Colin Wheeler
The Rail Accident and Incident Board (RAIB) has issued its annual report for the calendar year 2023. The bald statistics, ongoing reports, and investigations workload is worrying and will doubtless be on the agenda for the new Government. Hopefully whatever is changed as our railways become nationalised again, will lead to a safer railway staffed by committed individuals that meets the needs for improved and increased freight and passenger services, and contributes to reducing global warming.
In 2023 the RAIB published 14 full investigation reports and six Safety Digests. Seven letters were sent to coroners, and one to the industry. Two ‘Urgent Safety Advice Notices’ were also issued and 49 safety recommendations were made.
Trolley brakes became ineffective
RAIB is investigating an incident that took place at 05:00 on 26 May at North Rode, Cheshire, when a rail trolley ran away on a descending gradient towards a site of work and team of track workers. Fortunately, the trolley collided with some equipment that was being used for moving rails within the worksite and was brought to rest. It had run away for some 1,100 metres before the collision stopped it. The workers saw it approaching and moved clear, so no one was injured.
The trolley was being used to move equipment when, “its brakes became ineffective.” RAIB has begun its investigation which will consider the design and maintenance of the trolley, the actions of those involved and “the arrangements to manage and control the use of the trolley.”
Car and train collide on Redcar Level Crossing
At around 09:25, on 1 May, a passenger train travelling at just 23mph between Saltburn and Nunthorpe struck a car on Redcar Level Crossing. The car was “significantly damaged”, and its driver was injured. There were no injuries to passengers or staff on the train. Redcar Level Crossing has road traffic light signals and barriers on both sides of the railway. Fully extended, the barriers cross the whole width of the road.
The signaller had not closed the level crossing to road traffic. The train driver had been authorised by the signaller to pass a signal “showing a red aspect.” The signal provides protection to two level crossings including Redcar. RAIB’s investigation will identify the sequence of events, the actions of the signaller and train driver, the management of staff, engineering safeguards within both the signalling and level crossing control system, and any underlying management factors.
MOD wagon runs away
On 16 May, RAIB published its report following an incident at Kineton in Warwickshire on 23 May 2023. At around 21:08 in the evening an empty wagon from sidings within the Munitions Depot ran away. The runaway wagon went through two sets of trailing hand points, both set in the opposing direction. It broke through the gates at the exit to the sidings and passed over two farm crossings and a public road level crossing. No one was injured. The investigation found that the wagon had been stabled on a gradient with insufficient brake force to restrain it. It was owned by DB Cargo and leased to Kuehne Nagel who operated it for the MOD.
The report’s five recommendations cover management issues, and the need to review wagon maintenance procedures and “to ensure wagon brake components are scheduled for replacement at the end of their design life.”
Near miss with a track worker at 104mph
RAIB published a news story on 29 May saying it was investigating a near miss at 104mph between Harpenden and Luton involving an East Midlands train on the Down Fast line some 2.7 miles north of Harpenden. The worker involved was crossing an underbridge with insufficient clearance between its parapet and the nearest running rail. Seeing the worker on the bridge, the train driver sounded the train horn and made an emergency brake application. The worker reached the far side of the bridge just before the train passed.
The train stopped and its driver reported the near miss to the signaller, being unsure whether the trackworker had been struck. The worker was a group member who had earlier left the group and walked alone back to their van at the access point south of the bridge. RAIB’s investigation is underway.
SPAD at Stafford Trent Valley
RAIB issued this report on 17 June. The signal passed at danger is on the approach to Stafford Trent Valley Number 1. The incident occurred on 22 August last year. A Freightliner electric locomotive was on a test run following repairs when it passed a signal at danger (red). It ran for 740 metres beyond the red signal before running through points and coming to a stand at the junction.
When stopped, the position of the locomotive conflicted with the route which had been set for a southbound train. That train was fortunately not in the vicinity but a northbound train had passed over the junction just a few seconds before the locomotive reached the points. The locomotive did not foul the line on which the northbound train travelled. No one was injured and the locomotive did not derail, although running through the points caused damage.
The investigation found that the locomotive had been travelling too fast as it approached the red signal and so was unable to stop. The driver’s focus was diverted by the aspects of previous signals which warned that a red signal ahead should be expected. The driver was also dealing with a fault on the locomotive that caused the driver to come to a stand at a previous signal. The report states that: “it is possible that this previous signal was not clearly visible to the driver when restarting the train after resetting the fault.”
RAIB found that Freightliner had no formal process for managing risks associated with test runs and light locomotives. It also found that “its competence management system had not equipped the driver to deal with an unexpected and potentially distracting situation in an effective and safe manner.”
The consequences were exacerbated by the high level of acceleration applied after the driver cleared the fault. The locomotive was driven “at speeds above those permitted by operating rules”. Also, “no engineering safety system intervened to apply the locomotives brakes before they were applied by the driver.”
RAIB’s report makes two recommendations to Freightliner. First, it is to review risk assessments and processes for the operation of light locomotives to better manage operational risk. The second recommendation relates to how drivers are trained and assessed to manage out of course, abnormal, and potentially stressful events. RAIB’s additional learning points address compliance with locomotive speed rules, and the development and maintenance of route knowledge and settings for train protection systems.
Trackworker near miss in Lancashire
RAIB published Safety Digest 05/2024 on 19 June, relating to this near miss at Euxton Junction on the West Coast Main Line. It occurred on 14 March and was reported by the train driver at around 14:14. The trackworker involved was also the Controller of Site Safety (COSS) who had been looking for a location cabinet where scheduled maintenance was to be carried out.
The COSS was alerted by a shouted warning from a member of the public on a nearby footbridge and the train driver’s horn. The COSS moved to a position of safety with just two seconds to spare. The COSS had misidentified which lines were blocked despite signage on one of the access points used by the team. The signage correctly showed the track layout. The COSS did not realise the error nor was it challenged by team members during the COSS’s briefing.
At Euxton Junction there are four lines designated as Up and Down Fast and Up and Down Slow. The train involved was the 11:36 Glasgow Central to London. The Network Rail team was led by the COSS with a technician; a third team member was not at lineside.
The Safe System of Work (SSoW) had been sent out but the COSS received it after their shift began. It should have been received at least a shift earlier. Network Rail’s standard is specific – the person in charge is to receive the plan, review it and “verify it at least one shift in advance.” The pack sent out included three SSoW’s. It included a separated system of work at the incident location requiring the team to keep at least two metres between the site of work and the nearest running rail. A blockage of the Up Fast was planned along with a second one for the Down Fast to allow work to be done closer to the lines concerned.
Around noon, the COSS reported for duty at the depot near Preston Station. Their works order specified two maintenance items: testing within a lineside location cabinet (LOC) and a track circuit inspection in the same area. Before leaving the depot, the COSS checked the LOC location identifying two LOC’s with the same identifying number. One was adjacent to the Up Fast and the other adjacent to the Down Fast. The COSS left the depot understanding that the work was to be done adjacent on the LOC next to the Down Fast.
Consequently, the COSS contacted the Preston signaller and asked for the Down Fast to be blocked. This was done at 13:54. When briefing the technician, the COSS stated that the “closest line was blocked”. The COSS started walking to the Old School Lane access point using the four-foot of the Up Fast line believing it to be the Down Fast line.
The approaching passenger train, travelling at 110mph, was seen by the technician who assumed it was on the other line. The COSS heard the trains warning horn but acknowledged it without looking up. As it came closer, the COSS realised the error and moved to a place of safety with just two seconds to spare. The safe work plan gave location and access details, but the works order only gave the line reference number.
London Underground trap and drag accidents
On 27 June, RAIB issued report 06/2024 following its investigations into accidents at Archway and Chalk Farm stations which occurred on 18 February and 20 April last year, respectively.
On 18 February at 15:50, a passenger was trapped by the door of a Northern Line train at Archway Station by their coat. Exiting through a single leaf door at the rear of the fifth car, the passenger was dragged for two metres before the coat became free. The passenger’s companion, who was holding on to them, also fell to the ground. The train travelled 20 metres before it was stopped by the operator. The passenger received serious injuries.
The operator was not aware that the pilot light indicating doors closed could still illuminate when something was trapped in the doors.
On 20 April at 23:03, a similar accident occurred on the Northern Line at Chalk Farm. Having attempted to board the passenger stepped back, but being close to the train their coat was trapped and they were dragged for 20 metres before the coat became free. Unaware of the accident, the train continued its journey. The passenger sustained minor physical injuries to their left elbow and both knees, and suffered psychological harm. The door control system did not detect the trapped coat.
Four recommendations are made by RAIB. They stress the importance of documenting action plans, recording safety briefings, and promptly reporting notifiable accidents to the RAIB. The third recommendation stresses the importance of trainers and managers ensuring that train operators fully understand the risks of relying on pilot lights when deciding it is safe to start the train away from a platform. RAIB’s listed learning points, include action plans and recorded safety briefings.
Image credit: keir.starmer.mp (Flickr)
