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Rail investigation summary - June 2019

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. 

Contents

Czech Republic: Freight train derailment at Studénka, 18 November 2018

UK: Near miss between a train and a track worker at Peterborough, 20 July 2018

Romania: Passenger train fire between Bartolomeu and Cristian, 5 June 2018

Australia: Freight train derailment near Kimbura, Queensland, 28 September 2018

Czech Republic: Passenger train collision at Křemže , 3 May 2018

Republic of Ireland: Wrongside Door Failure at Ashtown Station, 12th August 2018

Belgium: Empty coaching stock derailment Neufvilles, 8 June 2018

Portugal: Freight train derailment at Linha do Douro, 4 February 2018

UK: Collision between a freight train and utility vehicle at Dollands Moor Yard, 4 September 2018

Belgium: Runaway and lateral collision between Brussels-North and Schaerbeek, 24 April 2018

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

  • Coupling / attachments 
  • Derailments
  • Near misses
  • Overspeeding
  • Runaways
  • Safety in yards, depots and sidings
  • Safety management systems
  • SPADs
  • Train door incidents
  • Train fires
  • Train maintenance
  • Wagon maintenance

4 June

Czech Republic: Freight train derailment at Studénka, 18 November 2018

Full report (includes summary in English)

At 21:28 (local time) on 18 November 2018, one wagon in a freight train derailed on pointwork at Studénka station. There were no reported injuries.

The Czech national investigation body (NIB) determined that gradual deterioration of the tyre on the wagon’s first axle caused it to work loose of the wheel rim, causing it in turn to come off on the points.  

Recommendation

The Czech National Safety Authority (NSA) should work to improve its wheel tyre inspection, repair and replacement regime.

5 June

UK: Near miss between train and track worker at Peterborough, 20 July 2018

Full report

At around 10:52 on 20 July 2018, a track worker acting as a site lookout for a colleague carrying out an inspection, narrowly avoided being struck by a train near Peterborough station. The train was travelling at 102 mph when its driver saw the lookout standing on the same line ahead. The driver immediately sounded the train’s warning horn and applied the brakes. The lookout responded to the horn and moved out of its path with about 2.5 seconds to spare.

RAIB’s investigation found that the site lookout was distracted and not adequately observing his distant lookout or looking for approaching trains. He had also chosen to stand on an open line when it was not necessary to do so. The track worker carrying out the inspection, who was also the Controller of Site Safety (COSS) and responsible for the safety of all the staff involved in the work, was not monitoring the unsafe actions of the lookout at the time of the incident. Furthermore, the distant lookout had left his position before the train arrived because he thought he had been stood down. A distant lookout who was visible to the site lookout was from a different team and was looking out for trains coming in the opposite direction. 

The investigation also found that the way in which the work was planned defaulted to using the least preferred safe system of work in the hierarchy within Network Rail’s company standard for managing the safety of people at work on or near the line. In fact, the current rules for communication when lookouts are used are impractical, leading to a disregard for the rules and the use of unofficial and uncontrolled practices

A key factor that mitigated the consequences of the incident was the driver’s prompt use of the train’s horn to provide a warning, which gave the track worker just enough time to move out of the train’s path.

RAIB also observed that, while not linked to the incident on 20 July 2018, the rail testing and lubrication section at Peterborough depot was not planning its work in accordance with the latest issue of Network Rail company standard NR/L2/OHS/019. It has also identified the following key learning points:

  • For train drivers, the incident highlights how the early use of a train’s horn to give track workers that are on your line an urgent warning (which is defined in the Rule Book as a series of short blasts) can avert an accident. 
  • For COSSs/ Safe Work Leaders (SWLs), the incident demonstrates the importance of briefing your site lookout on where to stand while carrying out their lookout duties and where their place of safety is. 
  • For COSSs / SWLs, the incident also highlights the importance of not becoming distracted by the work activities to the extent that you are no longer able to ‘personally observe and advise everyone in your work group’ as required by the Rule Book, while on or near the line. 

Action taken

After the incident, Network Rail allocated a section planner to cover both the rail testing and lubrication and the welding and grinding sections.

The infrastructure maintenance engineer responsible for the Peterborough delivery unit reported that he’s planning changes to the rail management team, which is responsible for both the rail testing and lubrication section and the welding and grinding section. At the time of the incident, the rail management team was responsible for delivering work from King’s Cross to Stoke tunnel south of Grantham (a distance of about 100 miles). The proposed changes will leave the existing rail management team to manage the rail assets from Stoke tunnel to just south of Peterborough, with a newly created rail management team based at Hitchin being responsible for the rail assets from just south of Peterborough to King’s Cross.

The competencies of the staff involved were immediately suspended. These were restored in January 2019 after Network Rail completed its investigation and the staff were re-briefed.

Shortly after the incident, the infrastructure maintenance engineer issued a special instruction to his maintenance staff prohibiting a second group from starting work using lookouts if another group is already working at that location with lookouts in place. The infrastructure maintenance engineer made this a permanent instruction from January 2019.

Network Rail has made changes to the way that it plans work for the rail testing and lubrication section. The section manager has been tasked with creating safe work packs that cover more specific areas, rather than having more generic packs covering much larger areas. Staff who will be the COSS for these planned tasks have been instructed to work more closely with the section planner when the task is planned.

Network Rail is considering the viability of adding another person to the Peterborough lubrication team for some tasks. This is to allow the team leader to work on the lubrication equipment while the additional person carries out the COSS duties, such as monitoring how the implemented safe system of work is being maintained. The use of this additional person will be dependent upon an assessment of the work to be done and the workload on the COSS when the work is planned. It will also be dependent upon someone who holds the COSS competency being available.

For all of the maintenance staff based at Peterborough depot, Network Rail has issued notices and carried out briefings covering the need to provide thorough and complete pre-work briefings to the group, the correct reporting of incidents (the team leader called his section manager to report the incident when he should have reported it to Route control), and awareness and use of the close call and work safe procedures.

Recommendations

Network Rail should promote an amendment to the Rule Book to require COSSs and SWLs to default to placing their site lookouts in a position of safety, unless this is not practicable to implement the safe system of work, e.g. the site lookout needs to be positioned elsewhere to achieve unrestricted sighting of intermediate / distant lookouts or trains, give a warning by touch, or be close by to give an audible warning. 

Network Rail should:

  • Investigate the common practices used by COSSs / SWLs and site lookouts to communicate with intermediate / distant lookouts using flag signals to indicate ‘all clear’ at the start of work and after a train has passed, and ‘work complete’; 
  • Seek to understand the reasons for the unofficial systems of communication currently used and the risks that they introduce; 
  • Investigate ways of improving communication between those at the site of work and intermediate / distant lookouts, including the use of technology; 
  • Implement, across its network, an improved system of communication, based on the findings from the above, including training of relevant staff and promoting amendments to the rule book as necessary; and 
  • Implement effective arrangements for the monitoring, audit and review of the improved system of communication that it puts in place. 
  •  

Network Rail should provide guidance and training for its staff holding the COSS / SWL competency, on the actions to be taken if more than one group wants to use a safe system of work with distant / intermediate lookouts that overlap at a location.

Network Rail should increase engagement of all maintenance sections across the London North Eastern and East Midlands Route, with the route’s ‘Safe and Effective Working’ project, so that as many of its cyclic maintenance tasks as possible are undertaken in planned possessions or using line blockage protection systems. 

Network Rail should: 

  • Reduce the number of cyclic maintenance tasks that are undertaken with lookout warning by establishing improved planning processes to substantially decrease the reliance on lookout warning by enabling more pre-planned activities to take place in planned possessions, or using line blockages protection systems; and 
  • Implement effective arrangements for the monitoring, audit and review of these revised planning processes.

12 June

Romania: Passenger train fire between Bartolomeu and Cristian, 5 June 2018

Full report (includes summary in English)

At around 06:12 (local time) on 5 June 2018, a fire started in the driving car of a diesel multiple unit (DMU) travelling between Bartolomeu and Cristian. There were no reported injuries. 

The Romanian NIB found that the fire had been caused by a faulty oil catch, which allowed oil deposits to escape and ignite. The engine cleaning and maintenance regime did not take the risk from fire by this means into account.

Recommendations

  • The Romanian Railway Safety Authority should ensure the railway undertakings involved redraft the relevant Technical Specification code to include provision for the performance and maintenance of diesel engines and their auxiliary parts. 
  • The Romanian Railway Safety Authority should reconsider the risks associated with the maintenance of the multiple units of the type involved in the incident, adjusting its risk register and associated actions accordingly.

13 June

Australia: Freight train derailment near Kimbura, Queensland, 28 September 2018

Full report

Full report (includes summary in English)

At 08:37 (local time) on 3 May 2018, a regional passenger train passed a signal at danger at Křemže station and struck another passenger train on the same line. Eighteen people were injured.

The Czech NIB determined that the driver of the train that passed the signal had made an error, but added that the train was fitted without a radio terminal fully compatible with those of the infrastructure manager. An emergency GENERAL STOP command was also not sent out in a manner that would have reached the incident train.

Recommendations

The Czech National Safety Authority (NSA) should:

  • Ensure that railway undertakings operate trains with radio systems that are compatible with those of the infrastructure manager. 
  • Ensure said rolling stock is also equipped with an active external ‘STOP’ module, which will enable it to be stopped in an emergency.

25 June

Republic of Ireland: Wrongside Door Failure at Ashtown Station, 12 August 2018

Full report

At around 20:04 on 12 August 2018, a Pearse-Maynooth service, operated by an eight-car 29000 class DMU was preparing to depart Ashtown. The driver pressed the ‘passenger doors close’ button in the cab when he saw that all passengers had disembarked and boarded the train. The driver noticed that the blue Door Interlock Light (DIL)  illuminated immediately while the platform side passenger door directly behind the driving cab was still in the process of closing; this is classified as a wrongside failure, as the blue DILs should only illuminate when the passenger doors have closed and locked.

The wrongside door failures re-occurred on the return journey from Maynooth to Pearse, with the unit being taken out of service at Connolly.

The immediate cause of the wrongside door failure was as a result of unwanted contact of the DIL ‘crimp’ with the battery positive spade, resulting in the circuit completing when a door was opened by a passenger on the front set and the doors of the rear set remained closed.

The investigation could not determine when and how the crimps became detached, but it is unlikely that they became detached due to in-service vibrations as force was required to re-attach the crimps to the spades.

The crimps detached on 6 June 2018 as a result of the collision. Their potential for failure had  not been identified between 6 June and 12 August, despite there being unscheduled maintenance on 6 June as a result of the collision and a number of other ‘exams’ (the last being on 11 August 2018).

The Chief Mechanical Engineer’s (CME’s) Safety Management Standards CME-SMS-001 and CME-SMS-006 included both rolling stock/bogie/wheelset safety and Occupational Health and Safety requirements, making the documents difficult to read. However, the responsibilities and accountabilities of CME staff are clearly and comprehensively stated, along with the management of rolling stock safety. That said, the risks associated with the coupler and the need to do more thorough inspections after an accident had not been identified.

The Traffic Regulators’ Manual did not specify that wrongside failures of safety critical equipment requiring withdrawal from service should be immediately reported to the Rail Accident Investigation Unit (RAIU).

The Traffic Regulators’ Manual contains section on how a Traffic Regulator deals with many incident procedures but does not contain a section on dealing with rail vehicle wrong sided faults.

Action taken

Iarnrôd Éireann (IÉ) has (inter alia):

  • Issued an operational manual which supersedes the Traffic Regulators’ Manual. The new manual gives clear guidance on the procedures to be carried out for wrongside rolling stock failures and the correct list of occurrences that must be reported immediately to the RAIU.
  • Updated the 29000 DMU maintenance schedule to include a note on the use of enhanced insulation of crimps.
  • Reviewed and revised safety standards relating to risk to best align them across the company. 
[1] Used to confirm that the passenger doors are closed and locked.

26 June

Belgium: Empty coaching stock derailment Neufvilles, 8 June 2018

Full report (requires translation)

At 10:27 (local time) on 8 June 2018, an empty coaching stock train derailed while switching from the main line to the slow line near Neufvilles-Garage. 

The driver sustained minor injuries and was taken to hospital.

The Belgian NIB determined that the incident occurred because the train entered the points at 128 km/h instead of the permitted 40 km/h, the driver having failed to respond to the signal indicating that the train was being switched to a slower line. 

The Belgian NIB said that the ‘most likely scenario [was] a lack of attention’. The level of European Train Control System in effect on the line would give an in-cab warning, but not trigger the brakes. As this issue has been covered in other investigation reports , it was decided to issue no further recommendations.

Recommendations

None issued.

[1] For example, Buizingen in 2015 and in Leuven in 2017.

27 June

UK: Collision between a freight train and utility vehicle at Dollands Moor Yard, 4 September 2018

Full report

At about 03:39 on 4 September 2018, a train arriving at Dollands Moor freight yard struck a small petrol-powered buggy which was stationary on a level crossing. The train driver only became aware of the buggy shortly before the accident and was unable to stop in time to avoid a collision. A shunter sitting in the buggy attempted to jump clear at the last moment, but suffered life-changing injuries. 

Dollands Moor was built to serve the Channel Tunnel, becoming fully operational in 1994. From the outset, small buggies were provided to transport staff and equipment around the extensive site. A subway, which could accommodate them, was provided at each end of the yard to allow staff access to individual sidings without crossing any tracks. Level crossings were also provided for emergency use by vehicles after signals had been set to stop approaching trains. 

Until 2010, safety documentation included a requirement that subways be used by buggies crossing the sidings, but by 2012 this requirement was no longer included. By 2014, only one of the two subways remained open, but lighting in this subway had failed. Use of this subway was not enforced so most shunters chose to drive across the level crossings instead. There were no barriers, signs or written instructions indicating that vehicles were not allowed to use the level crossings unless signals were being used to stop any approaching trains. The injured shunter started work at Dollands Moor in 2018 and had been trained to cross the sidings using the level crossings without signal protection. 

RAIB found that the buggy driver was unaware he was in an unsafe position, but there is insufficient evidence to determine why. The investigation also found that custom and practice at Dollands Moor had normalised use of the level crossings by buggies without signals being used to stop approaching trains, and that the buggy was not conspicuous so the train driver could not see it until it was too late to avoid an accident. The underlying factor was that DB Cargo’s management of the use of buggies, subways and level crossings at Dollands Moor was inadequate

Action taken

DB Cargo has stated that it has undertaken the following actions: 

  • Withdrawn the remaining buggy at Dollands Moor from use pending a review of operational arrangements at the yard. Shunters currently have to walk or use a road vehicle to access the west end of the yard. They then walk across the level crossing. 
  • Started a national project to look at providing digital radios which will allow radio calls to be recorded. 
  • Implemented a centralised document management and storage system so that safety documents are readily available. 
  • Instructed all sites to review signal box instructions where these exist.

Recommendations

DB Cargo should improve safety management arrangements at Dollands Moor including, as a minimum:

  • Ensuring that movement of people and vehicles to and from trains are covered by appropriately documented safe systems of work supported by appropriate risk assessments;
  • Ensuring that vehicles used on and/or near the operational railway are conspicuous to train drivers (e.g. by fitting orange flashing beacons, attaching reflective material and/or selection of appropriately coloured vehicles);
  • Consider reinstating one or both subways, and making provision for their future maintenance, if required for vehicular use; and
  • Establishing adequate arrangements for devising, documenting, checking and supervising safe systems of work.
  • DB Cargo should review, and if necessary improve, corporate oversight and verification of safety arrangements and safety supervision at DB Cargo locations across the UK.

28 June

Belgium: Runaway and lateral collision between Brussels-North and Schaerbeek, 24 April 2018

Full report (requires translation)

At around 11:00 (local time) on 24 April 2018, two empty passenger railcars were uncoupled from a train that had arrived at Brussels-North a few minutes earlier. As the parking brake was not applied on these vehicles, they ran away towards Schaerbeek, ran through a set of points and struck another empty train laterally about 800 metres from their point of origin. There were no reported injuries.

The Belgian NIB found that the two railcars had not been coupled correctly, insomuch as there was no electrical connection between them. This meant that the service brake and the European Train Control System (ETCS), which could have brought the runaway to a stand, were not operational.

Recommendations

None issued.

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