Railway Accident Investigation Unit - Ireland

A very severe storm was experienced between 9:30 and 10:30 pm on the evening of the 25th June, 1935, accompanied by heavy rain.  About 250 yards south of Dun Laoghaire station the track runs through a cutting faced with a vertical stone wall, 19 feet 6 inches high; a storm sewer loacted 8 feet 6 inches from the top and 5 feet inside the "up" track burst at about 10:05 pm, causing the retaining wall to collapse for 30 feet in length.  The fallen stone and earth blocked the "up" track to a height of about 4 feet and the "down" track to a height of about 1 foot.

The 2-coach Drumm battery "A" train, left Sandycove at 10:08 pm, travelling towards Amiens Street, Dublin, on the "up" track.

On the previous "down" trip the driver and guard noticed water in the cutting sufficient to cover the rails, and in view of this the driver slowed down on approaching the cutting, especially as the "up" track at this point is on the inside of a sharp curve and the sighting distance is short.  The driver estimates his approaching speed at 10 miles per hour, and when about 20 yeards from the point of derailment he noticed the blockage on the line.  The track was then flooded with storm water to a depth of 2 feet. He was unable to apply his brakes in sufficient time to stop the train before meeting the debris, and ran into the obstruction at an estimated speed of 6 miles per hour.

RAIU Investigation Report 2012-R001

At approximately 12:00 on Monday 14th February a waste collection vehicle crew, who regularly used the Morrough level crossing (XG173) to collect waste from the private residence, Murrough House, opened the gates of the level crossing and passed over the level crossing. The crew left the level crossing gates open while they collected waste, a task that usually took only a few minutes. At approximately 12:13 a Volkswagen Bora car approached the level crossing with the gates still open. The car slowly drove onto the level crossing. At approximately the same time, the 09:30 passenger service from Heuston to Galway approached the level crossing. On seeing the car, the train driver sounded the horn twice and applied the emergency brake. The train struck the car as the car's driver was attempting to reverse off the level crossing. Both occupants of the car were treated for their injuries at the local hospital and released later the same day.

The immediate cause of the accident was that the car stopped at the level crossing in a position that encroached into the path of the approaching train, and was then struck by the train while attempting to reverse off the level crossing.

The contributory factors were:

• The level crossing gates, which provide a barrier to the railway, were open when the car arrived at the level crossing;
• The signage present at the Level Crossing was not successful in communicating to the car driver that he was approaching a Level Crossing or in conveying any of the dangers associated with level crossings;
• There were no warning signs on the approach to the level crossing to alert the car driver that he was approaching a level crossing.

The underlying factors were:

• Iarnród Éireann did not comply with their own internal standard for the certification of changes to infrastructure on the network;
• Iarnród Éireann independently developed the new style signage, without proper consultation with the Railway Safety Commission or other parties;
• The Railway Safety Commission adopted an informal approach to the oversight of Iarnród Éireann's signage design.

As a result of the Railway Accident Investigation Unit investigation the following new safety recommendations, relating to the occurrence, have been made:

• Iarnród Éireann should review the suitability of the signage at user worked crossings on public and private roads, ensuring that human factors issues are identified and addressed.
• Iarnród Éireann should liaise with local authorities where private road level crossings can be accessed from a public road to ensure there is advance warning to road users.
• Iarnród Éireann should ensure that they adopt their own standards in relation to design changes to any plant, equipment, infrastructure or operations that have the potential to affect safety.
• The Railway Safety Commission should ensure that they adopt a formal approach to submissions made by IÉ in relation to design changes to any plant, equipment, infrastructure or operations that has the potential to affect safety.

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R007

At approximately 10:50 on Sunday 24th October 2010 as the 10:15 passenger service from Athlone to Westport approached Knockphunta Level Crossing, the train driver saw a car approaching the level crossing while the level crossing gates were open to the railway. The train driver sounded the horn and applied the emergency brake; however the train struck the car whilst it was trying to reverse away from the level crossing. There were no fatalities or injuries as a result of this accident. There was damage to the front of the car.

The immediate cause of the accident was:

The car stopped at the level crossing, in a position that encroached into the path of the approaching train, and then was struck by the train when attempting to reverse away from the level crossing.

The contributory factors were:

• There are no road markings or marker posts at the Level Crossing identify the decision point for users to allow them to stop clear of the railway line and make a decision to cross safely or wait;
• The level crossing gates, which provide a barrier to the railway, were open when the car driver arrived at the level crossing.

The underlying factor was:
Iarnrod Eireann has not introduced adequate measures to reduce the frequent misuse at the level crossing in relation to level crossing users leaving the gates open to the railway.

As a result of the Railway Accident Investigation Unit investigation the following new safety recommendation, relating to the occurrence, has been made:
Iarnrod Eireann should upgrade the Level Crossing to ensure that the operation of the Level Crossing is not reliant on any direct action by the level crossing user.

Two safety recommendations previously issued by the Railway Accident Investigation Unit in February and July 2008 have also been reiterated.

[Communications:  No telecommunications issues identified.]

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R006

At approximately 11:13 on the 2nd September 2010, the 09:30 freight service from Ballina to North Wall was travelling along the left hand curve on the approach to user worked level crossing XM096. As XM096 came into view, the Train Driver observed a tractor stationary on the track at the level crossing. The Train Driver sounded the horn and applied the brake. The Farmer driving the tractor was looking downwards as the train approached and had his arm between his legs in the area of the controls. Just before the train reached XM096 the Farmer looked up at the train. The tractor did not move clear of the railway line and  was struck by the train. The train came to stop 469 metres beyond the level crossing. The Farmer was fatally injured and pronounced dead at the scene.

The immediate cause of the accident was:

The tractor was stationary on the track as the train arrived at the level crossing.

The contributory factors identified were:

The tractor may have stalled on the track;

Vegetation may have obscured the Farmer's view of the approaching train from his position on the the track;

The Farmer may not have been looking for an approaching train as some of the level crossing users were known to incorrectly read the green aspect on the railway signal protecting level crossing XM093 as an indicatin that no trains were approaching.

The underlying factors identified were:
 There was no formal process in place to ensure communication with the known users of the level crossing other than through the signage at the level crossing, including addressing known issues in relation to their use of the level crossing;
 The information provided to level crossing users through signage at the level crossing was found not to include information provided in the level crossing user booklet relating to the advice that the signals are solely for the control of train movements and on what to do in case of difficulty when crossing the railway.

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R004

At 10:22, on Friday the 2nd of July 2010, the 08:00 Heuston to Cork passenger service passed through the Buttevant Level Crossing without incident. Approximately thirty seconds later a Track Recording Vehicle approached Buttevant Level Crossing in the opposite direction, as the Gate Keeper was in the process of closing the gates across the railway line. The Track Recording Vehicle struck one of the gates which resulted in damage to the gate and the Track Recording Vehicle. There were no injuries or fatalities as a result of this accident.

The immediate cause of this accident:

The Gate Keeper was in the process of closing the level crossing gates across the railway line as the Track Recording Vehicle arrived at the level crossing.

The causal factors were:

The Gate Keeper did not fully adhere to the operation instructions provided for the opening and closing of the level crossing gates;

The contributory factor was:

The Gate Keeper‘s co-ordination and concentration may have been affected by the presence of  Cannabis in his system;

There was no engineered safeguard introduced at the Level Crossing to ensure that the Level Crossing gates could not be opened to road traffic when a train was approaching, as the system was dependent on the full adherence of the gate keepers to the operation instructions.

The underlying factor was:

No formal risk assessment process was carried out at the Level Crossing since its initial installation to measure its compliance against criteria introduced in Iarnród Éireann‘s current  signalling standard.

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R005

At approximately 22:00 on the 27th June 2010 the Train Driver of the 21:45 service from Ennis to Limerick sounded the horn on the approach to user worked level crossing XE039. As the Train Driver was sounding the horn he observed a farmer, 162 metres ahead of the train, pushing a cow through the gates of XE039 onto the railway, approaching the railway line from the Train Driver’s right. As the train continued to approach XE039 the Train Driver applied the brake and sounded the horn twice. The Farmer continued to push the cow, the train struck the Farmer and the cow. As the train passed over XE039 the Train Driver heard a noise and saw the cow fall to  the left of the train, he was not aware that the train had struck the Farmer. The train stopped 200 metres beyond XE039. The Train Driver went back to XE039 on foot and found both the Farmer and the cow on the side of the track on the opposite side of the track to the one had they approached from. The Train Driver requested the assistance of the emergency services, who were contacted by the Galway Line Signalman. The ambulance service arrived via a bridge over the railway 552 metres from XE039 and was then guided to the access road for XE039. The Farmer was fatally injured and pronounced dead at the scene.

The immediate cause of the accident was:
The train arrived at XE039 as the Farmer was attempting to move the cow clear of the railway line.

The contributory factors identified were:
The vegetation at XE039 may have affected the Farmer’s ability to see the train.
The underlying factors were:
The information provided to staff carrying out measurement surveys at level crossings did not provide information on the minimum safe distance from the nearest rail that the viewing distances should be measured from;
The time required to cross the railway safely where the crossing route is skewed was not taken into account in the calculation of the warning time of approaching trains.
The additional issue identified was:
The information available to Centralised Traffic Control on the location and access to the level crossing was not used to assist the emergency services to locate and access the accident site. 

Railway Accident Investigation Unit - Ireland

Investigation Repot 2011- R003

On Thursday the 13th May 2010 LUAS Tram 3006 was travelling on the shuttle service between Dublin Heuston Railway Station and the Point Stop on the Luas Red line. At 22:10 Tram 3006 proceeded into The Point Stop with the intention of stabling at the Inbound Platform.

However Tram 3006 travelled forward a distance of sixty-four metres towards the Event Platform, and not the Inbound Platform as was intended. The Tram Driver stopped Tram 3006 and after communicating with the Controller in the Central Control Room, subsequently changed driving cab ends and drove Tram 3006 outbound, derailing the third bogie on a set of spring points.

The immediate cause of this accident was:

Tram 3006 had not travelled clear of the spring points before carrying out a reverse manoeuvre.

Contributory factors were:

The Controller was not fully aware of the exact position of the tram;

Communications between the Tram Driver and Controller were not clearly understood;

The Tram Driver momentarily forgot that Tram 3006 would derail over the spring points due to its current position.
An underlying factor was:

There is no mandatory procedure other than in an emergency call for a Controller and a Tram Driver to clarify and check any misunderstandings in radio transmissions.

As a result of the RAIU investigation the following safety recommendation has been made:

Veolia should introduce a communication protocol between normal and emergency for given situations where a clear understanding between a tram driver and Central Control Room are required.

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R002

At approximately 22:50 on the 7th May 2010 the 21:05 passenger service from Longford to Connolly Station arrived into Platform 1 at Connolly Station in Dublin. The service was operated by a four carriage Class 29000 Diesel Multiple Unit referred to as Unit 10. A member of the contract cleaning staff subsequently observed that there was a problem with one of the carriages and advised Iarnród Éireann personnel. Unit 10 was found to have returned from passenger service with its secondary suspension system over-inflated on one of the bogies of carriage 29310. The over-inflation had led to the failure of the centre pivot retaining plate bolts and the airbags lifting the centre pivot pin out of the bogie centre. Unit 10 had been undergoing maintenance prior to being released for passenger service on the 6th May 2010 and had entered passenger service with the secondary suspension functioning incorrectly on the trailer bogie of carriage 29310.

The immediate cause of the accident was:

The secondary suspension levelling valves were fitted to the incorrect sides of the bogie.
The contributory factors were:

The lack of clear instruction for maintenance personnel on the maintenance procedures to be carried out;

The lack of clear visual markings or written advice in procedures for maintenance personnel to distinguish between the two different levelling valves;

A job card was not generated to ensure sign off of the necessary post installation checks as complete.

The underlying factors were:

The design of the secondary suspension system allowing the fault to develop to the point that the train entered an unsafe state;

The ineffectiveness of maintenance and operational controls in place in managing the risks relating to over-inflation of the secondary suspension;

The ineffectiveness of the hazard log in addressing the hazards relating to the over-inflation of the secondary suspension;

The ineffectiveness of the hazard log in addressing the hazards relating to the failure of the centre pivot pin to perform its intended function.

Railway Accident Investigation Unit - Ireland

Investigation Report 2011-R001

At 15.25 hours on the 20th January 2010 a Class 22000 six carriage train was scheduled to leave Laois Traincare Depot after routine servicing. The intended destination of the train was Heuston Station. The Train Driver performed his pre-departure checks and the Shunter authorised the train to proceed out of Laois Traincare Depot as far as signal PL278, which controls the exit from the depot onto the down loop adjacent to the main line. The Shunter set the number 2A points for the train to leave the depot.

The Train Driver stopped at signal PL278 as he was unable to read it due to sunlight shining on the signal and requested that the Shunter walk forward to check the signal aspect. The Shunter had been waiting at the number 2A points for the train to exit the depot in order to reset the points for the headshunt, protecting the down loop. He walked forward until he had a clear view of signal PL278 and advised the driver he had a proceed aspect. The Train Driver moved the train forward checking the aspect displayed when the signal was shaded by the train. The Shunter then walked back towards the depot and as he passed the points handle for the number 2A points, he operated the points. The train was still travelling over the points and derailed.

The immediate cause of the accident was the movement of the number 2A points as the train was passing over them causing the carriages to take diverging routes and carriages three and four to derail.

Contributory factors in this accident were:

The Shunter was taken away from normal task to check the aspect of Signal PL278 for the Train Driver due to the effects of sunlight on visibility of the signal;

It was standard practice in Laois Traincare Depot to leave the points handle for the number 2A points engaged when not in use;

The points mechanism at the number 2A points required little effort to operate;

The remedial action taken to improve the visibility of signal PL278 was ineffective resulting in the occasional practice of shunters assisting train drivers with reading of the signal.

Underlying factors in this accident were:

The operating procedure for Laois Traincare Depot did not control the risk of accidental operation of the number 2A points; A Signal Sighting Committee was not convened to investigate concerns raised by train drivers with signal visibility.

Railway Accident Investigation Unit - Ireland

Investigation Report 2010-R006

At approximately 06.20 hours, on Monday the 16th of November 2009, an empty train travelling from Connolly to Arklow, derailed when it collided with an obstruction caused by a landslip.

The immediate cause of this landslip was the result of soil deposition by a landowner, at the crest of the cutting. This was as a result of the following combination of factors:

The blocking of the drainage ditch for the field which was adjacent to the field;

The presence of sand lenses in the cutting which facilitated the flow of water through the cutting;

The heavy rainfall for the month of November which resulted in the saturation of the field adjacent to the cutting.

Railway Accident Investigation Unit - Ireland

Investigation Report 2010-R005

On Wednesday the 2nd September 2009 scheduled upgrading work was being undertaken at the Ferns Lock Automatic Half Barrier. During these works an Iarnród Éireann power cable was inadvertently severed disabling the external power supply to the level crossing, this caused the crossing to fail and the barriers to automatically lower to the failsafe position.

An Emergency Operator from Maynooth took control of the crossing while repairs were being undertaken to the cables. The Emergency Operators function is to ensure that a train can only use the level crossing when the barriers are down, preventing road traffic from accessing the rail line, this is done in conjunction with the controlling signalman and train driver.

However, the signalman signalled the train through the crossing without advising the Emergency  Operator of the approach of a passenger service, which resulted in the passenger service travelling through Ferns Lock Automatic Half Barrier while the barriers were in the raised position – open to road traffic.

It was found during the course of the investigation that the controlling signalman, at the time of the incident, normally operates the Suburban Network which has no Automatic Half Barrier type crossings and only occasionally performs relief duties on the Sligo & Northern Line. This meant that the signalman was not familiar with his requirements in relation to the emergency operation of the Automatic Half Barrier and therefore he did not react to the indications displaying on the Sligo & Northern Line console which showed a fault at the Automatic Half Barrier and the fact that an Emergency Operator had put the Automatic Half Barrier into local operation and raised the barriers of the Automatic Half Barrier to road traffic.

Railway Accident Investigation Unit - Ireland

Investigation Report 2010 - R004

On the 21st August 2009 as an Iarnród Éireann passenger service, travelling from Balbriggan to Pearse, passed over the Malahide Viaduct the driver witnessed a section of the viaduct beginning to collapse into Broadmeadow Estuary. The driver reported this to the controlling signalman who immediately set all relevant signals to danger ensuring no trains travelled over the viaduct. Within minutes of the report of the accident, by the driver, Pier 4 of the Malahide Viaduct had collapsed into the Broadmeadow Estuary. All post accident emergency procedures were properly employed by the operating staff resulting in no fatalities or injuries to any members of the public or staff.

At the time of the accident, the Malahide Viaduct piers were formed on a grouted rock armour weir, with stones intermittently discharged along this weir to maintain its profile.

Railway Accident Investigation Unit - Ireland

Investigation Report 2010-R002

On Thursday the 16th of July at 15.57 hours, the driver took over the LUAS red line Tram 3006 at Tallaght (South County Dublin) and drove to Connolly (North Dublin City Centre). At approximately 17.10 hours the driver changed cabs at Connolly Station, and exited on the normal outbound route towards Tallaght with passengers on board.

Whilst travelling outbound, the tram travelled past the Points Position Indicator for the facing points and over the points when the driver heard a loud bang and stopped the tram. This loud bang was as a result of the second wheelset of the first bogie derailing and rerailing.

Two off-duty Veolia staff were present at Connolly and checked the tram not noticing any sign of derailment, however, they did notice an item of clothing under the tram. The driver then continued a short distance before stopping when seeing the driving cab was swerving towards the wall, due to the second wheelset travelling in the diverging direction.

The investigation found that the Points Position Indicator for the points was displaying a single dot aspect prior to the driver exiting Connolly, meaning the facing points were not properly set for the normal outbound route. The points not being set for the route was a result of an item of clothing being stuck in the points.

After reviewing the factual information and carrying out the analysis into the accident the RAIU has concluded that the driver was experienced, did not appear to be effected by the late running of the service, and there were no distractions present. Therefore, the driver not checking the PPI was a human error omission.

Railway Accident Investigation Unit - Ireland

Investigation Report R2010-003

At approximately 04.50 hours on the 3rd of July 2009 a train consisting of two coupled On Track Machines, ballast regulator 703 and tamping machine 743, was travelling from a work site on the Dublin side of Limerick Junction Station to the Limerick Junction Sidings. For the final part of the movement unit 703 was leading. The leading left wheel of unit 703 did not follow the route the number 27A points were set for, it travelled over the top of the left switch rail of the points and along the stock rail before derailing.

The immediate cause of the accident was:

The derailment of the wheels as a result of the wheels taking diverging routes on the track due to the poor interface created by degraded condition of the switch rail and the wheel profile.

The causal factors identified were:

The poor condition of the number 27A points;

The flange sharpness of the wheels on the leading wheelset of the On Track Machine.

The underlying factors were:

The lack of measurement of the wheel profiles as part of the maintenance of the On Track Machine;

The lack of measurement of the wheel profiles following previous derailments of the On Track Machine.
Recommendations

Iarnród Éireann should put in place a formalised process to ensure that life expired points are removed from service, where this is not possible a risk assessment should be carried out and appropriate controls should be implemented to manage the risks identified;

Iarnród Éireann should ensure On Track Machine maintenance personnel are trained and competent to examine the wheelsets.

Railway Accident Investigation Unit - Ireland

Investigation Report 2010 - R001

On the 29th of March 2009 at 20.12 hours the 17.35 hours service from Dublin to Waterford arrived on the Platform Line at Plunkett Station in Waterford. The carriages were uncoupled from the locomotive in order to move the locomotive from one end of the carriages to the other. The locomotive was moved over a set of points onto the Up Main Line. The train driver then tried to change cab to travel in the opposite direction but could not as the MU-2-B1 valve was defective and therefore drove from the rear cab of the locomotive without a shunter controlling the movement from the leading cab. The locomotive was incorrectly routed back onto the Platform Line towards the carriages by the signalman. When the train driver became aware the locomotive was mis-routed the train driver applied the brakes but the locomotive collided with the carriages. The coupling systems on all the carriages were damaged and the four wheels on one bogie of the first carriage struck derailed. A shunter who was at the rear of the carriages at the time was struck by the moving carriages. There were no fatalities. The shunter was hospitalised and released the same day. Two other members of staff who were in the carriages at the time of the collision suffered minor injuries. There were no passengers on the carriages at the time of the accident.

Immediate cause, causal factor and contributory factors

The immediate cause of the accident was:

The route was not set correctly for the locomotive movement causing the locomotive to collide with the carriages.

The causal factor identified was:

The locomotive movement was not controlled in accordance with the Iarnród Éireann Rule Book.

The contributory factors were:

The lack of formal requirements for refresher training and assessment of signalmen in cabins where they work as a relief signalman;

The locomotive was in service with a defective MU-2-B1 valve.

The lack of train driver instruction in the correct operation of the MU-2-B1 valve.
Recommendations

Iarnród Éireann should review their systems for training and competency management of signalmen ensuring working as a relief signalman is taken into account;

Iarnród Éireann should ensure procedures are put in place for the operation and maintenance of the MU-2-B1 valves.

Railway Accident Investigation Unit - Ireland

Investigation Report 08120201

On the 2nd of December 2008 at 09.40 hours an infrastructure maintenance train approached level crossing XH066 at Bridgetown when the level crossing gates were closed across the railway line. The train struck the gates and came to a stop approximately thirty-nine and a half metres beyond the level crossing. XH066 is a CX type level crossing, meaning that the gates are kept closed across the railway unless a train is passing. After the accident the mechanically operated semaphore signal protecting XH066 was found to be displaying an ON aspect, therefore indicating that trains should be prepared to stop in advance of the gates. The signal was reported by the train crew as displaying an OFF aspect, allowing trains to proceed and expect the gates to be open for rail traffic, at the time the train passed it. No fault was found with the signalling equipment. It was not possible to determine conclusively whether the signal was showing an OFF aspect to allow trains proceed through XH066 or it was displaying an ON aspect indicating that trains should stop in advance of the gates. The gatekeeper suffered shock and the gates of XH066 were destroyed. From the investigation weaknesses were identified within the training and competency management of staff, operating instructions, maintenance procedures and the design of the indicators.

Immediate cause, causal factor and contributory factors

The immediate cause of the accident:

The train struck the gates of Level Crossing XH066, which were closed across the railway line. The two possible causal factors identified were:

The Down Distant Signal was displaying either a WRONG or an incorrect OFF aspect when the train passed and this led the train crew to expect the gates to be open across the railway;

or The train passed the Down Distant Signal whilst it was at ON and the necessary actions to stop the train in advance of XH066 were not taken.
The possible contributory factors were:

The lack of an effective competency management system to ensure staff are suitably trained and competent to carry out their duties;

A lack of adequate training and procedures to assist the staff responsible for the equipment associated with XH066 and its Distant Signals with carrying out their duties correctly;

The indicator display was not observed or was mis-read by the gatekeeper when the lever was moved following the last train on the previous night;

Railway Accident Investigation Unit - Ireland

Investigation Report 08073101

On the 31st of July 2008 at approximately 17.20 hours, a Diesel Multiple Unit train collided with a road vehicle at level crossing XN125, Cappadine. The train involved was the 16.45 hours Iarnród Éireann service from Limerick to Ballybrophy (train identification number A463). As the train approached Level Crossing XN125, located in the townland of Cappadine in County Tipperary, the train driver saw a road vehicle stopped with its front protruding onto the railway line. The train driver sounded the horn and made an emergency brake application. The train struck the road vehicle, a Toyota Corolla car, and then continued to travel approximately 130 metres past the level crossing before coming to a stop. The car had been travelling towards XN125 from the direction of Ballinahinch when it stopped fouling the railway line. The train was crewed by a driver and a ticket checker with four passengers on board at the time of the collision. The car was occupied by a driver and a front seat passenger. There were no injuries, the front of the car was extensively damaged and there was minor damage to the train.

Immediate cause, causal factors and contributory factors

The immediate cause of the collision:

The road vehicle stopped in a position fouling the railway line.

The causal factors were:

The lack of clear marking of a safe stopping position clear of the railway line for road users;

The lack of effectiveness of the whistleboards as a mitigation for inadequate sighting distance.

The contributory factors were:

The condition of the level crossing surface;

The angle at which the road crosses the railway;

The changing orientation of the road through the crossing.

The overgrown condition of the vegetation.

Railway Accident Investigation Unit - Ireland

Investigation Report 08061401

On the 14th of June 2008 at 8.50 hours an empty Diesel Multiple Unit, identification number J851, travelling from Manulla Junction to Dublin, passed through the raised barriers of Ballymurray level crossing, XM 075. Approximately two seconds prior to the Diesel Multiple Unit passing, a car crossed through the level crossing and as Diesel Multiple Unit crossed the crossing another car approached but came to a stop.

The incident was a result of poor communications between staff involved in the maintenance of the Automatic Half Barrier. Staff had worked together regularly in the past, leading to familiarity and an informal approach to communications. The lack of a formal maintenance process, that should include a safe system of work, would also have contributed to the incident.

Immediate cause, contributory factor, underlying causes

Immediate cause:

• The barriers were raised to road traffic while maintenance works was being carried out, as a train approached.
Contributory factors:

• Poor communication between the signalman and the Special Class Linesman led to a misunderstanding of when there was a safe margin between trains to allow the maintenance work to be carried out;

• Staff had worked together regularly in the past and this familiarity led to an informal approach to communications and therefore did not follow communication procedures.
Underlying cause:

• Lack of a formal maintenance process for the maintenance of Automatic Half Barriers which
should include the communications process and when it was safe to commence work;

• Lack of competence auditing system for communications procedures.

Railway Accident Investigation Unit - Ireland

Investigation Report 08022801

On the 28th of February 2008 at approximately 11.07 hours the 10.50 hours service from Ballina to Manulla Junction passenger train collided with a car at user operated level crossing XX 032, which is located on the Ballina branch line, approximately 500 yards beyond the 153 milepost in the townland of Knockshanbally, County Mayo.

The train struck the car on its left hand side. The car became lodged at the front of the train and remained there until the train came to a stop approximately 350 metres (m) from the point of collision. The leading vehicle of the train was damaged but the train was not derailed.

The sole occupant of the car was fatally injured. There was a train driver and one passenger on the train at the time of the collision, neither were injured. The ambulance service, fire services and the An Garda Síochána attended the scene of the accident along with representatives of Iarnród Éireann (IÉ). The passenger was detrained and continued the journey by road.

The line remained closed until that evening to allow clearance and preliminary investigation work to be carried out. The train was removed from the scene of the accident to Ballina at 19.10, allowing the line to be reopened.

Immediate cause:

The immediate cause of the accident was that the vehicle was driven onto crossing XX 032 as the train approached.
Causal factors:

The gates of the level crossing were open when the car approached the crossing.

Underlying causes:

XX 032 and other local level crossings were habitually misused, with gates being left open on a regular basis.

Railway Accident Investigation Unit - Ireland

Investigation Report 08011001

At 22.53 hours on the 10th of January, 2008, a Tara Mines freight train operated by Iarnród Éireann consisting of a locomotive and eleven wagons derailed south of Skerries station on the Dublin to Belfast line. The first wagon of the train suffered a burnt off axle journal due to a catastrophic bearing failure, it derailed at the 17 ½ milepost and continued to travel a further 230 yards, damaged crossover SK 244 resulting in the derailment of five further wagons before the train came to a stop. Moderate damage was sustained by the leading wagon, the remaining derailed wagons suffered wheel impact damage, there was damage to sleepers over a distance of 230 yards and components of crossover SK 244 were broken as well as rail in its vicinity. There were no injuries and there was no release of the zinc concentrate that the wagons were transporting at the time. A Hot Axle Box Detector reading of 56 degrees Celcius was recorded eleven miles before the point of derailment, however, no alarm was triggered due to the detector’s alarm temperature settings and the train continued its journey. In addition, the bearing appears to have been in operation since its manufacture in 1981 without undergoing overhaul.

The immediate cause of the derailment:

The catastrophic failure of bearing 633A leading to a BOJ.

Probable contributory factors were:

The HABD settings not triggering an alarm;

The lack of a robust bearing maintenance regime.
Underlying cause:

Failure to detection bearing deterioration.

Railway Accident Investigation Unit - Ireland

Investigation Report 07062801

At approximately 20.00 hours (hrs) on the 28th of June, 2007, the 18.55 service from Ballybrophy to Limerick, train identification number A464, collided with a tractor and trailer at a farm crossing (XN 104). The crossing is located on the Ballybrophy to Killonan line situated at 35 miles 777 yards in the Roscrea to Birdhill section. The tractor and trailer were returning to a field to collect silage for storage when they were struck by the train. The train was not derailed and came safely to a stop 81 m beyond the crossing. The tractor and trailer uncoupled. The tractor struck fencing and then came to a stop on top of the adjacent signalpost, to the right of the direction of travel of the train, parallel to the railway line, facing the direction of Ballybrophy. The trailer struck fencing on the Down side and came to a stop in the ditch to the left of the direction of travel of the train, at an angle of approximately 60º to the railway line. The train crew established that the attendance of the emergency services was not required for the passengers, crew or the tractor driver. No injuries were reported and arrangements were made for the passengers to continue their journey by bus. The line was re-opened on the 29th of June at 15.45 hrs following removal of the train, tractor and trailer, and once repairs had been carried out to signalling equipment, track and the crossing.

Immediate cause:

• The tractor crossed the railway without stopping and checking for the approach of a train.
Causal factors:

• The gates of the crossing were being left open for movements back and forth while work was going on in the adjacent field;

• There was limited visibility of the line from the tractor due to vegetation at the lineside.

Underlying causes:

• The tractor driver was unfamiliar with the correct procedure for using unmanned level crossings as set out in Iarnród Éireann’s publication “The SAFE use of unattended Railway Level Crossings”.

Railway Accident Investigation Unit - Ireland

Investigation Report (Version 1.2)

At approximately 06.00 hours on 7th October 2003 a laden Iarnród Éireann (IÉ) bulk cement train travelling between the Irish Cement plant at Castlemungret, near Limerick, and Waterford derailed as it passed over the viaduct across the river Suir at Cahir. After derailing the rear twelve wagons fell through the deck of the viaduct ending up in the river and on the river bank.

While nobody was injured as a result of the accident the deck of the viaduct was substantially destroyed and the rear twelve wagons damaged beyond repair. Irrespective of other consequential loss, the capital cost of this damage to railway infrastructure and rolling stock was n excess of €3 million. The EU Railway Safety Directive 2004/49/EC, classifies a ‘serious accident’ as, inter alia, one which results in ‘extensive damage’ i.e. €2 million or more.

On the 14/10/03 the then Minister for Transport, Seamus Brennan T.D., under the provisions of the Railway Regulation Act of 1871, appointed the Chief Railway Inspecting Officer of the Department of Transport’s Interim Railway Safety Commission (IRSC) to conduct a Statutory Inquiry into the circumstances of the accident. The IRSC’s Inquiry utilised documentary evidence provided by IÉ and by consultants that it engaged to assist in it’s own internal inquiry into the accident, verbal evidence given in interview by various parties involved either directly or indirectly in the accident, and data obtained directly by the IRSC in its various site inspections.

Railway Accident Investigation Unit - Ireland

On Friday, 16th February 2001, the 03.08hrs liner train from Ballina to North Wall collided with the gates at Kiltoom level crossing at approximately 05.15hrs. The entire train passed through the level crossing. The accident happened during darkness. Weather conditions at the time of the accident were very foggy and freezing. All witnesses described the weather as such. There were no Met Eireann reports for that particular area. The nearest report was for Knock Airport, and conditions there were clear.
There were no reports of injuries. Both gate booms together with the locks, gate lamps, mesh and targets were broken beyond repair. There was no damage to the signalling equipment. The gate heel where the actuating equipment to operate the signal is attached to the gate was undamaged.

The gatekeepers’ husband rang the signalman at Knockcroghery to report the accident, the train driver also rang the signalman at Knockcroghery. The signalman at Knockcroghery reported the accident to Central Traffic Control (CTC), Connolly Station, Dublin. The train driver also contacted the CTC signalman from the level crossing telephone.

After a number of phone calls the train driver was authorised to proceed into Athlone by Iarnrod Eireann management.

Railway Accident Investigation Unit - Ireland

Fire Station Officer Patrick Mockler was on duty at Newbridge Fire Station on the evening of the accident. At 21.50 hours he received telephone message regarding a railway incident at Moyvalley, Co. Kildare. Shourtly after 22.00 hours he was told by the Ambulance Service at Naas Hospital that there had been a railway accident near Cherryville. He then telephoned Dublin Fire Brigade Station, Tara Street, and was told there had been an accident at Cherryville and that the Dublin Fire Brigade was under the impression that the train involved was carrying dangerous chemicals. Dublin Fire Brigade offered to provide assistance. Together with two Fire Service colleagues who were outfitted and equipped to deal with chemicals he departed to the accident scene. He arrived at the accident site at about 22.32 hours. His Fire Service colleagues confirmed that there were no chemical on either train but said they noticed gas leaking from the cylinders. Visibility was 500 to 600 yards. Some lights were working dimly in about half the carriages on the ex-Tralee train. He saw no lights in any carriage of the ex-Galway train. A man wearing a high-visibility jacket and carrying a hand lamp identified himself as a CIE employee. This man did not appear to be taking any part in the rescue operations.

Railway Accident Investigation Unit - Ireland

Driver Dennis Hogan was familiar with the railway through Buttevant Station since about 1982. He knew that the new facing points were not connected to the signal Cabin. He described how he had driven a ballast train from Buttevant to Killarney about a week before the accident. When he returned along the Down line to the unconnected facing points at the turn-out to the Down siding. These points were hand operated by a flagman. He had driven other trains over then and agreed that the procedure for movements points while waiting for the flagman to move them. The signalman always instructed the guard before any crossing movement commenced. He had noticed nothing unusual when driving an Uo fertiliser train through the Station about half an hour before the accident.

Railway Accident Investigation Unit - Ireland

Solicitor Maurice Kenny read a brief statement outlining the circumtances of the accident and on behalf of CIE expressing sympathy to those injured and thanking people and organisations who helped a the accident scene. Suburban Rail Manager John Fennelly said that at the time of the accident it was bright and there was heavy frost. The 08.17 train consisted of a locomotive, steam heating van and five passenger carriages. The 08.27 train consited of a locomotive, brake van, three passenger carriages and a s steam heating van. Mr. Fennely gave additional evidence later in the inquiry.

Railway Accident Investigation Report - Ireland

Signalman Alex Ebbitt has been a signalman at Arklow for over 30 years. On the evening of the accident he had accepted the Up cement train from Gorey under Signalling Regulation No. 3. He received the "train entering section" signal at 18.25 hours, the train arrived at 18.44 hours and he sent the "train out of section signal 18.46 hours before he had checked that the train had arrived compete. At about the same time he released the token to Gorey for the Up passenger train. The Up cement train was listed in the Working Timetable as due to arrive in Arklow at 16.10 hours. The Rail Control Office, Dublin, had requested, by telephone, that it should depart from Arklow at 20.00 hours. Mr Ebbitt was aware that the four rear wagons of the cement train were to be unloaded at Arklow and had he know in advance that the local fork-lift driver, Depotman Collins, would not have sufficient time to unload these four wagons before that train departed at 20.00 hours he would have brought the cement train initially into the Platform instead of directingi into the Goods Siding.

Railway Accident Investigation Unit - Ireland

The Minister for Transport and Power by Order dated the 9th day of January, 1976 directed that an Inquiry be made by Mr. J.V. Feehan, B.E., M.I.E.I. into the causes of a railway accident which occured near Gorey at about 09.28 hours on Wednesday, 31st December 1975.

Railway Accident Investigation Unit - Ireland

The Minister for Transport and Power by order dated 9th December, 1974, directed that an inquiry be made accident which occured at Rosslare Strand Stationon 13th August, 1974.

Railway Accident Investigation Unit - Ireland

The Minister for Transport and Power, by order dated the 29th day of October, 1974, directed that an Inquiry be made by Mr. J.V. Feehan, B.E.,  M.I.E.I. into the causes of an accident which occured at Gormanston Railway Station at about 07.40 hours on Monday, 21st October, 1974.