Elsenham crossing:
a wholly avoidable accident
. . . what can we learn from a serious incident in another sector?
Cranfield Healthcare Management Group
Research Briefing
9
How do they manage?
a study of the realities of middle and front line management work in healthcare
David A. Buchanan: March 2011
Elsenham crossing
On 3 December 2005, Olivia Bazlinton (14) and her friend
Charlotte Thompson (13) were heading out to do some Christmas
shopping. When they reached Elsenham railway station, the level
crossing barriers were closed for an approaching train. The
warning light was red, and the ‘yodel alarm’ was sounding. Their
train to Cambridge had just arrived and stopped in the station. The
girls knew that they were late, and they had been delayed buying
their tickets. Excited and in a hurry, they opened the unlocked
pedestrian wicket gate and ran across the track. They were struck
by the Birmingham to Stanstead Airport express, which was
travelling at speed on the other line. Both died instantly. The Essex
coroner’s inquest in 2007 reached a verdict of accidental death.
How did this tragic local accident become a national ‘rail scandal blunder’? Network Rail (private
company) was responsible for the crossing. In January 2011, a risk assessment from 2002 was found
among legal papers relating to a civil case that Network Rail decided not to defend. The assessment
recommended that, ‘consideration should be given to the practicality of incorporating the wicket gates
into the interlocking of Elsenham crossing controls and effectively lock them closed when trains are
approaching’. This was not done. When they were shown this risk assessment, relatives assumed that
it had been deliberately withheld to protect the company’s reputation. Charlotte’s father concluded,
‘this was a wholly avoidable accident’. If the gates had been locked, the girls would have been safe.
The events that occurred before, during, and after this incident show a common pattern, which is seen
in different incidents, in other sectors. Exploring this pattern may help to develop our understanding
of such events, particularly with regard to the conditions that can respectively encourage and inhibit
the actions and changes that would help to prevent or limit future harm.
Immediate and underlying causes
Why did this accident happen? The incident was the subject of two formal inquiries, by the Rail
Safety & Standards Board (RSSB), and the Rail Accident Investigation Branch (RAIB), and a
coroner’s inquest. All concluded that the immediate cause of the accident was the girls ignoring the
red light and audible alarm. Three underlying causes were also identified:
1.
that the gates could be opened when it was not safe to do so
2.
the need for Cambridge passengers to buy their tickets on the ‘up’ platform before crossing
back to the ‘down’ platform, as the girls had done
3.
regular misuse of the crossing by other (older) users, which the girls, who were familiar with
the station, would have witnessed
After the accident, when the gates were temporarily locked, users were still seen climbing over the
gates and barriers, against the visible and audible alarms, in sight of floral tributes, and contrary to
warnings from railway staff. The RAIB noted in its report that around 96 per cent of risk at level
crossings arises from the actions of users. The occurrence books kept by the crossing keepers
recorded 303 cases of misuse between 1999 and 2005. Some keepers kept better records, so that
number understates the problem. One crossing keeper was subjected to verbal abuse on four occasions
in the two years before the accident, when he had tried to point out the dangers.
There were no technical failures contributing to this accident. The main explanations lay with the
immediate human factors, with ‘motivation and distraction’. The crossing equipment was in good
working order, as were the trains. There was nothing that the driver of the Stanstead express could
have done to avoid hitting the girls. To understand why this incident was still making national news in
2011, we need to look more closely at the event sequence narrative - at the timeline.
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Incident timeline
This incident event sequence covers four periods, each suggesting a different management orientation:
1 background: 1989 - 2005 [management in anticipation mode]
November 1989
An elderly woman is killed at Elsenham - ignores the warning signs, walks onto the tracks, and
is struck by a train; minor changes to layout and signage; both inquiries later mention this
May 2002
Network Rail risk assessor recommends that pedestrian gates at Elsenham should have
automatic locks which activate when trains approach; recommendation not adopted
1994 - 2005
There are 124 accidental deaths, mostly older people, on Network Rail infrastructure, 86 of
which involve pedestrians, none at station footpath crossings with warning lights
April 2005
Elsenham gets a risk assessment score of 28, meaning no action required to improve safety;
crossing keeper does not inform assessor about frequency of misuse of the crossing
November 2005
Network Rail Safety Management Information System logs three near misses in the past two
years at Elsenham; marked for review by company risk management group, but not urgent
2 incident and inquiries: 2005 - 2006 [management in reaction mode]
December 2005
Charlotte Thompson and Olivia Bazlinton are killed when they open the pedestrian gate at
Elsenham crossing and step into the path of the Stanstead Express; two days later, a new risk
assessment gives a score of 47, requiring measures to be taken
May 2006
RSSB inquiry attributes cause of accident to the girls’ behaviour, unlocked gates, the location
of the ticket office, and the visible misuse of the crossing by other members of the public
December 2006
A wider-ranging RAIB inquiry into crossing safety notes the risk at Elsenham is among the
highest in the UK; recommends assessment of risk management across the network, the locking
of pedestrian gates for approaching trains at Elsenham, and the construction of a footbridge
3 incident closed [management in implementation mode]
January 2007
Parents put a banner at the crossing to
highlight the failure to install automatic
locks on the pedestrian gates
January 2007
After a five day hearing, the jury in the
coroner’s inquest reaches a verdict of
accidental death; the 2002 risk
assessment is not disclosed in evidence
August 2007
Network Rail opens a footbridge over
the track at Elsenham crossing and
installs locking gates
4 incident reopened [management in damage limitation mode]
December 2010
Civil case against Network Rail ends when no defence is given; company settles compensation
with families out of court; a copy of the 2002 risk assessment is found among legal papers
January 2011
The families see the 2002 assessment; The Times reports, ‘scandal of a rail blunder’; comment
shifts to the organization culture of ‘pressure and fear’ at Network Rail, and risk assessment
methods which are not ‘suitable or sufficient’. Charlotte’s father says, I want people named
February 2011
The Office of Rail Regulation explores whether Network Rail breached health and safety law could lead to criminal action; Olivia’s father writes to Transport Secretary asking for a full inquiry;
Network Rail’s new chief executive pledges to restore trust in the company’s safety record
The involvement of several organizations, no shortage of complex safety legislation, regulations,
standards and guidelines, multiple inquiries and recommendations, media influence, focus shifting to
organization culture and management practices - these are common features of such incidents.
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Timeline features, management questions
From a management perspective, there are five other common key features of the timeline in this case:
brief incident,
lengthy timeline
- over 20 years, from 1989 to 2011; from the time the girls arrived at the ticket office
until they were struck by the train, less than 10 minutes had elapsed
known risks,
slow actions
one previous fatal accident, three recent near misses, routine unsafe misuse of the
crossing; but improvements not seen as urgent, and changes take years to implement
accusation,
counter-claim
Network Rail was accused of withholding a key document; the company says it gave the
risk assessment to the coroner, and to family lawyers who did not act on it
give me names
those affected wanted to identify individuals to blame and to punish
newspapers write
your script
journalists want a clear, strong, simple, sensational story; what the company did or did
not do is less important now than what the media can say that the company did
regulations said that wicket crossing gates should not be locked, as users could be
trapped on the tracks, increasing accident risk; The Times reports omitted this detail

Do you need to look beyond the immediate incident, to distant events that still carry lessons?

Will failure to act, given weak but consistent cues, attract more criticism than actions that fail?

Are you prepared for public scrutiny of your internal documents, methods, organization culture?

How will you respond when others commit the fundamental attribution error, blaming
individuals while ignoring the context that influenced their behaviour?

Can you manage the flow of information to the media to give you some control over your script?
If you have a view on any these issues, please let us know.
***********************************
Sources
Pank, Philip (2011) ‘Scandal of a rail blunder that allowed girls to die at level crossing’, The Times, 12 February, pp.4-5.
Rail Accident Investigation Branch (2006) Rail Accident Report: Investigation into Station Pedestrian Crossings: With
Reference to the Fatal Accident at Elsenham Station on 3 December 2005, RAIB Investigation Branch,
Department for Transport: Derby.
Rail Safety & Standards Board (2006) Formal Inquiry: Two Girls were Struck and Fatally Injured by the 07.24hrs
Birmingham New Street to Stanstead Airport Train on the Station Footpath Crossing at Elsenham on 3 December
2005: Final Report, Rail Safety & Standards Board: London.
Thompson, Reg (2011) ‘My daughter paid with her life for the cost of two locking gates’, The Times, 14 February, pp.12-13.
The research
This part of the study is based on the analysis of cases of how changes are managed following serious incidents.
Project team
Prof David A. Buchanan (PI)
Dr Charles Wainwright
Prof David Denyer
Dr Clare Kelliher
Ms Cíara Moore
Dr Emma Parry
Dr Colin Pilbeam
Dr Janet Price
Prof Kim Turnbull James
Dr Catherine Bailey
Dr Janice Osbourne
Acknowledgements: The research on which this briefing is based was funded by the National Institute for Health Research
Service Delivery and Organization programme, award number SDO/08/1808/238, ‘How do they manage?: a study of the
realities of middle and front line management work in healthcare’.
Disclaimer: This briefing is based on independent research commissioned by the National Institute for Health Research.
The views expressed are those of the author(s), and not necessarily those of the NHS, the National Institute for Health
Research or the Department of Health.
For further information about this project, contact Jayne Ashley, Project Administrator
T:
01234 751122
E:
J.Ashley@Cranfield.ac.uk
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