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Rail Investigation Summary

​January 2018

This is a collation of some of the world’s railway formal inquiry reports. It includes 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.

Co-ordinated by Greg Morse, Operational Feedback Specialist, RSSB.


UK: Maintenance train runaway near Markinch, 17 October 2017

Australia: Near hit with detrained passengers at Kilbride, NSW, 22 May 2014

Australia: Locomotive fire near Cardiff, NSW, 4 April 2016

UK: Child nearly falling through missing toilet floor, South Devon Railway, 22 June 2017

Note that RSSB’s summary of RAIB’s report on the Sandilands tram derailment may be found here External link.

Some of the key issues raised and/or suggested by the stories in this edition:

  • Objects on the line
  • Braking system design

  • Vehicle acceptance

  • Evacuation rules and procedures

  • Management of organisational change

  • Roles and responsibilities

  • Fire risk (locomotives)

  • Locomotive maintenance

  • Safety management systems

  • Heritage operations.

11 January

UK:  Maintenance train runaway near Markinch, 17 October 2017

Full report External link

about 04:25 on Tuesday 17 October 2017, a multi-purpose vehicle (MPV) clearing leaf debris from the track struck a tree just north of Markinch station in Fife.

The impact disabled the braking system on the train, which came to a stand before running away (backwards) for around 4.7 miles. Its crew made an emergency call to the signaller before jumping clear (suffering minor injuries in the process).

The train came to a final stand at Thornton North Junction, after running back and forth between two adjacent gradients a total of nine times.

Freight train derailment at East Somerset Junction

RAIB found that the MPV's brakes had been fully released when debris from the tree operated the release mechanisms on the brake system distributors underneath both vehicles.

The driver was unable to reapply the brakes because the debris from the tree had also separated all three of the brake pipes between the two vehicles in the train.

An underlying cause was that the MPV had been approved for operation on Network Rail managed infrastructure with the brake distributor release mechanism vulnerable to operation by obstructions on the track.

Action taken

Network Rail issued a Rail Notice on 20 October 2017, outlining the circumstances of the runaway and reminded Network Rail's operations managers of the need to make specific consideration of the risk of collision with obstructions during adverse weather conditions. The notice highlighted that this is a particular risk where a train is the first to operate over a route for some time. It recommended that where this risk is identified, consideration should be given to requiring trains to run at speeds where they can stop short of any obstructions.

Network Rail then issued a National Incident Report on 10 November 2017. This gave details of the mechanism by which the brakes on the train were disabled and highlighted that the mechanism was a particular hazard on short train formations. It also indicated that it could affect other types of On-Track Machines (OTMs). The notice said that Network Rail was considering options to protect the brake distributor release mechanism from impacts with objects or debris on the track.

The company has also reported that it is reviewing the design of MPV brake distributor release mechanism arrangements in light of this accident, to determine if there are effective measures that could be taken that would address the risk from runaway without introducing other risks. Network Rail is reconsidering the suitability of such a design for similar, future short-formation trains.


  • Network Rail should identify and implement suitable measures to mitigate the risk from runaways initiated by multiple unintended operations of the brake distributor release mechanisms on its MPVs by objects and debris that might reasonably be encountered on the track during operation.

    This recommendation may also apply to other infrastructure managers and railway undertakings who own and/or operate similar short formation trains.
  • Network Rail should assess the risk of runaway on other short formation trains that operate on its infrastructure, such as On-Track Machines, as a result of a total loss of the air braking systems due to impact from objects and debris that might reasonably be encountered on the track. It should implement any necessary measures to mitigate the risk of runaway.

    This recommendation may also apply to other infrastructure managers and railway undertakings who own and/or operate similar short formation trains.

16 January

Australia: Near hit with detrained passengers at Kilbride, NSW, 22 May 2014

Full report External link

At 11:37 (local time) on 22 May 2014, an XPT passenger service departed Paterson towards Kilbride when its driver saw a bus at Mirari level crossing and people walking on the track ahead. The driver immediately made an emergency brake application and brought the train to a stand approximately 80 metres short of the interface.

Near hit with detrained passengers at Kilbride

There were no reported injuries.

The incident began when the locomotive of a coal train broke down as it entered a passing loop at Patterson, leaving a number of wagons foul of the main line. As priority was to be given to the XPT once the freight had moved clear, a decision was made to evacuate the six passengers on a local service running in the opposite direction and provide them with alternative road transport.

At approximately 11:25, a bus arrived at Kilbride, reaching the rail corridor via a maintenance access road. Once in the rail corridor, it parked alongside the local unit. Despite the close proximity of pedestrian access between the train and the bus, it was deemed unsuitable. The guard instructed the bus driver to move to Mirari level crossing, around 110 metres south of the Kilbride loop.

Two minutes later, the coal train had moved into the Paterson loop, thus clearing the main line for the XPT.

At Kilbride, the crew of the ‘local’ had informed the passengers that a bus had arrived and that they would be required to walk along the track to the crossing. The guard and driver assisted five passengers to disembark via the crew compartment door of the front carriage. They were instructed to walk in single file in the four-foot.

The XPT was approaching Kilbride at 118 km/h. As it neared the crossing, the driver saw the bus and people walking on the track approximately 300 metres ahead. The driver immediately made an emergency brake application and sounded the horn continuously as he brought the train to a stand.

The guard of the ‘local’ saw the level crossing activate and looked up to see the XPT coming towards them. He gave a verbal warning to the passengers to get off the track before realising it had already stopped.

The Australian Transport Safety Bureau (ATSB) found that the crew of the ‘local’ had not complied with the Australian Rail Track Corporation (ARTC) network rules when detraining passengers from their train and unknowingly placed the passengers in the path of the XPT. However, the operator’s procedure for detrainment did not preference the option of moving to a designated platform when available and would have required approval from network owner ARTC. This option was also absent from ARTC’s Network Rules and Procedures.

Key operational staff in NSW Trains and Sydney Trains continued to operate under older systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees probably contributed to inadequate communication between critical safe working positions.

Action taken

The operator (NSW Trains) began an immediate review of procedures for detraining passengers when a train is not at a designated station. It also informed the ATSB that the procedures had also been amended to clarify how passenger safety, their wellbeing and track protection will be managed when detraining.

Safety message

This incident illustrates the importance for train crews to adhere strictly to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.

It is essential that train crew and signallers implement an appropriate level of protection and confirm that the protection is in place before detraining passengers.

When the option is available, preference should be given to detraining at a recognised platform before electing to detrain passengers into the rail corridor.

Operators must confirm and ensure roles, responsibilities and limits of authority are clearly understood during organisational change.

18 January

Australia:  Locomotive fire near Cardiff, NSW, 4 April 2016

Full report External link

At approximately 05:05 (local time) on 4 April 2016, the lead locomotive on a freight train caught fire near the southern side of Cardiff station. The crew stopped the train 250 metres north of the station after being alerted to the fire by flames emanating from the locomotive’s engine cabin. The New South Wales Fire and Rescue team (NSWFR) were summoned. Both crew members escaped without injury, but the NSFWR could not immediately begin to put the fire out as the overhead line equipment remained energised.

Locomotive fire near Cardiff

At 05:35, an engine explosion displaced a number of engine crank case inspection covers. At 05:43, a passenger service was stopped from passing. The passengers were detrained to alternative transport. At 06:35, the overhead wiring was de-energised; by 08:30 NSWFR had extinguished the fire.

The ATSB found that two of the locomotive’s ten oil filter tank cover bolts had failed beneath the retaining nut due to fatigue and overload fractures. There was evidence of fretting damage on the tank cover at the failed bolt positions. This was consistent with a loose bolted joint associated with in-service movement of the assembly. The fire ignited when the displaced tank cover enabled high pressure oil to escape and come in contact with hot engine components.

Action taken

In response to the retaining bolt failures, the operator (Pacific National) has advised the ATSB that it has completed the following actions:

  • Developed and implemented a bolt tightening and removal procedure;
  • Reduced the bolt replacement frequency from 732 days to 366 days; and
  • Retrofitted a guard in its locomotives to minimise the risk from oil escaping from the filter tank and contacting hot engine components.

Safety message

Correct tensioning of bolts can be a critical aspect of ensuring equipment functions as designed. Operators should ensure their safety management systems provide appropriate procedures for bolt inspection and tensioning where there is a risk from equipment failure, especially when the consequence can escalate to fire.

30 January

UK: Child nearly falling through a missing toilet floor, South Devon Railway, 22 June 2017

Full report External link

At around 13:15 on Thursday 22 June 2017, a mother and her three-year-old child were travelling on a South Devon Railway train from Totnes (Riverside) to Buckfastleigh. Shortly after leaving Staverton station, while the train was travelling at about 20 mph, the child left his seat and went towards a toilet on the train, followed by his mother walking a short distance behind.

Child nearly falling through a missing toilet floor, South Devon Railway

The child entered the toilet, and as the door opened and the child stepped through, he fell forward because the floor was missing. A more serious accident was only prevented by the quick reaction of the mother, who grabbed the child’s arm and prevented him falling through to the track below. The child suffered minor bruising, and both mother and child were shocked.

In April 2017, the South Devon Railway (SDR) had carried out a repair to this carriage. The location of the repair was difficult to gain access to and required the floor of the toilet cubicle to be removed. The SDR’s management decided that the door would be secured and notices placed on it, allowing the carriage to enter service with the toilet floor missing. RAIB found that the method of securing the door was inadequate, so that over time the door became less secure to the extent it was possible for the child to open it. The risk associated with the absence of the toilet floor was not sufficiently appreciated nor adequately managed after the carriage was allowed to enter service. RAIB also found that the SDR had no formal competence management assessment for staff involved in carriage maintenance. Both of these factors led to no-one detecting that the door had become unsecure.

RAIB observed that the SDR’s maintenance regime did not identify the extent of the deteriorating condition of the carriage structure, and the railway’s fitness to run process was not being correctly applied.

RAIB also highlighted the importance, for heritage railways, of adhering to appropriate vehicle maintenance standards, and ensuring the examination regime will identify the foreseeable deterioration of vehicles before it reaches a stage that may affect safety.


  • The SDR should engage an external party (to be agreed with the ORR) to review its safety management system and the way it is being implemented in practice. The review should examine all aspects of and, if necessary, any revisions to the system that should be implemented. Any changes identified as necessary by this review should be implemented and reported to the ORR.

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