Formal Inquiries

Glen Douglas report and recommendations

Rail Safety and Standards Board has issued its formal inquiry report into the circumstances that led to the collision. 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 Thursday 12 June 2003, 5Z60, 0316hrs Carnforth to Fort William Yard operated by West Coast Railway Company Ltd, arrived in the Down loop at Glen Douglas at approximately 1507hrs, to make a scheduled crossing with 1Y24, 1320hrs Oban to Glasgow Queen Street operated by ScotRail.

After 5Z60 came to a stand in the Down loop, the train was declared to be clear inside the Down loop at 1509hrs.

1Y24 1320hs Oban to Glasgow Queen Street then arrived in the Up loop at Glen Douglas at 1511hrs and then departed towards Garelochhead at approx 1512hrs.

As 1Y24 departed from the Up loop, it collided with the rear of the last vehicle of 5Z60, which was standing foul of the south end connection between the single line and the Down loop. 1Y24 subsequently came to a stand on the single line, having suffered damage to the body sides of both its two coaches, at approximately 1513hrs.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the rear vehicle of 5Z60 being 9.5m outside the fouling point marker of foul of movements along the Up loop, this resulted in the collision between 1Y24 Oban to Glasgow Queen Street and 5Z60 Carnforth to Fort William Yard. Futhermore, 5Z60 was declared to be clear of the single line, when it wasn’t.

Underlying causes were found to be:

• 5Z60 was driven by an unauthorised member of staff who was not certified as competent to do so.
• Safety critical communications were handled by an unauthorised member of staff.
• Safety communication protocols laid down in the rule book (section A 5.2) were not obeyed by some members of staff.
• It was not recognised that the rear vehicle of 5Z60 was outwith the fouling point marker and foul of the line the train was one.
• Instructions relating to advising the signaller of train lengths.
• Action was not taken to ensure the effective maintenance of the fouling point markers and ensure their visibility by effective vegetation control.

Recommendations

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

• A review of procedures for controlling access to locomotive cabs and planning train crew rosters in respect of hours on duty exceedences.
• Daily advice notices for special trains should show the actual train length.
• Group Standard GK/RT0054 lineside operational safety signs should specify the form, shape and colour of fouling point markers.
• Group standard GK/RT0054 Radio Electronic Token Block should mandate the use of fouling point markers at crossing loops and other locations where running movements could come to a stand foul of adjacent running lines. GK/RT0054 should be reviewed to make sure that it meets current operational needs and practices.
• Training for train planners on RETB lines should be status as other train signalling regulation and become a group standard. Provisions to be made for the maintenance of fouling point markers on RETB controlled lines, including adequate vegetation control to ensure their visibility from any location within the crossing loop area.

Rail Safety and Standards Board 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. Rail Safety and Standards Board will track the industry's response to this report.