June 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 Kimberly,
Tasmania, Victoria, 25 January 2015
UK: Track worker struck by passenger train at Redhill,
24 June 2014
UK: Train driver receives electric shock at Sutton
Weaver, 23 September 2014
Bulgaria: Passenger train derailment at Kaloyanovets,
12 July 2014
Sutton Weaver
Some of the key issues raised and/or suggested by the stories in this edition:
Asset management
Track maintenance
Wagon loading
Work planning
Safe systems of work
Lookout protection
Staff actions
Culture
Overhead line maintenance and renewal
SPAD
Train protection equipment maintenance
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
14 June
Australia: Freight train derailment near Kimberly, Tasmania, Victoria, 25
January 2015
For the full report, click here: LINK
At about 21:51 (local time) on 25 January 2015, a
freight train derailed near Kimberly as it traversed
an occupation crossing. As a result, 10 wagons
came off and 220 metres of track were damaged.
There were no reported injuries.
The train was travelling on the Western Line
between Railton and Deloraine, and consisted of
two locomotives hauling 28 wagons. The trailing
load was about 1,254 tonnes and total train length
(including locomotives) was about 460 metres.
The Australian Transport Safety Bureau (ATSB)
found that the track in the area had been subject to various speed restrictions since 2008. In June
2014, a temporary speed restriction (TSR) was put in place due to poor track condition – reducing
linespeed from 30 km/h to 20 km/h. An increased track inspection frequency had been implemented
with track patrols monitoring defect deterioration at 96-hour intervals.
However, post-incident track measurement identified a number of track geometry defects in the
vicinity of the occupation crossing. The defects consisted of a sequence of (vertical) track twists and
horizontal misalignments. The defects exceeded the limits specified in the TasRail Track and
Structure Maintenance Standard.
Regarding the rolling stock, the first wagon to derail was a QL class wagon. This is a container flat,
originally built to standard gauge, but converted for use on the TasRail narrow gauge system.
Wagon QLE23/P (the first to derail) was loaded with two, 20-foot equivalent standard shipping
containers. Each was loaded with general goods, with a gross mass of 18.5 tonnes and 22.4 tonnes
respectively. The load within each container was stacked uniformly to almost roof height. While the
load generally conformed to the requirements of the TasRail Freight Loading Manual, calculations
indicated that the load most likely exceeded the maximum centre of gravity limit of 1,700 millimetres
(above rail). All other components and parameters of wagon QLE23/P were within maintenance
limits.
The ATSB concluded that the sequence of track defects (twist and alignment) initiated harmonic body
roll of the QL class wagon. When combined with the high centre of gravity of loaded wagon QLE23/P,
the harmonic behaviour likely resulted in wheel unloading, promoting flange climb and the
subsequent derailment.
Action taken
As a result of this occurrence, TasRail has advised that it is taking the following action to reduce their
safety risk:

Suspending QL wagons from intermodal traffic, pending the outcome of investigation;

Maintaining a register of known track faults;
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

Measuring major track faults every 96-hour inspection of the infrastructure, for track
deterioration;

Reviewing current condition monitoring methods and frequencies, and implementing changes
to detect and manage similar defects to those observed at the derailment location;

Re-writing/updating the Freight Loading Manual regarding container loading restrictions and
what wagons are applicable;

Reducing the TSR speed where legacy wagons are in use and rail faults dictate; and

Checking/updating the TasRail Operational Risk Register.
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15 June
UK: Track worker struck by passenger train at Redhill, 24 June 2014
For the full report, click here: LINK
At about 10:41, a track worker was struck by a
passenger train travelling at about 80 mph near
Redhill. He was the leader of a team of 12 who were
fitting emergency clamp plates to lengths of rail
where cracks had been identified during an earlier
inspection. The accident happened on the top of an
embankment about ten metres high, on a section of
line where trains can travel at up to 90 mph.
The team were fitting plates to one of the two lines
at the site while trains continued to run on both.
They were protected by lookouts, whom the controller of site safety (COSS) had positioned at site
and some distance away on both sides of the site. This was to enable warnings about approaching
trains to be made in sufficient time for the team to stop work and move to a position of safety.
At the time the accident occurred, the work had been in progress for about 40 minutes. The other
members of the team had completed their work, and the team leader was taking measurements for
the lengths of replacement rail that would be required. The lookouts had warned the team of the
approach of a southbound train and, a short time after this had passed, and before the COSS had
given permission for anyone to return to the track, the lookouts gave another warning – for a
northbound train.
At about the time this warning was given, the team leader began to walk along the trackside, with his
back to the approaching northbound train. As he went, he moved closer to the Up Quarry line. As a
result, the train struck him on his right shoulder and threw him down the side of the embankment.
Other members of the team gave him first-aid treatment and called the emergency services. An air
ambulance helicopter also came, and landed on the railway in order to airlift the casualty to hospital.
He had suffered life-changing injuries.
RAIB found that the team leader did not remain in a position of safety until the train had passed, he
was unaware of the imminent danger from the approaching train, and his actions were not observed
by anyone else on site, so no other warning was given.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Furthermore, the work was being carried out while trains were running. There were also deficiencies
in the planning, choice and implementation of the safe system of work used on the day, which
suggest there to have been a weak safety culture at Network Rail’s Three Bridges maintenance
depot.
In addition, working under lookout protection was not prohibited at this location and the cess is
narrow and treacherous, and not suitable as a position of safety.
Regarding the emergency response, RAIB noted that the helicopter ambulance landed on the track
without permission from Network Rail, its pilot believing that the ‘mandatory advice’ he had been
issued with still gave him discretion on where to land. He judged that the situation was sufficiently
safe given the nature of the emergency, his analysis of the events he could see on the ground, and
the advice he received from his control authorities.
Although not linked to the accident, RAIB also observed that:

The working practice used by the lookouts to reduce the risk that the gang might return to the
track while a lookout was unsighted by a moving train is not documented in any of the railway
industry’s rules, instructions or training material; and

The assistance of a trained first aider was, in the opinion of medical staff on site, important to
the survival of the injured person. The implementation of Network Rail’s policy on the
provision of first aiders is inconsistent across the company.
RAIB has identified the following learning points, as follows:

Although some staff said they considered that they were working in an unsafe location, none
of them expressed their concerns to the COSS. It is important that Network Rail emphasises to
its staff that it is imperative, for everyone’s safety, for them not to work in dangerous
locations, and that they must voice their concerns when they consider the working
environment to be unsafe.

It is important that train operating companies periodically remind all drivers, as part of the
routine briefing process, of the Rule Book requirement to sound a warning to anyone who is
on or near the line on which their train is travelling, and that a warning sounded for the first
person they encounter may not be sufficient for the whole of a group which is spread out
along the line.

Being trained in first aid might enable someone to save a life. Participation in such training
might increase if railway companies provided incentives to encourage employees to become
qualified in first aid at work, and emphasised to their employees the potential value of this
qualification.
Action taken
Following the accident, Network Rail prohibited working under lookout protection in the area where
the accident occurred, where the embankment does not provide a suitable position of safety.
Network Rail issued a revised Letter of Instruction to control managers and operations managers,
stating that there are no exceptional circumstances in which helicopters are allowed to land on or
near the line. It has also asked the Civil Aviation Authority and the British Helicopter Association
Emergency Services Committee to re-brief crews in the sector that there are no circumstances in
which helicopters may land on or near railway tracks.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Recommendations

Network Rail should:
o
Review each section of line where work while trains are running is authorised, and
assess the availability and suitability of the locations that are required to be used as a
position of safety. Where these are found to be inadequate, Network Rail should
prohibit work while trains are running.
o
Ensure that staff responsible for establishing a safe system of work on site are
explicitly prompted to consider potential hazards that might call into question the
suitability of the position(s) of safety throughout the site (such as the number of
people required to use it/them, and whether the ground is reasonably level, in good
condition underfoot and free of obstructions) before permitting work to commence.

Network Rail should review its policy on first aid provision and the way it is implemented, so
that a consistent and appropriate level of first aid cover is provided for people working on or
near the line, taking into account the nature of the work and the environment in which it takes
place.

Network Rail should review the training of Controllers of Site Safety (or Safe Work Leaders)
(COSS/SWL) and lookouts relating to setting up work under lookout protection. This review
should cover the way which the lookout(s) and the COSS/SWL interact to confirm that it is safe
for the work group to go on or near the line (particularly after a train has passed), and should
include the definition of suitable methods by which lookouts may positively indicate to each
other and to the COSS/SWL that the lookout(s) are unsighted and that work may not resume.
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24 June
UK: Train driver receives electric shock at Sutton Weaver, 23 September 2014
For the full report, click here: LINK
At 19:04, a train driver received a severe electric shock at Sutton Weaver, Cheshire. He had stopped
his train having seen damaged overhead power supply wires ahead of it. Following a call to the
signaller, he left his train and came close to, or made contact with, an electrically live wire which had
broken and was hanging low. The driver suffered serious injuries.
This accident occurred because one of the overhead wires had broken, was hanging down and was
electrically live. Two previous trains had come into contact with this hanging wire and consequently
tripped the power supply circuit breakers. Each time, the circuit breakers had been reset by the
Electrical Control Operators in accordance with procedures to make the overhead wires live again.
The driver had left the train to obtain information as to his location to assist in restoring train
services as he was trained to do, but did not see the broken wire.
RAIB found that the wire broke as some of its strands had fractured due to fatigue, likely initiated
and progressed from a high-stress area related to an attachment supporting the overhead wire.
Following a review of the actions of those involved in attending to the injured driver, one learning
point has been made reminding train operators of the importance of contacting the signaller by the
quickest means in emergency situations.
RAIB found the immediate cause of the accident was the driver coming close to, or making
contact with, live, low hanging OLE.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
RAIB listed the following underlying factors:

Network Rail OLE inspections did not include detailed examination of the condition of the
auxiliary wire strands within protective sleeves to identify wire strand breakage or fatigue
precursor indications possibly present on the wire and/or the sleeve; and

The train driver left the train when the OLE was known to be damaged and was still electrically
live.
RAIB has identified one learning point:

This incident reinforces the importance of contacting the signaller ‘in the quickest way
possible’ and of providing regular refresher training for train crew in the use of the in-cab
GSM-R radio for emergency calls. It also highlights the benefits of GSM-R, especially when the
train driver is not able to take the lead in emergency communications.
Action taken
Network Rail conducted a high-level intrusive inspection of the auxiliary wire from Weaver to Ditton
junctions (approximately eight miles of double track) in October 2014. No auxiliary wire damage was
found but some protective saddles were realigned and some missing droppers were replaced.
Network Rail is currently conducting more detailed inspections of the OLE between Weaver Junction
and Wavertree (approximately eight miles of double track and nine miles of quadruple track). This
includes inspecting for damage underneath the protective sleeves. As of March 2015 it had replaced
six sections of auxiliary wire (by splicing in new wire), two missing protective sleeves, two missing
droppers and realigned 450 droppers.
Network Rail LNW has identified 28 single track miles of its infrastructure where Mk 1 compound OLE
could, if it fails, come into close or actual contact with members of the public, eg adjacent to station
platforms. It has told the RAIB that it plans to request investment authority to remove the auxiliary
wires in these sections so that this can be completed by April 2016.
On 24 September 2014 (the day following the accident) Virgin Trains issued a general operations
notice to all of its operational staff. This informed its drivers that if the OLE is known to be damaged,
they are to remain on the train until the OLE has been made safe to be approached, but not touched.
On 25 September Network Rail issued a Rule Book instruction reminder via the NIR-online system
(the UK railway’s national incident reporting system) reminding train crew and others working in
proximity to OLE, to treat it as live and not to approach unless assured that the electricity is switched
off.
Virgin Trains has reported to the RAIB that it has briefed its train managers on the use of the
emergency call function on the GSM-R radio and this will form part of future briefings.
Recommendations

Network Rail should revise its work instructions so that inspection staff are aware of what to
look for, including possible fatigue damage precursors as found during the metallurgical
examinations of this investigation, and during the inspections Network Rail has already carried
out.
It should produce a plan for the extension of its current detailed examinations of auxiliary
wires close to, and within, protective sleeves to identify and rectify broken and damaged wire
strands and protective sleeves on all of its Mk 1 compound catenary. Following this, its routine
inspections should include this additional examination.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk

RSSB should review Module AC of the Rule Book (GE/RT8000/AC) and appropriately clarify the
actions that train crew should take if they are required to leave their train in situations where
the OLE is electrically live, and may be damaged.
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29 June
Bulgaria: Passenger train derailment at Kaloyanovets, 12 July 2014
For the full report, click here: LINK
At 15:17 (local time) 12 July 2014, an express
derailed on points and collided with a bridge at
the throat of Kaloyanovets station.
The locomotive overturned and became detached
from the rest of the train. The first five carriages
also derailed. The driver was killed and seven
people were injured (three passengers and four
staff).
The resulting investigation found that the
accident had been caused by the driver
overspeeding, passing a signal at danger and
entering the points at 104 km/h, when the limit is 40 km/h.
The train was fitted with Automatic Locomotive Signalling (ALS), a protection system that applies the
brakes should a signal be passed at danger or a speed restriction go unobserved. The operating balise
associated with the signal passed at danger was not functioning correctly on the day of the accident.
Recommendations

Licensed railway undertakings should not allow drivers who are unqualified in the use of ALS to
drive trains equipped with it.

Licensed railway undertakings should take trains not equipped with ALS or with faulty ALS out
of service.

The Railway Administrative Executive Agency (RAEA) should amend the rules of technical
operation to prohibit the movement of trains not equipped with ALS or with faulty ALS.

The RAEA should amend the medical and psychological requirements for operating personnel,
such that psychological tests and examinations are carried out on staff who ‘caused railway
accidents’.
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Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk