March 2016
This is a collation of some of the world’s railway formal inquiry reports. It includes a brief incident
synopsis, along with the main causes and recommendations from each investigation.
Readers may find some of the actions and recommendations useful to their own operations.
Co-ordinated by Greg Morse, Operational Feedback Specialist, RSSB
Contents: (Click to navigate)
UK: Passenger trapped and dragged at Clapham South
(LUL), 13 March 2015
US: Derailment and dangerous goods explosion in
Lynchburg, Virginia, 30 April 2015
Australia: Collision between track worker and passenger
train at Guildford, Western Australia, 10 February 2015
Australia: Collision between tamper and ballast regulator near
Greta, NSW, 14 July 2015
Clapham South
Some of the key issues raised and/or suggested by the stories in this edition:
Platform-train interface incidents
Dangerous goods
Tank wagon standards and vehicle integrity
Track maintenance (rolling contact fatigue)
Safe systems of work
Protection arrangements
Prescription drug use
Clarity of instructions
Yellow plant in possessions
Distraction
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
9 March
UK: Passenger trapped and dragged at Clapham South (LUL), 13 March 2015
For the full report, click here: LINK
At around 08:00 on Thursday 12 March 2015, a passenger fell beneath
a train after being dragged along the northbound platform of Clapham
South station. Her coat had become trapped between the closing
doors of a Northern Line train.
The train had stopped and passengers had alighted and boarded
normally, before the driver confirmed that the door closure sequence
could begin. The train operator, in the driving cab, started the door
closure sequence but, before the doors had fully closed, one set
encountered an obstruction and they were reopened. A passenger
who had just boarded, and found the available standing space to be
uncomfortable, stepped back off the train and onto the platform. The
edge of this passenger’s coat was then trapped when the doors closed
again and she was unable to free it.
The trapped coat was not large enough to be detected by the door control system and the train
operator, who was unaware of the situation, started the train moving. While checking the platform
camera views displayed in his cab, the operator saw unusual movements on the platform and applied
the brakes. Before the train came to a stand, the trapped passenger fell to the ground and then,
having become separated from her coat, fell into the gap between the train and platform. The train
stopped after travelling about 60 metres. The passenger suffered injuries to her arm, head and
shoulder, and was taken to hospital.
The investigation identified one learning point for the railway industry, as follows:

Designers of new and upgraded platforms should (unless shown to be unnecessary due to the
provision of platform edge doors and/ or other measures) include under-platform recesses to
mitigate the consequences of accidents where passengers fall between the platform and trains
or trams.
Action taken
London Underground reported that it had previously explored technical measures to address PTI
risks but considered that the safety benefit did not justify the costs unless implemented as part of a
major upgrade scheme. This included the following measures:

Installation of platform edge doors on existing lines as already provided on tunnel sections of
the most recently constructed part of the underground network (the eastern part of the
Jubilee line).

Installation of sensitive edge object detection – a system which detects smaller objects than
those detected by existing Northern line trains and which is fitted to the modern trains that
operate on the Victoria Line.

Converting fixed leaves to pushback leaves on double doors (this would require considerable
engineering change, and would have no effect on single leaf doors).
London Underground reported that it has trialled crowd control measures on the Northern Line.
However, trials of some northbound trains not entering service until Tooting, in order to provide
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
passenger space at Clapham stations, moved passenger crowding elsewhere and disrupted even
passenger flows. Restricting passenger entry at stations was successful in reducing crowding at the
platform, but led to overcrowded ticket halls and extended journey times.
In response to this accident, and in the light of other platform-train interface (PTI) accidents, London
Underground has set up a team to action recommendations and to co-ordinate PTI risk management
across all of its lines. Initially, this team is considering several potential measures to improve PTI
safety. These include:

Improving passenger awareness of the PTI risk at train doors using harder hitting, targeted
safety messages;

Localised briefing of customer service assistants (CSAs) allowing them to tailor announcements
to suit individual station conditions;

Encouraging CSAs to move around the platform to suit local circumstances rather than
mandating a defined position when undertaking station duties;

Using alternative types of baton including one incorporating a red emergency stop light;

Providing platform staff with a portable means of stopping trains in an emergency;

Repositioning, and reassessing the number of, CCTV cameras providing in-cab monitor images
of the PTI (higher-risk locations are being addressed in a programme which started in January
2016 and is expected to include relocating cameras, and providing an additional camera, on
the Clapham South northbound platform); and

Adjusting the configuration of yellow lines on platforms to alter passenger behaviour at doors
(a trial at four sites, including Clapham South, started in November 2015).
Recommendations

London Underground should review the feasibility and effectiveness of measures to reduce
risks associated with passengers being trapped in train doors and then dragged at the PTI. The
review should include measures already considered for all or part of the London Underground
network, techniques already used by other railway operators, measures already considered by
RSSB and measures made possible by the latest technology available when the review is
undertaken. The review should include, but not be restricted to, consideration of:
o
Improving detection of objects trapped in train doors;
o
Improving the ability of passengers to pull out objects trapped in doors (including by
improving door seal arrangements);
o
Improving train operator views of the PTI at despatch (eg increasing the number of
CCTV cameras, repositioning cameras and providing larger monitors);
o
Enhancing the methods available to staff performing SATS duties when they need to
alert train operators, or stop trains, in an emergency;
o
Using gap fillers or alternative means to reduce the gap between platforms and both
moving and stationary trains;
o
Adapting platform markings to reduce passenger crowding close to trains/doors; and
o
Raising passenger awareness of the safety risks associated with objects, fingers and
hands becoming trapped in doors.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
The review should conclude with a time-bound, funded plan for progressing development of
potentially viable measures. This should, if appropriate, include solutions which are only
applicable to some parts of the London Underground network.
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9 March
US: Derailment and dangerous goods explosion in Lynchburg, Virginia, 30 April
2015
For the full report, click here: LINK
At 13:54 (local time) on 30 April 2015, 17 CSX
Transportation (CSXT) tank wagons within a
petroleum crude oil block freight derailed in
Lynchburg, Virginia.
Three of the derailed wagons became partially
submerged in the James River. One was breached
and released about 29,868 gallons of crude oil,
some of which caught fire.
The Lynchburg Fire Department ordered the evacuation of about six blocks along the riverfront and
south of the derailment area, affecting about 350 residents and 20 businesses.
There were no reported injuries to the public or crew.
The derailed wagons were located in positions 35–51 from the front of the train (not including the
two locomotives). Fourteen were built to the standard outlined in the Association of American
Railroads (AAR) Casualty Prevention Circular (CPC) 1232; three were built to the DOT-111 standard
for wagons manufactured before October 2011.1
The wagon that was breached met the CPC 1232 standard.
Based on data from the locomotive’s event
recorder, the train experienced an emergency brake
application at 13:54. The crew said they saw a very
large amount of smoke about 30 wagons back from
the locomotive. They radioed that there was an
emergency and then notified the signaller and the
Lynchburg yardmaster.
Fearing an explosion, the crew jumped from the
locomotive, leaving the train consist and their
personal belongings behind. They walked to the
nearest level crossing, where they met a CSXT signal maintainer, who heard the emergency radio
transmission. The signal maintainer drove them to a nearby CSXT yard.
1
Wagons of the DOT-111 type featured in the Lac-Mégantic accident of July 2013. See pages 39-40 of the
2014/15 Learning from Operational Experience Annual Report.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
The National Transportation Safety Board (NTSB) determined the probable cause of the accident
to be a broken rail caused by a reverse detail fracture with evidence of rolling contact fatigue
(RCF).
RCF results from the cumulative effects of railhead wear and rail surface conditions, such as shelling,
head checks, or flaking. The detrimental effects of RCF can occur before a worn railhead profile or
side wear is noted. Rail wear on the gauge corner and side of the rail are easier to find and manage;
however, the detection of fatigue in the lower corner of the gauge face of the rail is more difficult.
That part of the railhead it not easily scanned by ultrasonic equipment, and a regulatory remedial
action was not mandated to address these flaws.
Federal Railroad Association (FRA) Track Safety Standards do not address this type of rail defect at
the size that failed in the Lynchburg accident (5% reverse detail fracture). The FRA remedial action
chart addresses transverse detail fractures, but does not mandate remedial action until the defect is
20% or four times the size of the defect that caused this derailment. At that time, the infrastructure
manager would be required to reduce speed to no more than 30mph and apply joint bars within 20
days to the defective rail condition.
Action taken
CXST
Prior to the Lynchburg accident, if a transverse detail fracture had been 20% of the cross-section of
the rail head, CSXT engineering standards required that the defective rail be changed out within 5
days or joint bars be installed to the rail at the site of the defect. Since ultrasonic testing data
indicated a transverse detail fracture near the location of the derailment, CSXT planned to replace
the rail on 1 May 2014. As the operating speed for that area was 25 mph, the rail defect did not
require a speed restriction in accordance with CSXT maintenance procedures or FRA regulations.
On 1 July 2014, CSXT modified its track maintenance instructions to require a 10-mph speed
restriction when a transverse defect is identified – such as the reverse detail fracture found in this
accident – until corrective action is taken (such as replacing the rail or applying rail joint bars at the
site of the defect).
Pipeline and Hazardous Materials Administration
This accident demonstrates that the thicker shell material used in tank cars designed to the
requirements of AAR Casualty Prevention Circular CPC-1232 (non-jacketed option) remain vulnerable
to breaches even in low-speed accidents.
The Pipeline and Hazardous Materials Safety Administration (PHMSA), in coordination with the FRA,
published a final rule 8 May 2015, adopting safety improvements in tank wagon design standards,
operational requirements, and notification requirements for tank wagons that are used in trains
defined as high-hazard flammable trains (HHFT).2 The rule also includes new requirements for a
sampling and classification programme for unrefined petroleum-based products. With respect to
tank wagon and train requirements, the rule specifically provides for:

Enhanced standards for both new and existing tank cars (for example, full-height headshields
and jackets);
2
Defined as a continuous block of 20 or more tank wagons or 35 or more wagons dispersed through a train
loaded with a flammable liquid.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Rail [train] routing (risk assessment and notification);

Reduced operating speeds; and

Enhanced braking
Congressional action
On 4 December 2015, the president signed the Fixing America’s Surface Transportation Act. This calls
for real-time emergency response information, a study to determine whether limitations or
weaknesses exist in the emergency response information carried by train crews transporting
hazardous materials, and additional tank wagon safety standards. Specifically, tank wagons used to
transport Class 3 flammable liquids must meet the new improved DOT-117, DOT-117P, or DOT-117R
specifications.3
The new law established a phase-out schedule for certain tank cars not meeting these specifications.
It also provides for:

The US Department of Transportation to issue regulations, as necessary, to require that each
tank car built to meet the DOT-117 specifications and each non-jacketed tank car modified to
meet the DOT-117R specification be equipped with an insulating blanket;

Minimum requirements for top fittings protection for class DOT-117R tank cars;

Rulemaking on oil spill response plans;

A reporting requirement to monitor industry-wide progress toward modifying tank cars used
to transport Class 3 flammable liquids; and

Research studies on crude oil characteristics; hazardous materials by rail liability; and study
and testing of electronically controlled pneumatic brakes.
FRA Rail Failure Working Group recommendations
The NTSB investigations into derailments in New Brighton (Pennsylvania), Columbus (Ohio), and
Ellicott City (Maryland) led the FRA to determine that each of the accidents resulted from rail
failures.
In September 2012, the FRA established a Rail Safety Advisory Committee (RSAC) Rail Failure
Working Group to address rail wear issues like RCF. The working group studied the effects of railhead
wear and resulting rail surface conditions, and how such conditions can adversely affect the results of
ultrasonic rail testing. The Rail Failure Working Group met four times beginning in January 2013, and
completed its task on 31 July 2013.
The group proposed new performance-based recommendations for determining rail wear and
internal rail inspection criteria. These ensured the FRA’s ability to effectively monitor rail integrity
programmes that require track owners to quickly identify and remediate areas that could lead to a
derailment. The FRA’s efforts and industry’s acceptance of these best practices should significantly
reduce rail accidents caused by broken rails resulting from RCF and improve the industry’s rail risk
management programmes.
The RSAC adopted the Rail Failure Working Group recommendations on 16 April 2014. The final
recommendations developed with industry and other stakeholders formed a consensus document of
3
In brief, these encapsulate the use of jacketed and thermally insulated shells of 9/16-inch steel, full-height
half-inch-thick head shields, sturdier, recloseable pressure relief valves and rollover protection for top fittings.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
best practices or guidelines to manage the risks related to rail wear and rolling contact fatigue.
Before the guidelines were implemented by CSX, the Lynchburg accident occurred; if they had been
implemented, this accident would likely have been prevented.
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10 March
Australia: Collision between track worker and passenger train at Guildford,
Western Australia, 10 February 2015
For the full report, click here: LINK
On 10 February 2015, a Public Transport Authority (PTA) maintenance crew started work at Meadow
Street in Guildford, Western Australia. The crew was maintaining the pedestrian gates adjacent to
the level crossing.
At about 10.35 (local time), one of the track workers was struck and killed by a Perth-bound
suburban service.
The Australian Transport Safety Bureau (ATSB) found that the PTA maintenance workers had not
implemented any form of track worker protection at the work site. This was partially due to the PTA
not having documented instructions specifying the level of protection required, preferring that track
workers make their own assessment based on their knowledge of the Network Rules. The ATSB
found that, under these arrangements, track workers could make an incorrect assessment, placing
themselves at a greater risk of being struck by a train.
A review of the ‘safeworking training’ provided to the track workers found that the training material
did provide a suitable level of safe-working knowledge.
Following the incident, the toxicology report on the deceased track worker identified the presence of
amphetamine and methamphetamine; methamphetamine being a prescribed drug under the Rail
Safety Regulations 2011. The use of stimulants such as methamphetamine is associated with a range
of neurocognitive effects in humans that may affect performance.
The ATSB found that in this instance, the presence of a prescribed drug within the worker’s system
appeared to be a relatively isolated case. An examination of the company’s drug and alcohol
policy/procedures found them to be generally effective in managing drugs and alcohol in the
workplace.
The PTA issued a safety alert following the incident to highlight the importance of implementing the
correct level of track worker protection. The subsequent introduction of new safeworking rules, track
access accreditation levels and training further supported this.
Furthermore, the PTA has created the role of Workplace trainer and assessor with the task of
ensuring track workers comply with the network rules by way of competency-based assessments.
Implementation of a new track access accreditation system, with improved training and job
mentoring, has also began.
Safety message
The ATSB note that this incident strongly emphasises the need for rail transport operators to provide
clear and concise work instructions to employees working within the railway corridor. It also
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Email address: Greg.Morse@rssb.co.uk
highlights the potential for recreational and other drug use to impair performance and affect
workplace safety.
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20 March
Australia: Collision between tamper and ballast regulator near Greta, NSW, 14
July 2015
For the full report, click here: LINK
After carrying out track resurfacing and tamping
works at Allandale, NSW, the Australian Rail Track
Corporation Network Control Officer (NCO)
granted permission for a Leighton Swietelsky Rail
Joint Venture (LS Rail) tamper and ballast regulator
to travel in convoy and stop before BN 87U signal,
near Greta.
The tamper led the ballast regulator, with the
Traffic Officer (TO) travelling in the rear vehicle.
Near Greta, the tamper operator contacted the TO, advising he was approaching a signal displaying a
stop (red) indication, but that he was unable to identify the signal number. Both the TO and the
operator thought that this was BN 87U.
The TO contacted the signaller for further instructions. During the discussion, both the operator (lead
vehicle) and the TO (rear vehicle) independently established that the signal ahead was BN 83U. At
about this time the tamper stopped near BN 83U, but the rear vehicle was still approaching from
behind. The TO continued to talk to the signaller about clearing BN 83U, so they could continue on to
BN 87U signal in preparation for stabling the vehicles at Greta.
While the TO was talking with the signaller, the TO sensed that the ballast regulator (rear vehicle)
was not slowing. He looked ahead to see the gap was closing between the two vehicles. The TO
noticed that the ballast regulator operator was looking at him and the TO hand-gestured in a forward
motion. The operator interpreted the hand gestures to mean ‘keep going’. Instead, the TO was
indicating that the operator ‘look forward’. Soon after, the TO called out for the operator to ‘STOP’.
The operator turned and quickly realised that the tamper was closer than he had realised and made a
full brake application. However, there was insufficient time to stop before colliding with the rear of
the tamper.
The collision saw the ballast regulator ride above the tamper coupler and remain supported on the
tamper deck. The ballast regulator also derailed the lead axle. The tamper operator sustained a
minor injury and there was moderate damage to both vehicles.
The ATSB found that the Traffic Officer’s telephone conversations distracted the ballast regulator
operator, drawing his attention away from the driving task and the location of the tamper ahead.
Although the operator was aware of the slowing tamper ahead, he did not maintain a safe distance
between the vehicles. When the operator became aware of the stationary tamper ahead, there was
not enough time for him to react and bring the vehicle to a stop before colliding with it.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Action taken
LS Rail has taken action to mitigate against the risk from further collisions between track
maintenance vehicles, including requiring greater attention to worksite planning, briefing,
communications, hazard identification and route knowledge.
Safety message
The ATSB notes that, when travelling in convoy, track vehicle operators should remain alert, focused
on the driving task and maintain a safe braking distance from other vehicles.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk