Report of a Formal Investigation

Report of a Formal Investigation held by the following organisation(s):

Network Rail Anglia Route, Network Operations

Direct Rail Services

into the following event

3S01 struck crossing gates at Lingwood Station Road manned level crossing – 31/10/14

SMIS reference QSE/2014/OCT/1648

CONFIDENTIAL © Copyright Network Rail

Template Version 3.2

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Lingwood Crossing, 3S01 struck crossing gates, 31/10/14 Issue 3 of 30

A. Event summary, conclusions, recommendations and local actions

A1. Summary of the accident/incident A1.1. On 31 October 2014 3S01 a rail head treatment train was travelling on its booked

route between Norwich and Great Yarmouth.

A1.2. At approximately 14:04 3S01 passed over Lingwood Station Road Crossing, with both level crossing gates closed to rail traffic; the gates were therefore struck, damaged and removed by the impact. No injuries were reported but the driver of 3S01, a technical operative who was travelling in the leading cab and the crossing keeper were both initially shocked by the incident.

A1.3. The driver reported to the crossing keeper and the controlling signaller at Acle that he believed L3 signal, a distant signal for Lingwood Station Road, had been in the “off” position for his train.

A1.4. The driver and crossing keeper were for cause screened and full functional testing of the signalling equipment was undertaken.

A2. Immediate cause A2.1. The driver of 3S01 failed to stop in the distance that was available following a

warning horn on the Automatic warning System (AWS) of L3 signal and after observing a signal that was imperfectly shown.

A3. Behavioural cause (using fair culture flowchart) A3.1. Driver:

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A5.2. (G4.5) Post incident management of the staff involved in the incident could have been handled with more recognition of the stress and trauma they had been exposed to.

A5.3. (G1.5) It is possible that CK1 suffered from fatigue leading to a loss of concentration or a micro sleep, as his fatigue levels were excessively high according to the fatigue index.

A5.4. (F6.2) Crossing Keepers on-going competency management process does not include any elements that cover the use of mechanical wire adjusters.

A6. Recommendations A6.1. (F6.2) Crossing Keeper competency process does not include on-going elements

on the use of mechanical wire adjusters, the academy process currently in use should be amended to cover the correct usage of mechanical wire adjusters and associated indicators. Intention : This will ensure that timely reminders on the correct use of wire adjusters and review of indicators is kept fresh and current in crossing keepers minds..

A7. Local actions A7.1. (A 4.1).Local Operations manager to facilitate the use of WIN VV within the

crossing huts to enable crossing keepers to have an accurate plan of train movements.

A7.2. (A 4 1) RAM signals to review the arrangements for Signalling Bells at Lingwood Station road crossing to see if improvements can be made, for clarity and loudness.

A7.3. (A4.3) RAM Signals to instigate a cost benefit analysis for the provision of an audible alert for slot indicators so as to draw the crossing keeper’s attention should a slot indicate wrong.

A7.4. (A4.4) IMDM Ipswich to assess whether the slot arrangement at Lingwood station road can be improved to assist crossing keepers when adjusting the mechanical wire adjusters.

A7.5. (A 4 5, 4.6, 4.7) DRS services to produce a briefing highlighting the importance of GERT8000, rule book module S7 section 5.2 and share this with other Train and Freight Operators.

A7.6. (A5.1) DRS services to provide a means for drivers to clean windscreens prior to the train departing the stabling point.

A7.7. (A5.2) The Area Manager GE, to carry out a debrief and share lessons learnt on post incident management when multi industry staff are involved in a traumatic event.

A7.8. (A 5.3) The Operations Manager GE Outer to review with HR assistance the risks posed to Network Rail, for the crossing keepers’ fatigue level with emphasis on the amount of travel time that is undertaken and how this may be mitigated. The results of this should be considered for any other staff in a similar set of circumstances.

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B. Purpose

B1. Objectives & authority B1.1. The objective of this formal investigation was not the allocation of blame or liability

and thus the information contained should not be construed as creating any presumption of these.

B1.2. This formal investigation was conducted with the objectives of:

a) determining the facts of the accident/incident,

b) determining the immediate and underlying causes and

c) making recommendations and local actions to prevent, or reduce the risk of recurrence and severity of a recurrence of the accident/incident.

B1.3. This formal investigation report is for the use of persons with a direct responsibility for improving, or maintaining, railway safety.

B1.4. The lead investigator had the authority to request information to be provided by Railway Group members involved in the incident, to interview witnesses, request technical evaluations to be conducted and obtain other information as required for the purpose of achieving this remit.

B1.5. The lead investigator was able to request similar information from non-Railway Group members. These organisations may not, however, have been bound by the requirements of Railway Group standard GO/RT3119 to provide this unless incorporated into contractual requirements with Railway Group members.

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C. Remit

C1. General C1.1. This remit requires a formal investigation to be held into the circumstances of the

following accident/incident.

C1.2. Title: 3S01 Struck Crossing Gates at Lingwood (Station Rd) Level Crossing

C1.3. Date: 31/10/14

C1.4. Lead organisation: Network Rail (Anglia Route), Network Operations

C2. Lead investigator C2.1. Route Investigations Manager

C3. Investigation team members C3.1. The following shall be invited to participate in the formal investigation as team

members:

a) Network Rail – Local Operations Manager

b) Network Rail

c) Direct Rail Services

– Signal Maintenance Engineer

– Regional Operations Delivery Manager (Scotland)

C4. Observers C4.1. In accordance with Network Rail company standard NR/L3/INV/0205 the following

shall be invited to participate in the formal investigation as observers:

a) - Network Rail – RMT Union Rep

b) – Operations Manager

c) – Operations Manager, Direct Rail Services

C5. Authority C5.1. The lead investigator has the authority to request information to be provided by

Railway Group members involved in the accident/incident, to interview witnesses, request technical evaluations to be conducted and obtain other information as required for the purpose of achieving this remit.

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C5.2. The lead investigator may request similar information from non-Railway Group members. These organisations may not, however, be bound by the requirements of Railway Group standard GO/RT3119 Accident and Incident Investigation to provide this unless incorporated into contractual requirements with Railway Group members.

C6. General objectives of the formal investigation C6.1. The investigation team is required to investigate the circumstances of the

accident/incident, including the following:

a) identifying the events leading up to the accident/incident;

b) identifying the immediate and underlying causes, including:

i) the relevance of the 10 incident factors (guidance on these is provided in Part 4 of the Investigators’ Handbook), and

ii) relevant management issues/processes;

c) identifying the behavioural cause of any unsafe act using the fair culture flowchart;

d) consideration of previous accidents/incidents of a similar nature;

e) consideration of the findings/intelligence from relevant audit/assurance activity (guidance on this is provided in Part 2 of the Investigators’ Handbook);

f) Consideration of the specific objectives listed below (as far as they are relevant).

C7. Specific objectives of the formal investigation C7.1. Condition and operation of the train:

a) the braking capabilities and characteristics of the train, b) in cab actions of the drivers on approach to L3 signal, c) speed and control of the train

C7.2 Condition and operation of the signalling equipment:

a) Maintenance of signalling equipment and signalling signage paying particular attention to the equipment that relates to operation of L3,

b) Fully understand the actions of the crossing keeper at Lingwood (London Road) operating location in relation to the movement of 3S01,

c) Fully understand the actions of the crossing keeper at Lingwood (Chapel Road) operating location in relation to the movement of 3S01,

d) Previous history/causes/recommendations and incidents associated with the equipment that day.

e) Signal sighting issues or SSC recommendations and any mitigation measures,

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C7.3 Risk:

a) likelihood of recurrence

C7.4 Potential consequences:

a) Damage to infrastructure

b) Risk at crossing

C7.5 The competency (knowledge, skills and experience), capabilities (mental and physical) and fitness for duty (including medical fitness) of any staff implicated in the incident and the systems for ensuring their fitness and competence. Particular emphasis must be place on fatigue levels and reference to HSE Fatigue Index.

C7.6 The adequacy of staff selection, training, assessment, and special monitoring processes for any staff implicated in this alleged incident, and in relation to the drivers previous safety of the line events

C7.7 The adequacy of and compliance with the relevant rules, standards, and instructions:

a) any unsafe methods of working

C7.8 Identify the contribution of human factors:

a) examine work patterns and rest periods of the staff involved,

b) communications between all parties concerned,

c) any preoccupations or distractions of all staff involved,

d) organisational and cultural factors

C7.9 External and environmental factors:

e) weather conditions,

f) visibility,

C8. Recommendations and local actions C8.1. The investigation team is required to formulate recommendations and/or local

actions to:

a) prevent a recurrence of the accident/incident,

b) reduce the likelihood of a recurrence of the accident/incident,

c) reduce the severity of the consequences of a recurrence of the accident/incident,

C8.2. Recommendations and local actions may be addressed only to Railway Group members participating as investigation team members.

Note: A recommendation should be made to:

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(a) propose a change to an existing control measure (e.g. a rule, instruction, standard or process), or

(b) define a new control measure.

