May 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: Passenger train derailment near North
Melbourne, Victoria, 11 July 2014
UK: Runaway and collision near Loughborough Central
station, Great Central Railway, 12 May 2014
UK: Fatal accident at Frampton level crossing, 11 May
2014
Lougborough
Some of the key issues raised and/or suggested by the stories in this edition:
Track design, testing and commissioning
Train stabling
Staff competence
Management check function
User behaviour
Level crossing signage
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
14 May
Australia: Passenger train derailment near North Melbourne, Victoria, 11 July
2014
For the full report, click here: LINK
On the morning of 11 July 2014, an XPT passenger
service was travelling from Sydney to Melbourne.
At Broadmeadows, a pilot boarded to provide route
familiarisation training for XPT drivers who were
working over a newly commissioned section of dual
gauge track leading in and out of Southern Cross.
At about 07:38, the train entered the dual gauge
‘Up’ flyover and passed over a mixed gauge turnout
(MYD882), which was part of the newly
commissioned layout. While certified for standard gauge revenue operations earlier that week, it had
not been used by XPT services until the day of the derailment.
As the train traversed the turnout at 8 km/h, it bounced heavily. The pilot described it as ‘a short
sharp dip in the track, similar to a short deep bog hole [mud hole]’ and explained that if the train
hadn’t kept rolling, he would have thought they had derailed.
The pilot immediately rang Southern Cross No 1 signal box and reported the occurrence. The ‘box
advised that a track inspection would be arranged. The train continued into Southern Cross, where it
was fuelled and joined by passengers and new crew, in readiness for the return journey to Sydney.
While the report had prompted the scheduling of a track inspection, an examination of turnout
MYD882 and the rolling stock had not occurred at the time train left Southern Cross.
At about 08:30, the train travelled along the dual gauge ‘Down’ flyover on its way back to Sydney. As
it approached MYD987 signal, the driver observed a ‘clear medium speed’ with ‘S’ indication.
To the driver, this meant that the route ahead was correctly set and that the train could traverse
MYD887 mixed gauge turnout at the designated line speed of up to 25 km/h.
Shortly after 08:31, as the train traversed the turnout at 22 km/h, the driver and pilot felt several
large jolts, followed by a series of fault indications on the driver’s display screen as the train came to
a standstill.
As a result of the derailment, there were minor injuries to some passengers and the train’s crew, as
well as damage to track and rolling stock.
The Australia Transport Safety Bureau (ATSB) found that the derailment occurred at a ‘type 37’ mixed
gauge turnout, as the wheelset of a carriage transitioned from the standard gauge short stock rail on
to the broad gauge switch blade. It was determined that there were design deficiencies of the type
37 turnout with respect to transfer area width, guard rail protection, and capacity of the tie bar to
resist elongation, that contributed to the derailment.
Earlier that morning, the same train derailed at a similar type 37 mixed gauge turnout (MYD882) but
re-railed a short distance later. The train crew felt the train bounce but were unaware that it had
derailed, so continued into Southern Cross Station. The incident was reported to operational staff
and the track was being inspected at the time ST24 derailed at turnout MYD887.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Post-derailment, an examination of the type-approved design of the type 37 turnout determined that
it was lacking, in that it had been assumed that the type 37 turnouts would perform safely in service
based solely on the performance of a similar (type 29) dual gauge turnout, although there were
significant differences between the two turnout types.
The ATSB determined that there were no maintenance deficiencies with the train that contributed to
the derailment.
Action taken
The operator – V/Line – has actively managed the redesign, alteration and validation of the type 37
turnout to support the safe operation of standard gauge rolling stock having wheel rim widths of 127
mm, including a comprehensive review of contractual arrangements, testing and commissioning
processes.
Safety message
Proposed infrastructure changes, including those put forward by contractors, need to be thoroughly
assessed at the design stage to ensure that they meet all operational and safety requirements.
Once constructed, infrastructure needs to be rigorously tested as part of the commissioning process
to ensure that the changes are safe and perform to the original design intent.
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21 May
UK: Runaway and collision near Loughborough Central station, Great Central
Railway, 12 May 2014
For the full report, click here: LINK
At approximately 12:35 on 12 May 2014,
an unmanned train ran away for around
1.8 miles before colliding with a set of
unattended coaches near Loughborough
Central, on the Great Central [heritage]
Railway (GCR). No public train services
were being operated on the day of the
accident.
Nobody was injured as a result of the collision, although significant damage was sustained by some
of the vehicles involved. The train had been previously left unattended within a possession on a main
line opposite Quorn signal box. The railway here is on a gradient that descends towards
Loughborough.
The train that ran away consisted of a Class 37 coupled to a single coach. RAIB found that, before it
was left unattended, the air brakes on the locomotive had been applied by the driver and a single
wheel scotch had been positioned by a member of staff. The handbrakes on the locomotive were not
applied. The coach was not secured with either brakes or a wheel scotch.
RAIB concluded that the train ran away because the wheel scotch was positioned against the
locomotive’s wheel in a way which made it ineffective. The handbrakes on the locomotive, had they
been used, would have provided enough braking force to have held the train. The driver did not
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
apply the locomotive’s handbrakes because he believed they were not effective on this class of
locomotive. He thought the wheel scotch would provide enough braking force, should the pressure in
the air braking system leak away. The driver may also have been influenced by the prevailing
practices on the railway which related to the use of handbrakes.
The train was not left in a location where it would have been protected from running away by the
arrangement of the infrastructure. This was probably because the staff involved thought these
locations were either not available or needed disproportionate time to access. It may also have been
because they had a reduced perception of the risks of leaving trains unattended outside these
locations.
RAIB found that checks by the GCR’s managers did not detect the full-extent of the unsafe and noncompliant practices present within possessions. The investigation also found that some of the rules
relating to the way in which rail vehicles were to be left unattended were inconsistent and
potentially unclear.
RAIB identified two key learning points, as follows:

The movement of trains not fitted with a continuous automatic brake or which do not include
a brake van under the control of a guard as the rearmost vehicle should be avoided due to the
possibility of a vehicle without operational brakes running away following a coupler failure.

Safety critical activities (such as the movement, shunting and stabling of trains) must be
undertaken by an adequate number of staff holding the correct competencies.
Action taken
On 17 May 2014, the GCR issued a bulletin entitled ‘Vehicles left on running lines’. This stated the
following;
‘All crews are reminded that trains must not be left on running lines unless absolutely necessary. In
other words when there is no alternative e.g. an emergency situation.
If it is necessary for a train or vehicles to be left unattended on a running line, ALL handbrakes must
be fully applied AND the wheels securely chocked in both direction to prevent movement…
The permission of the DTM [Duty Traffic Manager] must be obtained before any locomotive, vehicle
or train may be left in these circumstances.’
The requirements of the GCR Rule Book regarding the use of T3 possessions for train movements are
now being enforced and that only engineering train movements required in connection with the
work being undertaken are being permitted. In addition, a process has been introduced so that any
request for a possession must be submitted (along with a justification) to the operations manager for
approval at least 72 hours prior to its planned implementation, excepting emergencies.
The GCR introduced a new process which requires any additional train movements (ie those not
included within the working timetable) to be approved by the operations manager, who will also
ensure that an adequate number of staff holding the correct competencies are appointed to crew
them.
The GCR’s signaller rosters have been re-arranged to increase the number of signallers available in
the mid-week period. In addition, three full-time members of staff are undergoing training as
signallers, in order to provide further resilience.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
The GCR has reviewed the requirements for fitness to run examinations of diesel locomotives and
has now implemented changes to ensure that these examinations include any locomotives used on
non-passenger services and a check on the functionality of the handbrake.
Recommendations

The GCR should review those parts of its Rule Book, General Appendix and any other
instructions which relate to leaving trains or vehicles unattended. This review should consider
whether the rules and instructions contained within these documents are clear and consistent
and if they adequately address all of the risks involved in trains and vehicles being left
unattended. The review should specifically examine the use of handbrakes and wheel scotches
and the stabling of vehicles within locations which offer runaway protection. The GCR should
implement any changes identified as being necessary as a result of this review, and should
ensure that suitable briefing and training accompanies any changes which are implemented.

The GCR should review the arrangements currently in place which are intended to ensure that
the safety management system, rules and procedures are functioning as intended. This review
should ensure that these arrangements are suitable and able to identify any future noncompliances to policy, rules and instructions similar to those identified by this investigation.
The review should specifically ensure that arrangements remain effective during periods when
train services are not being run for the public and that the results of all inspections and audits
are recorded. The GCR should implement any changes identified as being necessary as a result
of this review.

The GCR should review the arrangements currently in place which relate to the training and
assessment of staff in order to ensure that they are effective at ensuring employees (including
volunteers) are fully competent to undertake their duties. This should specifically include roles
relating to the shunting of trains and the management of possessions. The GCR should
implement any changes identified as being necessary as a result of this review.

The GCR should review the arrangements currently in place by which it ensures that diesel
locomotives operating on its infrastructure are being maintained in a way which adequately
addresses the risks posed by the potential failure or reduced reliability of components and
systems. This review should specifically consider the maintenance of braking systems. The
GCR should implement any changes identified as being necessary as a result of this review.
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28 May
UK: Fatal accident at Frampton level crossing, 11 May 2014
For the full report, click here: LINK
At around 18:45, a passenger train approaching Frampton
Mansell, Gloucestershire, struck a motorcycle on
Frampton level crossing. The rider of the motorcycle was
fatally injured. The train did not derail, and there were no
injuries to anyone on board.
The rider was crossing the railway on a trail bike. He was
the last of a group of three who had reached the crossing
along an unsurfaced track leading from a minor road near
Sapperton.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Signage on the approach to the crossing instructed vehicle users (which would include trail bike
riders) to use a telephone located close by. This allowed the signaller to tell users whether it was safe
to cross the line or not. The riders did not use the telephone because they believed that they could
cross safely by looking for trains before crossing, and because the signs did not grab their attention
sufficiently for them to read the information on them.
The riders did not know that a curve in the line meant that they could not rely on seeing an
approaching train early enough to decide whether it was safe to cross. The train’s warning horn was
sounded as it approached, but the trail bike riders could not hear this because they were wearing
full-face crash helmets and their trail bike engines were noisy. Network Rail had received some
information that trail bikers were using the crossing, but had not taken effective action to manage
the associated risk of unsafe use.
Although permitted to use vehicles on both approaches to the crossing, the trail bike riders were
unaware they were not among the people permitted to use vehicles on it. The signs giving
instructions to vehicle users did not explain this, and there was no other indication at the crossing, or
on the approaches. There was no requirement for signs or other indications to be provided by
Network Rail, or any other organisation, to indicate that the general public were not permitted to
take vehicles onto the level crossing.
RAIB identified the following learning point:

It is important that train drivers sound the warning horn when passing whistle boards as
described in Railway Rule Book module TW1, and not before reaching them. Whistle boards
are intended be positioned to provide an optimal warning for crossing users. Sounding the
warning horn earlier means that the warning is less audible at the crossing and may not be
noticed by crossing users.
Action taken
Gloucestershire County Council has said it intends to provide highway signs on the approaches to the
level crossing to inform members of the public about the vehicular restriction that applies at the level
crossing.
It has also annotated its highway record to highlight that public vehicular rights were removed from
the level crossing on the route between Frampton Mansell and Sapperton, by virtue of the British
Railways Act 1970.
Network Rail has repositioned the signs at Frampton crossing. The ‘Stop. Look. Listen’ sign, and the
instructions about the user worked crossing gate, have been mounted on a post positioned 3 metres
from the Up Kemble line. It has also fitted signs at the level crossing that say ‘Level crossing closed to
motorised vehicles except for farm traffic’ and is intending to prepare a brief for relevant
organisations to raise awareness of the vehicular restrictions at Frampton crossing.
In November 2014, RSSB published research into traffic signs and signals at public road level
crossings (research project T756). This project looked at the effectiveness and comprehensibility of
existing road traffic signs and signals on the approach to public road level crossings. This report is not
directly relevant to the accident at Frampton level crossing because it is not a public vehicular level
crossing. However, it is likely that some of the learning from this research will apply to other types of
level crossing, including bridleway and footpath crossings.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
RSSB is currently undertaking research into signs at private road level crossings (research project
T983). This is considering the types of signs that should be presented to road users at level crossings
on private roads, including those at field-to-field level crossings. The project is exploring which signs
and signals best convey the particular points of information that road users need when approaching
these crossings. The report is due for publication in 2015. Again, this research is not directly relevant
to the bridleway element of Frampton level crossing, but it is likely that learning from this report
would also apply to bridleway and footpath level crossings.
Recommendations

Network Rail should identify locations where level crossing sign positions differ significantly
from the requirements of guidance and standards, and then install signs at the appropriate
location, unless the proposed position of the signs is contrary to recent research.

Network Rail should utilise the findings from this investigation, and all available research
(including the forthcoming RSSB research report T983), to update its guidance for signage, and
other user guidance, provided at bridleway and footpath crossings. The updated guidance
should take account of circumstances where another type of level crossing is located at, or
close to, the bridleway or footpath crossing. It should also take account of prohibitions and
circumstances when it is appropriate for pedestrians to use a telephone. Network Rail should
also:
o
Liaise with the Office of Rail and Road (ORR) to ensure that its updated guidance is
compatible with the ORR’s own version of good practice; and
o
Seek the assistance of the Department for Transport to enable any necessary
legislative changes needed to implement the updated guidance.

The ORR should utilise the findings from this investigation, and all available research (including
the forthcoming RSSB research report T983), to update its guidance for signage, and other user
guidance, provided at bridleway and footpath crossings. The updated guidance should take
account of circumstances where another type of level crossing is located at, or close to, the
bridleway or footpath crossing. It should also take account of prohibitions and circumstances
when it is appropriate for pedestrians to use a telephone. The ORR should seek the assistance
of the Department for Transport to enable the necessary legislative changes needed to
implement the updated guidance.

The Department for Transport should work with Network Rail and the ORR, to identify any
appropriate legislative changes needed to allow implementation of the improved level crossing
signage sought by Recommendations 2 and 3. If required, the Department for Transport
should help make the necessary legislative changes.

Network Rail should modify its procedures, guidance and/or training in order to obtain, where
reasonably practicable, an improved understanding of actual crossing use (eg use of bridleway
crossings by motorcyclists), and take action to ensure it adequately controls the associated
risks. This should include considering use of social media (eg videos uploaded to internet sites),
evening and/or weekend site visits to identify recreational use of the crossing, and the use of
surveillance equipment.

Network Rail should identify level crossings where safety management depends on the general
public being aware that they are not allowed to use the level crossing with vehicles, including
cars, motorcycles and trail bikes. For these crossings, Network Rail should:
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
o
Liaise with the relevant highway authorities to ensure their highway records, and any
related documents and publications, clearly show the absence of a public vehicle
route at the level crossing;
o
Share information about prohibitions with local and national organisations
representing groups such as 4x4 vehicle drivers and trail bike riders; and
o
Arrange for signs to be provided on the highway approaches to the level crossing,
and at or near the crossing itself, to show the prohibition that applies (taking into
account Recommendations 2 and 3).
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Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk