August 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)
UK: Freight train derailment at Porthkerry, South
Wales
UK: Freight train derailment at Angerstein Junction,
2 April 2014
UK: Train struck and damaged by equipment
cabinet door in Watford Tunnel, 26 October 2014
Finland: Overspeeding incident near Hyvinkää, 18
March 2015
UK: Class investigation into irregularities with
protection
arrangements
during
infrastructure
engineering work
Angerstein Junction
Some of the key issues raised and/or suggested by the stories in this edition:
Rail manufacture
Rail re-use
Rail inspection and maintenance
Delegation
Wagon loading
Risk assessment
Intersection of assets at the outer reaches of compliance
Lineside cabinet design, positioning and checking
Overspeeding
Distraction (mobile telephone use)
Automatic train protection
Protection irregularities (including miscommunication, violations, lapses and understanding of
protection limits)
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
6 August
UK: Freight train derailment at Porthkerry, South Wales
For the full report, click here: LINK
At 02:30 on 2 October 2014, a loaded coal train
derailed at Porthkerry, between Barry and
Rhoose, in South Wales. The last two wagons
came off when the rail beneath them collapsed.
There were no reported injuries.
RAIB determined the cause of the derailment to
be the failure of a section of the left-hand side
rail due to a metallurgical defect within it. The
defect arose due to impurities within the steel
which had been present since manufacture. The
rail had been in place since 2008, but had
previously been used at another site. The defect
was not discovered when it was installed at Porthkerry.
The rail was not replaced before it collapsed due to a combination of factors: visual inspections
intended to identify this type of defect had not been carried out, the regular track inspections had
not found it and none of the staff responsible for management of the track had identified that the
rail needed urgent replacement.
It was also noted that the most recent track maintenance inspection was done by an asset engineer
from the route asset manager (track) team (23 July 2014). The track maintenance engineer was on
leave, so delegated his inspection to the asset engineer. However, the findings of the inspection were
not discussed on the former’s return.
The defect that was later to cause the derailment was eventually discovered on 30 July 2014, during
an inspection that was being carried out to monitor a different type of defect. However, according to
Network Rail’s standards, a defect of the type identified did not require urgent attention and
therefore a period of 52 weeks was allowed for rail replacement. Consequently no action was taken
to address the reported defect before the date of the derailment.
RAIB also made the following learning point:

When a track maintenance engineer’s inspection is delegated, it is important that the person
who does the inspection and the engineer discuss the findings of the inspection and that it is
clear who shall follow up the identified actions.
Action taken
Network Rail requested the ultrasonic specialists, Sperry, to report the length of linear suspects.
Sperry duly issued the instruction to its analysts on 25 November 2014. The length information is
then transferred to Network Rail’s rail defect management system and is visible to the staff verifying
the defect on the track.
Network Rail made enhancements to its management systems in December 2014 to improve the
feedback of suspect verification information to Sperry.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
In addition, the company tested all low rail rolling contact fatigue (RCF) sites to check for loss of rail
bottom and to test of any pre-1976 rail installed as the low rail in those sites. No further defects of
the type featured in this derailment were found.
Network Rail issued a briefing note to its rail management engineers, advising them of the details of
the accident and specifying additional testing of pre-1976 rail. Its supply organisation, National
Delivery Service, also issued an instruction to its suppliers in 2011 not to supply pre-1976 rail as
serviceable rail.
Recommendations

Network Rail should review the methods it uses to verify suspected vertical longitudinal split
defects in rails and make improvements to increase the likelihood of their detection.

Network Rail should improve the detection of surface breaking cracks and head spread. The
methods to be considered should include the use of non-destructive test methods such as dye
penetration or magnetic particle inspection to look for cracks, particularly at the upper fillet
radius.

Network Rail should assess the risk from having unidentified pre-1976 rail in use, especially at
sites where cascaded rail has been installed, and take appropriate mitigation measures.
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11 August
UK: Freight train derailment at Angerstein Junction, 2 April 2014
For the full report, click here: LINK
At about 12:15 on 2 April 2014, two wagons of a
nominally empty freight train derailed on the
approach to Angerstein Junction, near Charlton
in south east London. They were pulled over the
junction and stopped partly obstructing the
adjacent line.
No other trains were involved in the accident
and there were no reported injuries, but there
was significant damage to the infrastructure.
The wagons derailed because the leading
right-hand wheel on one of them was carrying insufficient load to prevent it from climbing up
the outer rail on a curved section of track. The insufficient load was due to a combination of a
track defect, an unevenly distributed residual load in the wagon, and an uneven distribution of
load associated with a twisted bogie. The unevenly distributed residual load comprised finely
crushed rock which adhered to the side of wagon, and was not discharged by unloading
procedures. These procedures had been developed without recognising the derailment risk
associated with carrying relatively small, but significantly unbalanced, loads. This combination of
factors illustrates the derailment risk which arises when imperfect freight wagons are operated
on imperfect track in circumstances where both wagon and track are compliant with relevant
railway standards.
Although not linked to the accident on 2 April 2014, RAIB observes that:
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

The twist measurement used for track maintenance related to a base of three metres, which
differed significantly from the wheelbase of, and hence the twist that affected, the bogie on
the wagon in question; and

A small, but not insignificant, proportion of freight wagons operating on Network Rail
infrastructure have significant diagonal wheel unloadings on their bogies.
Action taken
RAIB issued an Urgent Safety Advice to the railway industry, which was also issued as a National
Incident Report. This highlighted the scenario where uneven retained loads were present in
nominally empty wagons, giving rise to increased derailment risk in degraded track conditions.
Freightliner has prepared a code of practice for Inspection of hopper wagons with uneven residual
load. This was accepted as good practice by the Rail Freight Operators Group, and shared with its
members, in December 2014.
Aggregate Industries has continued its work to identify possible alternative methods for releasing
retained loads from hopper wagons. This has included consideration of techniques such as sonic
vibration, mechanical flails and alterations to the existing sledgehammering procedure.
Aggregate Industries is now using a foam spray, instead of a water spray, to damp down dust at
Bardon Hill Quarry. Initial results indicate that this has improved the discharging of crushed rock fines
at unloading terminals, and reduced the number and magnitude of residual loads being returned to
the loading point.
Network Rail carried out maintenance work to rectify the gauge and twist faults that were present on
the line between Angerstein Junction and the Angerstein terminal. This included replacement of the
local trap points. However, a second derailment occurred at the same location in the replacement
trap points during the days leading up to 5 February 2015. The wheel that derailed on that occasion
rerailed itself at Angerstein Junction, and so the fact that there had been a derailment was not
recognised until track damage was found at the next visual inspection. Subsequent measurement of
the track geometry by Network Rail identified that the replacement points had not been installed
with the required cant, and so had introduced a twist fault. The trap points have since had the
geometry corrected to remove this twist fault.
RAIB has not investigated the February 2015 derailment but notes that Recommendation 3 of the
present report covers effective management of assets such as the trap points involved in these
derailments. Network Rail has reported to the RAIB in April 2015 that it is proposing to use a track
recording vehicle to routinely measure dynamic track geometry on the line between Angerstein
Junction and the Angerstein terminal from June 2015.
A third derailment occurred at the trap points on 3 June 2015. RAIB is currently examining the
circumstances of this event and will, if appropriate, publish its findings in due course.
Network Rail is also considering the circumstances of the Angerstein derailment as part of its ongoing
work to develop monitoring criteria for wheel weight distribution.
Recommendations

Aggregate Industries, in consultation with relevant train operators, should review its processes
for discharging aggregate hopper wagons, and for inspection of train loading and condition
prior to despatch, to ensure that the risks arising from uneven residual loads are identified and
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
effectively managed. Aggregate Industries should then implement appropriate control
measures to mitigate this risk so far as is reasonably practicable.

RSSB, in conjunction with freight wagon operators, freight operating companies and entities in
charge of maintenance for freight wagons, should review the extent to which diagonal wheel
unloadings are present within freight wagon bogies that are operating on Network Rail
infrastructure, and the contribution that this makes to derailment risk. This review should
consider:
o
Identifying the magnitude and prevalence of diagonal wheel unloadings caused by
bogie frame twist (and other possible causes);
o
Proposing criteria for acceptable levels of diagonal wheel unloading, or for bogie
frame twist; and
o
Proposing proportionate measures for identifying, and then managing, unacceptable
diagonal wheel unloadings.

Network Rail should review the processes by which track geometry is managed in sidings and
connections on the approach to running lines, in order to identify and implement any changes
necessary to ensure that the export of risk to running lines is effectively managed. This should
include consideration of how dynamic track geometry is assessed on infrequently used lines.

Network Rail should liaise with RSSB to review whether the existing 3 metre measurement
base used for identification of track twist is sufficient for managing the derailment risk
applicable to rolling stock currently operating on Network Rail infrastructure. If found to be
inadequate or insufficient, Network Rail should:
o
Update its process for assessing track twist by the inclusion of additional and/or
alternative measurement bases; and
o
Implement a time-bound plan to apply the new process to all of its infrastructure.

Network Rail should review the potential to use wheel impact load detection system data to
provide information about possible defects, such as uneven wheel loading or uneven load
distribution, relating to specific wagons. The review should include consideration of how this
information could be used to improve control of overall derailment risk (such as identifying the
need for entities in charge of maintenance to check the condition of suspect wagons and take
appropriate remedial action). Network Rail should seek inputs from relevant entities in charge
of maintenance as part of the review. If justified by the review, Network Rail should implement
track side and reporting processes needed for collecting and disseminating this information.

RSSB, in consultation with industry, should review the risks associated with the uneven loading
of wagons, with particular reference to partial loads, and propose any necessary mitigation, so
that the extent of permitted load imbalance is effectively controlled.
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13 August
UK: Train struck and damaged by equipment cabinet door in Watford Tunnel,
26 October 2014
For a summary in English, click here: LINK
At around 07:19 on 26 October 2015, a Milton Keynes Central–Euston service struck an open door of
a lineside equipment cabinet while travelling through Watford Tunnel. The door detached from its
hinges, hitting the side of the train and damaging a door on one of the carriages. This caused a safety
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
circuit to detect that the door was no longer properly closed and applied the brakes automatically.
On examining his train, the driver found that a door on the fourth carriage had been severely
damaged. Passengers in this carriage also reported they had been showered by flying glass from the
damaged door, although none reported any injuries.
RAIB’s investigation found that the cabinet door had opened under aerodynamic forces as the train
passed, probably because the door had been left closed, but unsecured, during work that had been
taking place on equipment in the cabinet overnight. A number of reasons that may explain why the
door had been left unsecured were identified, including poor task lighting, the methods that had
been employed during the work overnight, no-one being allocated the responsibility for checking
that cabinet doors were closed and secured and the possibility that the staff involved may have been
suffering from fatigue, making it more likely that a mistake would be made. An associated underlying
factor was that Siemens, the employer of the staff involved, had not fully implemented its policy on
fatigue management.
The cabinet involved had been installed recently as part of a re-signalling project for the Watford
area. It was equipped with two doors with side hinges and had been positioned such that an
open door could be struck by a train. An underlying factor was that the risk of this happening
had not been identified when this design of cabinet was selected for use in Watford Tunnel.
Previous risk assessments undertaken during the period when the cabinet was originally subject
to product acceptance were not available to the project team or Henry Williams Ltd, the
manufacturer of the cabinet involved.
RAIB also identified the following key learning points:


All staff involved in installation, maintenance, repair and inspection activity in tunnels need to
be made aware of:
o
The limitations of head/handheld lamps, and the desirability of risk assessments
undertaken at the work planning stage specifically considering the need for task
lighting; and
o
The need for staff on site to reach a clear understanding about who will be
responsible for closing cabinet doors.
It is important that project managers employed by Network Rail or its contractors who are
working to Network Rail’s standards for project management:
o
Conduct adequate risk assessments in order to identify and mitigate/eliminate the
risk arising from the installation of new or redesigned products as part of the
Interdisciplinary Design Check and/or Interdisciplinary Design Review;
o
Ensure that involved parties work to a proper ‘Approved for Construction’ design
when one is required;
o
Consider ergonomics, human factors and incidents of a similar nature within the
assessment process; and
o
Ensure all new or modified products have been subject to Network Rail’s product
acceptance process.
Action taken
Network Rail has:
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Recommended (in its own investigation into the incident) the establishment of a policy on the
use of refuges within tunnels;

Issued a safety alert to brief staff and contractors on the immediate cause of the accident and
to remind them to make sure they close and lock lineside equipment on completion of work;
and

Started a Product Acceptance Improvement Plan, in which it means to publish a clear scope of
product acceptance for its contractors and review the effectiveness of the process to improve
efficiency and communications. In the medium to long term, it plans to make improvements to
the online web based system for product acceptance to ensure that the process and
documents linked to product acceptance certificates and associated documents (eg risk
assessments) are accessible. The review was ongoing at the time of writing this report.
Siemens has:

In conjunction with the safety alert published by Network Rail, placed notices warning staff to
close and lock doors on all cabinets installed by Siemens;

Introduced a new checklist for signalling technicians to complete after they had finished work
to ensure that the line is handed back safe for trains to run;

Annotated all construction and design drawings for cabinets to incorporate padlocks and
included the requirement to place notices on the cabinets warning staff to close and lock
cabinet doors;

Re-briefed its senior managers and construction design engineers on their role and
responsibilities when working within construction projects requiring compliance with Network
Rail’s GRIP process and Construction (Design and Management) Regulations, highlighting the
need to ensure safety risks are identified and effective communication takes place between
the contractor and the client to efficiently resolve outstanding safety issues; and

Commissioned an independent review of its health and safety culture and Fatigue Risk
Management System. The associated report is due be published in September 2015.
Henry Williams Ltd has:

Contacted the Network Rail product acceptance services department and is currently applying
for a new product acceptance certificate for the modified design of the slimline cabinet; and

Re-briefed all its sales and design staff on the product acceptance processes to ensure all
products manufactured or modified by the company for the railway infrastructure have the
necessary product acceptance.
Recommendations

Network Rail should mandate a requirement in its company standards for a design of cabinet
that removes by design the risk of an open door infringing the gauge where the cabinet needs
to be located in an area of limited clearance. Where this is not practicable, the design of
cabinet should alert staff to an unsecured door.

Network Rail should implement a means to meet the rule book requirement for the designated
person (Engineering Supervisor or Safe Work Leader) to confirm to the PICOP that the railway
is safe and clear for the passage of trains when that designated person is not present on site.

Siemens UK should commission an independent review of the implementation of those
aspects of its safety management system relating to the welfare of safety critical staff working
on infrastructure projects, including its arrangements for managing fatigue, and take action as
appropriate to rectify any deficiencies found.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Network Rail should establish a policy and guidance on managing the risk from lineside
equipment that can foul the gauge, with specific consideration of the siting of equipment in
areas of limited clearance and, for example, the use of refuges in tunnels for that purpose.

Henry Williams Ltd, in conjunction with Network Rail as necessary, should review its current
range of railway products to ensure that it has full details of the certification associated with
each item, and take action as appropriate to rectify any deficiencies found.

Network Rail should, in consultation with its suppliers, make improvements to its systems for
product acceptance to ensure that all relevant information associated with those products,
such as risk assessments, is accessible to potential users. The exercise should consider
including a facility to enable each user to include information on its own application of the
product that may be beneficial to future users.
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18 August
Finland: Overspeeding incident near Hyvinkää, 18 March 2015
For the full report, click here: LINK (requires translation)
At 14:58 (local time) on Wednesday 18
March 2015, a Riihimäki–Helsinki service
traversed a set of points switched to the
reverse (diverging) position near Hyvinkää
station at 156 km/h.
The maximum permitted speed is 80 km/h.
There were no reported major injuries, but
one passenger travelling at the rear of the
train was thrown from his seat. Loose
fluorescent tubes on an overhead rack also
fell to the floor and broke.
The investigation determined that the
incident was caused by the driver forgetting to activate the Automatic Train Protection (ATP) system on
the locomotive and not realising this at any point.
His concentration was ‘likely compromised’ by a number of mobile telephone calls and messages.
However, the report notes that there was no visual indication in the cab to show that the ATP had
not been switched on.
Recommendations

The ATP engine device must always be switched on.

In-cab equipment should give drivers a clear warning if the ATP is not working.

If a train's ATP is not switched on, its speed should be restricted to a maximum of 80 km/h.

Clear instructions on the use of mobile devices by drivers while driving must be provided.

The Finnish Transport Agency should include in turnout inspection instructions situations
where a train has or is suspected to have been driven on to a switch guided to the diverging
track at a speed that is clearly higher than allowed for the switch type in question.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

The Finnish Transport Safety Agency should demand that the subject of human factors be
emphasised more in both the safety management systems of railway operators and training in
the field.
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20 August
UK: Class investigation into irregularities with protection arrangements during
infrastructure engineering work
For the full report, click here: LINK
RAIB has investigated a number of accidents involving track workers on Network Rail managed
infrastructure and has identified track worker safety as an area of particular concern in recent annual
reports.
The Branch also became concerned at the number of operating irregularities associated with the
protection of those carrying out engineering work, particularly where protection was planned to
block the line to traffic. This is because, in different circumstances, these irregularities could have led
to harmful, and possibly fatal, outcomes.
RAIB observed the regular occurrence of these operating irregularities in the daily incident reports
produced by Network Rail’s National Operations Centre. As a result, it decided to collect information
over a two-year period (April 2011 to April 2013) to understand more. This report describes analysis
that the RAIB has carried out based on this information, and its investigation of the safety issues that
this identified.
The data analysis showed that most of the reported operating irregularities were potentially harmful
and that their occurrence was neither infrequent nor reducing.
A systematic review of these was then undertaken to identify the various safety issues associated
with these events. Examples include miscommunication, violations, lapses, and the incorrect
understanding of protection limits. On average, these issues were placing railway staff at risk
between three and five times each week. In some cases, the public could also have been affected.
RAIB is aware that Network Rail is currently planning and implementing a major track safety initiative
known as ‘Planning and Delivering Safe Work’ (PDSW). The investigation has sought to understand
this and has established that Network Rail intends that PDSW will address a number of the safety
issues identified.
However, RAIB has observed that the initiative is currently only in the early stages of implementation
and that the envisaged benefits have yet to be demonstrated. It has also observed that the initiative
is intentionally focused on the roles of those working on site. This means that it will not have
significant benefits in areas where risks may be created by people in a number of other roles that are
important in safeguarding those carrying out work on the railway.
Recommendations

Network Rail should ensure that its post-implementation review of the planning and delivering
safe work initiative includes the collection of information on events that are indicative of
irregular working during infrastructure engineering work. It should then review this
information to verify that the initiative has yielded the benefits intended and, if not, to identify
and implement measures to remedy this.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Network Rail should develop an action plan to reduce the risk from the irregular application of
engineering protection arrangements by railway roles that are outside the scope of the current
planning and delivering safe work initiative (for instance signallers, persons in charge of the
possession and electrical control operators). As a minimum, consideration should be given to
ways of reducing the likelihood of:
o
Protection being set up when lines are open to traffic;
o
Errors when arranging for work to be carried out on or near electrical traction supply
equipment;
o
The signalling of trains into protected areas; and
o
Irregularities involving the operation of level crossings within protected areas.
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Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk