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Rail Investigation Summary

​October 2017

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.


US: Collision at Commerce Street, Valhalla, 3 February 2015

UK: Fatal accident at Alice Holt footpath crossing, Hampshire, 5 October 2016

UK: Serious irregularity at Cardiff East Junction, 29 December 2016

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

  • User behaviour
  • Third rail configuration
  • Level crossing risk assessments
  • Mobility scooter use
  • Good husbandry
  • Corporate knowledge
  • Briefing content
  • Planning and route proving
  • Signal commissioning
  • Corporate memory

1 October

US: Collision at Commerce Street, Valhalla, 3 February 2015

Full report External link

At 18:26 (local time) on 3 February 2015, a car driven by a 49-year-old woman travelled north-west on Commerce Street in Valhalla, New York, towards a level crossing on the Harlem Subdivision of the Metro-North Railroad.

Traffic on Commerce Street was heavy and congested when the driver turned onto the crossing boundary and stopped.

The crossing consisted of two road lanes (one for each direction) and two railway lines, equipped with reflective pavement markings, advance warning signs, flashing lights, and barriers.

The driver moved beyond the crossing boundary (‘stop line’) and stopped adjacent to the tracks. The crossing’s warning system activated and the barrier came down, striking the rear of her vehicle. She then exited the vehicle and examined the barrier. The driver returned to her vehicle and moved forward on to the railway. Meanwhile, an eight-car Metro-North Railroad service was approaching at 59 mph. The train driver applied the emergency brakes about 260 feet before the interface, reducing the impact speed to 51 mph.

The collision resulted in damage to the electrified third rail on the west side of the track. The third rail detached and pierced the passenger saloon of one of the carriages. The train and the car came to rest about 665 feet from the point of impact.

Metro-North Railroad estimated 645 passengers to have been on the train at the time of the accident. Five were killed, along with the road vehicle driver. Nine passengers and the train driver were injured.

The National Transportation Safety Board (NTSB) determined the probable cause of the accident to have been the road vehicle driver, who – for undetermined reasons – moved the vehicle on to the tracks while the crossing warning system was activated, and into the path of the train.

The fact that the road vehicle driver stopped beyond the stop line, within the crossing boundary, despite warning signs indicating the approach to the crossing, was a contributory factor, as was the fact that she was distracted by the barrier striking her vehicle.

The NTSB also noted that Metro-North Railroad’s third rail system was not constructed to fail in a controlled manner or break away when subjected to undesirable overloaded conditions such as those involved in this accident.


  • The Federal Transit Administration should notify all rail transit properties that have third rail systems at or near level crossings about this accident and advise them to conduct a risk assessment. After a full risk assessment has been completed, they should require all rail transit properties to implement corrections based on their findings in order to mitigate the associated risks
  • Metro-North Railroad should conduct a risk assessment for all level crossings that have third rail systems present at or near them and implement corrections based on the findings
  • The Long Island Rail Road, National Railroad Passenger Corporation, Port Authority Trans-Hudson Corporation, and Southeastern Pennsylvania Transportation Authority risk assess all level crossings that have third rail systems present at or near them, and implement corrections based on the findings
  • The State of New York Department of Transportation, once it has completed an assessment at intersections in its regions near level crossings with pre-emptive traffic signals, should proceed with making any necessary adjustments based on engineering principles and current industry guidance
  • The town of Mount Pleasant, New York, should take action based on the results of a traffic study and the Federal Highway Administration’s August 2007 guidelines to improve level crossing safety in its district.

26 October

UK: Fatal accident at Alice Holt footpath crossing, Hampshire, 5 October 2016

Full report External link

At 16:20 on Wednesday 5 October 2016, a mobility scooter user was killed when their vehicle was struck by a train at Alice Holt footpath crossing in Bentley, Hampshire.

Users of Alice Holt crossing are required to look and listen for approaching trains before deciding whether it is safe to cross the line. It is uncertain why the user decided to cross when it was unsafe to do so, as CCTV images suggest that he had previously crossed in a safe manner. It is probable that the user did not see the train or misjudged when it would arrive at the crossing, perhaps due to sun glare, when deciding to cross. The mobility scooter user’s opportunity to see the approaching train was limited by the design of Alice Holt crossing, in particular the fencing. The scooter user did not react to the train’s horn, possibly because he did not hear it.

RAIB also noted that the user continued to cross the railway after passing through a gap in the fence.

RAIB has found that Network Rail’s guidance for level crossing managers did not include any advice concerning use by mobility scooter users, and the management of the crossing had not allowed for vulnerable users such as these.

Action taken

Dissemination of vulnerable user definitions and proportions, has now been included in an update of Network Rail’s Level Crossing Guidance ‘census good practice’, published in October 2016. Network Rail has reported that this was distributed to level crossing managers (LCMs) by email on 26 October 2016, to be briefed at the next available team meeting. The document was further updated to version 3 in July 2017, with the same distribution and briefing methods.

Version 2 of this guidance has been readily accessible by LCMs on the ‘Level Crossing Hub’, Network Rail’s online resource for level crossing managers, since November 2016. Version 3 has been available since July 2017. These versions both include mobility scooter users as vulnerable users for whom LCMs may consider adding 50% extra crossing time. Neither version gives any guidance specific to this type of user.

Network Rail has a significant and continuing education programme, targeted at various level crossing users, including those with sight, hearing and mobility restrictions.

Network Rail has lowered all three fences at Alice Holt level crossing and has widened the path on approach to the south side of the crossing. Resurfacing of the crossing is included as a recommendation in the November 2016 risk assessment of the crossing.


Using the modifications already implemented at Alice Holt footpath crossing as an example, Network Rail should review and, where necessary, modify its management processes for passive level crossings to take account of use by people on mobility scooters in addition to other users. The review should include consideration of the following:

  • The size, speed and turning characteristics of mobility scooters
  • The position of users’ heads relative to ground level and relative to the front, back and sides of mobility scooters
  • The increasing use of mobility scooters
  • How risk assessments at individual level crossings consider:
  • The likelihood of use by people on mobility scooters; and
  • Whether it is both necessary and reasonably practicable to improve crossing arrangements (e.g. providing areas where scooter users can safely decide when to cross, improving sight lines and providing visual/tactile prompts encouraging safe use).
  • Educating mobility scooter users about how to cross the railway safely. Methods to be considered should include targeted advertising, working with appropriate interest groups and use of both social media and websites. Content should be compatible with risk assessment output (e.g. advertising any need to turn perpendicular to the railway before deciding whether to cross).

    31 October

    UK: Serious irregularity at Cardiff East Junction, 29 December 2016

    Full report External link

    Over the Christmas and New Year period from 24 December 2016 to 3 January 2017, Network Rail carried out extensive resignalling and track remodelling work in and around Cardiff Central station. This was the final stage of the Cardiff area signalling renewal scheme, a project which has been in progress for several years. This stage involved the closure of the power signal box at Cardiff, with control of the signalling in the area moving to the Wales Railway Operating Centre (WROC), and changes to the track layout and signalling on the east side of Cardiff Central station.

    Some of the new layout was brought into use on 29 December. At 08:37 on that day, the driver of a train from Cardiff Central to Treherbert, which had just left Platform 7, noticed that points in the route his train was about to take were not set in the correct position, and stopped the train just before reaching them.

    The points at which the train stopped were redundant in the new layout, and should have been secured in readiness for their complete removal at a later date. The project works required eight sets of points in two separate locations to be secured. In the event only six of the eight points were secured, and the line was re-opened to traffic without the omission having been identified by the testing team through the normal checking processes which should take place as part of this type of work. The two sets of points which were missed were left in a condition in which they were unsecured and not detected by the signalling system, and the points at which the train stopped were set for the diverging route. If the driver had not noticed the position of these points and stopped, the train would have been diverted on to a line which was open to traffic, on which trains can run in either direction, and on which another train passed over about three minutes after the train involved in the incident came to a stop. The new signalling system uses axle counters for train detection, and in this situation the system would not have immediately identified that the train was in the wrong place..

    The points had been left in this unsafe condition because they had not been identified as requiring securing by the team securing points during the works. Furthermore, no one had checked that all the points that needed to be secured during the works over the Christmas period had been. Route proving trains had been cancelled.

    The investigation also found that a work group culture had developed between long standing members of the project team that led to insular thinking about methods of work and operational risk. This meant that team members relied on verbal communications and assurances.

    The project team (excluding Atkins) had signed up to a fatigue management agreement, but it was not effectively implemented. Furthermore, Network Rail’s project governance was not sufficiently thorough.

    Although not linked to the incident on 29 December 2016, RAIB observed that:

    • The all-team briefing contained a considerable amount of information, much of which was superfluous to many of the attendees 
    • The signaller had no information about the presence of the redundant points in the layout that he was controlling.

    In this case, no-one was injured, no damage was caused by the event, and Network Rail acted quickly to secure both sets of points.

    RAIB has identified the following learning points: 

    • The importance of clear arrangements in every case to make sure that the tester in charge can check and confirm that all redundant wiring and equipment that cannot be removed is clearly detailed in the test copies, as required in NR/L2/SIG/300014/A110 Issue 4 (‘Signal works testing’, clause 4.6.5)
    • The need for each stage of works in which changes to the infrastructure have been made, and after which the railway is returned to operational service, to have a signalling plan that accurately reflects the infrastructure and assets on the ground, regardless of the functionality of those assets
    • The value and purpose of team briefings prior to large commissionings should be carefully considered in terms of the quantity and relevance of information being delivered. The number of slides and the length of presentations should be optimised to the audience, with the aim that people are given information that is appropriate and necessary for the work that they have to do
    • When considering whether it is necessary to run a route proving train as part of the commissioning process, it is important to identify the types of fault which the train is intended to detect, and assess whether any other measures may be appropriate to detect and/or deal with those faults if the train does not run.

    Simon French, Chief Inspector of Rail Accidents said:

    This alarming incident, in which a train came close to travelling down a track that would have put it on an unprotected collision course with other trains, serves as a timely reminder of how easily things can go wrong when railway infrastructure is being upgraded and renewed.

    ‘t is [...] important, when organising intensive periods of commissioning work, to properly manage the working hours of the people doing the job. Back in 1988, the disastrous collision at Clapham Junction happened in part because working for weeks on end without any days off was part of the culture in some areas of the railway. Rightly, things have changed a lot since then. However, the events at Cardiff showed how easy it is to forget the lessons of Clapham and slip back into those habits under the time pressures of a big commissioning.


    • Network Rail should review its project assurance process as applied to the CASR scheme, and identify the deficiencies which resulted in the management shortcomings described in this report. Network Rail should then use the findings of this review to establish suitable and sufficient management processes to assure itself that major projects deliver a safe railway on each occasion that it is handed over for service. These should cover, as a minimum, all aspects of project governance, including quality assurance throughout all stages of the project lifecycle, organisational structure, record keeping and administrative systems
    • Network Rail should review the document management system used for the CASR project and ensure that any identified areas for improvement are incorporated into systems currently and planned to be in use by other projects
    • Network Rail, in conjunction with its contractors, should review how it implements its standards and processes relating to the management of fatigue risk during major projects. The results should be used to identify measures to provide assurance that all project staff, whether direct employees or contractors, work within appropriate standards and good practice guidelines, and to minimise the risk that staff fatigue may contribute to an error or omission during the commissioning of safety critical equipment and systems.

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