December 2015
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: Freight train derailment near Hugh River, NT,
23 December 2014
UK: Container detachments at Scout Green (Cumbria),
7 March 2015 and Deeping St Nicholas (Lincolnshire),
31 March 2015
Australia: Passenger train collision with maintenance
equipment at Montgomery, Victoria, 16 February 2015
Australia: Freight train collision at Mile End, SA, 31
March 2014
UK: Unsafe events at Heathrow Tunnel Junction, 27
and 28 December 2014
Scout Green
Some of the key issues raised and/or suggested by the stories in this edition:
Dangerous goods
Wagon maintenance (lubrication)/ fault monitoring
High winds
Container retention (spigot design)
Risk assessment and mitigation procedures
Objects on the line (from engineering works)
Delegation management
Collision
Train routing
Situational awareness
Permissive working
Safe systems of working
Deviation from normal practice
Safety culture
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
7 December
Australia: Freight train derailment near Hugh River, NT, 23 December 2014
For the full bulletin, click here: LINK
On 23 December 2014, a freight train derailed near
Hugh River, in the Northern Territory. The
derailment resulted from a wagon axle bearing
failure.
The wagon, carrying distillate fuel, remained
upright and there was some minor damage to the
track (sleepers and rail clips).
There were no reported injuries.
The Australian Transport Safety Bureau (ATSB) found that the journal and bearing on the wagon had
seized and lost interference fit, generating high levels of frictional heating between the bearing and
axle journal, and the subsequent torsional shearing failure of the axle (a ‘screwed journal’). The axle
failure immediately caused the leading axle of the trailing bogie to derail.
The ATSB concluded that a loss of lubrication or an internal bearing cage failure was the most likely
contributor to the bearing breakdown and seizure.
Evidence also suggested the breakdown developed relatively rapidly, given the absence of a positive
fault detection from two bearing acoustic monitoring systems (RailBAM®) passed on the day of the
incident.
Action taken
The operator has investigated and implemented the following actions:

A grease nipple will be added to all axle boxes. This will ensure both the inner and outer
bearings receive a more even distribution of grease when axle boxes are regreased during
scheduled servicing.

Bearings incorporating bronze cages will be progressively withdrawn from service and replaced
with new steel-cage bearings.

The work instructions associated with bearing overhaul and preventative maintenance/
inspection have been reviewed and updated to reflect the process changes.

The updated instructions have been disseminated to all affected rolling stock maintenance
staff, and contracted bearing suppliers and maintainers.
Safety message
Bearing failures leading to derailment continue to occur within the Australian rail network. Rail
operators must continue to be vigilant and ensure axle bearings, and in particular axle box type
bearings, are correctly installed, maintained and monitored.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
7 December
UK: Container detachments at Scout Green (Cumbria), 7 March 2015 and
Deeping St Nicholas (Lincolnshire), 31 March 2015
For the full report, click here: LINK
At around 02:20 on 7 March 2015 an empty 30-foot container became detached from a freight train
on the West Coast Main Line at Scout Green, Cumbria. It passed over the adjacent track and came to
rest down an embankment. There was no damage to the railway infrastructure or to other trains. A
sleeper service had passed the site in the opposite direction about four minutes earlier.
At around 15:22 on 31 March 2015, an empty 40-foot container was blown from a freight train, near
Deeping St Nicholas, Lincolnshire. The container was dragged a short distance by the train, causing
extensive damage to the infrastructure, before coming to rest on the adjacent track. There were no
passenger services in the area at the time, though a freight train had passed the site about five
minutes earlier.
The container detachments were caused by strong gusting winds combined with the speed of the
trains, and a defective design of container retention.
The circumstances of these events were very similar to other container detachments at Hardendale
and Cheddington in 2008 which were investigated by the RAIB. That investigation report made a
number of recommendations which, had they been implemented, would have prevented these
further detachments. This report, therefore, makes no further recommendations. However, the
Branch have identified the following learning points:

When operating procedures are employed as a means of mitigating safety risk they must be
based on a good understanding of that risk. In this instance the wind speed thresholds for
applying company operating procedures were not derived from suitable modelling of all the
relevant risk factors, such as local topography (eg embankments) and peak gusts.

Container detachments are infrequent but not exceptional events and have the potential to
cause significant harm and damage to infrastructure. RAIB considers that the incidents at Scout
Green and Deeping St Nicholas reinforce the urgent need for an engineering solution to be
found for non-compliant UIC spigots.

The freight operators’ company operating procedures to mitigate the risk from container
detachment in strong winds were not fully integrated with procedures at Network Rail and as a
result could not be reliably implemented. It is important that, where risk reduction is achieved
using procedural measures, such procedures are agreed by all parties, are tested and are part
of a comprehensive system, including briefing, training, instructions, and monitoring, to ensure
their consistent implementation.
Recommendations

None made.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
9 December
Australia: Passenger train collision with maintenance equipment at
Montgomery, Victoria, 16 February 2015
For the full report, click here: LINK
On 16 February 2015, track maintenance was being
conducted at Montgomery between Sale and
Bairnsdale. In order to allow a V/Line passenger
train to pass through the section, the maintenance
gang cleared the track and the associated
protection was lifted. However, when the gang
vacated the line, an item of equipment was left
behind.
As the train approached the site, the driver saw the
obstruction. In response, he made an emergency brake application, but was unable to bring the train
to a stand before it collided with the equipment. The train remained on the track and there were no
reported injuries.
The ATSB found that an item of maintenance equipment had been moved along the track away from
the immediate area of works. Subsequently, this equipment was overlooked when the track was
cleared of workers and other tools.
The task of ensuring that the line was clear had cascaded to a third party within the maintenance
gang. There was no formal system in place to manage this process of informal delegation.
Action taken
As a result of this and other related ‘safeworking’ incidents, V/Line has advised that a review of
infrastructure rules, procedures and training has been implemented.
Safety message
The ATSB notes that track maintenance personnel should be particularly vigilant to ensure that no
obstruction remains on the line when authorising the passage of a train through a work site.
Network managers should also ensure that systems and processes minimise the potential for
maintenance equipment to be left on the track.
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16 December
Australia: Freight train collision at Mile End, SA, 31 March 2014
For the full report, click here: LINK
At about 07:30 (local time) on 31 March 2015, an intermodal freight train (2MP9) passed No. 1 signal
at the southern end of the Mile End crossing loop. The signal was displaying a 'Calling on/Low speed’
indication. The train proceeded at low speed, but subsequently collided with the rear end of another
intermodal freight (2MP1), which was stationary on the main line. The collision resulted in moderate
track damage and the derailment of three wagons at the rear of the waiting train. There were no
reported staff injuries.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
The ATSB determined that the signalling and communications systems were operating correctly and
as designed. The investigation found that the driver of 2MP9, on receiving a ‘Calling on/Low speed’
signal indication, proceeded at the prescribed speed of less than 25 km/h, but was unable to stop the
train. The driver was aware that the operational rules stipulate that the ‘block ahead may be
occupied or obstructed’, but did not expect 2MP1 to be so close ahead. As he approached 2MP1,
some stumpy vegetation and a low fence initially obscured his view of the empty flat wagons at the
rear of the train. When the driver finally saw the rear of 2MP1, he immediately made an emergency
brake application, but was unable to stop before colliding with 2MP1.
The ATSB noted that the pathing of a train by a Network Control Officer (NCO) onto a line occupied
by a preceding train, when an alternate route is available and not obstructed, presents an elevated
level of risk. Similarly, well considered and clear communications between an NCO and crew of an
approaching train, as to the proximity of a train occupying the track ahead, can significantly enhance
situational awareness and reduce operational risk.
Action taken
The Australian Rail Track Corporation (ARTC) and SCT Logistics have implemented a range of
proactive strategies for enhancing the safe operation of train movements when entering an occupied
section of track under a ‘Proceed restricted authority’ (PRA). This includes the use of all available
infrastructure to reduce risk, encouraging communications between train drivers and NCOs where
clarification of operational conditions is necessary, and a review of the National Train
Communications System (NTCS) for the Adelaide area.
Safety message
The ATSB notes that drivers should carefully consider their obligations when accepting a ‘Calling
on/Low speed’ signal indication in relation to sighting constraints, train speed and occupation of the
track ahead. In circumstances where sighting constraints may exist, drivers should consider
requesting further information from the NCO before moving through the track ahead.
NCOs should carefully consider the pathing of trains under their control, and the communication of
information that may mitigate collision risk when dispatching trains.
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17 December
UK: Unsafe events at Heathrow Tunnel Junction, 27 and 28 December 2014
For the full report, click here: LINK
On 27 December 2014, and again on 28
December 2014, track workers were at serious
risk from being struck by trains at the Stockley
Flyover construction site, on the Heathrow
Airport branch. In the second incident, a train
did collide with a small trolley which was being
placed on the line by track workers.
During the first incident, 14 track workers
walked along the open Down Airport line – an
area where limited visibility meant it was unsafe
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
to do this when trains were operating. They mistakenly believed that services had been stopped. A
Heathrow Airport–Paddington used the line shortly after the workgroup had been warned by other
staff and had moved clear.
RAIB found that an inappropriate system was used to control access to the track, permitting trains to
start operating when track workers could reasonably believe services remained suspended. Staff had
also been directed to walk along a line when paperwork showed it was open to traffic.
The following day, two track workers were placing a small trolley on the Up Airport line when a train
emerged from a nearby tunnel at 45 mph. The track workers moved clear of the line seconds before
the train struck the trolley. There were no reported injuries and only minor damage. The track
workers believed the line was closed – a consequence of being accustomed to working in a way that
differed from the mandated site safety system.
The two incidents, along with a number of other safety shortcomings, showed that site supervision
processes had not identified that deviation from the mandated site safety system had become
normal practice. Furthermore, formalised briefings had not been supplemented by any site signage
to increase the likelihood of staff being aware of which lines were open.
Although not linked to the incidents on 27 and 28 December 2014, RAIB observes that:

The engineering supervisor and other possession delivery staff were unaware that the Rule
Book requirements regarding management of worksites had changed on 6 December 2014.

The Signalling Solutions safe systems of working (SSoW) pack did not identify a safe access
point at which staff could enter railway infrastructure, and contained excessive amounts of
unnecessary information.
RAIB has identified the following key learning points:

The on 27 December 2014 highlights the need for engineering supervisors to follow the
requirements of the Rule Book (Handbook 12). In particular:
o
Authority to start work should only be given after confirming that the Controller of
Site Safety (COSS) sign-in entries match the content of the engineering supervisor’s
briefing in accordance with Handbook 12, section 4.1;
o
Worksites should not be handed back in accordance with Handbook 12, section 10
until:

The engineering supervisor has received positive confirmation that all COSSs,
Individuals Working Alone (IWAs) and Safety Work Leaders (SWLs) under
their protection are clear of the line or are no longer relying on the worksite
for protection; and

All safety related anomalies in the worksite paperwork have been
satisfactorily resolved.

It is important that COSSs and SWLs complete their SSoW paperwork and provide a full safety
briefing to their workgroup in accordance with Handbook 7 section 5, and remain close to, and
be able to observe, all work undertaken by the workgroup in accordance with section 6. This is
essential to maintain the integrity of the SSoW needed to allow the group to work safely.

COSSs, IWAs and SWLs should query and resolve any mismatch between their SSoW pack and
their understanding of the status of the railway, for example whether lines are open or
blocked, to reduce the possibility for misunderstandings or errors resulting in unsafe working.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Primary sponsors should ensure they have an effective means of:
o
Verifying that railway rule book updates have been acknowledged; and
o
Identifying and remedying those instances where acknowledgement by their staff is
outstanding.
This is necessary to allow staff who are required to comply with the rule book to be up-to-date
with its content.

Organisations preparing SSoW packs should avoid excessive amounts of unnecessary
information, reflect changes due to ongoing construction work and, where relevant, include
temporary construction access points to provide COSSs, IWAs and SWLs with comprehensive,
but concise SSoW pack information.
Action taken
Carillion has introduced a tier system for its COSSs, rating each as Gold, Silver or Bronze, based on
competence and experience and rewarding COSSs as they progress with more challenging and
preferred duties. This system encourages positive attitudes towards site safety culture as this is one
of the criteria used to assess when a COSS can progress up the tiers.
Carillion has also launched a behavioural culture initiative intended to promote safe behaviours and
to empower staff to challenge unsafe practices.
Signalling Solutions has revised its audit methodology so this includes action in respect of COSSs who
do not return packs, and promotes effective follow up of shortcomings found by the audit process.
Signalling Solutions has also modified the method of issuing SSoW packs so that safe system of work
planners are directly responsible for issuing, and recording the issue, of all SSoW packs. It expects
this to provide a more reliable record of packs issued.
Recommendations

Network Rail, liaising with Principal Contractors, should review management systems for
monitoring railway safety arrangements on major construction sites not separated from the
railway by a permanent barrier. The review should identify any improvements needed to
ensure that, in addition to appropriate auditing of paperwork after completion of shifts, the
management systems promote sufficient direct observation of on-site activities and
workgroup questioning to give adequate confidence that mandated safe systems of work are
being correctly implemented throughout each shift. Network Rail should then implement any
improvements identified by the review.

Network Rail should review the monitoring arrangements applying to engineering
supervisors/safe work leaders managing engineering worksites. The review should establish:
o
Any improvements needed to give adequate confidence that the monitoring
arrangements can identify where the actions of an engineering supervisor/safe work
leader are not in compliance with the railway rulebook (for example when ensuring
staff and equipment are clear of the line and concluding that the railway is safe to
return to traffic); and
o
How those actions can be corrected before they become habitual.
Network Rail should then implement any improvements identified by the review.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Network Rail, liaising with Principal Contractors, should identify and provide a process for
implementing, where practicable, improved arrangements for communicating safe working
limits to all workers on large construction sites not separated from the railway by a
permanent barrier. This communication, such as signage highlighting lines which have
recently reopened, should increase the likelihood of staff recognising and then challenging
the proposed safe system of work.

Network Rail should review whether the use of multiple forms should be replaced by an
alternative, risk assessed, process for engineering supervisors/safe work leaders controlling
worksites which comprise both multiple lines and activities undertaken by several
workgroups. If justified by this review, Network Rail should introduce an appropriate
alternative process.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk