AGENDA ITEM: D4 MEETING: RSSB Board Meeting DATE: 03 March 2016 SUBJECT: Industry Safety Performance SPONSOR: George Bearfield 1. Summary of key issues 1.1 The key safety reports to January below provide an indication of current safety issues, priorities and concerns. There are a number of key issues for the board to be aware of. 1.2 The derailment and collision chart shows 8 non‐passenger train derailments so far this year, following the 16 seen in 2015. The cross industry freight train derailment work group set up to consider the risk of such incidents in particular the combinational effects of track condition, vehicle sensitivity to track geometry and asymmetric loading of containers met on 2nd February. Following the meeting the interim report from the group was subsequently published on RSSBs website at http://www.rssb.co.uk/library/risk‐analysis‐and‐safety‐
reporting/2016‐02‐cross‐industry‐freight‐derailment‐working‐group‐interim‐progress‐
report.pdf. 1.3 Work is underway to: 
Revise and update the terms of reference for the group 
Fully develop the programme of work for the range of activities that is underway 
Complete the assessment of risks, and appraisal of safety measures, through a series of industry workshops. 1.4 ORR have responded that they would like further information on the governance arrangements for the group. A draft Terms of Reference has been produced and is to be supplied to the Chairs of NFSG and FTC for comment and consideration prior to circulation to the ORR. 1.5 With extensive work going on to integrate our safety incident and close call reporting systems through SMIS+ it is worth noting that safety concerns are coming to light through the analysis of close call and near miss data of the type not currently shown on the high level charts presented here. Following a review of close call data by the Infrastructure Safety Liaison Group (ISLG) began a review of near miss events relating to track workers outside of possessions. 1.6 In parallel with this The Rail Accident Investigation Branch (RAIB) has investigated a number of accidents involving track workers on Network Rail’s infrastructure and has identified track worker safety as an area of particular concern in recent annual reports. This caused them to review the occurrence of operating irregularities in the daily incident reports produced by Network Rail’s National Operations Centre. 1.7 A class report on this topic is in production by RAIB focussing on operating irregularities associated with the protection of those carrying out engineering work, particularly where protection was planned to block the line to traffic. 1.8 Although it is not within the reporting period here, details of the fatal collision on 9th February in Bad Aibling, Bavaria, are to be circulated separately. Signalling controls and behaviour are also at the route of this incident. The German authorities appear to have settled on a determination of human error as being the root cause of the accident. However, it’s worth noting that the signaller would not have been able to make the same error on the GB railway because our signalling interlocking arrangements would have protected against it. RSSB Board Meeting Final: 03 March 2016 Page 1 of 7 AGENDA ITEM: D4 Key safety reports to January 2016 * Public accidental fatalities include trespass and non‐trespass, but exclude RIDDOR‐reportable major injuries to each person type reported in SMIS. fatalities at level crossings (which are shown separately). The majority of passenger injuries occur in stations Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Statutorily reportable collisions (excluding roll back and open door (RIDDOR) reportable cases only. Includes derailments at level crossings collisions), derailments, buffer stop collisions and trains striking road after striking road vehicles. Does not include buffer stop and ‘open door’ vehicles. PHRTAs are normalised per million train miles. collisions. Passenger low‐speed collisions predominately occur at stations.
SPADs on or affecting Network Rail managed infrastructure. This update The dark blue bars refer to trains striking barriers where a previous incident regarding SPAD performance is based on data available at the date of issue had caused the barriers to encroach onto the running line, such as a road and is subject to change as further information becomes known.1 vehicle striking the barriers. 1
While investigating recent trends in SPAD risk, we identified a data entry error in our database of
SPAD risk rankings, which resulted in a single SPAD, occurring in August 2015, being incorrectly
analysed as having a high risk ranking. We have now rectified this error, and the above SPAD chart
shows the corrected risk trend
RSSB Board Meeting Final: 03 March 2016 Page 2 of 7 AGENDA ITEM: D4 2. Safety Performance 2.1 Safety Information 2.1.1 Summary safety information is included in section 2. The headlines since the last board meeting are: 
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During December 2015 and January 2016 there were no workforce fatalities. There were 7 public and 2 passenger accidental fatalities. During December and January, there were 48 signals passed at danger (SPADs). This is 5 fewer than during the same two months in the previous year. (Note that this figure is provisional until all cases have been agreed with the relevant parties.) Of the 48 SPADs, 5 were risk‐ranked potentially significant (16‐19), and 3 were risk‐ranked as potentially severe (20+) 2.2 RAIB Investigations and publications 2.2.1 Initiated investigations: 
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2.2.2 
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2.2.3 
Buffer stop collision at King’s Cross, 17 September 2015 Driver action raises issues about training, buffer stop design and on‐board fixture performance Overspeeding incident at Queen’s Park, 5 January 2016 Driver Manager error poses questions about ESR information and management regimen Investigation into trains passing over an undermined Lamington Viaduct, 31 December 2015 Adequacy of response to scour risk assessment and incident reports implicated Class investigation into accidents and near misses involving trains and track workers outside possessions Staff protection arrangements, practice and planning in focus Published reports: Container detachments at Scout Green (07/03/15) and Deeping St Nicholas (31/03/15) Strong winds combine with inadequate container spigots Unsafe events at Heathrow Tunnel Junction, 27 and 28 December 2015 Supervision and safety culture implicated Collision between a passenger train and a fallen bridge parapet at Froxfield, 22 February 2015 Inadequate signage and road user behaviour leads to incident that exposes flaws in post‐
incident communications and train assessment Freight train derailment at Washwood Heath West Junction, 23 March 2015 Incident highlights the problems that occur when inadequately maintained wagons run on inadequately maintained track Other reports published: There were no other reports published during December 2015 and January 2016 Further details relating to the RAIB reports and investigations is available on the RSSB board members extranet page RSSB Board Meeting Final: 03 March 2016 Page 3 of 7 AGENDA ITEM: D4 3. Summary of safety performance for December 2015 and January 2016 3.1 Fatalities During December 2015 and January 2016 there were no workforce fatalities. There were 7 public and 2 passenger accidental fatalities.  On 5 December, a passenger was struck by a sign that fell from a pole at Berwick upon Tweed station (London North Eastern).  On 5 December, a passenger fell between the train and platform at Battersea Park station (South Eastern). Alcohol was reported as a potential factor in this event.  On 5 December, a member of the public was struck by a fast train after falling onto the track at Coulsdon South station (South Eastern). Alcohol was reported as a potential factor in this event.  There were 6 fatalities during December 2015 and January 2016 involving members of the public found with injuries consistent with being struck by a train. These were on 9 December on the down line near to Lympstone Village (Western); on 18 December in the four foot at Leigh Golf Course level crossing FP (London North Western); on 28 December lineside near to Aston‐by‐Stone level crossing MCB‐CCTV (London North Western); on 1 January between London Paddington and Ladbroke grove (Western); on 1 January in the four foot at Burnley Manchester Road (London North Western); and on 26 January lineside within Lydden Tunnel (Kent).  There were 39 suspected suicides during December and January. The average monthly figure over the past 12 months has been 21.8. Suicide figures are subject to change as more information (eg, coroners’ verdicts) is made available. 3.2 Reportable train accidents: collisions, derailments and trains striking road vehicles There were no reportable train accidents in the above categories during December and January, including no passenger train derailments. 3.3 SPADs risk ranked 20+ There was 3 SPADs risk ranked 20+ during December 2015 and January 2016; there are no risk ranking forms outstanding for December or January. SPAD risk ranking 21 On 3 December a passenger train passed signal YH503 at danger on the Down Airdrie line on the approach to Hyndland station by approximately 404m. The driver stated that they had anticipated the signal to clear. YH503 is a signal protecting plain line with potential for rear‐end collision and the distance to the conflict point where a collision could have occurred is 178m. The signal is not protected by TPWS and the risk ranking overrun probability is 9 (the highest being 10). In terms of the potential consequences, should a rear‐end collision have occurred, the SPAD risk ranking consequence score was 12 (the highest being 18). This score arises because (a) the permitted speed of the SPAD train was 40mph and the speed of the conflict train was 0mph (potential collision speed in the calculation – 20mph), (b) the collision would have involved two MU MK3 passenger trains and (c) the passenger trains were both peak loaded. RSSB Board Meeting Final: 03 March 2016 Page 4 of 7 AGENDA ITEM: D4 SPAD risk ranking 20 On 8 January 2016 a freight train passed signal VS637 at danger on the Up Maidstone (down direction) line at Swanley by approximately 100m. The driver stated that they had read through to a signal ahead. VS637 is a signal protecting a junction during opposite direction movement with potential for head‐
on or side‐on collision and the distance to the conflict point where a collision could have occurred is 1220m. The signal is not protected by TPWS, and the risk ranking overrun probability is 7 (the highest being 10). In terms of the potential consequences, should a head‐on or side‐on collision occurred, the SPAD risk ranking consequence score was 13 (the highest being 18). This score arises because (a) the permitted speed of the SPAD train was 15mph and the speed of the conflict train was 70mph (potential collision speed in the calculation – 42.5mph), (b) the collision would have involved one non‐dangerous freight train and a passenger train and (c) the conflict train was 11%‐25% loaded. SPAD risk ranking 22 On 23 January 2016 an empty coaching stock train passed signal L848 at danger on the Up Main line at Kelvedon by approximately 160m. The driver stated that they had become distracted whilst getting a drink from their bag. L848 is a signal protecting plain line with potential for rear‐end collision and the distance to the conflict point where a collision could have occurred is 140m. The signal is not protected by TPWS, and the risk ranking overrun probability is 9 (the highest being 10). In terms of the potential consequences, should a rear‐end collision have occurred, the SPAD risk ranking consequence score was 13 (the highest being 18). This score arises because (a) the permitted speed of the SPAD train was 100mph and the speed of the conflict train was 100mph (potential collision speed in the calculation – 50mph), (b) the collision would have involved an empty coaching stock train and a passenger train and (c) the conflict train was 11%‐25% loaded. RSSB Board Meeting Final: 03 March 2016 Page 5 of 7 AGENDA ITEM: D4 4. Overseas accidents (December 2015 – January 2016) Dangerous goods Australia: Freight carrying sulphuric acid derails in Queensland, over 31K litres spilled, 27 December 2015 At 10:20 (local time) on 27 December 2015, a freight train carrying around 800,000 litres of sulphuric acid derailed near Julia Creek in Queensland. The locomotive and all 26 wagons left the rails; the three crew members sustained minor injuries. As diesel fuel and up to 31,500 litres of acid were spilled and leaked into the nearby Horse Creek, a 2‐kilometre exclusion zone was placed around the site. US: Freight carrying sulphuric acid derails in California, no leaks, no injuries, 20 January 2016 At around 08:00 (local time) on 20 January 2016, three wagons carrying sulphuric acid derailed In Martinez, California. There were no reported leaks or injuries. The cause of the incident has yet to be determined. An investigation has been launched. Other derailments – cause TBA US: Passenger train derails at Pompano Beach, Florida, one passenger injured, 28 January 2016 On 28 January 2016, a Tri‐Rail passenger service derailed in Pompano Beach, Florida. Of the 40 passengers on board, one was injured. Some diesel fuel was also spilled, though this was later contained. Reports suggest that the locomotive struck debris before leaving the track. Collisions – cause TBA Italy: Two light rail trains collide in Cagliari, 70 passengers injured, 20 January 2016 On the morning of 20 January 2016, two light rail trains collided head‐on in Cagliari, Sardinia. Some 70 passengers – mainly pupils of a nearby school – suffered minor injuries. The head of local transport company ARST, Giovanni Caria, said that, while it was not clear what happened, ‘a human error’ was certainly involved. An investigation has been launched. Level crossings Mexico: Level crossing collision kills 4 near Mazatlán, 22 December 2015 On 22 December 2015, a bus was struck by a train on an open level crossing in Mazatlán, Mexico, killing four people (including the driver) and injuring 22 more. The bus crossed the line moments after a car had successfully done so. Police believe this lulled the bus driver into thinking it was safe to follow. The driver's wife is reported to have said her husband had complained that the bus was old and did not have good brakes a number of times. RSSB Board Meeting Final: 03 March 2016 Page 6 of 7 AGENDA ITEM: D4 US: Level crossing collision injures 22 at Lake Worth, 4 January 2016 Just before 07:00 (local time) on 4 January 2016, a Tri‐Rail passenger train struck a dustbin lorry which had broken down on a level crossing at Lake Worth station, Florida. Twenty‐two passengers were injured; all were taken to hospital for treatment. Thailand: Crossing collision at Phetchaburi kills 1, injures 34, 8 January 2016 At 10:35 (local time) on 8 January 2016, a passenger train struck a cattle lorry on a level crossing at Phetchaburi station. Five carriages were derailed by the impact. The lorry driver, his passenger and one rail passenger were killed; 34 people were injured. The heavily laden lorry was reported to have been speeding as it approached the interface. It then crashed through the lowered barriers and into the side of the train. Philippines: ‘Jeepney’ driver charged with dangerous driving after 1 killed and 6 injured in crossing collision, 12 January 2016 At around 19:00 (local time) on 12 January 2016, a passenger train struck a ‘jeepney’ on a level crossing in Paco, Manila. One road vehicle passenger was killed and six more were injured. The ‘jeepney’ driver was later charged with dangerous driving. The France: Level crossing collision near Beuville, loco driver injured, 14 January 2016 At 04:05 (local time) on 14 January 2016, a lorry was struck by an empty freight train at a level crossing between Beuveille and Arrancy‐sur‐Crusne. The train was travelling at 80 km/h at the time of the incident. The locomotive and 21 wagons derailed, the track was damaged, the lorry was dragged some 100 metres and the train driver suffered minor injuries. The lorry driver – who just managed to jump clear – suffered shock/trauma. Egypt: Level crossing collision near Cairo kills 7, keeper blamed, 31 January 2016 At 07:30 (local time) on 31 January 2016, seven people were killed and three were injured when a passenger service struck a lorry at a level crossing in Giza, near Cairo. Initial investigations suggest that the crossing keeper ‘forgot’ about the train. Irregular working – runaway US: Boston runaway commuter train was ‘tampered with’, 10 December 2015 Just after 06:00 (local time) on 10 December 2015, a commuter train carrying 50 passengers left Braintree station in Boston without a driver. It passed four stations before Massachusetts Bay Transport Authority (MBTA) officials cut the power to the third rail. There were no reported injuries. Early investigations suggest that an on‐board safety system had been ‘tampered with’. However, later reports revealed that the driver had tied a cord round the train’s power handle and had not secured the brakes when leaving the cab for a ‘signal issue’. He has now been put on ‘administrative leave’. RSSB Board Meeting Final: 03 March 2016 Page 7 of 7