Learning from Operational Experience Annual
Report 2012/13
Greg Morse and Suzanne Taberneso
Operational Feedback
RSSB
Block 2, Angel Square
1 Torrens Street
London EC1V 1NY
020 3142 5400
enquirydesk@rssb.co.uk
The report may be downloaded from the RSSB website: www.rssb.co.uk.
 Rail Safety and Standards Board 2013
Contents
Executive summary
5
1
Introduction
9
1.1
Purpose of the report
9
1.2
Scope of the report
9
1.3
Report structure
9
2
What is ‘Learning from Operational Experience’?
11
3
Industry co-operative initiatives during 2012/13
13
3.1
Get on the Right Track
13
3.2
Measuring safety performance
13
3.3
Incident Factor Classification System
15
3.4
Close Call
16
3.5
CIRAS
16
4
5
7
Who reports to CIRAS?
17
3.5.2
Why do people report to CIRAS?
18
3.5.3
Key issues of concern in CIRAS reports during 2012/13
18
3.5.4
Positive outcomes from CIRAS reports
19
The role of investigations in the learning process
21
4.1
RAIB investigations in 2012/13
21
4.2
RSSB analysis of key RAIB recommendation themes
25
Lessons learned 2012/13 – train accidents
29
5.1
Statistical overview
29
5.2
Animals on the line
29
5.3
Derailments
33
5.3.1
33
5.4
6
3.5.1
Signals passed at danger
35
Lessons learned 2012/13 – passengers
39
6.1
Statistical overview
39
6.2
Platform-train interface
40
6.2.1
Passenger fall between train and platform at James Street, Liverpool, 22 October
2011 (pub. 11/12)
40
6.2.2
Multi-detraining incident near Kentish Town, 26 May 2011 (pub. 05/12)
43
Lessons learned 2012/13 – workforce
47
7.1
Statistical overview
47
7.2
Road vehicle driving
47
7.3
Track working
49
7.3.1
8
Derailment of a locomotive at Bletchley Junction, 3 February 2012 (pub. 11/12)
Track worker struck by train at Stoats Nest Junction, 12 June 2011 (pub. 08/12) 49
Lessons learned 2012/13 – members of the public
53
8.1
53
Statistical overview
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8.2
8.3
Level crossings
53
8.2.1
54
Road vehicle incursions
8.3.1
9
10
Fatal accident at Mexico footpath crossing, 3 October 2011 (pub. 06/12)
56
Road vehicle incursion and collision with train at Stowmarket Road, 30 November
2011 (pub. 11/12)
57
Lessons learned 2012/13 – beyond the boundary fence
61
9.1
61
Fukushima
Learning activities and initiatives
63
Appendix 1.
Progress against RAIB recommendations
69
Appendix 2.
Glossary
75
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Executive summary
Statistics show that the rail industry’s safety performance has steadily improved over time.
One of the main contributors to this improvement is the learning that flows from near misses
and accidents.
But learning is hard, as any student or schoolchild will confirm – though for a company it is
even harder: companies comprise a number of different and disparate memories, which do
not necessarily interface perfectly, and which are subject to change as staff retire, move on,
or move in from elsewhere. When you expand the idea to a complete industry like rail, it
becomes even more complicated.
Arguably, the current era of railway safety began after the Clapham multiple train collision of
1988, the inquiry into which led to changes in signal testing procedures and working hours
for safety critical staff. However, even in the relatively short period of time since then, the
railway has seen a huge amount of organisational change, and a variety of different regimes
and techniques for capturing (or not capturing) appropriate knowledge and learning.
The opportunity to help the industry think as a whole system and own a shared capability to
manage knowledge really came to life with the setting up of RSSB in 2003. RSSB provides
many outputs, including annual and periodic safety reports, RSSB Board strategic items on
specific risk areas, the regular publication of information about incidents within the railway
and other sectors, facilitation of the RED series of safety DVDs, Right Track magazine, and
the analysis and support we provide to national stakeholder groups.
In addition, RSSB plays a part in the accident investigation process by providing statistics to
help the Rail Accident Investigation Branch (RAIB) set incidents into context, by offering
RAIB expert knowledge from staff with extensive industry experience, and by bringing crossindustry groups together to tackle industry-wide issues.
We also produce a Learning from Operational Experience Annual Report (LOEAR) to
capture some of the lessons learnt during a given year. The LOEAR looks at areas of
general co-operative activity and specific issues affecting rail users and employees.
Summary of key points arising during 2012/13

Passenger risk at the platform-train interface is an issue which continues to have a
high profile. The role of the dispatcher, the role of the driver and the behaviour of the
passenger are all implicated.

Fatigue affects performance and can increase the likelihood of errors that have the
potential to result in serious accidents. Both the industry and individuals have a
responsibility to be aware of fatigue issues – including those centring around rail staff
driving road vehicles.

The risk from animals on the line is demonstrably low, but incidents can still occur, still
cause harm and can impact on the commercial aspect of the railway, in terms of
delays, rolling stock cleaning and line clearance.

Inadequate rescue provision and execution has highlighted the effect that being held
on a train can have on passengers (with specific reference to multi-trespass on open
lines). The use of electronic communications equipment is implicated.
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
The need to ensure safe systems of work in possessions has been highlighted, with
specific reference to training, briefings and the presence of management on site

A road vehicle incursion incident highlighted the need for co-operation and knowledgesharing between Network Rail, the Department for Transport and local councils.

While the majority of the risk at the road-rail interface arises from the behaviour of level
crossing users (some inadvertent errors and others deliberate), the rest lies within the
direct control of the railway. Effective training and adequate technology are both
necessary for the correct operation of level crossings.

During 2012/13, RAIB published 26 reports, 19 of which involved incidents on the
mainline railway. These 19 incidents led to 82 recommendations; the area of safety
critical communications received most focus.

CIRAS received 979 contacts on a diverse range of topics in 2012/13, of which 207
(21%) became reports after the screening process. Positive results were achieved in
65% of cases and included (inter alia) nuclear flask storage, diesel fumes at terminal
stations and child trespass. (Most of the remaining 35% is made up of clarifications,
whereby the company concerned has reviewed the report and responded, but has not
deemed it necessary to make any concrete change ‘on the ground’.)
Investigations and recommendations
During 2012/13, RAIB published 26 reports, 19 of which involved incidents on the mainline
railway. These 19 led to 82 recommendations (comparing to 90 recommendations from 23
RAIB investigations in 2011/12). The area of safety critical communications received the
most focus.
The investigations into accidents together with safety performance statistics, risk
assessments and others sources of information are analysed to help us focus effort where it
is most needed and, where reasonably practicable, minimise or eliminate the potential
recurrence of the identified causes.
For consistency with the ASPR, this LOEAR considers the learning that has been achieved
across the four key topic areas of train accidents, passengers, workforce and members of
the public.
Train accidents
The train accidents section of the report deals with the risks that can arise from animals on
the line, as well as providing an overview of the current situation re signals passed at danger.
A fatal collision between a push-pull train running in push mode and a cow in Germany led to
a cross-industry discussion of the risks from strikes with animals in Great Britain.
RSSB demonstrated the lessons learned after a similar accident at Polmont in 1984 (this
being the most recent event to have occurred in Great Britain as the result of a train striking
an animal). The issue grew in pertinence after a non-fatal derailment at Letterston Junction in
2012.
Though RSSB’s analysis indicates that the safety risk from animal strike incidents is
generally low, incidents can still occur, can cause harm, and can impact on the commercial
aspect of the railway, in terms of delays, rolling stock cleaning and line clearance.
Page 6 of 76
Passengers
The platform-train interface (PTI) continues to be a key area for industry risk management. A
number of recent events have highlighted areas for learning, including the dispatch
procedure itself, the role of the driver, the behaviour of passengers and door design and
maintenance. The industry has centred on passenger risk at the PTI over the last two years,
via a dedicated task force.
The train failure at Kentish Town showed how inadequate rescue provision and execution
can affect passengers (with specific reference to multi-trespass on open lines). The use of
electronic communications equipment is implicated.
Workforce
Fatigue can result in incidents that carry risk for the fatigued person, and for others. There
are a number of known factors that can increase worker fatigue, such as inadequate breaks,
inadequate rest between work periods, and workload. Lifestyle outside of work can also
affect fatigue levels in work. Fatigue is also emerging as an issue for rail staff driving road
vehicles to or from work – or worksites.
The need to ensure safe systems of work in possessions has also been highlighted again,
with specific reference to training, briefings and the presence of management on site.
Members of the public
The majority of the risk to members of the public arises from their own behaviour, although
this in no way negates the industry’s duty of care towards people using or interacting with its
environs.
Level crossings are key interfaces between the public and the railway. They represent low
risk to passengers and workforce, but more so to members of the public, who are largely
responsible for their own movements, taking account of warning signs and other controls.
The industry has a duty to ensure both that the signs and controls are fit for purpose and that
its operations allow the users to understand and follow them.
A road vehicle incursion incident also highlighted the need for co-operation and knowledgesharing between Network Rail, the Department for Transport and local councils.
Industry co-operation
During 2012/13, four key cross-industry learning initiatives were developed to help learning
from operational experience through the provision provide data, information, good practice,
tools and techniques to the industry and its cross-industry working groups.

RSSB published five issues of Right Track, a quarterly magazine aimed at front-line
personnel to capture, share and promote safety learning and initiatives in a down-toearth way. The magazine supports a culture of information sharing about good practice
and 'lessons learned' within the operational safety community.

During 2012/13, RSSB has continued to promote Measuring Safety Performance and
develop guidance to support it. The project is also investigating how to communicate
safety performance information.
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
RSSB and Network Rail have been working together to create an Incident Factor
Classification System (IFCS) within the industry’s Safety Management Information
System. Between January 2013 and March 2014, the IFCS will be populated by RSSB
and the Network Rail Ergonomics team with data from industry accident and incident
reports. Each report will be reviewed, summarised and classified into the IFCS system.

At the request of Network Rail and its contractors, RSSB has developed an internetbased Close Call System (CCS) that allows the industry to record and analyse ‘close
call incidents’ centrally. A ‘close call’ is defined as ‘an event that had the potential to
cause injury or damage’. After some further improvements to the system, CCS is going
to be extended to cover all maintenance staff and is expected to start generating
meaningful precursor intelligence over the next 12 months.
Beyond the railway
The industry is also mindful of the need to look beyond its own operations for insights or
initiatives. The main non-rail story of 2012/13 was the publication of the independent inquiry
into the Fukushima nuclear accident, which came in the wake of the Great East Japan
Earthquake of 11 March 2011.
The inquiry report contains learning points on issues such as the dangers of ‘not invented
here’ syndrome, a failure to learn, flawed training materials and a confused chain of
command.
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1
Introduction
The rail industry learns from operational experience by investigating
specific events and through the regular monitoring of trends.
RSSB’s Learning from Operational Experience Annual Report
(LOEAR) contributes to this process by summarising some of the
learning points that have arisen from investigations and other
sources of information.
RSSB’s Annual Safety Performance Report (ASPR) – the ‘sister’
publication to the LOEAR – contributes by providing decisionmakers with wide-ranging analyses of safety performance on the
mainline railway.
1.1
Purpose of the report
The primary purpose of LOEAR is to provide learning information to the management staff in
RSSB member organisations. However, like the ASPR, it is also intended to inform rail
employees, passengers, the government and the public at large.
Since 2009, RSSB has worked with industry groups to shape the definition and objectives of
Learning from Operational Experience (LOE) to meet industry requirements. This report
describes the LOE processes and their evolution, while retaining the RSSB
recommendations tracking function of previous documents.
1.2
Scope of the report
The LOEAR considers a range of learning sources and identifies
the key issues that have arisen during 2012/13, including:

Recent general developments in sharing learning from
operational experience;

Specific learning points arising in the areas listed below; and

A clear picture of rail industry progress against
recommendations from accident investigations.
1.3
Hyperlinks (underlined
blue text) have been used
throughout this document
to aid navigation and
access to relevant
documents and websites.
Green boxes have also
been provided to highlight
learning points that
readers might like to
consider further.
Report structure
The initial sections of this report deals with some of the operational learning that has
occurred between 6 April 2012 and 4 April 2013.
After an overview of the subject, the four main areas – train accidents, passengers,
workforce and members of the public – are dealt with in turn via the following sub-topics:

Animals on the line

Derailments

Signals passed at danger

The platform-train interface
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
Multi-detraining

Road vehicle driving

Track working

Level crossings

Road vehicle incursions
LOE also takes a look ‘beyond the boundary fence’ and Chapter 9 considers any lessons
that may have arisen from non-railway events, such as the Fukushima nuclear accident,
which came in the wake of the Great East Japan Earthquake of 11 March 2011.
Initiatives relating to specific issues raised are covered with each topic, but other industry
initiatives instigated during the reporting period are featured in Chapter 10; lessons
specifically from CIRAS may be found in Chapter 3.
Lists of all RAIB reports published in the period, along with analysis of the recommendations
contained, may be found in Chapter 4.
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2
What is ‘Learning from Operational Experience’?
The railway and its regulatory bodies have been learning
lessons from accidents and incidents since William
Huskisson MP was struck by Rocket at the opening of the
Liverpool & Manchester Railway in 1830.
Early incidents like this led to the first Railway Regulation
Act (1840), which required all injurious accidents to be
reported to the Board of Trade. Within 50 years, block
signalling, interlocking and continuous braking on
passenger trains had been made mandatory. The twentieth
century saw further advancements, ranging from
continuous welded rails and multi-aspect signalling,
through to automatic train protection systems.
The cycle of safety planning and performance reporting has become essential to ensuring
that this development continues, but much learning also comes from investigations into
accidents that have occurred, near miss data and reports to the industry’s Confidential
Reporting and Analysis System (CIRAS).
In this report, LOE is defined as the process by which knowledge from the operation of
systems is gained, exchanged and used, leading to continuous improvement and the
development of a positive safety culture.
LOE is discharged through the rail industry’s national stakeholder groups, all of which have
been established by the RSSB Board. During 2012/13 the Safety Policy Group (SPG)1 had
the overall stewardship role with the national stakeholder group structure comprising: the
Operations Focus Group (OFG); Road-Rail Interface Safety Group (RRISG); Community
Safety Steering Group (CSSG); Infrastructure Safety Liaison Group (ISLG).
However, following an RSSB-led review and
consultation, the industry is now in the process of
modernising and improving system safety co-operation.
The system safety lifecycle model will form the core of
the co-operation process between Safety Management
System (SMS) holders. This is based on the five-stage
cycle of:

Understanding the risk profile;

Monitoring performance data;

Planning improvements;

Delivering; and
1
The Safety Policy Group was a senior cross-industry body, consisting of RSSB members, who
supervised and advised on the delivery of RSSB’s functions that support the industry in managing
safety. The Office of Rail Regulation and Department for Transport were observers on the group.
Page 11 of 76

Reviewing.2
The current range of national and regional meetings will be replaced with:
i. A single Safety Risk Group (SSRG) formed from SPG, CSSG and OFG – responsible for
reviewing 100% of rail system risk, looking at future trends, identifying and sharing good
practice and supporting Route and National Groups.
ii. Dedicated National Safety Groups for freight operators, infrastructure contractors who
operate mainline trains, cross-country trains and charter operators.
iii. Route based Safety Groups between local train operators and their Network Rail route
counterparts or equivalent if part of an ‘alliance’.
The first stage of implementation, which has established the National Freight Safety Group
(NFSG), SSRG, a Wessex Route Safety Group and implementation of the groups, will
continue during 2013/14.
National stakeholder groups review the outputs from a number of RSSB activities, including:

Safety performance reporting – information on the latest trends, updated on a regular
basis.

Operational Feedback – RSSB’s arrangement for analysing and disseminating lessons
from rail and other industry accidents.

CIRAS – the rail industry’s Confidential Incident Reporting and Analysis System.

Human Factors

Safety Management Systems programme

R&D – RSSB’s management of research and development on behalf of government
and the railway industry.
2
An example of this learning loop in action may be seen in the work the industry has done on reducing
the risk at the platform-train interface. RSSB uses the data within the Safety Management Information
System (SMIS) to provide the cross-industry Operations Focus Group (OFG) with regular updates on
risk and safety performance. One report highlighted a rise in risk at the platform-train interface. This
prompted RED 28 to feature a poignant dramatisation on the subject and led OFG to develop a
Station Safety Improvement Programme, which strives to identify and share the many good practice
initiatives that exist within the station operator community. At the end of January 2012, RSSB also
held the first Station Safety Improvement Workshop. The purpose of the event was to provide an
update on operational risk management initiatives, promote sharing, encourage good practice and
obtain the views of front-line staff on the issues associated with the management of operational risk at
stations. Various research projects are also in development.
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3
Industry co-operative initiatives during 2012/13
Just as businesses have to work as one to make a profit, and football teams play as one to
win championships, the rail industry needs to think and act as a cohesive unit to maintain
acceptable levels of safety and performance. This section describes five key learning
initiatives which have progressed during 2012/13, along with details of CIRAS activity in the
same period.
3.1
Get on the Right Track
In 2012, RSSB launched Right Track, a quarterly magazine aimed at
front-line personnel to capture, share and promote safety learning and
initiatives in a down-to-earth way.
This year, the magazine has focused on station safety, suicide
prevention, SPADs, track worker safety, train dispatch and autumn
adhesion, among many other subjects relevant to drivers, guards, ontrain staff, station staff, dispatchers, signallers, shunters, depot
workers and track workers.
Right Track is available to all RSSB members, London Underground,
and other companies and bodies who have a role in supporting railway operations.
It is available as a pdf and in paper form. Hard copies are distributed in bulk by arrangement
with individual companies. For further details, see www.opsweb.co.uk.
3.2
Measuring safety performance
The Baker Panel review into the
BP Texas City oil refinery explosion
of 2005 recommended that BP
improve its safety performance
indicators (SPIs) by considering
proactive measures and monitoring
its process (as well as personal)
hazards.
This
encouraged
a
deeper
understanding of risk by the further
development of SPIs across a
range of safety critical industries.
After the Clapham multi-train
collision of 1988, British Rail made
several changes to its practices,
including the way it managed risk.
SPI concepts were also explored
by some GB rail organisations after
privatisation, but no consistent practice emerged. RSSB members therefore requested that
research (project T852: The application of leading and lagging indicators to the rail industry)
was undertaken to explore the application of SPIs within the rail industry. The results of the
Page 13 of 76
research were rolled out during 2011/12 via a series of workshops, supported by a guidance
document and toolkit. Further research (T953: Enhancing and promoting the use of safety
performance indicators) is in progress.
Traditionally, we have relied on failure and incident data to monitor safety performance, but
this creates a bias towards introducing improvements or changes only after something has
gone wrong. In addition, simply reporting the number of incidents does not readily support
the full understanding of the underlying causes. Without this understanding, there is a lack of
ability to focus on the important SPIs. This often leads to a large, cumbersome, and
potentially ineffective suite of indicators.
Good safety management is about focusing on the right things, and conversely a poor
accident record might suggest that focus has been in the wrong place. A successful football
team does not only pay attention to the final score, but looks at the balance of the team,
strategies, tactics and the strengths and weaknesses of each player. We too should not only
consider the final outcome, possibly an accident-free year, but the effectiveness, deployment
and the strengths and weaknesses of the risk controls that contributed to the accident-free
record.
Interrogate the risk
It is essential to understand the nature of the risk (relevant to the scope) in order to help set
and prioritise SPIs. The key to interrogating and understanding the risk is to consider the
following:

What hazards exist, and what controls are in place to manage them?

What can go wrong?

What has gone wrong?
Answering these questions requires evaluating information from:

Employees’ and managers’ knowledge and experience;

Recent reviews of key risks;

The Safety Risk Model (SRM) and the associated SRM Risk Profile Tool;

SMIS and other safety performance data;

Accident/incident/near miss investigation reports; and

Changes to the organisation or activities.
This LOEAR helps the industry by providing information on lessons learnt from investigations
and near misses, while the ASPR presents a comprehensive summary of the latest safety
performance and risk data to help the industry understand current levels of safety and
monitor the combined effects of its safety improvement initiatives. The comparative rarity of
serious train accidents results in a small dataset, so RSSB also tracks accident precursors in
order to assess changes underlying risk more effectively. The current output of this work –
the Precursor Indicator Model (PIM) – may be found in Chapter 8 of the latest ASPR.
Page 14 of 76
Update
During 2012/13, RSSB continued to promote Measuring Safety Performance and develop
guidance to support it.
As a dull safety report can result in key early warnings of a looming accident being
overlooked, data needs to be presented in an engaging manner that promotes appropriate
responses. Therefore the project is also investigating how to communicate safety
performance information effectively.
For more details on Measuring Safety Performance, contact kevin.thompson@rssb.co.uk or
jay.heavisides@rssb.co.uk.
3.3
Incident Factor Classification System
RSSB receives investigation reports from all railway organisations, which is a mandatory
requirement under Railway Group Standard GO/RT3119 (Accident and incident
investigation). Currently, around 4,500 investigations are stored, dating back to the late
1990s.
The conclusions in these reports hold much valuable information about event causes, but
once the recommendations therein have been acted upon, there is a danger that some of
their learning points will be lost or will not reach other parties who could benefit from them.
In 2009, RSSB developed a means to analyse accident reports through an Incident Causal
Classification System (ICCS), using a taxonomy developed by the Rail Accident Investigation
Branch (RAIB).
Previous editions of the LOEAR featured analysis using the ICCS. More recently, however,
RSSB and Network Rail have worked together to combine the ICCS, the Human Factors
incident taxonomy and the Network Rail ‘10 incident factors’ within SMIS. Software for a
single module – the Incident Factor Classification System (IFCS) – was commissioned in
November 2012 as part of research project T994: Development of an incident factor
classification system module for SMIS. It is now being populated with data, which will enable:

Cross-Industry learning Causal trends will be identified for all in the industry using a
consistent classification for key incidents. The information within the IFCS will be
heavily used by RSSB and Network Rail learning from operational experience
functions in their central reporting and analysis.

Incident investigation The IFCS will be able to be used by incident investigators to
identify past incidents with similar causes. This will aid analysis and help ensure that
previous recommendations are not duplicated or contradicted.
The IFCS module will contain causal classifications for all RAIB reports and Formal
Investigations, Network Rail completing the classification process for its own reports and
RSSB completing for the RAIB and non-Network Rail ones. It may, in future, be possible to
include causal classifications for some local investigations. As with the ICCS, the IFCS
module will also include non-UK rail and non-rail investigation reports, in order to ascertain
how other industries learn from safety events which may have parallels with our own.
Between January 2013 and March 2014, the IFCS will be populated by RSSB and the
Network Rail Ergonomics team with data from industry accident and incident reports. Each
Page 15 of 76
report will be reviewed, summarised and classified. This 15-month period will allow sufficient
time for the database contents to reach a meaningful sample size, and for the collected data
to be reviewed, analysed and presented to industry in a usable form.
The intention is to have reviewed and classified at least 300 incidents by February 2014 and
produce a set of deliverables, summarising the data from the IFCS and presenting its key
findings by March 2014. This will be developed in collaboration with industry stakeholders.
RSSB is also working with RAIB on their potential use of the IFCS.
3.4
Close Call
At the request of Network Rail and its contractors, RSSB has developed a new internetbased Close Call System (CCS) that allows the industry to record and analyse ‘close call
incidents’ centrally. This was managed as research project T1015: Revision of the close call
system. Use of the system is mandated for Network Rail’s principal contractors.
A ‘close call’ is defined as ‘an event that had the potential
to cause injury or damage’. This does not include near
misses with trains or on-track plant, which will continue to
be reported into SMIS.
After some further improvements to the system, CCS is going to be extended to cover all
maintenance staff and is expected to start generating meaningful precursor intelligence over
the next 12 months.
Because of the close links between SMIS operational incidents and CCS events, work is also
under way to harmonise these reporting categories and clarify the precise scope that these
terms and systems should cover. This should facilitate the production of more accurate and
meaningful safety performance data in future.
3.5
CIRAS
Learning does not only occur after an event; many valuable lessons
are revealed by what might be termed ‘accidents waiting to happen’.
Reports to the industry’s Confidential Incident Reporting and
Analysis System (CIRAS) focus mainly on such ‘near miss’ events
or perceived deficiencies in safety systems and arrangements, a
better understanding of which provides a solid foundation for shared
learning across different industry sectors.
By systematically capturing this knowledge, which comes from
workforce members who have daily operational contact with the
railway, it is possible to identify issues before they cause injury.
Maintaining confidentiality is a key aspect of CIRAS. It is recognised that this may restrict the
information that is to be disclosed. However, the advantage is that reporters may be able to
state their real concerns and describe underlying causes more openly than they might to
their line manager. This gives CIRAS the potential to provide unique insights into safety
issues.
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During 2012/13, CIRAS rolled out a new business plan, which aims to exploit this learning for
the benefit of all stakeholders through multi-level engagement: from Managing Director level
right through to front-line staff. A structured programme of industry engagement, and a
strong presence at both industry exhibitions and health and safety events around Great
Britain, will help ensure visibility.
The business plan also aims to capture the reasons staff report to CIRAS more effectively.
This will help address the common misperception that staff are using CIRAS as an
alternative reporting channel. In fact, evidence is growing that staff normally comply with the
need to use internal reporting channels first, but use CIRAS in a complementary manner
where concerns remain unresolved.
3.5.1
Who reports to CIRAS?
Chart 1 shows the distribution of reports categorised by reporter occupation.
Report distribution 2012/13 – by job category
Chart 1.
80
70
67
60
Reports
50
40
30
19
20
19
16
16
16
7
6
5
5
5
4
1
1
Train crew
8
10
Station mainenance
12
Shunter/groundstaff
Trainer
S&T
Engineer
Supervisor
Maintenance depot
Machine operator
Manager
Conductor/guard
Station staff
Signaller
Other
Infrastructure worker
Driver
0

Train drivers have consistently submitted the largest number of reports, but it is
particularly positive to note that other groups feel able to raise safety issues too,
including signallers, track workers, managers and other train crew.

Interestingly, there has been an increase in the number of signallers and machine
operators submitting reports to CIRAS during 2012/13.

Page 17 of 76
3.5.2
Why do people report to CIRAS?
Most issues (72%) reported have previously been taken through internal company channels,
a figure that remains consistently high from year to year. However, it is true that some staff
report to CIRAS because they find it difficult to raise sensitive issues with their managers.
Chart 2 shows the breakdown of why reporters feel it necessary to raise an issue with
CIRAS, even though a report had been first made internally.
Chart 2.
Reporters’ views of company response after issue raised internally
Other
2%
No response
20%
Inadequate
57%
Adequate but not
implemented
21%

57% believed the response from their company was inadequate;

21% believed the response to be adequate but had not seen any changes or
implementation at work;

20% claimed they had received no response whatsoever.
3.5.3
Key issues of concern in CIRAS reports during 2012/13
CIRAS received 979 contacts on a diverse range of topics in 2012/13. Of these, 207 (21%)
became reports after the screening process. A breakdown showing the percentage of these
reports recorded against industry risk categories is shown in Chart 3.
Reporters predominantly focus on the potential for accidents or incidents – the reports
therefore represent the perceived risks that reporters identify in the course of carrying out
their duties.

Chart 2 source: CIRAS.
Page 18 of 76
Chart 3.
Key CIRAS report topics – 2012/13
Level crossings
2%
Public safety
1%
Train
accidents
9%
Passenger safety
10%
Workforce safety
78%
3.5.4
Positive outcomes from CIRAS reports
CIRAS monitors the outcomes from the reporting process to ascertain the value and benefits
delivered to the railway industry. Positive outcomes from CIRAS reports are recorded where
the CIRAS report prompted an investigation, briefing, review or change. In 2012/13, 65%3 of
207 reports led to positive outcomes, some of the best examples of which are listed below:

Inaccuracies in lifting plans for Road Rail Vehicles Network Rail acknowledged
that the planning of lifting operations is often not carried in accordance with
regulations. It is working very closely with the relevant contractors and suppliers to
revise company standards, and is also developing new training and assessment
material.

Diesel fumes at Birmingham New Street The relevant TOC introduced a new
engine control policy, whereby drivers switch off engines at terminating stations if a
train is there for longer than ten minutes.

Children trespassing at West St Leonards Following a site visit, Network Rail retensioned the fencing and raised the ground with chippings to prevent access to the
railway. A proposal for palisade fencing has been made.

‘Poor’ lighting at Loughton and Woodford London Underground inspected all the
lighting and fixed those which required it.

Managing double-shifting across subcontractors Network Rail, supported by the
industry, is investigating how the Sentinel system can be improved to incorporate
‘smart’ technology. It expects to introduce the new service towards the middle of 2013.

Chart 3 source: CIRAS.
Most of the remaining 35% is made up of clarifications, whereby the company concerned has
reviewed the report and responded, but has not deemed it necessary to make any concrete change
‘on the ground’.
3
Page 19 of 76

Trains lifted whilst coupled and with no isolation The relevant TOC confirmed that
the correct process has not been followed. As a result of the CIRAS report, a safety
brief was issued to all staff performing this task.

Nuclear flask storage at Inverness yard The relevant freight operator confirmed that
the yard is only to be used as contingency storage area. In the event of a train having
to stable at the yard, appropriate safety and security measures will be deployed.

‘Not To Be Moved’ boards not being placed on trains An investigation was
conducted by the relevant supplier who provided their staff with lightweight ‘Not To Be
Moved’ boards. They also introduced a simple key lock system, which prevents a
driver from moving a train during servicing.
Page 20 of 76
4
The role of investigations in the learning process
Though the cycle of safety planning and performance reporting is essential to ensuring that
safety continues to improve, much of the industry’s learning comes from investigations into
accidents and incidents.
The principal investigation of any safety event is conducted by the party immediately
responsible for the activity. To facilitate this, railway companies have their own arrangements
for carrying out internal formal and local investigations, as defined in Railway Group
Standard GO/RT3119 (Accident and incident investigation) and its associated Guidance
Note, GO/GN3519. Possible action includes undertaking independently chaired
investigations when appropriate. The outputs are managed by the companies concerned,
with actions being picked up by their own tracking systems. The results of duty holder-led
formal investigations are also summarised in SMIS to give others the chance to learn from
the information.
The more significant accidents (involving loss of life or potentially significant consequences)
are investigated by the Office of Rail Regulation (ORR) as safety authority, and the Rail
Accident Investigation Branch (RAIB). RAIB was set up following a recommendation made
by Lord Cullen’s inquiry into the accident at Ladbroke Grove (a subsequent European
Directive on rail accident investigation also required Member States to create such bodies). It
was fully established in 2005, after which RSSB ceased its accident investigation role (2006).
If an accident involves a derailment or collision which results in, or could result in, the death
of at least one person, serious injury to five or more people or extensive damage to rolling
stock, the infrastructure or the environment, then RAIB will lead an investigation, draw
conclusions and make recommendations.4
RAIB investigates incidents on UK railway infrastructure without apportioning blame or
liability. It is independent of the rail industry and the ORR, with the Chief Inspector of Rail
Accidents reporting directly to the Secretary of State for Transport. RAIB’s recommendations
on the rail industry are addressed to the ORR5, which must then ensure that they are
considered and that, where appropriate, action is taken. More information on RAIB may be
found on its website.
4.1
RAIB investigations in 2012/13
RAIB published 26 reports between April 2012 and March 2013, covering the following
categories:

Heavy rail – on Network Rail managed infrastructure (NRMI) (19)

Heritage railways (1)

Metro (1)

London Underground (1)
4
RAIB may also investigate other incidents that have implications for railway safety, including those
which, under slightly different circumstances, may have resulted in an accident.
5
RAIB can also address recommendations to other safety authorities and other public bodies, such as
the police, the Department for Transport and so on.
Page 21 of 76

Tram (2).
Table 1 (overleaf) lists each of these investigation reports (with links to the reports in
question). Note that:

82 recommendations were issued from 19 RAIB investigations involving incidents on
NRMI. This compares to:

90 recommendations from 23 RAIB investigations in 2011/12

76 recommendations from 15 RAIB investigations in 2010;

167 recommendations from 27 RAIB investigation reports in 2009;

127 recommendations from 18 RAIB investigation reports in 2008; and

158 recommendations from 22 RAIB investigation reports in 2007.
Tables 1 to 4 contain hyperlinks aid navigation direct to RAIB’s investigation reports and bulletins.
Page 22 of 76
Table 1.
RAIB investigations published in 2012/136
Publication
Date
Report Title
Infrastructure
Owner
REPORTS PUBLISHED IN 2013
28/03/2013
Derailment of a tram at East Croydon, 17 February 2012
28/01/2013
Pedestrian struck by a tram at Sandilands tram stop, Croydon, 16 May
2012
Freight train derailment at Reading West Junction, 28 January 2012
14/01/2013
Fatal accident at Kings Mill No.1 level crossing, Mansfield, 2 May 2012
14/02/2013
20/12/2012
13/12/2012
03/12/2012
21/11/2012
21/11/2012
18/10/2012
27/11/2012
27/09/2012
27/09/2012
19/09/2012
30/08/2012
09/08/2012
06/08/2012
18/07/2012
12/07/2012
05/07/2012
02/07/2012
27/06/2012
21/06/2012
30/05/2012
REPORTS PUBLISHED in 2012
Near miss incident at Ufton automatic half barrier level crossing,
Berkshire, 04 September 2011
Fatal accident at a footpath crossing near Bishop’s Stortford, 28 January
2012
Person trapped in a train door and dragged at Jarrow station, Tyne and
Wear Metro, 12 April 2012
Road vehicle incursion and subsequent collision with a train, at
Stowmarket Road, 30 November 2011
Derailment at Bletchley Junction, Bletchley, 3 February 2012
Fatal accident at Grosmont, North Yorkshire Moors Railway, 21 May
2012
Fatal accident at James Street station, Liverpool, 22 October 2011
Collapse of the overhead line near to Jewellery Quarter tram stop,
Midland Metro, 20 April 2011
Collision between a train and a lorry and trailer on Llanboidy automatic
half barrier level crossing, 19 December 2011
Derailment at Bordesley Junction, Birmingham, 26 August 2011
Derailment at Princes Street Gardens, Edinburgh, 27 July 2011
Container train accident near Althorpe Park, Northamptonshire, 18 July
2011
Track worker struck by a train at Stoats Nest Junction, 12 June 2011
Fatal accident at Gipsy Lane footpath crossing, Needham Market,
Suffolk, 24 August 2011
Incident involving a runaway track maintenance trolley near Haslemere,
Surrey, 10 September 2011
Train departed with doors open, Warren Street, Victoria Line, London
Underground, 11 July 2011
Detachment of a cardan shaft at Durham station, 10 April 2011
Incident at Llanbadarn Automatic Barrier Crossing (Locally Monitored),
near Aberystwyth, 19 June 2011
Fatal accident at Mexico footpath crossing (near Penzance), 3 October
2011
Person trapped in doors and pulled along platform at King’s Cross
station, London 10 October 2011
30/05/2012
Fatal accident at Piccadilly Gardens, Manchester 5 June 2011
23/05/2012
Safety incident between Dock Junction and Kentish Town, 26 May 2011
Key:
Off NRMI
6
Source: RAIB website.
Page 23 of 76
London
Tramlink
London
Tramlink
NRMI
NRMI
NRMI
NRMI
Tyne & Wear
Metro
NRMI
NRMI
Heritage
NRMI
Midland Metro
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
NRMI
London
Underground
NRMI
NRMI
NRMI
NRMI
Manchester
Metrolink
NRMI
Ongoing RAIB investigations
There were a further 27 events that were still under investigation by RAIB at the end of
March 2013:
Table 2.
Incident
date
Ongoing RAIB investigations (at 5 April 2013)
RAIB investigation
22/03/2013
Serious injury to a track worker, near West Drayton, London Borough of Hillingdon
21/03/2013
Fatal accident at Athelney level crossing, near Taunton, Somerset
08/03/2013
Dangerous occurrence in a tunnel near Old Street station, London
24/01/2013
Fatal accident at Mott's Lane level crossing, Witham, Essex
23/01/2013
Derailment at Liverpool Street station, London
23/01/2013
Derailment at Ordsall Lane Junction, Salford
21/01/2013
Derailment of a freight train at Castle Donington, Leicestershire
08/01/2013
Electrical fault and fire on a metro train near South Gosforth
27/12/2012
Derailment of a freight train at Barrow upon Soar, Leicestershire
04/12/2012
Fatal Accident involving a track worker at Saxilby
04/12/2012
Fatal Accident at Beech Hill level crossing
28/11/2012
Fatal Accident at Bayles And Wylies footpath crossing
24/11/2012
Serious Accident at Charing Cross (main line) station
28/10/2012
Engineering possession irregularity near Dunblane, Stirling
14/09/2012
Broken rail incidents on the East Coast Main Line
10/08/2012
Collision between on-track machines near Arley, Warwickshire
06/08/2012
Trackworker struck by a train at Bulwell, Nottingham
16/07/2012
Near miss involving track workers at Roydon, Essex
07/07/2012
Derailment of a freight train at Shrewsbury
28/06/2012
Accidents due to landslides at Loch Treig
28/06/2012
Train runs over washed-out track formation at Knockmore, Northern Ireland
26/04/2012
Investigation into a Signal passed at danger (SPAD), near Stafford
Investigation into the collision of a road-rail vehicle with a buffer stop at Bradford Interchange
station
25/03/2012
22/03/2012
Investigation into a dangerous occurrence at Lindridge Farm, near Bagworth in Leicestershire
19/03/2012
Investigation into a dangerous occurrence involving an engineering train at Blatchbridge Junction
05/01/2012
Investigation into an incident involving the overhead line near Littleport, Cambridgeshire
23/09/2011
Investigation into the partial failure of a structure inside Balcombe tunnel, Sussex
Page 24 of 76
RAIB Bulletins
When RAIB’s preliminary examination of an incident suggests that a full investigation would
not lead to further significant safety lessons for the rail industry, in some cases it provides
related information or advice in the form of a bulletin.
Between April 2012 and March 2013, RAIB issued six such bulletins:
Table 3.
RAIB bulletins published in 2012/13
Publication
Date
Title
19/09/2012
Near miss at Four Lane Ends level crossing, near Buscough Bridge, Lancashire, 28
September 2012
Train derailment near Letterston Junction, between Clarbeston Road and Fishguard, 12 July
2012
Blowback of a locomotive fire at Wood Green tunnel, London, 27 May 2012
16/08/2012
Accident at Margam Yard, near Port Talbot, 12 June 2012
13/08/2012
Derailment at Clarborough tunnel, near Retford, Nottinghamshire, 27 April 2012
16/04/2012
Track worker struck by passing train near North Kent East Junction, 2 February 2012
11/03/2013
20/11/2012
4.2
RSSB analysis of key RAIB recommendation themes
Recommendations tend to reflect the nature of the incident from which they arise, but the
selection of incidents and the number of recommendations also indicate the weighting given
to the event by the investigating organisation. In other words, only the tip of the
accident/incident/unsafe act or condition ‘pyramid’ is represented by looking at
recommendations in detail.
It should be noted, therefore, that numeric analysis of recommendation trends has little
statistical validity. Indeed, a single report may generate multiple recommendations for one
category. In the interests of continuity, however, we have used the categorisation process
applied in previous years to RAIB recommendations.
Page 25 of 76
Table 4.
SMIS recommendation categories
A
Cat code
Recs category
Signalling system
B
Competence management
C
Rules, standards and instructions
D
Vehicle operation and integrity
E
Infrastructure asset management
F
Event mgmt/investigation/ reporting
G
Monitoring and audit
H
J
Research and development
Safety communications
K
Culture
Chart 4.
Description
Lineside SPAD controls, signal sighting issues, train
planning and regulation, operation of the signalling
equipment.
Training and development, driver management,
competence systems, briefing, assessment, staff
selection procedures, drugs and alcohol, fitness for
duty, fatigue.
Modification /development of rules and predefined
standards for operation, standards/process change
management.
Train-borne safety equipment, fire protection, vehicle
maintenance, train data recorders, crashworthiness, incab ergonomics.
Managing contractors, track/signalling maintenance
operations, work planning, technical specifications,
method statements.
SPAD management, public accident investigation, site
investigations, post-accident management, formal
investigations, formal inquiries, public inquiries, fault
reporting, emergency procedures.
Monitoring activities, safety performance monitoring,
follow-up processes.
Suggested research topics/specific areas of research.
Defining and communicating safety responsibilities,
general safety related communications, meetings,
techniques, methods and equipment.
Management commitment, organisational change.
RAIB recommendation distribution (%) – 2012/13
Signalling system
5%
Competence
management
7%
Safety communications
24%
Rules, standards &
instructions
12%
Research & development
1%
Vehicle operation &
integrity
12%
Monitoring & audit
11%
Infrastructure asset
managment
18%
Event mgmt/investigation/
reporting
10%
RSSB’s figures suggest that, in 2012/13, the largest recommendations component was
safety communications (24%). This is a move away from the emphasis on infrastructure
asset management evident in the previous two reporting periods.
Page 26 of 76
Recommendation categorisation – by year (%)
Chart 5.
40
38 37
36
Recommendations issued in:
35
2008/09
Percentage of total categories
31
2009/10
30
2010/11
25
24
2011/12
20
19
18
2012/13
18
15
15
13
12
1112
11
10
10
7
1
11
10
7
4 4
4
3
8
7
6
5
4
5
1313
13
12 1211
4 4
1
4
3
2
6
7
3
1
1
0
Recommendations category
Comparing 2012/13 with 2011/12, reductions in the percentage of recommendations can be
seen for:

Competence management;

Vehicle operation and integrity;

Infrastructure asset management;

Research and development; and

Culture.
However, there has been a rise in the percentage of recommendations which deal with:

Signalling system;

Rules, standards and instructions;

Event management/investigation/reporting;

Monitoring and audit; and

Safety communications.
The ORR also keeps a
record of the status of all
RAIB recommendations.
This is available on its
website.
The rise in recommendations pertaining to safety critical communications has been evident
since 2007/08. Though not published until May 2013, RAIB’s bulletin into the near miss at
Southwark Bridge Junction, near Elephant & Castle on 21 January 2013 highlights how this
subject continues to be a cause for concern.
Page 27 of 76
This incident involved a wrong direction move that resulted in two trains being routed onto
the same line. The units stopped when they were about 160 metres apart. RAIB noted (inter
alia) that this particularly highlights the necessity of both parties coming to a clear
understanding of the message being conveyed. In this case, the driver of one of the trains
did not repeat an instruction received back to the signaller and undermined the signaller’s
lead in the conversation. Similarly, the signaller did not insist that the driver repeat the
instruction. This, says RAIB, demonstrates the need to emphasise that the responsibility for
good communications lies with both parties. Furthermore:

Signallers should not rely on train drivers knowing the identification number of a signal
unless the driver is approaching from the direction in which the front of the
identification number plate can be seen;

When giving a landmark to a train driver, a signaller should do so in clear and simple
terms, and ensure that the driver gives a positive confirmation that he knows the
position of that landmark; and

Repeating back the words of a message may be insufficient to determine that the
meaning has been understood.
Finally, RAIB notes that managers, and refresher training, should encourage signallers to
actively consider use of the ‘stop all trains’ radio command when they need to stop more
than one train in an emergency.
What’s being done?
OFG has set up a cross-industry subgroup to consider the safety critical communications
question with a view to reviewing communications protocols and producing a guidance
document and Rail Industry Standard. See www.opsweb.co.uk for further details.
Page 28 of 76
5
Lessons learned 2012/13 – train accidents
5.1
Statistical overview
Version 7.5 of the Safety Risk Model (SRMv7.5) calculates the risk from train accidents to be
8.2 fatalities and weighted injuries (FWI)7 per annum, which is 5.9% of the total risk
(excluding suicide). Of this, fatality risk is 6.2 per year, which is around 9.3% of the total
fatality risk.
There were no passenger or workforce fatalities or major injuries in train accidents in
2012/13. There have been six consecutive years without passenger or workforce fatalities in
train accidents (the last being the Grayrigg derailment of 2007, in which one passenger died).
Train accident risk at a glance
Train accident risk in context (SRMv7.5)
Trends in train accident risk (PIM)
PIM indicator
200
150
100
148.8
132.4
108.3 103.8
98.8
92.0
79.7
90.6
87.7
74.9
50
0
For more statistical analysis on train accidents, see Chapter 8 of the ASPR.
Topics covered in this section:

Animals on the line

Derailments

Signals passed at danger
5.2
Animals on the line
On 13 January 2012, a Hamburg-bound push-pull service running in ‘push mode’ struck a
herd of cattle and derailed. One passenger was killed; the driver and one further passenger
were injured.
For Deutsche Bahn, the accident raised questions about the fencing of main lines. For OFG,
the obvious question was ‘have we learned from Polmont?’ – Polmont being the most recent
fatal accident to have occurred in this country as the result of a collision between a train and
an animal.
7
Fatalities, injuries and shock and trauma are combined into a single figure, termed fatalities and
weighted injuries (FWI). For more details on the injury classifications and their associated weightings,
see the Annual Safety Performance Report.
Page 29 of 76
The subsequent investigation centred not only on fencing, but also driving trailer
crashworthiness, radio communications and the rules governing the reporting of animal
sightings.
The pertinence of these lessons grew on 12 July 2012 when
a passenger train struck cattle on the line and derailed at
Letterston Junction (see photo).
In response, RAIB produced a bulletin and RSSB produced
a Special Topic Report on ‘animal on the line’ incidents in
Great Britain.
Photo: Network Rail.
Polmont
On 30 July 1984, a passenger train – lightweight Driving Brake Second Open (DBSO)
leading – struck a cow at 85 mph and derailed. Thirteen people were killed and 14 suffered
major injuries, including the driver. The main lessons learnt were as follows:

Fencing: the cow had accessed the line through a vandalised fence at an abandoned
level crossing.

Rules: the driver of an earlier train had seen the cow on the bank inside the boundary
fence. The rules in force at the time only required the reporting of groups of animals, or
those actually on the line.

Communication: at the time, there was no way of contacting the driver to stop a train
other than via the signalling systems.

DBSO: the vehicles had a light axle weight of 8.4 tonnes, and were not fitted with
obstacle deflectors.
Action taken

The Scottish Region of British Rail (BR) used surplus funds to erect new fences along
many of its routes. Where push-pull operation was to be introduced, BR also began to
consider fencing as part of the route development plan.

A Rule Book change was made to make sure any large animal within the boundary
fence was treated as an immediate danger to trains.

The National Radio Network (NRN) was introduced from 1986. (It is now being
replaced by GSM-R, whose implementation is due for completion in 2014.)

Obstacle deflectors were fitted to DBSOs, while the carriage of passengers in driving
trailers at speeds above 100 mph was banned (hence the Mk III and Mk IV DVTs’
status as luggage vehicles). This was challenged by later designs like the Voyagers
and Pendolinos.

DBSOs continued in Scottish front-line passenger service until displaced by new
DMUs in the late 1980s. They were cascaded to the Great Eastern Main Line, where
they worked until withdrawal in 2006, having been displaced by Mark III DVTs.
Page 30 of 76

Mark III DVTs also remain in use on selected services from London Marylebone, while
their Mark IV counterparts continue to be rostered on East Coast Main Line services.
Since the late 1980s, however, the move has been towards unit train operation.

In the late 1980s/early 90s, BR fitted its Sprinter multiple units with snowploughs that
also had the capability of deflecting minor obstacles on the track.
Together, improvements in fencing, mobile communications, the rules and rolling stock
design since 1984 explain why the risk from post-animal strike derailment remains low.
Statistical headlines

Train accidents constitute 6% of the total railway system risk. Of this, 0.6% is
concerned with trains striking animals, around 60% of which refers to the associated
risk from derailment.

The risk is generally low because on-board injuries are rare (although the potential for
harm remains when a train derails).

Despite this, the safety performance figures suggest a rise in animal strike incidents
over the last ten years.

The average FWI level for the reporting period is 0.03. Most of the harm from animal
strikes takes the form of shock/trauma to the train driver. Drivers can also suffer minor
injuries when the impact between train and animal breaks the windscreen.

There are very few minor injuries to train guards and passengers; most involve
persons being thrown against the saloon interior during a collision.

The total reported number of animal on the line incidents has fallen by 43% since
2002/03. However reported cases of animals being struck by trains have risen by 77%.
When normalised by train kilometres, the rate has risen by 56%.
Animal type
Deer and stags8

Although there has been no clear trend in the number of reported cases of deer and
stags on the line, reported cases of these animals being struck by trains has gone up
almost 400% since 2002/03.

The deer population has grown to around 2 million, and is reportedly higher now than
at any time in the last 1000 years. The reasons for this include milder winters, the
planting of winter crops, increased woodland cover and greater connectivity between
green spaces in urban areas.

The number of reports of stags on the line is low compared to other animal types.
However, the proportion of cases where stags on the line are struck by trains is high
8
Note that some SMIS inputters use ‘stag’ and ‘deer’ to mean the same thing. It is therefore difficult to
ascertain which incidents occurred to which animal.
Page 31 of 76
(though the derailment consequences are considered to be lower than with cattle and
horses).9
Sheep

Reports of sheep on the line have fallen by 68%. This accounts for most of the overall
reduction since 2002/03.

Although a large number of sheep access the line, less than 1% are struck by trains.
Cattle and horses

Reports of cattle or horses on the line have fallen by 20% since 2002/03. Of all cattle
and horses that access the line, 6.7% are struck by trains.
Other10

There has also been a 70% increase in the number of other animals struck by trains
since 2002/03. Most are birds, the next highest category being dogs.
Fencing

The recurring causal theme throughout the analysis is damaged fencing. Sometimes
vandalism is to blame, sometimes maintenance.

In at least one case, poor reporting of damage exacerbated the problem; in another,
flooding weakened the fence posts. This makes climate change a possible cause in
the future.

The quest for food is the main motivator for cattle using holes in fences. However, two
reports in SMIS noted herds that had stampeded the boundary fence after being
unnerved by criminal activity.
Train type

Most animal strike incidents involve passenger trains. The increase in incidents is due
to a rise in the number of deer/stag incidents since 2006/07.

On average, the number of freight trains involved in strike incidents is around one-fifth
of the number of passenger train strikes. Reported freight train strikes have also fallen
by 43% since 2002/03 (16 events in 2011/12).
Route

Over the period as a whole, London North Western Route experienced the greatest
number of animal strike incidents, with Scotland taking second place.

There was a 190% rise in incidents on the Scotland route in 2009/10, compared to
2008/09.
9
See Railtrack Great Western’s Formal Inquiry into the derailment of 1A91, the 15:30 Penzance–
Paddington HST service following an animal strike at 15:52 on 17 August 1999 at Carn Brea (p.15,
section 3.6).
10
Animals in the ‘Other’ category include badgers, birds, dogs and foxes.
Page 32 of 76

Most of the incidents involving deer and stags occur in the Scotland and South East
territories, although London North Western has seen an increase since 2007/08.
Cost

On average, 130,000 delay minutes are caused each year by trains striking animals or
animals on the line. According to Network Rail, the associated cost of animal on the
line incidents was around £4.9 million in 2012/13.
Many of the risks posed by cattle (and, by implication, other large boned animals) were
addressed after the Polmont accident of 1984. However, when such animals do access the
line, the chance of a derailment has been minimised by the subsequent upgrade, and later
withdrawal, of lighter passenger driving trailers, along with the general improvement in train
crashworthiness exemplified by Classes 220, 221 and 390.
As a result of more recent accidents like Letterston Junction, Network Rail has put standards
in place to mitigate the different types of fence-related risks evident at different locations. The
latest standard for the Management of Fencing and other Boundary Measures will use the
likelihood of unauthorised access, the consequences of unauthorised access, adjacent land
use and the condition of existing boundary measures to determine the initial level of fencing
required and the subsequent level of inspection, repair or replacement needed.
However, RSSB’s analysis shows that the cattle question has largely been replaced a deer
one. At two million, the deer population is reportedly higher now than at any time in the last
1000 years. The reasons for this include milder winters, the planting of winter crops,
increased woodland cover and greater connectivity between green spaces in urban areas.
Despite the ability of these animals to jump fences of varying heights in order to access
woodland habitats and so on, the derailment risk is considered to be less than with a cow or
horse.
In summary, the industry can have a degree of confidence that risk from animal incursion has
been reduced by industry improvements in fence management, cab-to-shore
communications, the rules for reporting incidents and the robustness of trains to collision.
But while Network Rail will continue to monitor the situation, it is noted that the occasional
incident can still cause harm, and can impact on the commercial aspect of the railway, in
terms of delays, rolling stock cleaning and line clearance.
5.3
Derailments
5.3.1
Derailment of a locomotive at Bletchley Junction, 3 February 2012
(pub. 11/12)
At 02:27, a Class 90 derailed as it negotiated the 15-mph diverging route at Bletchley
Junction at 65 mph.
The driver received minor injuries. Significant damage was caused to the underside of the
locomotive, the track and the overhead line equipment (OHLE).
The driver correctly reduced the locomotive’s speed on the approach to the red signal before
the junction but when this changed to green (with an ‘F’ indication for the diverging route), he
applied full power in the belief that he was going straight on. It is likely that the driver only
realised that he was to take the diverging route around the time he was passing the signal,
by which time it was too late to prevent the derailment.
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Causes
RAIB found that the driver did not immediately observe and/or register what was displayed
by the signal’s route indicator. This was despite the fact that the approach view of the route
indicator was found to be satisfactory, free from obstruction and with sufficient time for a
driver to see and understand its meaning. RAIB has concluded that the driver’s belief that he
was continuing on the Up Slow overcame the fact that the ‘F’ indication was clearly visible to
him.
What was done?
The locomotive is owned by Freightliner, but was on hire to Virgin Trains and was being
driven by a Virgin driver. Virgin Trains no longer works this light engine manoeuvre,
Freightliner having assumed responsibility for moving the locomotive to Wembley depot.
Virgin Trains now routinely analyses the downloads of data recorders fitted to Class 90
locomotives as part of its driver assessment competence arrangements. It has also issued a
reminder to its drivers about the maximum speed of light locomotives.
Virgin Trains led the railway industry’s investigation of the Bletchley derailment and made a
recommendation to review its processes covering route risk assessments and the
examination of drivers’ route knowledge, so that they include low speed diverging junctions
with alphanumeric route indicators. A further recommendation was to review and consider
additional controls to verify drivers’ methods of route learning.
Network Rail is planning to replace Bletchley Junction with a new, higher speed, junction, just
south of the current site.
RAIB has also recommended:

Reviewing and amending the route knowledge and assessment process so that the
risk from drivers exceeding permissible speeds at diverging junctions is adequately
controlled.

Assessing the risk from overspeeding at potentially high risk diverging junctions with
approach control following the clearance of the junction signal.

Reviewing and modifying the Weekly Operating Notice to identify the information that
drivers need to assure safety and how this content is presented so that it can be
readily assimilated.
Learning point:

Does your competence management system specifically monitor the driving of light locomotives?
OFG has asked RSSB to consider research into compliance with speed restrictions. A
research idea, R540: A review of the process used to introduce speed restrictions and driver
compliance with them is in development.
Page 34 of 76
Further information
RAIB, Bulletin 05/2012: Derailment near Letterston Junction, between Clarbeston Road and
Fishguard, 12 July 2012 (RAIB, 2012) LINK
RAIB, Rail Accident Report: Derailment at Bletchley Junction, Bletchley, 3 February 2012
(RAIB, 2012) LINK
Research and development
‘T’ no.
Title
Link
T147
Mental workload assessment for train drivers – This project began with a review of existing
measurement tools applied in other industries. A set of tools were specifically developed for assessing
the manual workload of train drivers. The tools were then been tested with drivers in simulators, in the
field and through workshops. Workshops with driver managers and human factors professionals were
also undertaken in order to assess them. The key output of the project is a set of workload assessment
tools which can be used for: comparing workload for different driving systems or routes, evaluating
design changes and equipment upgrades, appraising staffing levels, establishing training
requirements, and incident analysis.
CLICK
T150
Driver route knowledge – This project studied route knowledge in order to understand its
fundamental role in the effective performance of train driving, and to optimise the tools and techniques
that drivers use to obtain and retain route knowledge. The study reviewed current training techniques
and identified and highlighted best practice in the rail industry. It also assessed the impact of change
through the introduction of new technology and the implications for route knowledge.
CLICK
5.4
Signals passed at danger
In the aftermath of the high-profile SPAD accidents at Southall (1997) and Ladbroke Grove
(1999), the rail industry took a closer look at the causes of SPADs, the precursors to SPADs
and the risks that surround them. Groups were set up nationally and locally to monitor the
situation and implement various initiatives to bring the risk down. When this work began,
there were over 500 SPADs a year; now there are fewer than 300.
The professionalism of drivers, the relevance of driving policies and practices and the
success of TPWS (see below) have combined to achieve this. However, we know that with
complacency comes risk, so we continue to monitor the SPAD situation closely.
At 250, the number of signals passed at danger (SPADs) for 2012/13 was lower than the 276
occurring in 2011/12.
At the end of 2012/13, the number of SPADs showed a 10% reduction on the number for
2011/12. In contrast, the estimated level of SPAD risk increased notably from the (unusually
low) level at the end of 2011/12. Nevertheless, at the end of March 2013 it was still 40%
lower than the September 2006 baseline level. The main reasons for the low level of risk
seen in 2011/12 were:

A reduction in the number of trains that reached a conflict point where a collision
involving a passenger train could have occurred;

A reduction in the length of the average overrun distance;

A relatively mild autumn/winter period, which resulted in fewer weather-related issues
than averaged.
Page 35 of 76
However, none of the reductions were sustained into 2012/13, resulting in SPAD risk
returning to previous levels.
Measuring SPAD risk
The risk from each SPAD is measured in a consistent and objective way using the SPAD risk
ranking tool (SRRT). The risk ranking scores assigned to all SPADs are then combined to
track changes in SPAD risk over time. The method of assessing trends in SPAD risk is
designed to assess whether the changes are representative of any underlying change in risk
rather than just volatility in the data. Thus the metric is not overly vulnerable to one high-risk
SPAD.
It is rare for a SPAD to be the subject of an RAIB investigation, but an incident occurred just
after the year-end which is still being looked into.
On 26 April 2012, a Class 47 en route from Washwood Heath to Crewe passed SD4-81
signal at danger without authority. This signal is located on the Down Slow line south of
Stafford on the West Coast Main Line. It controls entry into the station and protects any train
movements traversing Stafford South Junction. The locomotive passed the signal at a speed
of about 30 mph and came to a stand approximately 80 metres beyond.
Although this SPAD was included in general information provided to the railway industry, it
was not until September 2012 that the RAIB was notified of the full circumstances leading up
to it. By this time, the incident had already been the subject of an investigation by an
experienced railway professional, which found that the driver had not responded correctly to
the restrictive aspects on the signals before SD4-81. As a consequence, the locomotive
approached Stafford at too high a speed and there was insufficient distance for it to stop
before passing SD4-81.
RAIB has identified a number of areas of concern based on the information that it has
currently received, including:

The locomotive was driven at speeds above those permitted in the circumstances;

The locomotive’s speedometer was faulty; this caused it to display a speed lower than
the actual speed of the locomotive;

There was insufficient documentary evidence of the driver’s competence.
RAIB is aiming to identify the management factors that contributed to this outcome, in
particular any management systems that were in place related to the competence of drivers,
the safe operation of trains and the management of contracted staff. It will include a review of
the relevant elements of the operator’s safety management system and examine how these
had been implemented.
TPWS – industry strategy
TPWS was implemented in Great Britain as an interim measure to reduce the consequences
of SPADs, pending the implementation of full protection through systems that monitor driver
performance continuously. It was envisaged that this higher level of protection would be
delivered by the roll-out of the European Rail Traffic Management System (ERTMS). In the
intervening period, it has become clear that this roll-out will take considerably longer than
Page 36 of 76
planned, leaving TPWS as the primary means of mitigating SPAD risk for some time to
come.
At the operational risk conference in July 2008, the ORR gave a presentation on Managing
and Reducing Operational Safety Risk, which highlighted a concern regarding the lack of a
clear strategy for the long-term future of TPWS.
In response, the RSSB Board considered the issues and directed the Vehicle/Train Control &
Communications System Interface Committee (V/TC&C SIC) to develop a long-term strategy
for TPWS. In turn, the V/TC&C SIC created a TPWS Strategy sub-group to aid with
development, which is being achieved via close co-operation from Network Rail, the train
operators, RSSB, the ROSCOs and the Railway Industry Association. It has been reviewed
at senior industry level at each stage.
The strategy was approved by the RSSB Board.
There is also a TPWS strategy action plan on Opsweb.
If you require information on the strategy, contact: Colin Dennis, Director of Policy, Research
and Risk at colin.dennis@rssb.co.uk.
TPWS – ‘reset & continue’
A TPWS ‘reset & continue’ incident occurs when a train SPADs a signal, is stopped by
TPWS, but the driver then resets the TPWS and continues without the signaller’s authority.
When this happens, the protection which was provided by TPWS is reduced. Since the
installation of TPWS was completed in early 2004, there have been 26 ‘reset & continue’
incidents. None have resulted in either a collision or a derailment, although in one instance
the SPAD train did run through a set of points.
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6
Lessons learned 2012/13 – passengers
6.1
Statistical overview
There were no train accident fatalities to passengers during 2012/13, but four passengers
were fatally injured in separate incidents in stations. In two cases, intoxication was recorded
as a of the potential contributory factor:

One person was struck by a train after getting too close to the platform edge;

One person died as the result of a fall on stairs;

One person died after falling on the concourse;

One person fell between a train and the platform as the result of a fight.
The average level of harm to passengers over the last ten years has been 42.7 FWI per
year, of which 7.2 have been fatalities. As SMIS data does not contain complete information
on passenger assault, it is likely that the level of harm to passengers is slightly higher than
this. The modelled risk from assault, as estimated by the SRM is 8.4 FWI, and is based on
data obtained from BTP.
Note that research project T992: Safer stairs and escalators in public places is being
managed by the Construction Industry Research and Information Association (CIRIA) and
co-funded by RSSB and London Underground.
Passenger safety at a glance
Passenger risk in context (SRMv7.5)
Trend in passenger harm
80
45.8
42.7
38.9
2009/10
2011/12
38.6
2008/09
42.8
39.6
44.7
2006/07
40
2007/08
42.2
45.2
2004/05
2005/06
46.6
50
FWI
Public
39%
(54.7 FWI
per year)
2003/04
60
2010/11
Weighted injuries
Fatalities
70
30
20
10
For more statistical analysis on passenger risk, see Chapter 5 of the ASPR.
Topics covered in this section:

The platform-train interface (PTI)

Multiple trespass and detraining
Page 39 of 76
2012/13
0
Workforce
6.2
Platform-train interface
Over the last ten years, there has been an average of 5.5 FWI per year occurring to
passengers while boarding or alighting from the train. Over the same period, other accidents
at the PTI (those not occurring during boarding or alighting) have accounted for an average
of 4.2 FWI per year, which is around 10% of the total average harm to passengers over this
period. However, they have accounted for an average of 2.9 fatalities per year, which is more
than 40% of the average number of passenger fatalities seen over the last decade.
There are many factors which affect the occurrence of
accidents at the PTI. These factors overlap, making up a
complex list of criteria that contribute to the accident rate.
The factors include the age and gender of the passenger,
whether or not they are intoxicated, and their familiarity
with rail travel.11 The accident rate varies throughout the
year, with changes to the passenger demographic (and
the weather), and also changes according to the time of
day or week that the journey is taking place.
RAIB published two reports on ‘trap and drag’ incidents:
Jarrow (12/04/12) and King’s Cross (10/10/11). The latter
incident involved a passenger being trapped in the doors
and pulled along the platform for around 20 metres,
suffering bruising to the fingers of her left hand.
RAIB noted (inter alia) that the passenger could have
withdrawn her fingers from the doors if alternative door
edge seals had been fitted on the Class 365 involved in
the incident. It thus recommended that the design of the
seals be reviewed and, if appropriate modified, when they
are renewed as part of a Class 365 mid-life refurbishment
due in 2013.
Train doors
The Class 365 door seal issue also
featured in an incident at
Huntingdon on 15 February 2006.
At 15:59, a member of the public
was standing on the edge of the
platform to wave a passenger off
when he became trapped by the
edge of his coat in one of the doors
of the train (a Class 365). The DOO
service departed and the person
ran, being pulled along the platform,
before falling down the gap between
the train and platform edge. The
person sustained serious injuries to
his left arm and hand.
Among the causal and contributory
factors, RAIB raised the point that a
combination of the design of the
Class 365 door seal and the closing
forces of the door allowed the coat
fabric to be trapped such that it
could not be removed. Furthermore,
the design and construction of the
door allowed the interlock to be
given when the coat fabric was
trapped.
Arguably the most important RAIB report published in 2012/13, however, was the one
dealing with the James Street fatality of 22 October 2011.
6.2.1
Passenger fall between train and platform at James Street, Liverpool,
22 October 2011 (pub. 11/12)
At 23:29 on Saturday 22 October 2011, a young person was struck and killed by the
Merseyrail train she had left 30 seconds earlier.
She was leaning against the train as it began to move out of the station and when she fell,
the platform edge gap was wide enough for her to fall through to the track. Her post-mortem
toxicology report recorded a blood alcohol concentration nearly three times the UK legal
drink drive limit.
11
A commuter who is a more experienced rail user may be able to deal with hazards unique to rail
travel better than a tourist who has little experience.
Page 40 of 76
Causes
RAIB found the immediate cause to be that the young person fell through the platform edge
gap and onto the track as the train began to move out of the station. It also found the causal
factors to be that:

The guard sent the driver the ‘ready to start’ code, and no subsequent ‘stop’ code,
while the young person was leaning against the train. He did this possibly because he
expected her to move away or possibly because he had not seen her;

The young person fell as the train was moving out of the station;

When the young person fell, the platform edge gap was wide enough for her to fall
through and onto the track;

By the time the guard warned the young person to stand back; she had been leaning
against the train for approximately 11 seconds. It is not known when the guard saw her
during this time or, if he saw her, whether he delayed taking action in the expectation
that she would move away. Platform video camera footage shows him warning her to
stand back in the moments before the train departs and it is likely he did this because
he thought that it would be immediately effective and because he had no direct and
immediate way to stop the train.
Court case
In the resulting court case, the guard told the jury he had not known how drunk the young
person was and thought she was moving away from the platform edge when he gave the
‘right away’. However, the court ruled that the guard was guilty of manslaughter and gross
negligence, sentencing him to five years in prison.
In closing, the judge told the guard that he was ‘satisfied that you merely hoped and
assumed she would get out of the way when the train began to move, and on that wholly
inadequate basis you took a terrible risk.’
What was done?
After the accident, Merseyrail added an alternative process to its dispatch procedure. The
alternative process allows guards, at their discretion, to send a driver the ‘ready to start’ code
before their door has fully closed, which reduces the dispatch time.
RSSB had already established the Station Safety Improvement Project (June 2011) after
monitoring of safety risk across the railway system identified issues with the platform/train
interface.
The project is supported by ATOC, train operators, Network Rail and the ORR. To date, it
has delivered:

Increased awareness across all operators and Network Rail through one-to-one
interviews, surveys, conferences, workshops and newsletters;

A network of ‘station safety improvement champions’ in each of the supporting
companies;

An improved understanding of the risk with publication of a special statistics report;
Page 41 of 76

New tools and guides to improve risk assessment and competence; and

A new Station Safety Resource Centre on Opsweb to provide operators with easy
access to all project outputs and other relevant information, including a station safety
management plan (adopted by Network Rail at Leeds) and indicators of non-technical
skills for train dispatch (being adopted at Birmingham New Street).
The project is continuing with the objective of developing a holistic approach to the
assessment of all types of station risk, specialist research into potential human factors, and
engineering and asset solutions. Recognising the future challenges of passenger growth,
ageing population and station investment opportunities, the move is now to develop a longerterm strategy for the co-ordinated improvement of station safety across the rail network.
On 27 March 2013, the ORR and RSSB hosted a joint
workshop to discuss the issues highlighted by the
James Street fatality and subsequent report. The day
was attended by train operators, Network Rail, the
trades unions and representatives from the ORR, RAIB
and RSSB. The need to take a consistent approach to
station safety management and the potential for a
national media campaign to raise public awareness of
the hazards associated with the PTI were strongly
supported. RSSB also agreed to develop guidance on
the management of the PTI.
RED 28
RED 28 covered the risks at the platformtrain interface.
Copies are still available from RSSB –
A Thameslink initiative under consideration by the
contact catherine.gallagher@rssb.co.uk for
Infrastructure Standards Committee is to develop a
details.
standard for a ‘level’ platform. This would have limited
application (such as Heathrow Express), but it is important there is only one, common,
standard for such platforms. As use of a level platform would also restrict the rolling stock
type able to use the route, it must not be seen as a panacea for accidents at the PTI. The
subject was discussed by the RSSB Board in May, with the result that RSSB now has an
action to undertake a review to look at the implications.
RAIB also recommended:

Evaluating and, where practical, improving the means of train dispatch accident
prevention.

Evaluating the equipment and methods to reduce the likelihood of persons falling
through the platform edge gap and to implement these measures when practical.

Ensuring there is industry guidance on reducing the risk at the platform-train interface.
Further information
RAIB, Rail Accident Report: Fatal accident at James Street station, Liverpool, 22 October
2011 (RAIB, 2012) LINK
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Research and development
‘T’ no.
Title
Link
T426
Minimisation of accidents at the platform-train interface – This research investigated PTI
accidents, exploring their primary causes and the extent to which they can be reduced in number and
severity. It examined public (and staff) behaviours and made recommendations on how minor changes
to procedures or designs could make cost-effective improvements.
CLICK
T743
A review of passenger train dispatch from stations – This project reviewed passenger train
dispatch arrangements in the light of current operations, taking risk and human factors principles into
account.
CLICK
T866
Investigation of platform edge positions on the GB network – This project built on previous RSSB
and Department for Transport research to improve the platform/train interface on the existing network,
for the benefit of passenger accessibility and compliant stepping distances.
CLICK
Project T1029: Designing a tool to improve the quality of train dispatch risk assessment is
also under way, along with another project (T1037) to consider stepping distances.
RSSB’s station safety booklet covers slips, trips and falls, PTI risk and mitigation actions, and
related research into issues such as crowd management, tactile edges, wayfinding and
signs, and how to deal with winter conditions. A new edition is in preparation.
The current edition is available from RSSB, or can be downloaded here: LINK
6.2.2
Multi-detraining incident near Kentish Town, 26 May 2011 (pub. 05/12)
At around 18:26 on Thursday 26 May 2011, a First Capital Connect
service lost power and became stranded between St. Pancras and
Kentish Town. Almost three hours elapsed before the train, with its
passengers still on board, was assisted into Kentish Town station.
During the period that the train was stranded, conditions for
passengers became increasingly uncomfortable because it was
heavily loaded and the air-conditioning and toilets stopped working at
an early stage. Some passengers opened doors to improve
ventilation and passenger alarms were repeatedly activated.
The strategy for rescuing the stranded train was to bring another unit onto the front and haul
it into Kentish Town. The arrival of the assisting train was delayed and it did not couple onto
the front of the failed train until around 20:20. During the next 50 minutes, the driver of the
combined train tried to complete the arrangements necessary for its movement into Kentish
Town. He was hampered by further operation of alarms by passengers frustrated at the
continuing delay, and his uncertainty over the status of the doors (open or closed) on part of
the train. A number of passengers also started to alight.
Eventually, the driver over-rode a safety system in order to move the train. At the time when
the train moved a short distance for the driver to test that it was properly coupled, some
passengers were still alighting from the train to the track. When the train subsequently
moved into Kentish Town, it did so with at least two doors open.
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Causes
RAIB found the immediate cause to be that the driver moved the train ‘when it was not safe
to do so, with passengers standing in the vicinity of one or more sets of open doors’. But of
course it was much more complicated than that, as RAIB also described:



The loss of power came when foliage got stuck in the
pans. It happens, but when the driver told the signaller
about the problem at St. Pancras, it was decided to let
the train go on to Kentish Town, instead of terminating.
FCC’s policy for dealing with trains in a vulnerable
condition was to avoid detraining passengers in the
‘Thameslink core section’ (which included St. Pancras).
FCC controllers chose to move the train to Kentish
Town because they’d been criticised by management
after an earlier incident of crowding when a train had
been evacuated at St. Pancras.
More passengers were allowed to get on the train
before it left St. Pancras. This led to crowding and made
everyone on board even more uncomfortable when the
train got stuck.
Other options…
Instead of using another train to haul
the failure forward, passengers could
have been moved to a train brought
alongside, via a transboardment
bridge.
Instead of coupling a rescue train to
the front of the failure (a Class 377),
there was a train behind which could
have been used instead. This was
formed of two Class 319s, which
would have needed an emergency
coupler to attach to the failure. FCC’s
policy for dealing with stranded trains
showed that emergency couplers
were located at Kentish Town and
Farringdon.
FCC’s controllers asked for the
coupler to be found and a fitter at
Farringdon located it on the station.
The MOM was asked to take the
coupler to site, but the plan was
overtaken by events and by the time
that the coupler was ready to be
transported, the decision had been
taken to a different train for rescue
purposes.

A fitter based at Kentish Town was sent to St. Pancras
to examine the train, but arrived after it had left…for
Kentish Town.

There had been very little communication with
passengers during the incident because the PA system
on the train failed about 45 minutes after it became
stranded.

Options for evacuating passengers, other than the use of an assisting train, had either
been discounted or had not been briefed to staff responsible for the rescue on the day
(see box).

80 minutes passed before the rescue train coupled up. This was partly down to the
time it took to decide which type of unit could be coupled to which type of unit (there
were issues and misunderstandings about software compatibility). However, the
unwillingness of the rescue train’s passengers to get off at Hendon, a
misunderstanding at Cricklewood about splitting the rescue train and its driver’s
inexperience of uncoupling all added vital minutes.

While the rescue train was on its way, the signalling shift manager decided that the
failed train should be evacuated. He authorised a Network Rail MOM, a Network Rail
OHLE engineer and a FCC fitter to walk along the track from Kentish Town to the train
to supervise. This decision was taken in light of the ongoing delays to the rescue train
and was not communicated to FCC control room staff.

However, as the assisting train was leaving Cricklewood, the signaller told the MOM
that its arrival was imminent. The signaller then cancelled the evacuation and asked
that the three members of staff return to Kentish Town.
Page 44 of 76

FCC’s control room staff saw their role to be one of support to the signaller, rather than
working in partnership to develop a strategy with set ‘milestones’. This meant
information was not shared or communicated effectively and allowed different
strategies to be formed.

As the incident escalated, a number of passengers operated alarms and opened doors
in an attempt to freshen the air. The driver fought his way through the crowded
carriages, resetting alarms manually with a key, and closing two doors that he found to
be open. Some passengers verbally abused him. Others complained of the high
temperatures, and the lack of announcements and progress. The driver explained that
a rescue train was expected in 5 minutes, but was only able to tell individual groups of
passengers, because of the inoperative PA.

Passengers continued to operate communication alarms. The driver stopped resetting
them due to the number being going off and his difficulty in moving around the train.
This, coupled with his attempts to liaise with the signaller and the fitters at Cauldwell
depot, reduced his ability to find the possible causes of the tripping via the train
management system.

In an attempt to do something – anything – around 40 passengers got out of the train.
The situation was made worse by the lack of information they received, and may have
been worsened still by their use of information from social networking sites like Twitter.

Messages about the dire on-board conditions sent by passengers to FCC via the same
social networking sites were not acted upon.

After the rescue train had coupled up, the driver still couldn’t gain traction because the
operation of the emergency door release handles and passenger communication
alarms continued. Although a fitter walked through the train and asked passengers not
to operate the alarms, some ignored him. It was eventually agreed that the driver could
override the safety interlock in order to move the train.

The driver then carried out a short pull test, but did not inform passengers of his
intention (although only the PA system in the rescue train was working at this point).
He was not aware that 40-odd passengers had got off.

The MOM told the driver and signaller that both he and the fitter had checked the train
and that all passengers had re-boarded and the train was safe and ready to move.
However, at least two doors remained open or had been reopened when the train set
off for Kentish Town.
What’s been done?
At the time of the incident, FCC’s stranded trains policy had just been published, but few
actions had been taken in response to the lessons learnt. RAIB noted that if appropriate
action had been taken, it might have helped in the management of the incident and sped its
resolution. Since the incident, however, FCC has reviewed its disruption management policy
and emergency response procedures for trains that may be at risk from failing in the
‘Thameslink core section’. It has also re-briefed staff on the availability and location of
emergency couplers and the use and location of transboardment bridges.
Page 45 of 76
Improvements have been made to the FCC competence
assessment, training and briefing regime, ensuring that
drivers have the necessary skills to deal with failures, like the
how to couple and uncouple trains and how to get additional
power for the PA system on a temporary basis.
FCC and Network Rail have organised annual desk-top
exercises to take place in order to share best practice.
Network Rail has re-briefed its response staff who cover the
‘Thameslink core section’ on the locations of key equipment
such as emergency couplers and on emergency evacuation
strategies. It has also briefed route control managers to
consider the appointment of a Rail Incident Officer in all
cases where they are requested to attend a train failure in the
‘Thameslink core section’.
RED 33
This edition of RED features a
dramatization which explores how a
minor mechanical failure can
escalate into widespread disruption.
The film highlights the importance
of drivers, conductors, signallers,
controllers, platform staff and fitters
working as a team when getting the
railway moving again after an
outage.
It also stresses that the way
passengers are kept informed of
developments can affect behaviour
– and even lead to multiple
detraining and trespass in some
cases.
Network Rail and ATOC have reviewed the lessons learnt from recent incidents involving
stranded trains and jointly published a new guidance document Meeting the needs of
passengers when trains are stranded. Among other things, the document suggests that train
operators and Network Rail should develop joint protocols for handling stranded train
incidents.
RAIB also recommended:

Developing a set of principles for dealing with stranded trains.

Reassessing existing processes for undertaking incident reviews so that safety lessons
are captured, tracked to closure and shared with other industry stakeholders.

Reviewing the management processes for emergency preparedness.
Further information
RAIB, Rail Accident Report: Safety incident between Dock Junction and Kentish Town, 26
May 2011 (RAIB, 2012) LINK
For a ‘snapshot view’ of how passenger risk is being tackled, see Chapter 10.
Page 46 of 76
7
Lessons learned 2012/13 – workforce
7.1
Statistical overview
There were no workforce fatalities in train accidents during 2012/13, although there were two
workforce fatalities from other causes: one infrastructure worker died as a result of a road
traffic accident while on duty, while another was struck by a train and fatally injured.
When normalised by workforce hours, the rate of harm to the workforce decreased by 11% in
2012/13, compared with 2011/12.
Slips, trips, and falls pose the greatest risk to the workforce as a whole. Around 23% of the
total FWI risk is from this source, although the contribution to the fatality risk is relatively low,
at around 1%.
The greatest source of fatality risk is being struck by a train, which accounts for 8% of the
overall workforce risk profile, but 48% of the fatality risk profile.
The greatest causes of workforce shock or trauma are assault and abuse, and witnessing
suicide and trespass fatalities.
Workforce safety at a glance
Workforce risk in context (SRMv7.5)
Trend in workforce harm
45
Weighted injuries
Fatalities
39.1 37.6
40
35
31.1
Passengers
Public
FWI
30
26.3 26.2 26.3 25.1
25
23.2 24.5 22.6
20
15
10
5
2012/13
2011/12
2010/11
2009/10
2008/09
2007/08
2006/07
2005/06
2004/05
0
2003/04
19%
(26.9 FWI
per year)
For more statistical analysis on workforce risk, see Chapter 6 of the ASPR.
Topics covered in this section:

Road vehicle driving

Track working
7.2
Road vehicle driving
Many GB rail companies employ large road vehicle fleets to support their operations –
including incident response. Studies have shown that fatigue and accidents are subject to a
wide variety of factors, like irregular working hours, shiftwork, and so on.
Page 47 of 76
The rail employee road vehicle-related deaths in 2011/12 was joined by another in 2012/13.
Both have highlighted the need to focus on this area.
Fatigue – the hidden issue
While fatigue has been investigated in relation to train
drivers and the performance of other safety critical staff,
its impact on staff driving on the roads has perhaps not
received sufficient attention, accidents too often being
recorded as merely down to ‘driver error’.
Nevertheless, it is clear that many employees are
required to drive substantial distances, during which
incidents – including death, injury and damage – can
occur. This does not just apply to drivers, but also
includes track workers, contractors and engineering staff
that may need to travel between jobs, and potentially
early in the day or late at night (depending on their shift or
role). This opens these workers to the potential for
fatigue-related road accidents.
In some organisations, the control of vehicle driving
activities is seen as peripheral and therefore outside of
the scope of formalised safety management systems.
However, it is an essential feature of their business and
needs to be subject to the same controls and discipline.
The issue is further compounded by the acknowledged
problem of driving at antisocial times and/or when
fatigued after shift working.
Fatigue – general points
A number of studies have highlighted
specific factors that contribute to fatiguerelated accidents:

Younger drivers are more prone to
fatigue in the early hours of the
morning, whereas older ones are
more likely to fall asleep at the wheel
during the afternoon.

Compared to driving at 10:00, drivers
are three times as likely to fall asleep
at the wheel between 15:00 and
16:00 and 50 times more likely at
02:00.

Lack of sleep can have cumulative
effects – risk increases significantly if
a driver has had only seven hours of
sleep, while less than five hours will
increase risk by six times. On the
other hand, having just woken up
can also effect driving in a similar
manner.

The risk from crashing doubles after
11 hours of work, with as little as 8 to
9½ hours of driving raising the risk of
an accident significantly.

Fatigue-related accidents are often
more severe (casualties can be 50%
higher), as drivers may experience a
delayed reaction or may fail to make
any manoeuvres to avoid a collision.

Shift workers are part of the high-risk
category, with those working
irregular shifts being even more at
risk than regular shift workers.
What’s being done?
Although research projects have been undertaken by the
rail industry in the past (such as T059 Human factors
study of fatigue and shift work and T699 Fatigue and
shiftwork for freight drivers and contract trackworkers),
these projects have investigated the effects of fatigue in
rail staff particularly on the performance of safety critical
tasks, not the risks from fatigue while driving road vehicles.
Clearly, many of these factors could
impact on workers in the rail industry.
T997 Managing occupational road risk associated with road vehicle driver fatigue proposes
to produce guidance on road vehicle driver fatigue with a specific rail industry slant.
The project’s recently published suite of four deliverables included two specific good practice
documents aimed at different audiences: one for rail staff who drive road vehicles as part of
their day-to-day work, the other aimed at their managers.
The other two deliverables were:

An awareness raising poster for such places as canteens, staff rooms and reception
areas to remind staff of the key fatigue risks, employer and employee responsibilities,
Page 48 of 76
effective countermeasures, the consequences of driver fatigue, and how to access
associated driver guidance produced by RSSB

A double sided folding A4 leaflet for drivers to highlight key work and non-work factors
that increase driver fatigue, responsibilities of a driver, effective countermeasures
before setting off and during a journey, the law, and responsibilities of an employer.
Designed to be left in the vehicle, company contact details in an emergency, or need to
report a fatigue-related issue, can be added by the driver.
By helping drivers and their managers to identify risks
and implement mitigations that are practical and feasible
in the rail environment, it is hoped that this project will
help to reduce fatigue-related road vehicle accidents,
the harm that arises from them, and their associated
costs.
In January 2012, the ORR published Managing rail staff
fatigue, a new guidance for employers, which covers all
rail worker types and includes a useful checklist. Whilst
not mandatory, this document represents good practice
which ORR inspectors will use as a benchmark in their
audits of rail companies.
Further information
RED 35
RED 35 covered the risks from road
vehicle fatigue.
Copies are still available from RSSB –
contact catherine.gallagher@rssb.co.uk for
details.
More information on fatigue – and how to fight it – may be found in RSSB’s leaflet Fatigue
and Shiftwork and on www.opsweb.co.uk.
Research and development
‘T’ no.
Title
Link
T059
Human factors study of fatigue and shift work – This project investigated and sought to reduce the
risk introduced by fatigue to passenger train drivers. It aims were to optimise, cost-effectively, changes
to current shift work planning and practice, to reduce safety risk, particularly from SPADs, and to
improve human performance and productivity.
CLICK
T699
Fatigue and shiftwork for freight drivers and contract trackworkers – Following on from the
research conducted on fatigue and shiftwork involving train drivers working for passenger train
operating companies (T059), this project focuses on staff employed in contract track work, and by
freight operating companies.
T997
Managing occupational road risk associated with road vehicle driver fatigue – THIS PROJECT
IS CURRENTLY IN PROGESS
CLICK
CLICK
For a ‘snapshot view’ of how workforce risk is being tackled, see Chapter 10.
7.3
Track working
7.3.1
Track worker struck by train at Stoats Nest Junction, 12 June 2011
(pub. 08/12)
At 05:28, a Gatwick Airport–London Victoria service, travelling at about 60 mph, struck and
seriously injured a track worker at Stoats Nest Junction.
Page 49 of 76
Causes
RAIB found that the track worker did not move to a position of safety and remained in the
path of the train as it passed the site of the work. Although one of the lines at the site had
been returned to use shortly before the accident, having been closed as part of a
possession, work continued in the vicinity, and no measures were put in place to protect
personnel from the passage of trains on that line.
Underlying this was the fact that the COSS was a relatively junior member of staff, whose
role was undermined by the presence of the section manager and assistant section manager
acting in a team leader capacity. This, as RAIB note, ‘introduced potential conflicts’ regarding
who was actually in charge.
Furthermore, when the COSS was requested by a track worker to assist off site, he did not
question it, believing the section managers to have taken proper charge. For the same
reason, the ES did not question work he was asked to undertake without the authority of the
COSS. The problem was that the managers had not taken proper charge.
The safety culture training that came out of Network Rail’s research into the impact of peer
pressure, group communications and dynamics (after the fatality at Ruscombe Junction on
29 April 2007), had yet to reach the depot where the Stoat’s Nest team were based (East
Croydon).
RAIB says that witness evidence also revealed ‘that Network Rail prioritised work relating to
selection of new COSSs over work relating to behaviours of existing staff. This was because
resources were limited and because Network Rail specialists believed that this would have
the greatest immediate effect on safety. The latter judgement was partly based on the belief
that line managers within Network Rail would give greater immediate support to
implementing changes for new COSSs. The progress of both these work streams was
delayed by organisational changes being implemented within Network Rail during 2008/09.’
What’s been done?
After the accident, Network Rail carried out an audit of the planning and management of the
safe systems of work for possessions over a single weekend. This focused on the planning
of safe systems of work to be used by staff during work in possessions. It also examined the
timeliness of the provision of this information to PICOPs, engineering supervisors and
COSSs. The audit found no examples where safe systems of work had not been planned
appropriately, and found only minor non-compliances with the completion of paperwork.
However, it would not have identified circumstances where the safe system of work was
compromised by staff at the worksite, unless this was reflected in the paperwork.
Network Rail also issued a safety bulletin to all maintenance areas, describing the Stoats
Nest Junction accident. It started to brief the initial circumstances of the accident to track
staff in the Sussex route maintenance area on 14 June 2011. This briefing was also given to
contractors on 26 June 2011. Training, delivered in October 2011 to section managers in
Sussex route, also incorporated the lessons identified from Network Rail’s initial review of the
Stoats Nest Junction accident.
Partly in response to the RAIB recommendation made after Ruscombe, Network Rail
undertook work aimed at identifying and, where necessary, improving safety related staff
behaviour within COSS-led work groups.
Page 50 of 76
In January 2010, the separate work streams addressing COSS behaviours were brought
together under the COSS Programme with a view to integrating them into Network Rail’s
processes. The programme recognised that control of safety at site was also affected by the
behaviour of managers and team leaders, so additional work was carried out to develop and
deliver training to them. Delivery of ‘Managing Site Safety’ training, which includes specific
modules on behaviour and COSS/Team Leader responsibilities, started in May 2011.
In addition, a number of safety culture improvement days have been delivered to both
Network Rail staff and contractors. Separate ‘Managing Safely’ training for line managers,
focusing on safety responsibilities, including a small module on behaviours, has been
developed, and this is expected to be fully delivered during 2013.
Southern has taken steps to brief drivers on the use of the horn, as part of scheduled driver
assessments. This includes an assessment of driver familiarity with the requirements of the
rule book and the avoidance of the low volume setting when on the running line.
RAIB also recommended:

Implementing processes intended to deter managers from undermining the safety
related duties of other staff.
It also highlighted the following learning point:

This accident forms an effective example for use in training material and briefings
given to track workers and their managers, and for use in industry safety publications.
Further information
More information on fatigue – and how to fight it – may be found in RSSB’s leaflet Fatigue
and Shiftwork and on www.opsweb.co.uk.
RAIB, Rail Accident Report: Track worker struck by a train at Stoats Nest Junction 12 June
2011 (RAIB, 2012) LINK
Research and development
‘T’ no.
Title
Link
T059
Human factors study of fatigue and shift work – This project investigated and sought to reduce the
risk introduced by fatigue to passenger train drivers. Its aims were to optimise, cost-effectively,
changes to current shift work planning and practice, to reduce safety risk, particularly from SPADs, and
to improve human performance and productivity.
CLICK
T070
Common factors in SPADs – This research helped to improve industry understanding of the
underlying causal factors of SPADs (including fatigue).
T148
Human factors associated with driver error and violation – The main objective of this research was
to understand how protective devices are used and the types of driver error they may mitigate or
introduce. The study assessed the impact of device unavailability or unreliability on driver performance
and risk, and highlighted a number of potential human factors problems with the operation of protective
devices. It also investigated the so-called 'post-break phenomenon' whereby it was believed that
drivers are more prone to error on the first day of work after a day off.
T328
Human factors of CCTV monitors – The rail industry uses CCTV in a wide range of applications,
including level crossing control tasks, driver-only operation (DOO), crowd management and security at
stations, and in-train security monitoring. This project identified how operator tasks should be defined
to minimise fatigue and maximise effectiveness.
T699
Fatigue and shiftwork for freight drivers and contract trackworkers – Following on from the
research conducted on fatigue and shiftwork involving train drivers working for passenger train
operating companies (T059), this project focuses on staff employed in contract track work, and by
freight operating companies.
Page 51 of 76
CLICK
CLICK
CLICK
CLICK
Other initiatives
Network Rail continues to implement its Safety Leadership & Culture Change Programme
with the establishment of a Vision for Safety & Wellbeing.
The New Approach to the Rules Project is progressively delivering a simplification to national
operating and safety rules. Network Rail is also embarking on a major project to review and
modernise its complex suite of standards and therefore the approach to training and
competency management of large numbers of the workforce is going to require
modernisation. This could provide an opportunity to positively influence the culture and
behaviour of key groups of workers.
Learning points:

Do you have a dedicated fatigue risk identification, assessment, control and evaluation process in
place?

Are documented arrangements in place to ensure the systematic monitoring, review and audit of
fatigue risk management processes?

How do you manage/support employees who have had insufficient sleep when they book on?

Do you encourage feedback from staff on fatigue issues?

How much notice are safety critical staff given of their shifts?

What other systematic steps do you take to ensure workers are fit for duty and are not fatigued?

What action do you take when safety critical staff are fatigued?

Does your company’s safety culture allow staff in positions of responsibity to make decisions despite
the rank of those in their team?
Page 52 of 76
8
Lessons learned 2012/13 – members of the public
8.1
Statistical overview
Excluding suicides and suspected suicides, there were 49 fatalities to members of the public
during 2012/13. When non-fatal injuries are taken into account, the total public FWI was
53.9, compared with a total of 63.5 FWI (59 fatalities) recorded last year.
Of the 49 fatalities, 39 occurred to trespassers, nine occurred at level crossings and one did
not involve trespass or level crossings (compared to 52 trespass fatalities, four level crossing
fatalities, and three public fatalities not involving trespass or at level crossings in 2011/12).
Trespass accounts for 77% of risk to members of the public. Accidents at level crossings
account for a further 16%. Of this, about two-thirds occurs to pedestrians struck by trains.
Most of the rest occurs to road vehicle occupants involved in collisions with trains. The small
remainder arises from slips, trips or falls, being hit by level crossing equipment, or being
involved in a road traffic accident at a level crossing.
Public safety at a glance (excluding suicides and suspected suicides)
Public risk in context (SRMv7.5)
Trends in public harm
100
63.5
41.1
53.9
68.2
65.0
64.9
60.2
2006/07
2008/09
61.4
FWI
Passengers
47.5
60
42%
(57.7 FWI
per year)
2005/06
63.7
80
2007/08
Weighted injuries
Fatalities
40
20
2012/13
2011/12
2010/11
2009/10
Workforce
2004/05
2003/04
0
For more statistical analysis on public risk, see Chapter 7 of the ASPR.
Topics covered in this section:

Level crossings

Road vehicle incursions
8.2
Level crossings
Between 2003/04 and 2012/13, the average level of harm to members of the public at level
crossings was 10.1 FWI per year, and the average number of fatalities was 9.3.
At nine, the number of public fatalities at level crossings recorded in 2012/13 is close to the
ten-year average of 9.3, and five greater than 2011/12. Four of the fatalities were
Page 53 of 76
pedestrians; the other five involved road vehicles struck by trains (one motorcycle and four
cars).
Most accidents at level crossings are caused by user behaviour – whether by error or
deliberate violation. However, a small proportion of the risk is due to workforce error or
equipment failure.
8.2.1
Fatal accident at Mexico footpath crossing, 3 October 2011 (pub.
06/12)
At around 15:50 on 3 October 2011, a pedestrian was struck and killed by a train on Mexico
footpath crossing, near Penzance.
On approaching the crossing round a curve, the train driver had seen a person standing to
the side of the line and had sounded the warning horn immediately before the train reached
the crossing. However, the pedestrian then tried to cross, being struck and killed
instantaneously.
Causes
Although RAIB could not be certain why the pedestrian attempted to cross, it considers that
she either misjudged the speed of the approaching train or misjudged her position in relation
to the approaching train. She probably saw the train too late to make a reasoned judgement
about whether she should cross.
The driver had also sounded the train’s horn as required by a lineside ‘whistle’ board when
the train was approximately 15-16 seconds from the crossing, and out of sight. If the
pedestrian had heard and responded to the sounding of the train’s horn at this stage, it is
likely that she would not have passed through the gate and onto the crossing until the train
had passed. RAIB considers that the sounding of the horn when the train was 15-16 seconds
from the crossing did not serve its function of warning the crossing user of the approaching
train for one of the following reasons:

The sound of the horn was inaudible to her; or

She heard a horn being sounded, but did not distinguish it as coming from a train; or

She did not register that the train horn was sounded, because she was only
approaching the crossing at this time and not yet focused on crossing the railway.
What was done?
In January 2012, Network Rail moved the sign on the south side of Mexico footpath crossing
to a position two metres from the nearer rail.
It also applied to Cornwall Council to have the crossing closed, diverting users to the nearby
Long Rock CCTV crossing, where they would be fully protected from the railway by barriers
when trains are approaching.
RAIB has also recommended:

Improving the sighting and warning arrangements for pedestrians at Mexico footpath
crossing.
Page 54 of 76

Developing a national approach to the location and marking of decision points at level
crossings.

Optimising warning arrangements for pedestrians at level crossings provided with
whistle boards.
Finally, RAIB’s report contained the following learning point for train operating companies:

It is important that drivers sound train horns when passing whistle boards rather than
at some distance on the approach to them, in order to ensure that the likelihood of the
horn being heard at the crossing is maximised.
Other work in this area
Network Rail has recently centralised responsibility for level crossing management under a
separate asset area in National Operations. It has put a level crossing risk reduction
programme in place, and aims to reduce level crossing risk by 25% by 2014, and a further
substantial reduction by the end of Control Period 5 (from the baseline date of 1 April 2009).
Among the safety projects currently under way are:

A programme of level crossing closures, which has already resulted in more than 700
level crossings being closed since 2009.

Replacing high risk footpath crossings with footbridges, in line with a policy decision to
remove the need for pedestrians to cross high-speed main lines unprotected by
barriers.

Improving sighting and warning times at passive level crossings, which has resulted in
enhancements to more than 1,100 crossings since 2010.

Providing red light enforcement cameras with number plate recognition technology at
150 AHB or AOCL crossings. Candidate crossings are being selected based on the
level and type of misuse and crossing risk.

The deployment of mobile enforcement vehicles staffed by British Transport Police
(BTP). A pilot vehicle detected and prosecuted more than 1,200 motorists responsible
for dangerous and careless acts since 2012.

Introducing spoken warnings (Warning: Another Train is Approaching) at around 150
level crossings at stations. This is to ensure that pedestrians understand that it is not
safe to cross when the crossing sequence continues after a train has passed through
or is in the station.

Introducing GPS-based technology to locate trains in long signal sections. A solution
that provided precise information to the signaller was demonstrated in December 2011
on the Sudbury line, which went to full trial in January. The next phase aims to provide
this information directly to crossing users, removing responsibility from the signaller.

Trialling the installation of overlaid barriers at AOCL crossings. These can be installed
at a fraction of the cost of a full crossing upgrade.

Installing approach locking at more than 70 high-risk manual crossings to remove the
risk of the crossing being opened to road traffic with a train approaching (but the
signals set to danger behind it).
Page 55 of 76

A major campaign to educate level crossing users. This includes running a national
television and radio campaign (Don’t run the risk and See track / think train), holding
awareness days at level crossings, and working directly with schools and user groups.
RSSB is managing research project T984: Research into the causes of pedestrian accidents
at level crossings and potential solutions on behalf of the industry. An early output will be
advice on decision points.
8.3
Road vehicle incursions
On 28 February 2001, a Land Rover and trailer came off the M62 motorway just before a
bridge carrying the motorway over the East Coast Main Line railway near Great Heck, North
Yorkshire. The Land Rover and trailer went down the embankment and came to rest
obstructing the southbound railway line. The vehicle was then struck by an express
passenger train travelling close to 125 mph.
The leading vehicle of the train was derailed. The train continued for some distance, before
running into the path of, and colliding with, a northbound freight. Ten people were killed and
82 required hospital treatment.
The driver of the Land Rover was subsequently convicted of ten counts of causing death by
dangerous driving and sentenced to five years’ imprisonment.
The railway industry conducted a Formal Inquiry into the accident, resulting in 27
recommendations (all of which have been closed out).
The (then) Deputy Prime Minister asked the Health and Safety Commission (HSC) to
examine the obstruction of railway lines by road vehicles. He also asked the Highways
Agency (HA) to review its standards for near side road safety barriers. Both the HSC and HA
reports presented their findings in February 2002.
The Department for Transport (DfT) produced a report, Managing the accidental obstruction
of the railway by road vehicles, in response to the recommendations in these two documents.
It set out the steps to be taken jointly by railway infrastructure authorities and highway
authorities to manage the risk from the accidental incursion of road vehicles onto the railway.
It also included a protocol for apportioning responsibility and costs of mitigation measures.
Approximately 11,000 potential public road to rail incursion sites have so far been identified,
of which:

9,400 were eliminated as low risk after assessment;

400 assessments still outstanding (up to 150 high/medium risk sites may be identified);

1250 sites identified so far as medium or high risk, of which:

450 have been remediated;

150 deemed to be ‘remediation not practicable’;

650 sites still awaiting remediation, of which up to 200 deemed to be high-risk.
Page 56 of 76
The cross-industry Road-Rail Interface Safety Group (R-RISG)12 seeks to track progress with
the mitigation plan and help facilitate solutions. Since the first report in March 2010, the
number of sites requiring initial assessment has been reduced from 400 to 80. However,
new sites continue to be identified (although they are less likely to be high scoring and in
need of mitigation).
There are currently 600 sites that still need remediation (which is down from 650 in March
2010). About half of these have the mitigation agreed with a programme extending to 2015
for completion. The other 300 still need to have mitigation plans agreed. The ORR has
written to the highway authorities that have sites outstanding. Wiltshire, Lancashire and East
Cheshire appear to have particular difficulties. ADEPT (the professional body for local
highway authorities) has been helpful in progressing this, through membership of the RRISG. DfT continues to maintain an overview of progress.
While the total number of non-level crossing road vehicle incursions has been decreasing
over the years, an incident in November 2011 highlighted the need to retain focus in this
area.
8.3.1
Road vehicle incursion and collision with train at Stowmarket Road,
30 November 2011 (pub. 11/12)
At around 19:36 on 30 November 2011, a car left the road and passed through the wire
fence onto the railway line north of Stowmarket.
The driver was injured, but was able to escape to a place of safety, reporting the accident to
Suffolk Police. A short time later the car was struck by a Cambridge–Ipswich service.
Fortunately the train did not derail and neither passengers nor members of the train crew
were physically injured.
Causes
RAIB found the immediate cause of the accident on the highway to be that the driver of the
car lost control of his vehicle. The subsequent collision with the train occurred because the
car came to rest in a position where it was obstructing the railway line and there was
insufficient time to stop the train.
Suffolk County Council had undertaken a risk assessment in 2005 and assessed the risk
from road vehicle incursion (RVI) at the location where the accident occurred. It had not
implemented steps to control that risk. Network Rail was also aware of the risk at the
location, but had no process in place to monitor the actions of local highway authorities to
address RVI risk and had assumed that Suffolk County Council was taking suitable actions.
RAIB identified a number of underlying factors which showed Network Rail’s awareness of
RVI incident sites to be limited, and the joint risk management process adopted by Network
Rail and Suffolk County Council in 2003 (following Great Heck) to be incomplete.
12
The R-RISG and the National Suicide Prevention Group are facilitated by RSSB and meet regularly
to address public risk. They are led by the parent group, the Community Safety Steering Group
(CSSG), and are focussed on understanding the risk from inappropriate public behaviour and sharing
good practice that will help to manage the risk. They are supported by regional and local groups.
Page 57 of 76
As a consequence, the investigation identified that there were nine locations within Suffolk
where action to reduce RVI risk had still to be taken. Network Rail has identified over 200
sites on the national rail network where action has still to be taken to reduce RVI risk.
It was also found that the DfT’s monitoring of progress to mitigate the risk at known sites with
significant RVI risk was not effective, nor did it emphasise to local highway authorities and
Network Rail the requirement to complete such works. RAIB considers that regulatory
oversight by the HSE and ORR of works to address the risk from RVI was affected by a lack
of clarity as to which body has enforcement powers to require local highway authorities to
take action.
What’s been done?
Since the accident, Network Rail has reported the following changes to its practices:

If an RVI incident has taken place it now requires an asset manager (structures) to
attend the local route safety meetings with the operational risk team to discuss safety
of the line issues.

A data analyst is currently compiling a route specific RVI database, which will be
supplied to the DfT for the purpose of providing an accurate status of all known high
risk incursion locations within Great Britain and to enable the RVI ‘project’ to be
completed.

From 27 February 2012, Network Rail introduced a specific category for RVI incidents
within the national control centre log to highlight not only that an incursion has
occurred, but also to improve the accuracy with which the location can be identified.
The Suffolk Constabulary reports that it has briefed all operational staff on the RVI process to
ensure all incidents involving motor vehicles which may result in incursion or near misses in
the proximity of the railway boundary are notified to the road safety management unit, who
will liaise with the relevant local highway authority.
The Cabinet Office has said it was commissioning the updating of local risk assessment
guidance documents in autumn 2012, at which point the RVI locations which have been
assessed by Network Rail and the local highway authorities and scored as high risk, but
which have yet to receive risk reduction work, may be added.
The Law Commission is in the process of drafting a report on the law relating to level
crossings. The Commission has identified a lack of clarity and understanding over whether
ORR or HSE has responsibility for the enforcement of breaches of health and safety
legislation where vehicle incursions from the highway onto the railway occur and are
considering how to address the issue. The Law Commission intend to publish a report in
2013, together with a draft Bill and Regulations. If the recommendations are made and
accepted by the Lord Chancellor and Secretary of State for Transport, they are not likely to
be implemented until after 2014 and will require parliamentary approval.
Suffolk County Council (SCC) has reported that it has:

Installed a barrier at the location where the accident occurred to prevent further
incursions onto the railway;
Page 58 of 76

Agreed a common internal procedure for undertaking and reviewing risk assessments
at known RVI sites and reviewing all sites where road and rail run parallel to each
other to ensure that all such sites have been identified;

Contacted DfT to review the list of incursion sites relevant to the county to ensure all
locations within the county are known;

Sought to involve the police and Network Rail in agreeing new processes with a view
to ensuring that information about incidents and changes in rail operations are fed into
the risk assessment process;

Put processes in place for relevant information from highway inspectors and other
highway staff about these sites to be entered into the risk assessment;

Reviewed the measures taken at the B1113 site and considered whether any further
measures should be put in place to further reduce the risk taking account of the
findings of this investigation;

Introduced a temporary speed restriction at the location pending a further safety
evaluation survey;

Discussed internally the lessons learnt from the RAIB investigation regarding the
management of documents and other records and modified SCC procedures
accordingly; and

Ensured that records are properly indexed and archived for the purposes of
reassessment and review of such locations.
Furthermore, Suffolk County Council has reported that it has:

Created and implemented a process to enable all RVI locations to be identified,
monitored and reviewed to ensure long-term or short-term mitigation measures are
considered and if necessary, implemented;

Developed a database to ensure that information related to RVI locations and
associated documents are maintained and secured to enable staff to view historical
documents in an effective manner; and

Implemented a briefing programme to ensure that all relevant and newly appointed
staff are made aware of the DfT guidance and, if necessary, trained in the process.
RAIB also recommended:

Reviewing current data on RVI sites.

Improving the way RVI risk is monitored

Clarifying who has regulatory and enforcement responsibility relating to RVI risk
management.

Establishing a mechanism for sharing lessons learnt.

Improving the way information is exchanged.
Page 59 of 76
Further information
RAIB, Rail Accident Report: Road vehicle incursion and subsequent collision at Stowmarket
Road, 30 November 2011 (RAIB, 2012) LINK
Research and development
Road-Rail interface research is conducted in nine main areas:

Understanding the risk at level crossings to enable prioritisation of remedial actions;

Identifying and sharing good practice in Britain and overseas to facilitate the adoption
of appropriate solutions;

Identifying new technical and operational solutions to prevent errors and misuse of
crossings;

Understanding the costs of level crossings and the benefits of adopting alternatives to
optimise societal benefits;

Working in collaboration with highway and planning authorities to design out safety risk
and reduce the overall cost to society;

Understanding the needs of vulnerable users at level crossings to facilitate social
inclusion;

Review and overhaul of the legislative framework for level
crossings to identify legal requirements and consolidate
disparate regulations;

Research into bridge strikes and vehicle incursions; and

Research to support inquiry recommendations, government
and regulatory policies, proposed and new legislation.
RSSB’s Road-rail interface safety guide pulls together summaries
of this research in one document to provide a useful resource to
assist industry with accessing relevant information. A new edition is
in preparation.
Page 60 of 76
9
Lessons learned 2012/13 – beyond the boundary
fence
Our industry does not exist in a vacuum. Clearly, there will be accidents and incidents in
other sectors that carry lessons from which we can all benefit.
It is widely recognised that the Baker Panel review into the BP Texas City oil refinery disaster
of 2005 and the Haddon-Cave report on the Nimrod accident of 2006 contain lessons from
which the rail industry could benefit. Indeed, as we saw in section 3.2, the Baker review led
our industry to take a closer look at safety performance indicators and the proactive
management of risk.
During this reporting period, an independent commission published its findings into the
Fukushima nuclear accident, which came in the wake of the Great East Japan Earthquake of
11 March 2011.
9.1
Fukushima
On 11 March 2011, the Great East Japan Earthquake, which killed around
19,000 people and destroyed the lives of many more, triggered a nuclear
accident at the Fukushima Daiichi nuclear power plant.
The series of failures, meltdowns, and radioactive releases was ultimately
declared a ‘Severe Accident’ (Level 7) on the International Nuclear Event
Scale (INES).
The report by the Fukushima Nuclear Accident Independent Investigation
Commission highlighted some worrying failings in the nuclear industry from
which we can all learn.
The Commission’s report contains the following learning points that could be of relevance to
the rail Industry and may warrant consideration in the context of your company and its safety
management system:

Reluctance to ask questions

Insularity

‘Self-interest’ vs ‘public interest’

‘Not invented here’ syndrome

Failure to learn

Low levels of knowledge

Flawed training materials and manuals

Poor crisis management co-operation

Interference by politicians
Page 61 of 76

Confused chain of command

Poor regulation

Lack of transparency

Ignoring potential risk to public health and welfare
More detail may be found in RSSB’s summary of the report, or the full report itself.
Page 62 of 76
Learning activities and initiatives
10
During 2012/13, the RSSB Board considered a number of strategic papers and presentations
on the main elements of system risk.13 This chapter presents ‘snapshots’ of that risk – and
some of the initiatives our industry has been working on to help mitigate it – in the following
key areas:

Passenger

Workforce

Public
Chart 6 summarises the system safety risk, and shows that the Board considered 100% of
the modelled residual risk on the mainline railway, as defined by SRMv7.5.
Each of risk papers focussed on particular areas of risk within the category under discussion
represented by the darker shades. Risk areas represented by lighter shades were covered
in the main paper or appendices, which showed all of the risk from the SRM, including
summaries of how industry and RSSB address all risk areas. The public risk paper also
addressed suicides (inter alia). Together this shows how the industry is managing all safety
risk.
Chart 6.
How system risk is considered by the RSSB Board
100%
Cumulative proportion of total system risk, excluding suicide
and suspected suicide
100%
Passenger risk (also covered)
90%
11%
Passenger risk (highlighted in paper)
Public risk (also covered)
80%
Public risk (highlighted in paper)
Station safety
Train accidents
Workforce risk (also covered)
70%
26%
Worforce risk (highlighted in paper)
63%
3%
60%
50%
Trespass
Road-rail interface
40%
41%
30%
20%
10%
19%
13%
7%
Assault and abuse
Road traffic accidents
Slips, trips and falls
0%
Jul 2011 - Workforce
13
Sep 2011 - Public
Covering safety, performance and efficiency.
Page 63 of 76
Nov 2011 - Passenger
Passenger risk
Engineering failures
Environment
Workforce behaviour
Passenger behaviour
Risk from
In stations
Burns; Manual handling;
Slips, trips and falls;
Platform-train interface
accidents
RSSB R&D projects to support industry
T157 on slips etc and falls updated by T829 (published)
T426 (published) on platform/train interface.
T749 (published) Protection from aerodynamic effects of passing trains
T759 (published) Improving the methods used to provide access to and from trains for
wheelchair users.
T866 published Investigation of platform edge positions on the GB network
T978 Development of new ‘Suburban’ passenger vehicle standard gauge
T605 (published) crowding covered on-train accidents to some extent.
T358 (published) Risk from on-board accidents
T052 a/b, T246, T422 (all published) passenger signage
T686 (published), T769 (Published) – Guidance on SDO
T910 published) Review of interiors crashworthiness research 1989 – 2009
SK&P analysis of injuries associated with internal doors in response to request form VV
SIC/Passenger Focus.
Industry co-operative actions
Arson; Assault; Objects
thrown at trains; Passenger
trespass
Assaults, trespass and vandalism all covered in large number of published projects, mostly
supported by RPSG and now CSSG.
Duty holder actions
OFG sponsored Station Safety Improvement Project successfully delivered all remitted
objectives. Proposal submitted to OFG requesting new remit and sponsorship in order that a
Programme of stairnose marking, increased use of the slip, trip and fall toolkit, passenger
station safety improvement strategy be developed, capable of meeting the industry’s
safety awareness campaigns. Improved emergency preparedness training of staff, improved
requirements over the next 30 years. The project focuses on all aspects of station safety risk, eg
winter preparedness, increased CCTV coverage, improved passenger communications..
PTI and STF accidents. Objective is to build on existing research delivering safety
improvements to the industry.
A train dispatch risk assessment template and improved guidance on the factors that affect
station safety risk has been developed and added to RIS-3703-TOM. Work undertaken with
Falls from train in running;
Charter Operators, Network Rail and TOCs to improve management of passenger risk
On trains
Slips, trips and falls; Struck
associated with Heritage Operations. Furthermore, guidance for Station Managers produced to
against objects
assist duty holders improve the way passenger risk is managed at stations – this includes
development of station safety plans, risk identification, target setting and performance
measurement techniques.
RIS for Passenger Train Dispatch and Platform Safety Measures (RIS-3703) approved and
T743 & T132 (published) train despatch/ train despatch risk tool: to be updated
issued. This standard provides information on factors that should be considered when
T248 & T425 (published) relating to train slipstream effects on platforms.
conducting train dispatch risk assessment and methods by which positive safety behaviours can
Train despatch; Station
Station staff
Station safety issues all covered in station safety research guide (as T828)
be engendered in both staff and members of public. The Station Safety Improvement Project
management
T881 Evaluating wayfinding systems for blind and partially sighted customers at stations
has delivered a range of tactical solutions that positively shape workforce behaviour – including
(published)
development of behavioural markers and guidance on professional behaviours for train dispatch
staff.
Evacuation covered in T626 (published) – for high temperatures only.
TPWS initiatives related to fitment of TPWS at PSRs and in-cab modifications are being
SPADs covered in some 20+ projects, all published. See RSSB website and Operations safety considered by the TPWS Strategy Group set up in 2009 by the RSSB Board to determine the
Evacuation; SPADs; Train
research guide (published as T838. Fatigue and obstructive sleep apnoea studied in several
way forward for TPWS as part of a long term Train Protection Strategy. The latest outputs are a
Train crew
despatch
projects eg T059, T299 (published) and T699 (published) Train despatch – as above.
draft handbook on the use of AWS and TPWS and an update to the TPWS Strategy Group’s
T512 (published) Buffer stops.
action plan.
Crashworthiness and Vehicle Interior research, T118, T189, T310, T424
Proposals to change GO/RT3119 and to propose a review of the Standard.
Signaller
Review of Rule Book.
Maintained by TOM Delivery Unit.
Maintenance work/error;
Track worker
Detecting rail flaws T060a (published)
Errors in possessions
ISLG are addressing Occupational Health issues as a programme of wok for 2012/13
OFG have sponsored the development of a generic shunter training course in DVD format
Shunter
Shunting safety special topic report, published February 2008.
which provides a standardised, modular, and interactive training package.
This is now available to the industry.
T096, T173, T371, T643 (all published) – Weather, climate change,
T112, T554 (published) - scour/flood
Sustainable Development Steering Group is looking at effects of environment on future rail
Weather
Weather
T796 (published) Sanders, T797 (underway) Performance and installation criteria for sanding industry.
systems, T959 (underway) Onboard detection of low adhesion
Project 11/005 New guidance on winterisation
T925 TRaCCA (published). Next stage as T1009 (in development).
Adjacent
T360 (published) – management of structures & earthworks
Adjacent property/land
property/land
T679 (underway) – The effects of railway traffic on embankment stability
T078, T207, T330, T357 (published) – derailment risk
Bridges; Broken rail;
Station roof design and maintenance covered by CIRIA-managed project T038
Buckled rail; Drainage; Fire
Infrastructure
Crashworthiness and Vehicle Interior research, T118, T189, T310, T424
Input to RGS and TSIs.
or explosion; Stations; Track
T854 Reducing the number and impact of vehicle strikes on railway underline bridges
twist; Points failure
(published) T988 (developing) Bridge design requirements
T209, T356, T550, T551, T607 (published); T774 (underway) – Human factors in axle
RISAS accredits Approval Bodies (RISABs) who in turn assess and, where suitable, certify
inspection
suppliers involved in train maintenance. This process is designed to encourage and promote the
T201, T314, T424 (all published) Windows
Bogie/suspension; Brakes;
continuous improvement of products supplied.
Rolling stock
T118, T189, T310, T424 (all published) Crashworthiness ,Vehicle Interior research,
Electrical; Interior; Other
Following the publication of T883 which highlighted the potential for significant savings resulting
T988 (developing) Bridge design requirements
from a review of major supplier approval systems. T908 initiated, to set up a framework to
T860 (underway) All electric braking
realise these savings. Input to RGS and TSIs.
T843 (published) / T1018 (underway) Fire standards
Level X’ings
Covered by the Road Rail Interface Safety Group
Crime
Public behaviour
Type of event
Passenger safety awareness campaigns, further installation of CCTV , improved emergency
preparedness training of staff, enhanced luggage storage space, review of internal door
operation, maintaining secure station accreditation and review of processes for ensuring
passenger welfare during service disruption
Hazard awareness and accident prevention campaigns for staff, review of train despatch
arrangements, improve safety culture and development of a Station Managers Safety
management training programme..
Increased use of driving simulators, improved rostering to reduce fatigue, unobtrusive
monitoring of driver performance, development of a competency standard for on board
hospitality staff, personal development plans for drivers and review of SPADS to ensure all
lessons learnt
NR communication initiatives
Improved briefing and training, increased use of lookout operated warning systems, Improved
possession management systems and safety critical communication protocols.
Commitment to undertake shunting risk assessments.
Scour/flood and coastal infrastructure – action to take forward resides with Network Rail.
Network Rail infrastructure management processes.
Improved management processes for bridge strikes, mitigation of risk from buckled rails,
improved management of sleepers to reduce risk from gauge spread, improved analysis and
intervention from use of the New Measurement Train and improved signalling maintenance.
Fitment of laminated windows, improved interior design and crashworthiness, consider
further installation of CCTV and ongoing modifications to address specific risks and
improving the man/machine interface of TPWS
Covered by Network Rail Level Crossing Strategy Group
Covered by T846: A guide to RSSB research in community safety.
Crime topics are reviewed nationally, enabling industry organisations to consider local
measures working in partnership with local authorities. CSSG sponsors annual Community
Safety resources to inform industry and share good practice. Rail Personal Security Group
focusing on assaults, shares good practice across companies improves reporting and ensures
appropriate offender sentencing takes place. A guide to the new ASB legislation will be
produced. A second SWeRVe DVD has been produced. BTP continued with Operation Shield.
Operation Tornado is a BTP scheme that is designed to crack down on metal theft.
Rail enforcement officers (REOs) given direct access to BTP radio network. Improved conflict
training for members of staff using SWeRVe.
BTP is the ACPO lead on metal theft. Network Rail is working hard to prevent cable theft:
including extra BTP staff; using securing cables; using forensic marking agents. New bill that
legislates scrap metal dealers is being developed. Network Rail has a series of initiatives
running to tackle railway crime, including trespass. Network Rail’s Partnership Awards
recognize work by groups to encourage the public to act responsibly when using the railway.
Several TOCs have working groups to manage assault risk in their areas.
NR appointed a Head of LX, produced a policy on management of LX to reduce train and
accident risk by 25%, by the end of CP4. NR continuing with awareness campaigns and
manages Road-Rail Partnership Groups with local authorities. BTP operate NR funded
mobile camera fitted vans which have been operating in various areas which can issue Fixed
Penalty Notice letters. BTP and CPS to produce guidance for prosecutors on
careless/dangerous driving at LX.
RVs at LX
Road users at level
crossings
Large number of research projects published and eight in progress covering all areas of road
/rail interface
Covered by the RRISG including industry participation in the International Level Crossing
Awareness Day (ILCAD) and the Network Rail Don’t Run the Risk campaign. RSSB hosts an
RR forum and European Level Crossing Forum, with additional sponsorship from NR and ORR,
is organising the Global LX Symposium in London in October 2012.
Pedestrian
Passengers on footpath
crossings
T332 (published) on station crossings
T652 (published) on another train coming warnings
T730 (published) on Elsenham RAIB recommendations.
T984The causes of pedestrian accidents at LX and potential solutions (in progress)
NR is risk assessing all crossings and trying to educate users through signs, etc. The four
Covered by the RRISG including industry participation in the European Awareness day and the
highest risk/busiest station crossings have been or are due to be closed. A new awareness
Network Rail Don’t Run the Risk campaign
campaign will focus on distraction events.
Page 64 of 76
Workforce risk
Workforce behaviour
Risk from
Risk to
Track workers
RSSB actions to support industry
Occupational hazards including
electrocution and being struck by
trains. Road vehicle safety working
with plant and at height.

Facilitation of ISLG and OFG

Network Rail PSLG

NR Vision for Safety and Well Being

Specific research

M & EE Group

NR life saving roles

Occupational health programme

Modernisation of Safety co-operation

NR RRV Improvement programmes

New approach to rules project

Development of Close Call

NR track safety strategy

CIRAS

Management of fatigue - initiatives

Contractor culture and leadership programmes

Road vehicle

New Induction programme

Fatigue control improvements

National Skills Academy
Public
Station staff, train
crew, crossing
keepers
Engineering
failure
Workforce behaviour
Station staff
Infrastructure workers,
train crew
Engineering failure
Train crew
Workforce
behaviour
Signaller/
Public
Duty holder actions
Facilitation of OFG

National Operators Risk Conference and workshops

NR level crossing strategy

TPWS strategy support

New approach to route learning

Station safety improvement project

Personal track safety of train crew

TPWS risk management

Individual company injury prevention

New approach to rules project

Good practice share

Fatigue management

RED, Right Track and OPSWEB

Specific research
Assaults. Arson, missiles thrown at
trains, objects on the line and other
acts of vandalism. Witnessing
suicides and accidents to / near
misses with trespassers.

SWeRVe II

Track off

Facilitation of CSSG and RPSG

NR trespass campaigns

Specific research

National Suicide Prevention Group

BTP Annual Plan
General improvements made to CCTV systems across a number of stations. Rail enforcement officers given direct access to
the BTP radio network. Improved conflict training for members of staff. Fencing priorities matched with trespass hotspots.
Campaign run during school holidays to deter trespass and anti-social behaviour. Closure of access to unused platforms.
Placing of Samaritans posters around stations and additional staff training to identify potentially suicidal people. Utilise
SWeRVe v2.0 to educate staff on conflict avoidance and management.
Personal injuries. Accidents related to
train despatch and station
management.

RSSB facilitation of OFG

Aerodynamics Project

Station Safety Improvement project

Enhancement of train dispatch RIS

Specific research
Problems with the track, signalling
systems, or bridges, embankments,
tunnels etc.

Specific research

Specific standards
Faults with train interior (including
seats and windows). Electrical faults.
Brakes, bogies etc.



RISAS

RSSB facilitation of CSSG and
RPSG

SWeRVe II

RSSB facilitation of CSSG and
RRISG

ALCR model

Specific research

Chair of European LX forum
Personal injuries, public assaults.
crossing keepers
Crossing keepers,
train crew,
infrastructure
workers
Industry co-operative actions

Personal injuries. Train accidents.
Workforce
behaviour
Train crew
Main types of event relevant to
workforce risk
Accidents at level crossings. Road
vehicle incursions. Bridge strike.
Continued use of the slips, trips and falls toolkit and the HSE’s ‘shattered lives' campaign, review workforce footwear and
communication campaigns. Training needs analysis for conductor and train dispatch staff duties and use outputs to update
training courses. Publicity campaign highlighting the hazards to station staff of doors, drawers and floors. Improve Driver Only
Operation (DOO) dispatch equipment on stations. Provision of mobile panic attack alarms for use when staff open and close
offices and stations.
Industry co-operative input to Railway Group Standards and
Technical Specifications for Interoperability.
Strategic replacement of softwood sleepers. Application of latest technology to monitor and reduce track defects. Focussed
risk assessment on track stressing & effects of weather on embankments and structures. Identification and remedy of ‘roughride’ sites. Bridge examination intervals based on risk.
Specific research

ATOC Engineering Council
Specific standards

ROSCO collaboration
Introduction of a digital reader to measure axle box temperatures and new rolling stock with improved interior design. Fit high
intensity headlights to class 142 and 143 fleet to enable increased visibility to track workers and people working on or near
the line. Improve cab environment of class 66 locomotives to minimise fatigue levels. Fitment of a second interlock switch to
class 150 to reduced the risk of ‘wrong-side’ door interlock failure.

BTP Annual Plan Objectives
NR internal communication and line management

DfT and ORR follow up to risk assessment

Participation in ILCAD

Continued development of NR’s ‘Don’t Run the Risk’ campaign with a new strapline ‘ lifesavers not time wasters’. NR risk
assessment of crossings through the Level Crossing Risk Model. Cameras installed at all level crossings and deployment of
enforcement vehicles. Strategy to upgrade AOCLs and close UWCs when possible.
BTP Annual Police Plan Objectives
Page 65 of 76
Train crew, track
workers
ment
Environ-
Public
Train drivers, station
staff
actions
Passenger
Workforce
behaviour
Shunters
Train drivers, Station
staff
Attending to or witnessing accidents
similar to passenger accidents in
stations
Train accidents due

Specific research

Facilitation of CSSG

Annual Community Safety Forum

Station Safety Improvement project

Sustainable Rail Programme
T845 is also evaluating the Network Rail campaign with
Samaritans which is raising awareness of the hazards of
railways.

TSLG and technical strategy
to effects of adverse weather
conditions.
Personal injuries (including crushed
by trains). Coupling/train preparation
errors.

RSSB facilitation of OFG

Shunter Interactive training DVD
Shock and trauma due to attending to
or witnessing passenger accidents.

Station Safety Improvement project

Specific research and topic reports.

Establishment of new National Freight Safety Group
Red 28 focussed on the platform-train interface using a fictional
dramatisation.
A Rail Industry Standard (RIS) for passenger train dispatch and
platform safety (RIS-3703-TOM) completed in June 2011.
Page 66 of 76

Individual company programmes

Station enhancement programmes

NR Asset Management plan

Improved drainage management

Operational client controls
Developing and reviewing individual training plans and examining supervision and monitoring guidelines for shunters.
Introduction of unobtrusive monitoring. Development of a manual handling brief. Improvement to loading and train preparation
processes.
Passenger safety awareness campaign for boarding/alighting trains. Improvements to customer display screens and public
address systems to reduce crowding around signs and late rushes to trains. Review of incidents of passengers being taken ill
on trains to establish common causes and develop plans to reduce the numbers of such incidents.
Public risk
Risk from
Main types of event
RSSB actions to support industry
Industry co-operative actions
Crime topics reviewed nationally by the Community Safety Steering Group
and regionally by Community Safety Partnership Groups, which enable
industry organisations to consider local measures and work in partnership
with local authorities.
Trespasser struck by
train or electrocuted.
Crime
Assaults, threats and
verbal abuse
11
A large portfolio of previously published research on trespass issues is
available from the RSSB website. More recently published:
T704: The contribution of alcohol to personal safety and security risk on the railways
(Including Good Practice Guide); T723: Making the most of data associated with railway
crime;
T943 Addressing crime and disorder through planning and design; T954 Evaluating
measures to improve personal security and the value of their benefits.
The Trackoff website supplies educational materials to teachers to enable them to warn
their students of the dangers of inappropriate behaviour on the railway network. During
2009 a DVD was sent to more than 30,000 schools throughout the country.
RSSB manages the annual Community Safety Forum, Newsletter and Resource Centre
website to inform industry and share good practice.
Public behaviour
Pedestrian
Road vehicle
Rail Personal Security Group – focusing on assaults, aiming to share good
practice across companies and improve reporting and ensure appropriate
offender sentencing takes place, made a submission to the Home Office
consultation on managing ASB. A guide to the new ASB legislation will be
produced.
SWeRVe (Stop Workplace Related Violence) DVD helps staff manage
conflict situations. A second SWeRVe DVD has been produced.
Actions by individual organisations
General improvements made to CCTV systems across a number of stations; general
management and maintenance of systems also upgraded.
Rail enforcement officers given direct access to the BTP radio network, enabling them to contact
BTP immediately when necessary. TOCs, Network Rail and BTP use a variety of staffing
measures including security guards, rail enforcement officers, special constables and police
community support officers.
Improved conflict training for members of staff using SWeRVe.
BTP is the ACPO lead on metal theft. Use of mini-helicopters and regular visits to scrap dealers,
to combat cable theft. Network Rail is working hard to prevent cable theft: Funding extra,
dedicated British Transport Police officers around the country; using CCTV to detect people are
on the network and to support the police; trialling methods of securing cables; using forensic
marking agents; introducing cables which are harder to steal and easier to identify; setting up
dedicated security teams.
A new bill that legislates scrap metal dealers is currently being developed. It has had it second
reading in parliament and has wide support.
Fencing priorities matched with trespass hotspots.
BTP continued with Operation Shield: handheld and portable metal detectors
to detect and deter knife carrying on the railway.
Network Rail has a series of initiatives running to tackle railway crime, including trespass. Some
examples are: Rail Life, a new website aimed at teaching young people about the dangers of
Operation Tornado is a BTP scheme involving scrap metal recyclers that is misusing the railway; media campaign with 400m hurdler Dai Greene – this is showing that if an
athlete at the peak of fitness can not outrun a train, an average person will not stand a chance;
designed to crack down on metal theft.
Partnership with Streetgames – offering local kids the chance to engage in sport and not mess
Following a successful pilot in the North East of England Operation Tornado around on the tracks; Rail Reps – a mentoring relationship between school and BTP volunteers.
is being rolled out across the UK
Network Rail’s Partnership Awards recognize work by groups to encourage the public to act
responsibly when using the railway.
Published: T335, Improving road user and pedestrian behaviour at level crossings, T650
Improving safety and accessibility at level crossings T653, Safer European level crossing
assessment and technology (SELCAT); and T730 Understanding human factors and
Pedestrian struck by
developing risk reduction solutions for pedestrian crossings at railway stations. In progress
train at (footpath) level
T984 Research into the causes of pedestrian accidents at level crossings and potential
The Road-Rail Interface Safety Group has a broad remit, eg covering level
crossing
solutions.
crossings, incursions and bridge strikes. Supported at local level by Road
Rail Partnership groups involving local authorities.
In 2011, a new level crossing teaching package was added to the Trackoff website.
Network Rail working with BTP and CPS, providing evidence to prepare
Impact Statements for courts.
Network Rail, helped by BTP, has had several awareness days in support of
Published: T729: Further work on obstacle detection at level crossings; T737: Documenting
ILCAD to inform the public of the need to act safely at level crossings.
the All Level Crossing Risk Model; T863: Updating the Level Crossing Risk Management
Train collision with road Toolkit, T738: Trialling the national roll out of the level crossing cost model; and T854:
BTP has commissioned vans with ANPR cameras to detect red light running
vehicle at level
Reducing the number and impact of road vehicle strikes on railway underline bridges. In
at level crossings, funded by Network Rail. Vans are being rolled out across
crossing; road vehicle progress: T756: Research into traffic signs at level crossings (second stage) and T983:
all routes.
incursion not at level
Research into signs at private level crossings. RSSB chairs the European Level Crossing
crossing and bridge
Forum, to share good practice and coordinate public awareness campaigns (ILCAD) and
RSSB will host the 12th Global Level Crossing Symposium in October 2012,
strikes
encourages the EU to hold workshops on managing risk at level crossings.
in partnership with Network Rail and the ORR.
RSSB holds an annual road-rail information forum to update public groups on safety at the
road-rail interface.
Several TOCs also have working groups to manage assault risk in their areas, with BTP. Each
company has its own policy for dealing with abuse against staff.
Network Rail risk assessment of crossings through the Level Crossing Risk Model.
Network Rail has developed a new communications plan to address the issue of pedestrian safety
at crossings and a specific campaign targeting schoolchildren has been launched.
Network Rail has engaged a theatre company to perform ‘off the level’ a play highlighting the
dangers of misusing a level crossing. This initiative is being considered nationally.
Network Rail has produced a new level crossing safety leaflet to hand out during enforcement
days to both pedestrians and road vehicle drivers.
Cameras installed at level crossing to identify incidents of road vehicle misuse.
Network Rail has centralized level crossing management into a single system considered as a
separate asset. There are programmes to the end of CP5 to reduce the risk.
Opportunities to close private level crossings will be pursued with landowners
Network Rail manages the Bridge Strike Prevention Group (BSPG) working with the Road
Haulage Association, Highways Agency, ADEPT, LUL and others to reduce the frequency of
bridge strikes through information booklets, awareness/education events for lorry drivers,
producing a database of low bridges for truckers’ atlases, correct signing of bridges and other
initiatives.
Network Rail is continuing to work with DfT and ORR, to implement the protocol of “Managing the
accidental obstruction of the railway by road vehicles”.
General
Level crossing
Rolling stock
Non-trespass related
slips, trips and falls at
stations
LX equipment
malfunctions
Third party injury from
train accidents
Engineering
Workforce
behaviour14
14
Infrastructure
Third party injury from
train accidents
Station staff
Non-trespass related
slips, trips and falls at
stations
Industry groups looking a similar risk to passengers, eg Operations Focus
Published research projects: T157a: The best flooring materials for stations; T157b: Safer
Group (OFG), will also address same risks to members of the public.
surfaces to walk on - reducing the risk of slipping; T158: The use of tactile surfaces at rail
OFG has formed a sub-group (inc ATOC, RSSB, ORR and NR and
stations; T532: An evaluation of frost, ice and snow precautions at stations; T829: Safer
Southeastern) to look at accidents occurring at the platform train interface.
surfaces to walk on: an updated guide. T834 Reducing accidents through inclusive design:
They have appointed a dedicated PM (Andy Wallace) to support the station
steps, stairs and ramps T749, Guidance on protecting people from the aerodynamic effects
safety sub group. His programme of work will focus on initiatives, analysis,
of passing trains in progress. . In progress: T992 Safer stairs and escalators in public
toolkits and potential good practise outside the railway industry. Also a
places
means of exploiting investment in CP5.
No research specifically addressing public risk.
Engineering research predominantly focused on rolling stock itself and passengers.
Covered by individual duty holder actions aimed at reducing passenger risk at stations.
Obstacle detectors have been developed and trailed.
The work of systems interface committees and standards committees related Warnings on approach to level crossings have put into Garmin satellite navigation systems.
to engineering issues.
T359: Management of stressed continuously welded track, T569: Development of risk
based examination intervals for Network Rail bridges, T696: Appraisal of Eurocodes for
Railway Loading, T683: Research to investigate and advise on optimisation of close- and
long-range viewing of signals, T804: Automatic Warning System (AWS) Infrastructure
Characterisation all completed;, and T808, AWS Testing - the way forward in progress.
RSSB has worked closely with Network Rail and appropriate European
In addition to internal studies and the development of standards and management processes,
committees (CEN/UIC) to establish requirements that are relevant to the GB Network Rail have actively participated as a stakeholder representative on research project
railway industry in the Structural Eurocodes.
steering groups and the review of project outputs. Following the publication of T569, Network Rail
has used the guidance provided to establish examination intervals for their bridge assets on the
basis of risk. Work is also targeted at reducing the frequency and consequences of bridge strikes.
The OFG sub-group looking at station safety has produced a RED 28 DVD
which looks at risks at the Platform Train Interface. The DVD provides hard
Published: T743, Improving the arrangements for train dispatch from stations. T749,
Duty holder responsibilities and initiatives related to competence management and development
hitting re-enactment of a dispatch situation where a member of the public is
Guidance on protecting people from the aerodynamic effects of passing trains in progress.
that address the prevention of train accidents will be relevant here.
waving off their loved one and is caught in the train doors and falls between
the train and platform edge.
Third party risk also has the potential to arise from workforce activity away from the mainline railway, for example road traffic accidents whilst driving between sites. This is not covered by the SRM.
Page 67 of 76
Train crew
Track worker
No research specifically addressing public risk
Third party injury from
train accident
Signaller
Public
behaviour
Suicide
No research specifically addressing public risk
No research specifically addressing public risk
Suicide, suspected or
attempted suicide
Initiatives such ATOC Driver Managers group.
Continued implementation of SAF6 National Voice Communications Training
Programme to improve quality of communication between key railway roles
such as signallers, drivers, contractors and maintenance staff.
Working with Samaritans to train rail staff to recognise behaviour that might
lead to suicide. Two courses are available: managing suicidal contacts and
trauma support.
Network Rail’s cross-industry National Suicide Prevention Steering Group
and Working Group addresses suicide prevention..
Network Rail are working with FCC regarding using external bodyside ‘skins’
Project T845 Improving suicide prevention measures on the rail network in Great Britain, in to promote the campaign on the outside of two of their units.
progress
Closure of access to unused platforms. Placing of Samaritans posters around stations and
additional staff training to identify potentially suicidal people.
Network Rail are working as part of the European RESTRail project to tackle trespass and
suicide prevention.
Network Rail has produced a Drivers Guidance document outlining the behavioural impacts and
strategies for recovery should a driver be involved in a suicide event. In addition they have also
produce Memorials Guidance on how to deal with requests for memorials.
Emotional Support Outside the Branch (ESOB) – All Network Rail priority
locations are covered by local Samaritans branches.
BTP have launched a new fatality guidance document that has already had a positive impact on
the delay impact of events.
The Samaritans/Network Rail suicide reduction campaign will be refreshed
and re-launched in September 2012.
British Transport Police Referral Scheme – this is being piloted in the London North area but will
be rolled out this year to all areas. BTP officers are able to refer individuals to the service through
the Central London Samaritans branch.
Page 68 of 76
Appendix 1.
Table 5.
Progress against RAIB recommendations
RAIB recommendations closed out (all years) per ORR website
Total
recs
Recs in
progress
Recs
closed in
2012/2013
Total
recs
closed
Autumn Adhesion incidents 2005 including Esher and
Lewes. Reports 1, 2 and 3
25
4
3
21
30/01/2007
Derailment incident at Edinburgh Haymarket
3
0
0
3
30/01/2007
Derailment incident at Waterside, East Ayreshire
7
0
0
7
31/01/2006
23/01/2007
Derailment incident at Cricklewood
6
0
0
6
09/02/2006
23/01/2007
Derailment at Brentingby Junction, near Melton Mowbray
10
0
0
10
15/02/2006
30/04/2007
Train door incident at Huntingdon
6
0
0
6
21/02/2006
21/02/2007
Unsecure load incident at Basford Hall
5
0
0
5
19/03/2006
25/07/2007
Near miss involving track workers at Manor Park
3
0
1
3
07/04/2006
30/04/2007
SPAD incident at Camden Road
9
0
0
9
01/05/2006
29/05/2007
Near miss incidents at Crofton Old Station Level Crossing
6
0
0
6
22/05/2006
26/04/2007
Train collision with a road vehicle at Bratts Blackhouse
Level Crossing
8
0
0
8
10/06/2006
30/08/2007
Power door incident at Desborough
9
0
0
9
28/06/2006
18/07/2007
Derailment at Maltby Colliery
4
0
0
4
29/07/2006
29/05/2007
Fatal accident at Deal
9
0
9
9
18/08/2006
08/08/2007
SPAD incident at Purley
5
0
0
5
27/08/2006
24/05/2007
Runaway incident at East Didsbury
8
1
0
7
08/09/2006
21/09/2007
Derailment at Washwood Heath
4
0
0
4
11/09/2006
18/12/2007
Derailment at London Waterloo
14
0
1
14
12/09/2006
13/09/2007
Derailment at Epsom
3
0
0
3
25/09/2006
05/09/2007
Collision at Copmanthorpe
2
0
0
2
31/10/2006
22/08/2007
Collision at Badminton
4
1
0
3
17/03/2007
18/12/2007
Near miss at Tinsley Green
8
0
4
8
12/09/2006
13/05/2008
Derailment at Croxton Level Crossing
158
11
6
0
18
4
152
11
13/01/2007
28/02/2008
Derailments at Merstham, near Redhill and Kemble
9
0
0
9
28/02/2008*
23/12/2008
Network Rail's management of existing earthworks /
Kemble (15/01/2007)
6
0
6
6
15/01/2007
27/03/2008
Derailment of a passenger train near Kemble
2
0
2
2
28/01/2007
24/04/2008
Runaway wagon at Armathwaite
3
0
0
3
23/02/2007
23/10/2008
Derailment at Grayrigg in Cumbria
29
3
2
26
29/04/2007
28/02/2008
Fatal accident at Ruscombe
7
0
5
7
10/05/2007
31/01/2008
Derailment at King Edward Bridge, Newcastle Upon Tyne
4
0
0
4
01/08/2007
10/01/2008
Collision near Burton on Trent
4
0
4
4
0
7
8
Incident
date
Recs
issued
25/11/2005
08/01/2007
14/01/2006
21/01/2006
RAIB investigation
Recs issued 2007 Total
10/08/2007
31/07/2008
Derailment at Duddeston Junction
8
22/08/2007
20/11/2008
Incident at Didcot North Junction
9
3
0
6
27/08/2007
11/06/2008
Incident at Aylesbury North
4
0
0
4
Incident at Ty Mawr
7
3
0
4
0
5
6
29/08/2007
30/10/2008
29/08/2007
23/10/2008
Accident at Leatherhead
6
29/11/2007
28/10/2008
Member of staff hit by a train at Reading East
5
2
1
3
Damaged footbridge at Barrow on Soar
4
0
0
4
0
2
5
0
4
4
01/02/2008
25/09/2008
20/01/2008
23/12/2008
Near miss at Bishop's Stortford
5
16/04/2008
23/12/2008
Fatal level crossing accident at Staines, Surrey
4
Page 69 of 76
Recs issued 2008 Total
127
11
42
116
04/07/2009
19/11/2009
Collisions between container doors and passenger trains
at Eden Valley
3
0
3
3
30/03/2009
19/11/2009
Track worker injury near Dalston Kingsland Station
3
0
3
3
19/12/2008
12/08/2009
Incident involving a container train at Basingstoke Station
3
0
0
3
18/12/2008
14/12/2009
Collision and derailment of a passenger train at North
Rode
3
0
2
3
07/12/2008
27/08/2009
Workforce struck by a train at Stevenage
6
0
2
6
22/11/2008
19/11/2009
Fatality at Bayles and Wylies footpath crossing
8
2
0
6
10/11/2008
10/11/2009
Derailment at East Somerset Junction
11
5
0
6
03/11/2008
07/10/2009
Level crossing fatality at Wraysholme
5
3
0
2
21/10/2008
28/07/2009
Near miss at Llanbadarn Level Crossing
8
0
2
8
27/07/2008
24/06/2009
Incident at New Southgate
5
1
0
4
01/07/2008
11/06/2009
Incident at Poplar Farm level crossing
2
0
0
2
18/07/2008
29/10/2009
Collisions and runaways involving road-rail engineering
machines / Whinhill (18/07/2008)
3
3
0
0
24/06/2008
18/06/2009
Collision at Acton West
8
2
0
6
19/06/2008
06/03/2009
Investigation into User Worked Crossings / Loover Barn
Level Crossing (19/06/2008)
8
1
0
7
28/05/2008
20/08/2009
Incident at Bridge GE19 near London Liverpool Street
station
7
0
0
7
23/05/2008
12/11/2009
Workforce hit by a train at Kennington junction
3
0
2
3
26/04/2008
14/09/2009
Collision at Leigh on Sea
7
0
0
7
31/03/2008
30/03/2009
Level crossing fatality at Tackley station
6
0
0
6
25/03/2008
18/03/2009
Derailment of a freight train at Moor Street station
3
0
1
3
01/03/2008
29/05/2009
Two incidents at Cheddington and Hardendale
10
1
4
9
22/01/2008
20/01/2009
Level crossing fatality near Haltwhistle
4
1
0
3
25/01/2008
30/04/2009
Derailment at Scunthorpe
9
4
2
5
05/12/2007
25/02/2009
Collision at Glen Garry
7
0
3
7
13/11/2007
16/07/2009
Workforce struck by a train at London Victoria
9
0
4
9
04/11/2007
27/05/2009
Runaway engineering machine at Romford, Essex
6
0
4
6
03/09/2007
12/02/2009
Derailment at Glasgow
4
0
4
4
22/06/2007
22/01/2009
Derailment at Ely
16
0
1
16
167
23
37
144
12/06/2008
14/01/2010
Derailment of a freight train at Marks Tey
7
7
0
0
27/01/2009
03/02/2010
Derailment of a freight train near Stewarton
12
0
12
12
22/03/2009
18/03/2010
Incident at Greenhill Upper Junction, near Falkirk
6
0
6
6
06/05/2009
12/05/2010
Fatal accident at Fairfield level crossing
3
0
1
3
01/06/2009
25/03/2010
Derailment of a passenger train near Cummersdale
5
0
5
5
25/08/2009
18/08/2010
Derailment at Wigan North Western station
4
3
0
1
23/09/2009
05/08/2010
Overhead line failure, St Pancras International
7
7
0
0
29/09/2009
23/09/2010
Fatal accident at Halkirk level crossing
6
0
2
6
11/10/2009
05/08/2010
Derailment at Windsor and Eton Riverside station
3
3
0
0
14/11/2009
23/09/2010
Failure of Bridge RDG1 48 (River Crane) between
Whitton and Feltham
6
5
0
1
28/11/2009
28/10/2010
Derailment near Gillingham tunnel, Dorset
5
1
0
4
02/12/2009
02/09/2010
Fatal accident at Whitehall West Junction
2
0
2
2
19/12/2009
07/10/2010
Near-miss at Victory level crossing
4
0
4
4
04/01/2010
21/06/2010
Collision at Exeter St Davids station
1
1
0
0
14/02/2010
09/12/2010
Incident at Romford station
Recs issued 2009 Total
Recs issued in 2010 Total
5
0
5
5
76
27
37
49
23/03/2011
15/12/2011
Train passed over Lydney level crossing with crossing
barriers raised
3
2
1
1
28/01/2011
28/11/2011
Passenger accident at Brentwood station
5
1
4
4
Page 70 of 76
08/11/2010
17/11/2011
Station overrun at Stonegate, East Sussex
3
0
3
3
20/10/2011
Derailment of a passenger train near Dryclough Junction,
Halifax
5
0
5
5
29/09/2011
Derailment in Summit tunnel, near Todmorden, West
Yorkshire
5
1
4
4
15/08/2011
Uncontrolled freight train run-back between Shap and
Tebay Cumbria
4
3
1
1
11/082011
Collision between an articulated tanker and a passenger
train at Sewage Works Lane UWC
6
0
6
6
05/11/2010
04/08/2011
Bridge strike and road vehicle incursion onto the roof of a
passing train near Oxshott station
5
0
5
5
29/09/2009
&
03/11/2008
28/07/2011
AOCL Class Investigation
4
0
1
4
06/06/2010
14/07/2011
Accident at Falls of Cruachan Argyll
6
5
1
5
11/07/2011
Runaway and collision of a road-rail vehicle near
Raigmore, Inverness
4
0
4
4
10/07/2010
07/042011
Collision between train 1C84 and a tree at Lavington,
Wiltshire
4
0
4
4
04/05/2010
24/03/2011
Runaway and derailment of wagons at Ashburys
6
6
0
0
30/03/2010
23/03/2011
Track worker struck by a train at Cheshunt Junction
2
1
1
1
16/01/2010
28/02/2011
Fatal accident at Moreton-on-Lugg, near Hereford
4
3
1
1
24/02/2011
Derailment of a freight train at Carrbridge, Badenoch and
Strathspey
4
3
0
1
22/12/2009
31/01/2011
Near miss involving a freight train and two passenger
trains, Carstairs
3
0
3
3
06/03/2010
24/01/2011
Passenger train struck by object at Washwood Heath
4
1
3
3
77
26
47
55
04/09/2011
20/12/2012
Near miss incident at Ufton automatic half barrier level
crossing, Berkshire
7
7
0
0
28/01/2012
13/12/2012
Fatal accident at a footpath crossing near Bishop’s
Stortford
3
3
0
0
12/04/2012
03/12/2012
Person trapped in a train door and dragged at Jarrow
station, Tyne and Wear Metro
5
5
0
0
30/11/2011
21/11/2012
Road vehicle incursion and subsequent collision with a
train, at Stowmarket Road
9
9
0
0
03/02/2012
21/11/2012
Derailment at Bletchley Junction, Bletchley
3
3
0
0
22/10/2011
27/11/2012
Fatal accident at James Street station, Liverpool
3
3
0
0
19/12/2011
27/09/2012
Collision between a train and a lorry and trailer on
Llanboidy automatic half barrier level crossing
6
6
0
0
26/08/2011
19/09/2012
Derailment at Bordesley Junction, Birmingham
4
4
0
0
27/07/2011
30/08/2012
Derailment at Princes Street Gardens, Edinburgh
5
5
0
0
18/07/2011
09/08/2012
Container train accident near Althorpe Park,
Northamptonshire
4
4
0
0
12/06/2011
06/08/2012
Track worker struck by a train at Stoats Nest Junction
1
0
1
1
24/08/2011
18/07/2012
Fatal accident at Gipsy Lane footpath crossing,
Needham Market, Suffolk
4
4
0
0
10/09/2011
12/07/2012
Incident involving a runaway track maintenance trolley
near Haslemere, Surrey
6
6
0
0
10/04/2011
02/07/2012
Detachment of a cardan shaft at Durham Station
6
6
0
0
19/06/2011
27/06/2012
Incident at Llanbadarn Automatic Barrier Crossing (local
monitored), near Aberystwyth
6
6
0
0
03/10/2011
21/06/2012
Fatal accident at Mexico footpath crossing (near
Penzance)
5
2
3
3
10/10/2011
30/05/2012
Person trapped in doors and pulled along platform at
King's Cross Station
1
1
0
0
26/05/2011
23/05/2012
Safety incident beetween Dock Junction and Kentish
Town
3
3
0
0
05/02/2011
28/12/2010
17/08/2010
17/08/2010
20/07/2010
04/01/2010
Recs issued 2011 Total
Page 71 of 76
25/09/2011
29/03/2012
Collision between a train and tractor at White House
Farm User Worked Crossing
0
0
0
0
06/04/2011
22/03/2012
Partial failure of Bridge 94, near Bromsgrove
3
2
1
1
08/03/2011
27/02/2012
Two incidents involving track workers between Clapham
Junction and Earlsfield
5
5
0
0
08/01/2011
15/02/2012
Tamper driver struck by a train at Torworth level crossing
1
1
0
0
30/01/2012
Passenger train derailment near East Langton,
Leicestershire
4
4
0
0
Recs issued 2012 Total
94
89
5
5
25/04/2013
28/10/2012
Dangerous occurrence involving engineering possession,
near Dunblane
0
0
0
0
28/01/2012
28/01/2013
Freight train derailment at Reading West Junction
5
5
0
0
02/05/2012
14/01/2013
Fatal accident at Kings Mill No.1 level crossing, Mansfield
1
1
0
0
Recs issued 2013* (up to 05/04/2013) Total
6
6
0
0
705
188
186
521
20/02/2010
Total
All recommendations completed/closed previous years
Recommendations closed in 2012/2013
Page 72 of 76
Table 6.
RAIB recommendations on RSSB to 30/04/13
Incident
date
Published
date
11/01/2006
18/06/2006
Cutting of rail on line still open to
traffic near Thirsk
1

04/11/2005
02/11/2006
Derailment near Oubeck North,
Lancaster
4

8

10
25/11/2005
02/11/2005
08/01/2007
02/11/2006
Type of report and location
Rec.
no.
Closed in
SMIS
Closure
accepted
by ORR

28/03/2007
16/01/2009

13/08/2007
01/11/2007
N/A
17/11/2008
15/11/2011

N/A
17/11/2008
15/11/2011
11

N/A
17/11/2008
15/11/2011
12

N/A
17/11/2008
15/11/2011
15

N/A
17/11/2008
In progress
16

N/A
17/11/2008
In progress
17

N/A
27/02/2008
08/12/2009
18


07/09/2012
15/11/2011
2


19/12/2008
09/09/2008
10




28/03/2007
13/08/2007
19/10/2010
16/01/2009
3


13/01/2009
30/04/2008
4


02/06/2008
30/04/2008
7
1


02/06/2008
30/04/2008


28/03/2007
19/10/2010


15/11/2008
16/06/2010
5
1




18/07/2007
06/04/2008
25/07/2008
09/11/2009
4


19/03/2008
09/11/2009
5


11/03/2008
09/11/2009
8


25/07/2008
09/11/2009
4


02/05/2008
30/06/2009
1


07/07/2008
06/11/2008
3

03/11/2007
01/10/2010
19/12/2008
08/12/2009
04/08/2008
02/11/201215
Trolley runaway, Larkhall
26/11/2005
29/11/2006
Derailment near Moy
09/02/2006
23/01/2007
Derailment near Brentingby, Melton
Mowbray
14/01/2006
30/01/2007
Derailment at Haymarket, Edinburgh
16/04/2006
30/01/2007
Blowback of loco fire at Grosmont
15/02/2006
30/04/2007
Train door incident at Huntingdon
18/08/2006
29/05/2007
08/08/2007
Action
plan in
progress?
Autumn Adhesion
9
29/07/2006
Accepted
by RSSB?
Fatal accident at Deal
SPAD at Purley
9
31/10/2006
22/08/2007
Collision at Badminton
10/06/2006
30/08/2007
Train door incident at Desborough
9

29/04/2007
28/02/2008
Track worker fatality at Ruscombe
Junction
4

27/08/2007
11/06/2008
Two trains in the same section at
Aylesbury
3


08/09/2009
18/09/2009
01/02/2008
25/09/2008
Collision of a train with a demolished
footbridge, Barrow upon Soar
3


15/06/2009
08/12/2009
23/02/2007
23/10/2008
Derailment at Grayrigg
22

31/07/2009
08/12/2009
15
N/A

N/A
N/A
The RAIB 2011 Annual Report states the following: ‘Network Rail has reported that it has taken actions in
response to this recommendation. ORR proposes to take no further action unless they become aware that the
information provided becomes inaccurate’.
Page 73 of 76
27/08/2007
30/10/2008
Train overspeeding through an
emergency speed restriction at Ty
Mawr Farm Crossing
22/08/2007
20/11/2008
Signal passed at danger and
subsequent near miss at Didcot
North junction
01/03/2008
21/10/2008
26/04/2008
27/05/2009
Detachment of containers from
freight wagons near Cheddington
and Hardendale
28/07/2009
Near miss at Llanbadarn AOCL near
Aberystwyth
14/09/2009
Freight train collision at Leigh-onSea on 26 April 2008
23

N/A
31/07/2009
08/12/2009
25a16

N/A
31/07/2009
25/01/2011
25b

N/A
31/07/2009
25/01/2011
25c

N/A
31/07/2009
25/01/2011
25d

N/A
31/07/2009
25/01/2011
25e

N/A
31/07/2009
25/01/2011
1

N/A
14/01/2009
13/11/2008
3

N/A
18/09/2009
26/01/2010
4

18/09/2009
26/01/2010
8

N/A

09/11/2009
09/11/2009
6

N/A
14/10/2009
01/02/2010
7

N/A
14/10/2009
19/10/2010
9

N/A
14/10/2009
01/02/2010
3

05/10/2009
05/05/2010
6

N/A
08/02/2010
22/01/2010
7

N/A
08/02/2010
22/01/2010

22/11/2008
19/11/2009
Double fatality at Bayles & Wylies
Crossing, Bestwood, Nottingham
7


In progress
In progress
04/05/2010
24/03/2011
Runaway and derailment of wagons
at Ashburys
4


27/05/2011
In progress
17/08/2010
15/08/2011
Uncontrolled freight train run-back
between Shap and Tebay, Cumbria
4


In progress
In progress
28/01/2011
28/11/2011
Passenger accident at Brentwood
station
2


In progress
In progress
03/10/2011
21/06/2012
Fatal accident at Mexico footpath
crossing (near Penzance), 3 October
2011
2


In progress
In progress
19/06/2011
27/06/2012
Incident at Llanbadarn Automatic
Barrier Crossing (Locally Monitored),
near Aberystwyth, 19 June 2011
6


In progress
In progress
12/04/2012
03/12/2012
Person trapped in a train door and
dragged at Jarrow station, Tyne and
Wear Metro, 12 April 2012
5


In progress
In progress
16
The RAIB 2011 Annual Report states the following: ‘This recommendation intended that the industry should
capture learning related to vehicle crashworthiness arising from Grayrigg, and where appropriate, make changes
to standards. ORR has reported that the Rail Safety and Standards Board (RSSB) has considered and assessed
the reasonable practicability of the recommendation and concluded that no changes to current standards are
justified. ORR has concluded that RSSB has given due consideration to this recommendation. However, the RAIB
remains concerned that potential lessons regarding vehicle roll over strength, and vehicle penetration resistance
may not have been captured. The RAIB is proposing to inform the industry (by means of the Vehicle/Vehicle
System Interface Committee) of its residual concerns regarding the status of this recommendation’.
Page 74 of 76
Appendix 2.
Glossary
For a full list of definitions, see the Annual Safety Performance Report.
Acronym
AHB
ALARP
AOCL
ASPR
ATOC
BTP
CCS
CCTV
CIRAS
COSS
CSSG
DfT
ECS
ERA
ERTMS
EU
FCC
FOC
FWI
GB
GSM-R
HSE
ICCS
IFCS
IM
INES
ISLG
LOE
LUL
MCB
MCG
MOM
NRMI
NRV
OFG
OHLE
ORR
PA
PHRTA
PICOP
PIM
PTI
Expansion
automatic half-barrier crossing
as low as reasonably practicable
automatic open crossing, locally monitored
Annual Safety Performance Report
Association of Train Operating Companies
British Transport Police
Close call system
closed circuit television
Confidential Incident Reporting and Analysis System
controller of site safety
Community Safety Steering Group
Department for Transport
empty coaching stock
European Railway Agency
European Rail Traffic Management System
European Union
First Capital Connect
freight operating company
fatalities and weighted injuries
Great Britain
Global System for Mobile communications – Railway
Health & Safety Executive
incident causal classification system
incident factor classification system
infrastructure manager
International Nuclear Event Scale
Infrastructure Safety Liaison Group
Learning from operational experience
London Underground Ltd
manually controlled barrier crossing
manually controlled gate crossing
mobile operations manager
Network Rail managed infrastructure
national reference values
Operations Focus Group
overhead line equipment
Office of Rail Regulation
public address
potentially higher-risk train accident
person in charge of possession
Precursor Indicator Model
platform train interface
Page 75 of 76
Acronym
RAIB
RGS
RIDDOR
ROGS
RRISG
RRV
RSSB
RVI
SMIS
SMS
SPAD
SPG
SRM
TOC
TPWS
UK
UWC
V/TC&C
SIC
Expansion
Rail Accident Investigation Branch
Railway Group Standard
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Railway and Other Guided Transport Systems (Safety) Regulations 2006
Road Rail Interface Safety Group
road–rail vehicle
Rail Safety and Standards Board
road vehicle incursion
Safety Management Information System
safety management system
Signal Passed At Danger (Without Authority)
Safety Policy Group
Safety Risk Model
train operating company
train protection and warning system
United Kingdom of Great Britain and Northern Ireland
user-worked crossing
Vehicle/Train Control & Communications Systems Interface Committee
Page 76 of 76