January 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)
Australia: Derailment of track maintenance vehicles
Singleton, NSW on 11 June 2015
UK: Freight train derailment at Washwood Heath West
Junction, Birmingham, 23 March 2015
Australia: Freight train derailment at Newport, Victoria, 30
October 2013
UK: Collision between a train and a fallen bridge parapet
at Froxfield, Wiltshire
Germany: SPAD and collision at Mannheim, 1 August
2014
Froxfield
Some of the key issues raised and/or suggested by the stories in this edition:
Local signalling instructions
Reporting of equipment failure
Familiarity with rules
Track twist
Track maintenance issues
Standards compliance (wagons)
Wagon maintenance
Clarity of maintenance instructions
Effects of maintenance of track geometry
Track gauge
Track inspection and interpretation of findings
Road user behaviour (HGV)
Road signs
Risk assessment
Post-incident procedures (comms and operations)
SPAD (‘reset and continue’)
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
7 January
Australia: Derailment of track maintenance vehicles Singleton, NSW on 11 June
2015
For the full bulletin, click here: LINK
On 11 June 2015, four Rhomberg Rail Australia track
machines were travelling in convoy on the
Australian Rail Track Corporation (ARTC) Hunter
Valley corridor between Maitland and Scone.
To allow a passenger train to pass, the consist was
required to leave the Down Main and enter a siding
at Singleton. On arrival, the Traffic Officer (TO) on
board accessed a local control panel to operate a
crossover from the Down Main to the siding. The
points at each end of the crossover appeared to
operate, but the indication light on the panel did not illuminate to confirm detection in the required
position. The TO visually inspected the position of the points from a location adjacent to the control
panel.
As the points appeared to be set, the TO concluded there was likely to be a fault with the indicator
light. He contacted the ARTC Network Control Officer for authority to enter the siding, but did not
mention that the indication lamp had not illuminated.
At about 08:23 (local time), as the vehicles entered the turnout from the main line, the driver saw
that the ‘swing-nose crossing’ in the turnout ahead was not in the correct position. The vehicles were
travelling at about 15 km/h. The driver was unable to stop before passing over the crossing and the
leading vehicle and the leading axle of the trailing vehicle derailed. There were no reported injuries,
but the derailed vehicles obstructed the Down Main line.
Action taken
The ARTC issued an Incident Notice, instructing the Network Control Officers not to authorise passing
signals at stop for the turnout route if the panel light did not display.
Additionally, new Network Information Books and revised guidance for the operation of locals panel
were developed.
Rhomberg Rail Australia implemented actions to ensure track personnel are familiar with the
operation of local panels and the implementation of the ARTC Network Rules.
Safety message
The Australian Transport Safety Bureau (ATSB) said that staff must fully implement and adhere to the
applicable network operational procedures in response to any anomalies observed when operating
rail infrastructure.
Infrastructure managers must ensure that operating procedures and instructions for track equipment
are maintained and fully representative of the equipment installed.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
11 January
UK: Freight train derailment at Washwood Heath West Junction, Birmingham,
23 March 2015
For the full report, click here: LINK
At 08:03 on Monday 23 March 2015, one bogie of a wagon in a
container train derailed on a set of points as it crossed at
Washwood Heath West Junction. The bogie ran derailed for 121
metres before re-railing itself as it ran through another set of
points.
The driver was not aware that a derailment had occurred.
The signaller noticed irregular indications on his display panel,
stopped the train and asked the driver to examine it. The driver
found that the tenth wagon showed signs of having run derailed.
The train of 24 container wagons was being hauled by a Class 66
at 15 mph while negotiating the series of crossovers. The wagon
that derailed was a ‘Megafret’ IKA, which consisted of two flat
platforms permanently coupled together. The derailment caused significant damage to track and
signalling equipment. There were, however, no reported injuries.
The track where the wagon derailed was curved and found to contain a twist fault of a magnitude
which Network Rail’s track maintenance standard specified should be rectified within 36 hours.
Network Rail was not aware of the existence of this fault at the time.
Wagons should be capable of negotiating a track twist of a magnitude which the track standard
allows to remain in a line open to traffic. When tested, the wagon which derailed was found not to
meet the requirements of the relevant Railway Group Standard for resistance to derailment due to
track twist.
When examined after the derailment, the liner on the centre pivot of the bogie was found to be
worn beyond its maintenance limit. The centre pivot liner is made from a plastic material and is
provided to allow relative movement between the body centre pivot and the bogie. The worn liner
had restricted the freedom of the bogie to rotate, increasing its rotational stiffness. Furthermore, it
resulted in reduced side bearer clearances, increasing wheel unloading in track twist conditions. Both
the increased rotational stiffness and the increased wheel unloading reduced the wagon’s resistance
to derailment, causing it to derail when it encountered the track twist on the curved track.
The worn centre pivot liner had not been identified during maintenance of the wagon as the
maintenance instructions were unclear about when it should be inspected.
Following another derailment, at Doncaster on 11 April 2015, the wagon owner instigated a check of
part of its UK fleet which revealed that a number of other wagons of the same type had experienced
a similar degree of centre pivot liner wear.
RAIB has identified the following key learning points:

Centre pivot liners made of differing materials have different wear rates. This illustrates the
importance of ‘entities in charge of maintenance’ (ECMs) ensuring that their maintenance
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
plans for wearing components mandate an inspection interval which is compatible with the
rate of wear of the components.

The derailment may have been avoided had the track twist been measured following the
maintenance work on 7/8 March 2015. This highlights the importance of staff who are
responsible for certifying that track is safe for traffic after maintenance work confirming, by
measurement, that the track geometry has not been adversely affected by the work.

The mixing up of the two-levelled baseplates during maintenance over the years since the
switches and crossings (S&C) were installed highlights the importance of Network Rail track
maintenance staff being made aware of, and referring to, the relevant guidance documents
when conducting track maintenance.

There have been four derailments in the last 15 years on this crossover. This highlights the
importance of paying particular attention to the maintenance of the alignment at locations
where the design of track is close to maintenance limits (as here).
Actions taken
ECM responsibility for the wagons has been transferred from AAE in Switzerland to VTG AG in
Hamburg. VTG AG has told RAIB that it plans to change the maintenance scheme from AAE’s
Technical Specification for Overhaul (TSO) to the system used for its other wagons, which was issued
by the Vereinigung der Privatgüterwagen-Interessenten (an association of German private wagon
owners). RAIB has not made a recommendation related to the previous system, because it will no
longer be relevant to the UK Megafret fleet. Neither has it investigated the Vereinigung der
Privatgüterwagen-Interessenten system, as it did not apply to the accident wagon at the time of the
derailment.
AAE issued version 3.0 of TSO module 22 (Wagon body and vehicle superstructure) on 1 June 2015.
The changes from version 2.0 included allowing the vehicle to be lifted one end at a time for ‘mobile
maintenance’ (ie maintenance carried out away from a workshop) and the addition of a highlighted
note which stated ‘Important: Before mounting the bogies the centre pivot bearings... must be
inspected and replaced if necessary.’ The revised module did not, however, mandate removal of the
bogies for inspection of the centre pivot liners.
AAE asked DWS to carry out a special inspection of the centre pivot liners of the Megafret wagons it
maintains for AAE following the derailment at Doncaster. AAE also wrote to DRS on 21 July 2015 to
ask that it checks the wear of the centre pivot liners during maintenance.
Recommendations

VTG AG should update the maintenance instructions for its Megafret wagons operating in the
UK to clarify the method to be used to check for wear of the centre pivot liner, and clearly
specify the periodicity for these checks. In defining this periodicity, VTG AG should take into
account the wear characteristics of centre pivot liners that it permits to be installed and the
distance travelled by the wagons.
This recommendation may also be applicable to VTG AG’s Megafret wagons operating in other
countries.

VTG AG should review, and update as necessary, the processes that will apply if a systemic
defect is identified with a former AAE wagon. The processes should ensure that the risk from
continued fleet operation is understood and any necessary mitigation measures are put in
place to reduce it to an acceptable level. It should also provide for adequate communication of
safety related information to all other owners, operators and maintainers.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Network Rail should review, and update as necessary, its S&C training course(s) to confirm that
there is adequate coverage of two-levelling of S&C. It should ensure that S&C maintenance
staff who undertake maintenance of two-levelled S&C are competent to identify and maintain
two-levelled S&C. In addition, Network Rail should introduce a system to make the necessary
information available to enable correct maintenance of two-levelled S&C. The knowledge,
skills and experience required to ensure that two-levelled S&C can be maintained competently
should be made explicit within Network Rail’s competency management system. The
competency requirements should cover all staff likely to be involved in planning, executing and
supervising the maintenance of two-levelled S&C.
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12 January
Australia: Freight train derailment at Newport, Victoria, 30 October 2013
For the full report, click here: LINK
At about 16:15 (local time) on 30 October 2013, a Pacific National standard-gauge freight derailed at
Newport in Melbourne. The train came off on a curve between two turnouts resulting in track
damage to the main line and an adjacent siding. There were no reported injuries.
The ATSB found that the track had a significant wide-gauge defect at the point of derailment. The
defect had been present for more than 12 months and was at a level that exceeded the network
standard. During the passage of the train, the gauge widened further and a wheel on the inside of
the curve dropped inside the rail.
The section of track was being managed by the ARTC. The wide-gauge defect had been detected by
the track geometry recording vehicle several times, although the location designated to the defect
was about 58 metres from its actual location. The ARTC had subsequently and incorrectly attributed
the wide gauge readings as being associated with the transition area in a nearby dual-gauge turnout.
The track was also subject to weekly patrols by the ARTC, many conducted on foot. However, these
inspections did not recognise the critical level of the wide-gauge at the derailment location and the
defect remained in the track.
The ATSB also found that another Pacific National freight had derailed at the same location about
seven weeks prior. Following that incident, the ARTC did not identify the need for priority remedial
works at the location and the defect remained.
Safety message
Network managers should ensure that track geometry recording machinery accurately identifies the
location of track defects. Track patrols should also be vigilant in their monitoring of track conditions
against network criteria.
Following a rail incident, the parties involved should prioritise the identification and rectification of
safety factors, including local conditions like track defects.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
20 January
UK: Collision between a train and a fallen bridge parapet at Froxfield, Wiltshire
22 February 2015
For the full report, click here: LINK
At around 17:31 on 22 February 2015, Paddington–Penzance HST service struck and ran over part of
the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.
The train was fully loaded with around 750 passengers and was travelling at 86 mph when the driver
saw the obstruction. He applied the emergency brake, but there was insufficient distance to reduce
the speed significantly before the train struck the parapet. The train did not derail and came to a halt
around 720 metres beyond the bridge. There were no reported injuries. The leading power car
sustained damage to its leading bogie, braking system, running gear and underframe equipment.
The immediate cause of the collision was that the eastern parapet of Oak Hill Road Bridge had been
pushed on to the track by a heavy goods vehicle which had reversed into it. The train had not been
stopped before it collided with the debris because of delays in informing the railway about the
obstruction on the tracks.
RAIB also listed the following underlying factors:

In accordance with West Berkshire Council’s policy on fitting road signage, there were no road
signs to warn drivers that Oak Hill Road was not suitable for HGVs;

Network Rail’s procedure for fitting identification plates to overline bridges did not apply
directly to the Oak Hill Road overline bridge, because it had no prior history of bridge strikes;
and

The DfT and Network Rail procedures for assessing the risk from road vehicle incursions (RVI)
do not specifically address the risk of incursion of bridge debris from a road traffic accident on
an overline bridge.
Although not linked to the causes of this accident, RAIB observes that:

The train was allowed to run between Bedwyn and Westbury at a maximum speed of up to
100 mph with a missing lifeguard and damage to the bogies; and

The description of the hazard on the tracks below Oak Hill Road Bridge changed during the
transmission of the emergency message to the railway.
RAIB add that the consequences of this accident could have been much more serious had the train
derailed or had the parapet debris not broken up to the extent that it did or had a train passed on
the London bound, Up Westbury line.
RAIB has identified the following learning points5:

For police forces, this accident reinforces the importance of ensuring that their enquiry and
control room:
o
Procedures are clear about immediately informing the relevant railway control
centre on its emergency number, with an accurate description of the hazard, when
the safety of the railway is affected, before informing other police forces or agencies;
and
o
Staff are fully briefed on the procedures and practised in their use.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

For road vehicle standards bodies and the road haulage industry, this accident demonstrates
the benefit of having reversing sensors or cameras on HGVs and other lorries, to assist drivers
when manoeuvring their vehicles in unfamiliar, restricted spaces.
Action taken
Network Rail fitted bridge identification plates to each end of the remaining parapet of Oak Hill Road
overline bridge. The plates contain the railway telephone number to contact in the event of a road
vehicle striking the bridge.
On 28 May 2015, RAIB wrote to West Berkshire Council (WBC) and advised that it should install
signage on the approaches to the section of Oak Hill Road between and including the overline and
canal bridges as soon as possible, to warn HGV drivers that the road ahead was unsuitable for HGVs.
WBC liaised with Wilshire Council about the installation of the signs and on 17 December 2015, WBC
reported to the RAIB that it had installed ‘unsuitable for HGV’ signs within its own jurisdiction and
that Wiltshire Council was due to fit its own signs on 19 January 2016.
The Thames Vallley Police (TVP) reported to RAIB on 22 May 2015 that it had:

Briefed relevant staff to reiterate the correct actions to be taken when dealing with incidents
on railways and that the first call should always be to the relevant railway authority; and

Reviewed its procedures on dealing with incidents on the railway to check that they were fit
for purpose, and concluded that they were.
BTP reported to RAIB on 29 October 2015 that it had reviewed the communications to and from its
control room in relation to the accident. As a result of this, it had implemented various
improvements, including re- briefing relevant staff on the actions to be taken when a call is received
from another police force about an incident affecting railway safety. Additionally on 2 November
2015, the Deputy Chief Constable of BTP wrote to the Chief Officers of the Home Office police forces
about the importance of informing the railway immediately of any potential hazard in any railwayrelated incident.
Recommendations

Network Rail should develop and implement a programme for the timely installation of
identification plates on all overline bridges with a carriageway for which it is responsible
(unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a
particular bridge are assessed as likely to be minor). Installation should be prioritised so that
those bridges assessed as being at highest risk are fitted first. Network Rail should also modify
its standards relating to the installation of identification plates accordingly (paragraph 103b).
This recommendation may also apply to other infrastructure managers.

The Department for Transport should include in its guidance for assessing the risk of road
vehicle incursion (RVI), a method for specifically assessing the risk of road vehicles damaging a
bridge parapet and knocking debris onto the track below, so that proportionate mitigation can
be considered by both railway and highway RVI assessors (paragraph 103c).

Network Rail should:
o
Include a requirement (aligned with any revised DfT guidance arising from
recommendation 2) in its RVI assessment procedures for overline bridges, to
specifically assess the risk of road vehicles damaging a bridge parapet and knocking
over debris onto the track below so that proportionate mitigation (eg road signage)
can be considered by its RVI assessors; and
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
o

Brief its RVI assessors accordingly.
RSSB, in consultation with industry, should propose, and then promote, the introduction of an
additional specific requirement in an appropriate Railway Group Standard, so that in the event
a train is damaged in an incident (including striking objects on the track) and is to be moved
(with or without fitter attention), the conditions of any such movement, including the
maximum permissible speed, are subject to a full consideration of:
o
The circumstances of the incident (including the train speed and nature of any
obstacle struck);
o
The limitations of any on-site assessment of damage; and
o
Whether or not there are passengers on board.
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24 January
Germany: SPAD and collision at Mannheim, 1 August 2014
For the full report, click here: LINK (requires translation)
At 20:51 (local time) on 1 August 2014, a freight
train was involved in a side-on collision with a
passenger train at Mannheim. Four passengers
suffered major injuries and 34 sustained minor
injuries.
The investigation found that the driver of the
freight train had passed a signal at danger, but
over-rode the train protection system and
continued without informing the signaller.
Recommendations

The National Safety Authority should continuously strengthen – via targeted training – the
‘awareness and competence’ of staff dealing with automatic train control.

The railway undertaking should undertake research to minimise instances of drivers resetting
the equipment after an emergency brake application.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk