Rail investigation summaries
These are a collation of some of the world’s railway formal inquiry reports. They include a brief incident synopsis, along with the main causes and recommendations from each investigation.
Readers may find some of the actions and recommendations useful to their own operations.
The summaries are co-ordinated by Greg Morse, Operational Feedback Specialist, RSSB.
Learning from incidents
Where available, key learning points from live investigations of worldwide rail incidents are available exclusively to RSSB members. For some incidents and issues, summaries are made available to all.
Learning from operational experience in 2015-6
We used to produce an annual report on learning from operational experience, aimed at rail employees, passengers, the government, and the public at large. Learning points from incidents on railways at home and abroad, as well as other industries, all hold potential transferable safety lessons for Network Rail, train and freight operators, infrastructure contractors, as well as the government and regulator.
This can be used by our members to improve their safety management systems and manage risk better. It is deliberately written in a more conversational style, in order to help the stories it tells and the learning points it raises stick in the minds of the readers.
Lives were saved in the last fatal passenger train accident at Grayrigg 10 years ago, thanks to the crashworthiness of the train involved and the laminated glass used in its windows, which prevented the ejection of passengers, and which was the culmination of significant in-depth research and learning.
The 10th anniversary is the ideal moment to publish our latest annual learning report. 10 years without a fatality to passengers of workforce in train accidents is unprecedented, but the risk of an accident is still there, and so retaining the appetite to look beyond the numbers and learn from incidents remains a crucial part of the approach to safety on Britain’s railways.
Summary of learning points in 2015/16
Though the risk from signals passed at danger (SPADs) is low, the incident at Wootton Bassett on 7 March 2015 showed that industry cannot afford to be complacent, cultural issues being demonstrably able to negate the effects of technology if unchecked.
- The risk from freight train derailments is low, but an incident still a possibility, so a Cross-Industry Freight Derailments Working Group is seeking to find ways to reduce underlying issues around track and wagon condition.
- Two incidents in 2015 revealed that an illuminated traction interlock light does not necessarily mean a passenger train is safe, a lesson that had in fact already been learned after a similar incident in 1989.
- Incidents in and around engineering possessions are informing new guidance, as well as supporting better messages about driving at caution.
- Most level crossing risk arises from user behaviour, but recent reports and incidents highlight questions around crossing design and signaller error in addition.
- A range of other issues are covered including fatigue, road driving risk, the balance between safety and delivery, and mental health and wellbeing.