Formal Inquiries

Norton Bridge report and recommendations

Rail Safety and Standards Board (RSSB) has issued its formal inquiry report into the circumstances that led to the collision involving two freight trains at Norton Bridge, Staffordshire, on 16 October 2003.

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

Considerable infrastructure renewals work was planned for the Norton Bridge area as part of the West Coast Route Modernisation Project and, at the time of the incident, a major blockade of lines between Norton Bridge and Crewe was underway.

Because of this blockade, only one of the four tracks between Norton Bridge and Crewe was open to traffic. However, a short emergency possession of the line of approximately 20 minutes had to be taken around 0300 hrs. The requirement was for trains to be detained at Norton Bridge awaiting line clearance. The possession was later extended to an hour.

The signals were used to stop trains and freight train A was brought to a stand at approximately 0308 hrs and its driver (A) advised of the situation. Almost immediately, the signaller heard a very loud bang. Driver A had been standing in the doorway and was making his way back to his seat when he experienced a violent shunt forward which threw him off balance.

The driver of train B, which had collided with the rear of train A, was physically unhurt in the incident, but had to be released from his cab by the fire service. He advised the Norton Bridge signaller of the incident, and the signal aspects he believed he had received.

Conclusions

The formal inquiry panel concluded that the immediate cause of this accident was the failure of driver B to respond appropriately to the cautionary aspects at NB152 and NB151 signals, leading to signal NB149 protecting train A being passed at danger without authority.

The panel also concluded that driver B may have been distracted and influenced by the following:

• Fatigue due to his working hours in previous weeks.
• Complacency due to his long experience of driving.
• Expectations of proceed aspects, having no recollection of receiving restrictive aspects previously at Norton Bridge.
• Previous involvement in a signal passed at danger (SPAD).

The panel also considered the emergency T(iii) possession, details of which could not be published or advised of in advance to be a contributory underlying cause, creating the circumstances requiring trains to be detained at Norton Bridge.

Recommendations

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

• A review of those driver rosters, and actual working hours for driving turns, which are on or near the limit of the maximum permitted should be undertaken. Using methodologies such as the HSE Fatigue Index should be used to facilitate such a review.
• In respect of opening, or re-opening, lines to traffic after wrong side failure allegations, which may call into question the wider integrity of signalling, any new or overt requirement for positive assurance from the professional head of signalling should be clearly documented in the control manual.
• The current relevant documents held by the region relating to management of incidents – namely control manual, operations manual and emergency information manual – should be reviewed to provide a clear and consistent managerial framework for control staff.
• The arrangements for declaring the incident command structure should be reviewed in the light of the incident.
• The responsibilities of the rail incident officer (RIO), in respect of the care and welfare of staff involved in serious incidents, should be strengthened to require positive management of staff not physically injured.
• Arrangements for progressing managerial action and discipline following safety of the line incidents should be reviewed.

RSSB 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. RSSB will track the industry's response to this report.