Formal Inquiries

Dr Day's Junction report and recommendations

Railway Safety has issued its formal inquiry report into the circumstances that led to a SPAD and subsequent run through points, by a St Blazey to Bescott freight train, at Dr Day's Junction on 31 July 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

The driver of 6M72, a freight train owned and operated by English Welsh and Scottish Railway Ltd (EWS), had been about to leave his train, at Bristol Temple Meads for relief, when he was asked by a signaller to move his train forward in order to clear the line for an 'exceptional loads' train.

Having agreed to do this, the driver departed from signal B51 set to green and then passed signal B57 at yellow.

At approximately 2043hrs, 6M72 passed signal B131 at danger at Dr Days Junction. Signal B131 was protecting a crossing movement by another train although there was no collision. Having passed the red signal 6M72 failed to stop, and continued to run through No.847 points.

The signaller sent an emergency stop signal via the National Radio Network (NRN) system but the driver did not react to this.

The train was finally stopped 0.8km further on when a ground frame operator, who had been contacted by the signaller, 'Flagged-down' the driver of the train using his high visibility vest.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the failure of the driver of 6M72 to respond correctly to a previous signal and associated automatic warnings.

The panel also concluded that there were a number of underlying causes of the accident, summarised as follows:

• Substantial and systemic failures in the employer's selection and training regime.
• Failure of managerial processes to identify a lack of capability of drivers to retain detailed information.
• Pressure experienced by the driver to meet operational expectations despite being ill prepared.
• The driver's sub-conscious expectation to receive a through route having received a green starting signal which may have prompted him to cancel AWS warnings.

Recommendations

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

• Review driver training arrangements to include structured route learning, identification of individuals' capabilities, and pre and post qualification assessment.
• Review the instructions for using NRN in emergencies.
• Single telephone keypad depression for emergency calls to the Railtrack Zone Control.
• Review the adequacy of actions taken by the company in response to recommendations from previous inquiries.
• Review existing drivers to ensure that those trained under revised arrangements but before the use of simulators are suitably trained and competent.

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.