September 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: SPAD at Warnervale, New South Wales, 24
November 2014
Australia: Freight train derailment at Nambucca Heads,
NSW, 14 May 2014
UK: Collision between a train and a collapsed signal
post at Newbury, 17 November 2014
UK: Freight train derailment at Heworth, 23 October
2014
Australia: Level crossing collision at Woodvale,
Victoria, 19 December 2014
Newbury
Some of the key issues raised and/or suggested by the stories in this edition:
SPAD
Worksite protection
Signaller handover
Distraction
Situational awareness
Wagon loading
Track twist
Deficient guidance
Signal maintenance and monitoring
Track maintenance (cyclic top)
Wagon maintenance
User behaviour
Sighting at crossings (vegetation)
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
16 September
Australia: SPAD at Warnervale, New South Wales, 24 November 2014
For the full report, click here: LINK
At 11:59 (local time) on 24 November 2014, a freight train passed 66.8 signal (between Wyee and
Warnervale) at danger without authority.
The SPAD was a breach of the Network Rules and Procedures involving the use of Absolute Signal
Blocking (ASB) that had been granted as part of worksite protection arrangements for a workgroup
conducting electrical maintenance tasks at Warnervale.
The Protection Officer (PO) for the workgroup was granted ASB shortly after a change in the Network
Control Officers (NCO) at Morisset, from where the signals protecting the section were controlled.
Although assurances were given to the PO that the section was clear, two trains were still travelling
between the protecting signals and the worksite at the time ASB was implemented. The first passed
the worksite shortly afterwards without incident. The second, travelling some eight minutes behind,
came to a stand approximately 1,300 metres before the worksite after the driver reacted to a signal
returning to danger in front of the train. The signal had returned to danger because of electrical
testing being conducted as part of the maintenance tasks. Its return also (fortuitously) prevented the
train from entering the worksite and potentially injuring the track workers on duty.
The Australian Transport Safety Bureau (ATSB) found that, when the NCOs changed over at Morisset,
a breakdown in the handover process occurred, caused partly by the arrival of police officers trying
to obtain information about an unrelated incident that had occurred two nights before. This resulted
in ASB being granted to the PO at Warnervale without the exact location of trains being established,
signals V8 and V6 being set back to stop and blocking facilities applied in accordance with the rules.
At the time of the incident, Sydney Trains was trialling a modified ASB methodology to address
previously identified safety issues, however trial had not been extended to Morisset. If it had been,
the progress in granting ASB would have been documented and would have assisted the NCOs during
the handover process.
Additional interim arrangements for ASB were not implemented at the time of the incident as the
requirements listed in the memorandum of July 2013 had not been promulgated to all staff.
The ATSB notes that the incident illustrates the criticality of minimising interruptions and distractions
that may affect the process for the granting or authorisation of work on track authorities, particularly
Absolute Signal Blocking. Similarly, it reinforces the importance of information and situational
awareness exchange between personnel during the handover process for the control of dynamic rail
network operations.
Action taken
Sydney Trains advised that it has expanded its trial of the ‘Coded Authorisation Process for Absolute
Signal Blocking’ to include signal box locations on the Main North Line between Gosford and
Broadmeadow. It further advised that, on completion of the trial, the Network Rule and Procedure
for Absolute Signal Blocking will be rewritten to improve its readability and application.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Recommendations

Sydney Trains should take further action to expedite the implementation of safeguards and
procedural safety enhancements where Absolute Signal Blocking is to be used for worksite
protection.
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23 September
Australia: Freight train derailment at Nambucca Heads, NSW, 14 May 2014
For the full report, click here: LINK
At around 14:04 (local time) on 14 May 2014, the fourth wagon from the end of a Pacific National
(PN) freight derailed whilst exiting a loop at Nambucca Heads. The train travelled a further 1,397
metres before the derailed vehicle tipped on its side, causing the consist to separate and
subsequently stop.
The ATSB found that the load had probably shifted, mostly to the left in the direction of travel. This
would have transferred vertical forces from the wagon’s right side-bearer to the left side-bearer,
causing the right-hand wheels to unload.
At the point of derailment, the track geometry was transitioning out of a left-hand curve, which had a
relatively high superelevation with respect to the actual speed of the train (about 21 km/h). The
relatively high superelevation and subsequent twist as the superelevation ramped down through the
transition, likely resulted in additional transfer of vertical force from the wagon’s right side-bearer to
the left side-bearer, resulting in a further unloading of the right-hand wheels.
The combination of superelevation, twist and (more importantly) uneven lateral loading, combined
to unload the right-hand wheels which, when steering through a left-hand curve, resulted in flange
climb and derailment of the wagon.
Furthermore, the Pacific National Freight Loading Manual (FLM), and the application of it, was
ineffective at preventing load shift in this case.
Action taken
PN has engaged a consultant to conduct an audit of its procedures and operational processes relating
to the development and implementation of the FLM, specifically performing a gap analysis in relation
to current steel loading processes.
In addition, PN will be arranging an external engineering group to undertake a twist test and/or
computer simulation modelling of an RCOF wagon to record its wheel loading performance
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
characteristics during scenarios based on the data. The final report will contain recommendations
that can be utilised to further refine its FLM and associated procedures and loading practices.
The ATSB acknowledges that PN has initiated a review of its FLM and has taken action to ensure
freight is loaded in accordance with established procedures prior to departure.
However, it draws attention to a fundamental requirement of freight loading, in that it is essential
that the load be prevented from moving in any direction relative to the wagon, as a shifting load at
any point during transit is an undesirable condition that can affect the dynamic behaviour and safety
of the vehicle. While PN’s action serves to ensure freight is loaded in accordance with the FLM on
starting its journey, no action has been proposed to specifically address the demonstrated potential
for shifting and movement of the rod-in-coil product while in-transit. Accordingly therefore, the ATSB
issues the following safety recommendation.
Recommendation

Pacific National should undertake further work to address the possibility that rod-in-coil
product could shift during transit, thereby creating an undesirable condition that could affect
the dynamic behaviour of the vehicle.
Safety message
The ability for a load to shift during transit is an undesirable condition that can affect the dynamic
behaviour of the rail vehicle. All rail freight operators should consider the safety implications of
shifting/moving loads and should ensure that all loads are restrained and/or enclosed in such a way
that prevents movement in any direction relative to the wagon.
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23 September
UK: Collision between a train and a collapsed signal post at Newbury, 17
November 2014
For the full report, click here: LINK
At about 14:35 on 17 November 2014, a passenger train travelling at 110 mph struck the top of a
signal which had collapsed and fallen across the line near Newbury. The signal post completely
obstructed one track and partially obstructed a second (the one on which the train was travelling).
There were no injuries and the train did not derail, but it did sustain some exterior damage. The
outcome could have been much more serious if the first train to encounter the signal had been
travelling at speed on the line that the signal had completely obstructed.
The signal collapsed because the base of the post, which was of hollow tubular steel construction,
had corroded through, causing an almost complete loss of wall thickness at and just above ground
level. Corrosion had occurred to both internal and external surfaces: internally because water had
entered the post and there was no drainage for it to escape, while the external corrosion was
affected by the base being buried in ballast, which held water around the base and damaged the
protective coating on the signal post.
Signal posts are subject to annual visual examinations, but the examinations of this signal did not
detect the problem because the main area of corrosion was hidden by ballast, and the examinations
regime was vulnerable to missing such defects. A separate examination in 2012 for a resignalling
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
project in the area also did not detect the defect for similar reasons. Because the defect was not
detected, it was not subsequently reported and remedied through maintenance.
The investigation identified possible underlying factors associated with the management of ballast
levels around post bases, competence management of structures examiners and corporate
knowledge about the original design specifications for signal structures.
Although not linked to the accident on 17 November 2014, RAIB observes that, as well as the risk
from train accidents, there had been a potential risk to anyone climbing or working on the signal.
RAIB has identified the following learning point:

Those involved in managing and undertaking the Line of Route examinations of ancillary
structures are reminded that the actual examination process for each structure is no different
from that for ordinary visual examinations. While the reporting format is abbreviated, the
examination itself is not.
Action taken
The ORR served an Improvement Notice on Network Rail (Western route) on 5 December 2014,
which required it to examine all the straight signal posts on the route and amend its examinations
process. The Improvement Notice had a deadline of 1 June 2015, but this was subsequently extended
to 1 October 2015 in light of the need to consider internal corrosion, as identified in the corrosion
analysis commissioned by RAIB. The ORR is also pursuing the issue of internal corrosion at a national
level with Network Rail.
Network Rail (Western route) responded to the accident with the following actions:

As an immediate response, local inspections had been carried out on 35 signal posts in the
Newbury area by the end of November 2014. Nine were found to have their bases buried by
ballast, of which two showed signs of corrosion.

A wider exercise involving closer examination of all 1,754 straight signal posts on the route was
implemented, including multiple photographs of the structures and bases. The purpose was to
determine whether the bases of these structures were buried by ballast and, if so, to assess
the condition of the base. At the same time, ballast boards would be installed where
necessary. As of 30 July 2015, 1,704 signal posts have been examined while an additional 13
were not inspected as they were recently installed. A proportion of these revealed the need
for supplementary examination and/or minor works – for the Swindon maintenance delivery
unit, this amounted to 85 out of 404 structures requiring some level of ballast removal (as at 7
September 2015). In total across the route, 407 structures need to be revisited (as at 30 July
2015) and one signal post required follow up action to ensure its structural integrity.

Network Rail (Western route) has also commissioned a retrofit design to strengthen any weak
assets.
At a national level, Network Rail has reported the following actions:

A briefing note about the accident was issued on 23 December 2014, which included a number
of recommendations for action at both route and central (ie national) level. These actions
covered a review of all straight signal posts to confirm the condition of hidden components
followed by risk-based remedial actions where necessary, processes for managing the effects
of track work on structures, and a review of management controls for ancillary structures. As
of 30 July 2015, all of the central actions had been completed and most of the route actions
were either complete or on target to be completed by their nominal deadline. Where these
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Email address: Greg.Morse@rssb.co.uk
actions have not yet been completed, Network Rail has reported difficulties in gaining track
access as the reason and completion dates have been rescheduled.

A workshop was held on 29 January 2015 to understand the limitations of the existing
examination process. The workshop produced a high-level failure analysis of various forms of
structure, which then fed into the development of a new examination methodology and report
form for all ancillary assets that currently only receive visual examinations. At the time of
writing, this methodology is still in development.
In addition, Amey has:

Issued a technical brief (December 2014), offering guidance on examining the interface
between post and ground, positively reporting its condition and any parts not examined, and
removing ballast.

Briefed examiners that Line of Route reports should include a clear statement of where the
structure was examined from and whether there were any parts not examined.

Changed its method of examining and reporting information on straight signal posts, by
providing more photographs and including parts not examined on the examination form, as
well as restricting examinations to cover only those where the structure can be directly
approached.
Recommendations

Network Rail should review its asset management strategy with the objective of improving the
examination and maintenance of its ancillary structures. The review should consider:
o
Identification of structures at greatest risk of failure (eg by age of the structure,
those of hollow section, those without galvanised or otherwise treated surfaces,
those in hostile environments) and the possible consequences of failure in the
context of wider safety risks to the railway;
o
Steps to mitigate the risk (such as periodic replacement); and
o
Specific measures to deal with planted posts as well as those structures fixed to
foundations.

Network Rail should develop and implement a risk assessment process to determine when it is
necessary for the critical elements of ancillary structures to be exposed for the purposes of
examination and/or to mitigate the risk of corrosion. The process should take into account the
specific risk of corrosion of buried metalwork on hollow section ancillary structures that are
fixed to foundations.

Taking account of the emerging findings from the implementation of Recommendation 1,
Network Rail should review its examination and maintenance regimes for ancillary structures
and make any necessary improvements to ensure that its processes are commensurate with
the risk arising from the failure of those structures. The review should include, but not be
limited to, consideration of the following areas:
o
A regime of periodic enhanced examinations for ancillary structures (such as the
Detailed Examination regime applied to bridges and other complex structures);
o
Consideration of the special requirements for examination of the buried elements of
planted posts;
o
A means for assessing the internal condition of hollow section structures as well as
their external condition;
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Email address: Greg.Morse@rssb.co.uk
o
Re-designing the examination forms (whether electronic or paper versions) to
improve usability for the examiners, to clarify the need to report hidden critical
elements that were not examined and to improve reporting lines between Network
Rail and its examinations contractors;
o
Revising the competence standards for staff involved in the examination of
structures to ensure consistency in the level of training received both by those who
are new to the industry as well as experienced examiners; and
o
Cyclical maintenance of any surface treatments on ancillary structures.
Changes made as a result of the review should be re-briefed to all those involved in structures
examinations and relevant company standards and other documents should be updated as
appropriate.

Without waiting for Network Rail’s actions in response to Recommendation 3 above, Amey
should immediately review and revise its competence management processes for its staff
involved in structures examinations in accordance with the findings from this investigation.
The revised processes should allow for further adjustments to be made as necessary once
Network Rail has completed its response to recommendation 3.
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24 September
UK: Freight train derailment at Heworth, 23 October 2014
For the full report, click here: LINK
At about 15:25 on 23 October 2014, a freight
train derailed just after passing through
Heworth station. It was travelling at 51 mph
when the leading wheelset of the tenth wagon
derailed on track with cyclic top.1
The train continued for about 1.4 miles, where
it was stopped by the signaller, who had
become aware of a possible problem with the
train from damage to the signalling system. By
the time the train stopped, all of the wagon’s
wheels had derailed and its suspension had been damaged.
RAIB found the immediate cause of the accident to be a combination of a loss of damping within the
suspension on one corner of the wagon that made it susceptible to derailing on the cyclic top track
defect it passed over. This was because:

The wagon had a worn suspension component that made its leading left-hand wheel
susceptible to unloading and lifting up when responding to dips in the track. The wagon’s
maintenance regime had not identified this worn component. The excessive wear was most
likely due to misalignment of the wheelset within its suspension.

The severity of the dips in the track required Network Rail to impose an emergency speed
restriction, but no such restriction had been put in place.
1
That is, regularly spaced dips in both rails.
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Email address: Greg.Morse@rssb.co.uk

The cyclic top defect formed due to water in the track not draining away and although the
track inspection regime had identified this defect many times, often no repair took place.
Occasionally the local Network Rail track maintenance team carried out manual repairs but
these were ineffective.

The local Network Rail track maintenance team was unable to cope with the volume of work it
had to do. This was due to insufficient numbers of track maintenance staff over a long period
of time, changes to the arrangements for working safely while on the track, restrictions on
gaining access to the track and changes to how the track was inspected. Network Rail’s
management arrangements did not identify the extent of non-compliances to its maintenance
processes, or take earlier action to resolve the persistent problems that were affecting track
maintenance in this area.
RAIB has identified the following key learning point, which was also included in its report on the
derailment near Gloucester that occurred on 15 October 2013:

Network Rail should remind its staff responsible for managing the maintenance of its track
(such as Track Maintenance Engineers and Track Section Managers) of the requirements in
Network Rail standard NR/L2/TRK/001/mod11 relating to the imposition of a speed restriction
due to persistent poor track quality:
o
If the vertical track geometry of an eighth of a mile long section of track is recorded
in the maximum band (ie its SD value places it in the super- red category) and the
remedial work undertaken is not sufficient to move the SD value out of the
maximum band, then a speed restriction must be imposed.
o
This speed restriction should remain in place until a further repair is made and it is
confirmed that the repair work has improved the vertical track geometry.
Action taken
Freightliner, the wagon owner and operator, carried out additional checks to identify any other
wagons with the same worn suspension component and modified the maintenance regime for these
wagons.
Network Rail instructed its staff to always impose an emergency speed restriction for cyclic top
defects, which shall remain in place until monitoring has shown that its staff have made an effective
repair.
Recommendations


Freightliner should amend its vehicle maintenance instructions for its fleet of PCA wagons so
that each damper pad is removed and measured during the VIBT examination to identify those
wagons which have had levels of damper pad wear (on any corner) that exceed the permitted
wear limit since the last VIBT examination. For each wagon identified, Freightliner should
implement measures to prevent it being used in service with a damper pad that could wear
beyond the permitted wear limit before its next VIBT examination. These measures could
include:
o
Additional monitoring or checks for that wagon in between VIBT examinations;
o
Replacing damper pads on that wagon at an earlier interval; or
o
Carrying out work to identify and address the reasons why that wagon has had a high
level of damper pad wear, such as pedestal or wheelset alignment.
Network Rail should investigate why water is not draining from the track bed in the vicinity of
where the train derailed (between 99 miles 220 yards and 99 miles 264 yards on the Down
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Sunderland line between Pelaw and Newcastle) and implement measures to control the risk of
excess water affecting the track’s vertical geometry. Such measures could include ballast
cleaning, remedial work to improve the effectiveness of the installed track drainage, through
to a renewal of the track.

Network Rail should review the condition of the track assets in the area covered by the
Newcastle Track Section Manager against the records on its system for maintaining its track
assets (Ellipse). The aim of the review should be to identify track defects requiring
maintenance action which are either not recorded on Ellipse, do not have a planned date for
repair, or have not been correctly prioritised for repair. Once identified, these defects should
be recorded on Ellipse, prioritised and given a date for repair.

Network Rail should investigate why its track assets within the area covered by the Newcastle
Track Maintenance Engineer consistently have the highest numbers of reportable track
geometry defects and sections of track in the super-red category on LNE Route. The
investigation should include consideration of:
o
The number of staff needed to maintain the track assets in the Newcastle Track
Section Manager area, so that both reactive and planned volumes of preventative
maintenance activities are delivered;
o
The effect that changes to safe systems of work used by the track maintenance
teams has had on the time spent working on the track;
o
The effect that the introduction of PLPR within the track inspection regime has had
on increasing the track maintenance workload;
o
The types and numbers of track assets in the Newcastle Track Maintenance
Engineer’s area, their age, and their condition, in comparison to the other Track
Maintenance Engineer areas on LNE Route; and
o
The effect that any other factors have had in contributing to the high number of
track asset defects.
Based on the findings of the above investigation, Network Rail should determine what the
appropriate target values are for the numbers of reportable track geometry defects and
sections of track in the super-red category in the Newcastle Track Maintenance Engineer area.
Network Rail should then take action to improve the maintenance of the track assets in this
area to a level that allows these targets to be met.

Network Rail should investigate why its management arrangements allowed non-compliances
to processes for track asset maintenance to go undetected in the area covered by the
Newcastle Track Maintenance Engineer, which correspondingly had the highest numbers of
reportable track geometry defects and eighth of a mile sections of track in the super-red
category when compared to other areas. The investigation should include consideration of:
o
Why its audit and self-assurance framework did not identify the full extent of the
non-compliances to processes found by RAIB;
o
Why its reporting and monitoring processes did not trigger earlier action by senior
management within the Route to resolve the persistent problems affecting the track
assets in the Newcastle Track Maintenance Engineer area; and
o
Whether there are other Track Maintenance Engineer areas, like the one at
Newcastle, with persistent non-compliances to processes that are affecting the
maintenance of its track assets.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Based on the findings of its investigation, Network Rail should take action to improve the
management arrangements at Route level that audit, monitor and review the performance of
a local area to highlight non-compliances which are resulting in persistent deficiencies with the
maintenance of its track assets.
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25 September
Australia: Level crossing collision at Woodvale, Victoria, 19 December 2014
For the full report, click here: LINK
On 19 December 2014, a lorry collided with a
Swan Hill–Melbourne service at a level
crossing on Rileys Road, Woodvale, Central
Victoria. Both occupants of the lorry and one
rail passenger were taken to hospital with
minor injuries.
The lorry sustained significant damage to its
front right-hand corner; the train also
sustained damage to its side panel and the
underfloor sections of several of its carriages.
The ATSB found that the truck driver did not approach the level crossing with sufficient caution to be
able to stop once he became aware of the approaching train. A road-user’s view of an approaching
train was partially obscured due to lineside vegetation.
Safety message
The ATSB note that this incident highlights the responsibility that rests upon road vehicle drivers to
remain aware when approaching railway level crossings, especially those with passive protection.
Road users who frequently use a level crossing that sees limited rail traffic should be alert to the
potential of developing a sense of expectancy that trains will not be present. Drivers of heavy
vehicles have a special responsibility to ensure they remain aware of the dangers of railway level
crossings.
To ensure that road users can make a determination regarding crossing the track safely, it is
important that the infrastructure manager ensures that any lineside vegetation that might reduce
the road user’s distant view of the track approaches be kept to an effective minimum.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk