Formal Inquiries

Dalston Junction report and recommendations

Railway Safety has issued its formal inquiry report into the signalling irregularities at Dalston Junction on 14 August 2002.

The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

On 14 August 2002 a signaller at Dalston Junction authorised a passenger train to proceed past a red signal (D24) located at the west end of the platform at Hackney Cental. Arrangements were in place at the time to manage trains whilst an intermittent failure of a track circuit was present ahead.

Rather than proceeding in the direction anticipated, the train crossed over at the points and was brought to a stand on the opposite line with a freight train directly ahead of it.

The passenger train was set back to its previous position. The signaller then authorised the passenger train to pass D24 (at red) again.

There was some delay before the move was made whilst the driver contacted his control to inform of the incident. During this time the signaller gave the passenger train as being out of section and authorised another freight train into the section even though it was in fact still occupied.

The driver of the freight train, realising the danger, applied the brakes and came to a controlled stand approximately 50 metres to the rear of the passenger train.

There was no damage or injury arising from the two incidents.

Conclusions

The formal inquiry panel concluded that the immediate causes of both incidents were due to failure of the signaller to follow the requirements of the Rule Book, incorrectly setting the points, failure to confirm that the correct route had been set for the passenger train, failure to report the first incident immediately and failure to check that the section had become clear. These in turn were caused by concentration failure in the first instance and the signaller becoming flustered and over keen to resume normal movement in the second.

The panel also considered that the driver failed to observe the line ahead and alter speed of the train accordingly.

The panel also identified a number of underlying causes which may have contributed to the incident:

• Deficiencies in the selection, training and assessment processes for signallers particularly with regards to operating in abnormal circumstances and in specific locations.
• Inadequate assessment of this signaller.
• Environmental contamination of equipment in this area leading to intermittent failures, having adverse affects on the attitudes of signalling and infrastructure staff.
• Delay between the second authorisation to pass the signal and the movement itself.

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows:

• Review of processes for selection training and assessment of signallers, to include box specific assessments for working in abnormal situations.
• Review of working methods including the use of route cards.
• Review of training of drivers to include knowledge of applicable sections of the Rule Book .
• Review of processes for ensuring the reliability of signalling equipment and aids to signallers.
• Review of Rule Book centred on the delay between drivers being authorised to drive trains past signals and movements taking place.

Railway Safety has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. Railway Safety will track the industry's response to this report.