysis of performance during autumn 2005 reported in Part 3.

The railhead on the up fast line at Esher had not been included within Network Rail's autumn adhesion treatment programme. This location was not a known low adhesion site and there had been no history of adhesion incidents on the up fast line. Railhead swabbing undertaken after the incident found no evidence of contamination. However, data gathered from the On-Train Monitoring and Recording (OTMR) equipment of the unit involved indicated that train 1A12 experienced severe low adhesion conditions for a distance of approximately 2500 metres. It is likely that available levels of adhesion were less than 0.03, whereas normal dry rail would offer at least 0.20 (see paragraph 8). The phenomenon of severe low adhesion conditions is discussed in the Part 3 report as is the industry's process for investigating adhesion incidents.

The actions of the signaller involved in the Esher incident were instrumental in avoiding a much more serious incident and the signaller is commended. The driver of train 1A12 advised the signaller that the train was sliding at an early stage and this enabled the signaller to manage the incident effectively. The driver is also commended.

The movement of train 1A12 into Surbiton station after the incident was not fully in accordance with procedures. There was also confusion in the aftermath of the incident regarding the effectiveness of the braking system on the unit involved, which resulted in the initial decision to allow train 1A12 to continue to Waterloo being changed, but not until the train had already left Surbiton.

Three recommendations specific to the incident at Esher are made to improve safety, all relating to procedures that govern the movement of trains after a serious incident. The Part 3 report contains a number of recommendations that are relevant to the causal and contributory factors associated with the Esher incident.

RAIB Report 03/2012 February 2012

At around 06:00 hrs on Tuesday 8 March 2011, two gangs of Network Rail track maintenance staff were involved in incidents with trains between Clapham Junction and Earlsfield stations. The gangs were setting up an emergency speed restriction after the discovery of a rail defect earlier that morning. The work was being carried out following the late handback of an engineering possession. There were no casualties, and only minor disruption to train services following the incidents.

The staff involved did not follow the rules for setting up safe and appropriate systems of work. This was due to a combination of factors including excessive workload, the pressure to complete the work, fatigue and / or tiredness, the complexity of the rules, the absence of checking of the arrangements by a third party, the ineffectiveness of Network Rail's competence management process and a shortage of staff.

The RAIB has made five recommendations to Network Rail. These relate to the arrangements for carrying out unplanned and / or emergency work, the pressure on those responsible for setting up protection arrangements for access to the railway in such situations, the workload of Track Section Managers, the competence of staff in situations which are encountered infrequently and the provision of confirmation to the signaller that an emergency speed restriction has been set up.

RAIB Report 04/2012 March 2012

A steam locomotive hauling a passenger train on the Kirklees Light Railway on Sunday 3 July 2011 ran low on water in the boiler. The train crew did not take prompt action to deal with the situation and the boiler overheated, damaging the locomotive and giving rise to a risk of injury to the train crew if the overheated metal had ruptured.

The cause of the incident was that the driver did not ensure that sufficient water was put into the boiler during the journey and did not remove the fire from the locomotive when he realised the water had run low. The driver had just completed his training for driving steam locomotives. The underlying cause was that the Kirklees Light Railway's safety management system was inadequate to deal with the risks arising from operation of a steam railway.

Two recommendations have been made to the Kirklees Light Railway concerning their safety management system and operating procedures.

RAIB Report 02/2012

At about 23:55 hrs on Saturday 8 January 2011, a tamper driver walking to a tamper in a work site on the East Coast Main Line, was struck a glancing blow by a passenger train travelling at 100 mph (161 km/h). The tamper driver took evasive action when alerted by the train’s horn, and suffered minor injuries.

The investigation found that the tamper driver, who entered the railway in contravention of rules and his training, wrongly assumed that the line he was walking on was closed to normal traffic. The unsafe actions of the driver were found to have been a causal factor. However, the investigation also found that the driver did not have the information he needed to get to his tamper in safety.
Industry practices in which it was not uncommon for drivers to walk to trains in?work sites without having first received a safety briefing were found to be an underlying cause of this accident. There were also deficiencies in the organisational arrangements for providing the tamper driver with information.

The RAIB has made a recommendation relating to the procedures followed by Network Rail and its contractors for providing train crews with safety briefings when accessing work sites.

RAIB Report No 01/2012

On 20 February 2010, at around 15:49 hrs, a seven-car Meridian diesel multiple unit passenger train derailed by one axle of the fourth vehicle, while travelling on the Midland Main Line near East Langton. The train was travelling at a speed of 94 mph (151 km/h) when the derailment occurred, and it subsequently ran for a distance of approximately 2 miles (3.2 km) before it stopped. The train remained upright during the derailment and did not foul the adjacent line. There were no injuries among the 190 passengers and 5 crew who were on board the train, but there was damage to the track and the train, including loss of diesel fuel.

The immediate cause of the derailment was the complete fracture of the powered trailing axle of the leading bogie on the fourth vehicle. The fracture occurred underneath the gear-side output bearing of the final drive and was caused by this bearing stiffening up so that it could no longer rotate normally. When this happened the axle spun within the inner race of the bearing to which it is normally tightly fitted. The consequent generation of a large amount of frictional heat between the axle and bearing resulted in the axle being locally heated to a high temperature and weakened to the point it could no longer carry its normal loading.

Key evidence about the condition of the bearing and its fit onto the axle was destroyed in the failure, making it impossible to determine with certainty, the precise sequence of events leading to the bearing becoming stiff in rotation. The RAIB investigation has interpreted the available evidence in order to identify the most likely cause of the failure from the possible causes. The RAIB concluded that the most likely cause of the bearing failure which preceded the overheating of the axle was a loose fit between the gear-side output bearing and axle.

The RAIB has made four recommendations. Two recommendations relate to reviewing the design and overhaul procedures for final drive gearboxes on Meridians and other rolling stock. They also cover consideration of the detection of overheating output bearings in order to mitigate risk to persons resulting from a failure of the output bearings, regardless of the cause. A third recommendation relates to the oil sampling regime used for the Meridian fleet and the fourth relates to the provision of practical, simulation based alarm handling training for drivers and train crew.

RAIB Report 20/2011

At approximately 14:24 hrs on Wednesday 23 March 2011, train number 1M68, the 13:45 hrs service from Cardiff to Nottingham, passed over Lydney manually controlled barrier (MCB) level crossing while the barriers were in the raised position. This crossing is on the main line between Gloucester and Newport. The railway signal protecting the level crossing was showing green, and the train was travelling at 59 mph (94 km/h). The red flashing lights intended to instruct road users to stop were operating and there were no road vehicles on the crossing. No injuries or damage resulted from the incident.

The crossing keeper had raised the up side barrier manually during the 90 minutes before the incident, due to a defect in the equipment controlling the barrier motors. Shortly before the incident, the crossing keeper lowered the barriers for a train approaching from the direction of Gloucester. He then raised both barriers manually just before the Cardiff to Nottingham train arrived at the crossing. An annunciator (buzzer) intended to warn the crossing keeper about approaching trains did not give the usual warning.

The railway signals protecting Lydney crossing should have been placed at danger before the barriers could be raised safely. The crossing keeper had no facility to control these signals, and did not inform signallers at Newport who could have kept the signals at danger while the barriers were raised. Several possible reasons for not informing the signaller have been identified.

The RAIB has made recommendations to Network Rail relating to the adequacy of instructions and training given to crossing keepers and signallers; and, the process used for on-going assessment of staff competencies. The RAIB has also recommended that Network Rail should modify standards for new and upgraded crossings so that protecting signals always display a stop aspect when the crossing barriers are raised.

RAIB Report 19/2011

RAIB Report 18/2011

RAIB Bulletin 05/2011

On 1 August 2011 a steam hauled passenger train on the ‘heritage’ Wensleydale Railway in North Yorkshire and a Volkswagen ‘Lupo’ car collided on a user worked level crossing1. The front of the car was extensively damaged but its driver was not injured. The train sustained only superficial damage and was not derailed. No one on the train was injured.

RAIB Report Report 12/2011 July 2011

Following the fatal accident at Halkirk automatic open level crossing, Caithness, on 29 September 2009, the RAIB decided to carry out two separate investigations. The first of these was into the Halkirk accident, while the second was to investigate the more general safety issues associated with automatic open level crossings installed on Network Rail’s managed infrastructure. This report addresses the more general safety issues.

The RAIB’s investigation confirmed that automatic open level crossings, which are protected only by road traffic light signals, and have no barriers, are the highest risk form of level crossing for vehicle drivers on public roads, and some of them have a significant history of incidents and accidents.

The investigation found that the lack of barriers at automatic open level crossings is the most significant factor contributing to vehicle drivers passing the road traffic light signals when they are operating, either deliberately or as a genuine error. The RAIB considers that the crossings with the highest risk of collision between trains and road vehicles should be upgraded, probably by fitting half barriers, but there may be other means which deliver an equivalent or better level of safety (eg closure).

The high cost of new level crossings is a reason why it can be difficult to justify upgrading existing crossings based on a cost benefit analysis. However, a system is being developed to retro-fit half barriers to existing automatic open crossings at a much lower cost than that of a new crossing. If this initiative is successful, it will be easier to justify the upgrade of existing crossings. The RAIB believes that this work should be prioritised accordingly.

The safety of level crossings can be improved by taking action against vehicle drivers who deliberately pass the flashing red lights. Where this behaviour is prevalent, red light enforcement equipment is a deterrent. The RAIB believes that the development of fixed digital cameras and their installation at selected level crossings, particularly in combination with greater penalties, would be beneficial in improving safety and should be prioritised.

The identification of factors at each crossing that lead to deliberate risk taking behaviour or genuine errors would enable appropriate risk reduction measures to be implemented. The RAIB believes that the existing risk assessments of automatic open level crossings should be reviewed to check whether all the relevant factors have been identified, and to determine whether additional mitigation measures are required.

Finally, the RAIB believes that Network Rail’s process covering the risk assessment of level crossings should include guidance to its staff on how to identify the relevant human factors, and take account of the associated risk, at specific level crossings in order to determine the adequacy of existing mitigation measures and the need for additional measures. This builds upon a similar recommendation the RAIB made following its investigation of the Halkirk accident.

RAIB Report 04/2011

On 16 January 2010, a collision occurred between a passenger train and two cars at the level crossing at Moreton-on-Lugg, near Hereford. The front-seat passenger in one of the cars was fatally injured. The driver was seriously injured and detained in hospital.
The two occupants of the other car attended hospital as a precaution. There were no casualties on the train, which did not derail.
The level crossing is controlled from the adjacent signal box. The cause of the accident was that the signaller raised the barriers in error when the train was approaching and too close to be able to stop before reaching the level crossing. He had just been involved in an absorbing telephone call that had interrupted his normal task of monitoring the passage of the train. As a result he believed that the train had already passed over the crossing.
There was no safeguard in the signalling system to prevent this from happening. There was no plan to fit such a safeguard, and no industry requirement to formally consider the safety benefits of one.
The RAIB has made four recommendations to Network Rail. They include assessing the need for additional engineered safety measures at level crossings like Moreton-on- Lugg and targeted improvements to its processes for managing risk at level crossings, and for determining when it should bring signalling assets into line with latest safety standards.

RAIB Report 15/2011

In the early hours of Tuesday 17 August 2010, a northbound freight train was travelling uphill on the West Coast Main Line between Tebay and Shap Summit in Cumbria. At 02:04 hrs the train slowed to a stop and then ran back until the driver braked and the train came to a stand at 02:09 hrs. During the run-back the train reached a maximum speed of 51 mph (82 km/h) and travelled 2.2 miles (3.5 km). The incident caused no injuries or damage; however the consequences could have been worse. If the driver had not braked when he did, the rear of the train would have travelled over a turnout into Tebay sidings at an excessive speed, which may have led to derailment, damage and obstruction of the adjacent line on which trains travel south.
The investigation found that DB Schenker’s train driver, who was working the first of a series of night shifts, was probably fatigued and not sufficiently alert at the time of the incident. It also found that although DB Schenker had used a recommended mathematical model and industry guidance to plan the shift, the driver had been exposed to a work pattern that was likely to induce high levels of fatigue. The report concludes that the mathematical model adopted by most of the rail industry is likely to under-predict the probability that high levels of fatigue will be experienced by people working a first night shift.
This report makes one recommendation to DB Schenker concerning its management of fatigue, two recommendations to the Office of Rail Regulation concerning guidance on the management of fatigue and the accuracy of mathematical models used to predict fatigue, and one recommendation to RSSB on improving rail industry information on fatigue-related accidents and incidents.

Bulletin (Dalchalm) 03-2011

At around 16:50 hrs on 23 February 2011, train 6E69, the early running 17:45 hrs freight service from Georgemas Junction Sidings to Hartlepool South Works, derailed at Dalchalm level crossing, Highland. The train was travelling at around 25 mph (40 km/h) in the up direction (towards Inverness) when it derailed.

Train 6E69 ran derailed for around 340 metres before becoming re-railed as it passed over East Brora Muir No.2 level crossing. Damage was caused by the derailed train to the road surface at both level crossings, to the permanent way and to signalling equipment. Nobody was injured in the derailment.

RAIB Report 16/2011

In the early hours of 28 December 2010, a passenger train was travelling from Manchester to Leeds when it struck a large amount of ice that had fallen onto the tracks from a ventilation shaft in Summit tunnel. All wheels of the front bogie were derailed to the left in the direction of travel causing the front driving cab of the train to strike the tunnel wall. The train remained upright and once it had stopped, the train crew took action to protect the train and raise the alarm. About three hours later, the passengers and train crew had been led out of the tunnel by the emergency services. No injuries were reported, while the train suffered damage to its cab windscreen, a coupler, bodywork and underframe. There was minor damage to the track.

The ice formed as water, seeping through the lining of a ventilation shaft, froze during a long period of freezing temperatures. This ice fell onto the track after a thaw which started on 27 December 2010. The train, which was the first to pass through the tunnel in over 3 days due to the Christmas holiday period, then collided with it. A combination of factors led to this accident:

• the risk of ice, particularly ice falls onto the track, was not identified before the train service resumed so the train was allowed to enter Summit tunnel while running at its maximum permitted speed; and
• the routine maintenance regime did not identify excessive ice in the tunnel and no additional inspections were carried out.

The RAIB has made five recommendations, all directed to Network Rail. The first recommendation relates to how water in Summit tunnel is managed. The second is about identifying those structures which are at risk from extreme weather and then checking they are safe to use after periods when no trains have been running. The third calls for the potential hazards due to extreme weather and thaw conditions to be taken into account in Network Rail’s weather management processes. The fourth calls for training and information to be given to staff who need to carry out the additional inspection of structures that are at risk in extreme cold weather. The fifth relates to the management of safety related information (and details of actions taken) that is passed from Network Rail’s buildings and civils – asset management function to other parts of the company.

RAIB Bulletin 06/2011

On Tuesday 19 July 2011, shortly after train 1S94, the 17:57 hrs service from London Euston to Glasgow Central had begun its journey, one of the doors on the left-hand (looking in the direction of travel) side of the train came fully open. The train had just passed Wembley Central and was travelling at 109 mph (175 km/h) on the down fast line at the time.

The train manager, who was checking that the door was secure when it opened, had to grab an adjacent handrail to stop himself falling out. He was shocked, but otherwise unhurt. No other persons were put at risk.

The train’s brakes were applied automatically when the door opened, and it came to a stop near North Wembley station.

RAIB Bulletin 04/2011

The Bure Valley Railway (BVR) is a narrow gauge heritage railway that runs nine miles (14.5 km) from Aylsham to Wroxham in the county of Norfolk. The track gauge is 15 inches (381 mm).

At approximately 15:25 hrs on 30 May 2011, the leading bogie of the second coach of the 14:40 hrs train from Wroxham derailed close to the village of Brampton, about two miles (3.2 km) from Aylsham. The train was formed of nine coaches and was hauled by a steam locomotive.

When the derailment occurred, the train was running at about 16 mph (26 km/h). The driver became aware of jerking and stopped the train. No-one was injured as a result of the derailment. Most of the 61 passengers on the train completed their journeys by walking to Aylsham; a few were transported by road.

The BVR quickly established that the derailment was caused by the failure of an axle fitted to the derailed coach; one of the journal ends had fractured from the remainder of the axle adjacent to one of the wheels.

RAIB Report 17/2011 October 2011

At 06:07 hrs on Saturday 5 February 2011 a derailment occurred close to Dryclough Junction, in Halifax. Both vehicles of a two-car passenger train were derailed when the train ran into stone rubble on the track. The rubble had fallen from a retaining wall beside the line which had collapsed during the night. There were eight passengers and two crew members on the train and nobody was injured in the accident.

The collapse of the wall followed a period of heavy rain.

The local authority highways department had reported cracks in the pavement behind the wall to Network Rail on several occasions, most recently in October 2010, and had closed the footpath as a precaution.

The investigation found deficiencies in the examination of the wall by Network Rail’s examination contractor and in the way in which Network Rail handled reports from Calderdale Metropolitan Borough Council concerning problems with the wall. The limited extent of repairs made to the wall in 2006 also contributed to its failure.

The RAIB has made five recommendations to Network Rail, relating to the structures examination process, the control of minor civil engineering construction works and the system for dealing with reports from third parties of problems with Network Rail infrastructure.

[Communication Issues:

The driver’s emergency NRN call was answered by the Network Rail operations controller. The driver initially gave the wrong location for the accident, stating that he had just left Summit tunnel instead of Bank House tunnel. This was due to the driver being shocked and disorientated by the accident. The controller subsequently established the correct location by speaking to the relevant Network Rail signaller.  Page 10]

RAIB Report 13/2011 August 2011

At about 15:29 hrs on Friday 5 November 2010, a lorry fell from the Warren Lane (A244) road bridge onto the railway at Oxshott, Surrey, and struck the roof of a passing train. The lorry had collided with the bridge’s parapet and partly demolished it. Road users who witnessed the accident responded by contacting the emergency services and assisting the injured lorry driver who was trapped in the lorry’s cab.

The rear three carriages of the train were damaged and the rear carriage of the train derailed. One passenger, sitting directly beneath the point of impact, was seriously injured, and five other passengers received minor injuries. No other trains were involved.

The RAIB has made two recommendations to the Department for Transport concerning issuing guidance for local highway authorities, two recommendations to Surrey County Council concerning highway safety inspections and safety measures at the bridge where the accident occurred, and one recommendation to Network Rail to enhance existing structural examinations at bridges carrying roads over railways.

RAIB Report

On 17 August 2010, train 2T27, the 17:31 hrs service from Sudbury to Marks Tey, collided with a loaded 44 tonne articulated road tanker on Sewage Works Lane user worked crossing (UWC) near Sudbury in Suffolk.  The collision caused the train to derail.  Several passengers and the conductor on the train were injured in the collision; four passengers and the train driver were seriously injured.

The RAIB investigation identified that the tanker driver drove onto Sewage Works Lane crossing when it was not safe to do so.  He had not used the telephone provided to contact the signaller before driving onto the crossing, although it was a requirement to do so, and that he did not see (and may not have looked for) the approaching train.

The investigation also found that:

• the company employing the road tanker driver had not been briefed by the authorised user of the crossing, Anglian Water, on how staff could use Sewage Works Lane UWC safely;
• the long waiting times that road vehicle drivers sometimes experienced before being given permission to use the crossing at Sewage Works Lane led to a high level of non-compliance with the correct procedures for its use;
• Network Rail's processes for identifying misuse at user worked crossings did not identify this issue; and
• Network Rail's data gathering exercise at Sewage Works Lane UWC (for the purposes of risk assessment) were characterised by errors and omissions and the amount of time devoted by Network Rail staff to analysing the results form the risk assessments and considering possible risk mitigation measures was limited.

With regard to the consequences of the accident, the RAIB concluded that the design of the tables in the type of train involved at Sewage Works Lane may have exacerbated the injuries suffered by the passengers.

Network Rail has informed the RAIB that it has commenced the process of installing miniature stop lights at Sewage Works Lane and at other similar crossings on the same branch line.

Recommendations

As a consequence of this accident, the RAIB has made six recommendations.

Five recommendations are targeted at Network Rail covering the following areas:

• improving safety at Sewage Works Lane UWC;
• reminders to business users at user worked crossings of their responsibility to brief contractors on how to use such crossings safely;
• Network Rails management of risk at crossing where there are long waiting times for road users;
• improvements in Network Rail's process for gathering information at user worked crossings; and
• changes to Network Rail's approach to the management of risk at level crossings.

The sixth recommendation is aimed at the owners of the type of train involved in the accident and covers:

• a review of the crashworthiness performance of the tables in the type of train involved.

RAIB Report 09/2011

Shortly before 07:00 hrs on Friday 13th August 2010, an engineering train ran away along part of the Northern Line of London Underground.

The train consisted of a self-propelled diesel-powered unit designed for re-profiling worn rails. It had been working between Highgate and Archway stations on the southbound line during the night of 12/13 August. At the end of grinding operations that night, the crew of the unit found that they were unable to restart its engine to travel away from the site of work.

An assisting train, consisting of a six-car train of the 1995 stock used for passenger services on the Northern line, was sent to the rescue of the grinding unit. The assisting train was coupled to the grinding unit by means of an emergency coupling device, and the braking system of the grinding unit was de-activated to allow it to be towed. The combined trains then set out to run to East Finchley station. At about 06:42 hrs, after passing through Highgate station, the coupling device fractured and the grinding unit began to run back down the gradient towards central London. The crew of the grinding unit, who had no means of re-applying the brake, jumped off the unit as it passed through Highgate station. It then ran unattended for about four miles, passing through a further six stations, and came to rest near Warren Street station about sixteen minutes later. LUL control room staff took action to clear trains away from the path of the runaway unit.

No-one was hurt. There was some damage to the grinding unit, and points at Mornington Crescent station were damaged when the unit ran through them.

The emergency coupling broke because it was not strong enough for the duties it was intended to perform, and had been inadequately designed and procured. The RAIB has made seven recommendations to London Underground Ltd, covering the processes for introducing new engineering equipment, review of existing equipment, investigation of incidents, training of staff, the operation of unbraked vehicles, and the quality assurance processes used by LUL and its associated companies.

RAIB Report 10/2011

At about 23:39 hrs on 20 July 2010, a machine operator was placing a road-rail excavator onto the railway near Drumrosach farm, near Raigmore, Inverness. As the machine was being placed on the track it began to run down the gradient. The people who were in attendance were unable to stop the machine before it gathered speed.

The machine ran for 0.88 miles (1.41 km) with the machine operator on board, and then collided, at between 40 and 50 mph (64 to 80 km/h), with the rear of a stationary freight train which was standing on the bridge over the line that runs between Inverness and Aberdeen.

In the collision, the machine operator was thrown out of the cab and landed on top of the rear wagon of the freight train, sustaining serious injuries. The excavator was derailed by all wheels and the leading axle of the rear wagon became derailed. Both the excavator and the freight wagon sustained damage.

The RAIB’s investigation identified that the excavator was placed into an unbraked condition while being manoeuvred onto the track. This is likely to have occurred due to a combination of operator errors and a transient single point failure of the machine’s control system. The machine operator was then unable to slow, derail or stop the excavator as it ran away.

The RAIB has made four recommendations relating to modifications to the design of the excavator, a review of the safety requirements that are specified for this type of machine, and a review of the training of people who control this type of machine on site.

RAIB Report 08/2011

At around 14:09 hrs on Saturday 10 July 2010, the 13:06 hrs First Great Western service from Paddington to Penzance collided with a tree which had fallen from adjacent land at Lavington, Wiltshire. The train was travelling at about 90 mph (145 km/h) at the time the collision occurred and the leading cab was extensively damaged. The train was disabled by the collision and was subsequently hauled to Westbury station, arriving at 19:03 hrs.

The driver sustained minor injuries, but no-one else was injured. The RAIB has made four recommendations. Two recommendations have been made to Network Rail concerning the evaluation of risk from trees on adjacent land and communicating with landowners. A further recommendation has been made to Network Rail regarding the actions of signallers when undertaking safety-critical communications. One recommendation has been made to First Great Western regarding their policy on the use of mobile telephones by traincrew.

RAIB Report 11/2011

?At 20:55 hrs on Sunday 6 June 2010, the 18:20 hrs train from Glasgow Queen Street to Oban struck a boulder that had fallen onto the track just west of the station at Falls of Cruachan, in the Pass of Brander, on the line from Crianlarich to Oban. The boulder lifted up the front coach of the two-coach train and derailed it to the left and down an embankment. The leading bogie of the rear coach came to a stand supported by the boulder with the rear bogie still on the track.

Of the 64 passengers and three crew on the train, eight of the passengers were taken to hospital with minor injuries.

The boulder had fallen down the cutting slope onto the railway from within the railway boundary. It had become insecure due to the growth of tree roots around it, which gradually prised it from its stable position, and soil erosion from normal rainfall. Network Rail’s earthworks management system applied to cutting slopes had not identified the hazard of loose boulders in the area that the accident occurred.

The RAIB has made five recommendations to Network Rail relating to the management of earthworks. These include:

•  improving the clearance of vegetation growing on earthworks so that hazards to thesafety of railway operation can be identified;
•  improvements to the collection of slope data so that a full appreciation of the condition of slopes is obtained; and
•  improvements to the process for the implementation of remediation works to prevent future earthworks failures.

A further recommendation has been made relating to the prevention of lighting diffusers and other saloon panels on rolling stock becoming displaced during accidents.

RAIB Report 05/2011

On the morning of 12 May 2010, the leading wheelset of a locomotive that was hauling an engineering train derailed when it was travelling westbound between Gloucester Road and Earl’s Court stations on the Piccadilly Line of the London Underground system.

As a result of the derailment, the locomotive and infrastructure were damaged and the driver of the engineering train reported suffering from trauma. The westbound Piccadilly Line was closed between Gloucester Road and Earl’s Court stations until the start of the passenger service the following day while the locomotive was re-railedand infrastructure repairs were undertaken.

The derailment occurred because  the track was not able to maintain gauge within safe limits as the train passed over it. A combination of factors led to this situation occurring, including:

•  the non-identification and misclassification of track faults which led to those faults not being rectified;
•  no action being taken in response to the identification of dynamic wide gauge at the location of the derailment in the previous months;
•  there were insufficient staff to maintain the track in good condition; and
•  the Piccadilly Line team within Tube Lines was mainly focused on managing safety faults and had not identified the safety risks from combined groups of less serious faults.

The RAIB has made nine recommendations. The recommendations include changes to how data from asset inspection equipment is presented, an analysis of the tasks involved in track patrolling and inspecting, changes relating to the training and assessment of track patrollers and inspectors, improvements to assurance processes and consideration of the use of available technologies that can assist track patrollers and inspectors in recording and classifying track faults.

RAIB Report 07/2011

A derailment occurred on the night of 3/4 May 2010 at Ashburys in Manchester. Five wagons loaded with aggregate ran away from a siding for 890 metres before two of them were derailed at trap points. The wagons had been left in the siding three days earlier.

The runaway was caused by ineffective handbrakes on the wagons. The investigation found deficiencies in the maintenance plan for the wagons and raised a concern about the way in which safety related information from other industries was brought to the attention of the rail industry.

The RAIB has made six recommendations, relating to operating instructions, maintenance plans, distribution of safety related information from other industries and improved brake testing.

RAIB Report 06/2011

At 11:44 hrs on 30 March 2010 train 2B13, a passenger service running from Stansted Airport to London Liverpool Street, travelling at about 30 mph (48 km/h), struck a member of railway staff at Cheshunt Junction in Hertfordshire. The person who was struck was one of a team of eight people carrying out maintenance work on the track, and he was seriously injured. There was no damage to the train or infrastructure.

The investigation has identified that the track worker who was struck did not moveto a position of safety and remained in the path of the train as it passed through the junction. The track worker had not expected the train to follow the route which took it onto the line on which he was working.

No satisfactory safe system of work had been established, and staff did not always move to a position of safety when the lookout warned that trains were approaching.

The RAIB has made two recommendations to Network Rail relating to reducing the risk of working at junctions, and the behaviour of staff working at locations with extended sighting of approaching trains.