A local action is a response directed at line management due to an existing control measure not being followed or applied.

C9. Reporting and timescales C9.1. The formal investigation shall commence as soon as possible. The lead

investigator shall provide:

a) a draft report which is unsigned, but agreed by the investigation team members, within 8 weeks of the accident/incident,

b) a completed report, taking into account the comments made during the consultation period and which is signed or agreed by the investigation team members, within 12 weeks of the accident/incident.

C9.2. The format and structure of the report shall be in accordance with the template and guidance, including the Investigators’ Handbook, thereto authorised by the Corporate Investigation Manager.

C9.3. The lead investigator shall inform the DCP in the following circumstances:

a) if it is believed that the objectives of the remit (including the timescales) will not be achieved,

b) if, at any time, the investigation reveals a safety issue of significance such that, in the investigation team’s opinion, a need exists to inform Railway Group members prior to the completion of the formal investigation.

C10. Authorisation by designated competent person (DCP)

Signature:

Area Manager GE Inner/Thameside and Designated Competent Person, Network Rail, Network Operations. Date: 5th November 2014

Issue No.: 1

C11.

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D. Details

D1. Description of the location D1.1. Lingwood Station Level Crossing is located on the Brundall to Great Yarmouth line

at 08 miles and 3 chains in the county of Norfolk.

D1.2. This is a single line where trains can be signalled in either direction along the line, either from Brundall or Acle signal boxes.

D1.3. The crossing has manually operated gates.

D1.4. It is believed the crossing has been present since the construction of the station in 1885. To the Brundall side of the station is another manually operated level crossing called Chapel Road, located at 7 Miles and 55 Chains.

D1.5. Lingwood Station Level Crossing is intersected by a public highway Station Road which serves the village of Lingwood.

D1.6.

D1.7. D1.8. Picture of crossing prior to incident.

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D1.9. D1.10. View to the direction that 3S01 would approach from.

D2. Description of the train(s) and rail vehicles involved D2.1. 3S01 is a rail head treatment train operated by Direct Rail Services on behalf of

Network Rail Anglia Route.

D2.2. The leading locomotive 57010 is a class 57 locomotive weighing 114 tons

D2.3. Waggon 642041 and 642019 followed with locomotive 57009 trailing.

D2.4. The total weight of 3S01 was 370 tons with a brake force available of 190 tons; the maximum permitted speed of the train was 60 mph.

D2.5. Using table E1 of GORT3056 the maximum weight that this configuration could transport would be 645 tons, no issues exist with the configuration and brake force availability of 3S01 and are not thought to be contributory to this event.

D3. Description of the infrastructure and equipment involved D3.1. In the direction of travel (Down) the driver would have come across the following

relevant infrastructure:

a) AWS magnet for CR1 mechanical Distant Signal.

b) CR1 mechanical Distant Signal operated by Chapel Road Crossing keeper and located at 7 miles

c) AWS for L3 mechanical Distant Signal

d) L3 mechanical Distant Signal operated by Lingwood Station Crossing keeper, with slotting arrangements from Chapel Road, located at 7 miles and 23 chains.

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e) Chapel Road, manual operated level crossing, located at 7 Miles and 55 chains

f) Lingwood Station which is situated on a left hand curvature of track, located at 7 miles and 78 chains

g) Lingwood Station Road, manual operated level crossing, located at 8 miles 02 chain.

D3.2. L3 signal is slotted with lever no. 2 at Chapel Road and L3 lever at Lingwood Station Road.

D3.3. An explanation of the slotting arrangements are contained within section F1.1

D4. People involved D4.1. Driver 3S01 – DRS Services

D4.2. Rail Head Treatment Operative – JSD Rail

D4.3. Crossing Keeper (CK1) Lingwood Station Road – Network Rail.

D4.4. Crossing Keeper (CK2) Chapel Road – Network Rail

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E. Sequence of events E1.1. On 31 October 2014 the driver signed on duty at Stowmarket having travelled from

his home .

E1.2. The JSD operative joined the driver and train preparation was carried out.

E1.3. At 09:20 3S01 departed Stowmarket and proceeded on its booked circuit of rail head treatment.

E1.4. The RHTT arrived at Kings Lynn early and the driver took a break and purchased some food from the station buffet.

E1.5. At 11:22 the RHTT departed Kings Lynn for Ely where the booked physical needs break was taken, as a path towards Norwich was not available to allow earlier travel.

E1.6. 3S01 recommenced its journey following the physical needs break.

E1.7. At 13:54 Brundall junction signal box received the train description for 3S01 and offered the train to Acle at 13:58

E1.8. At 14:00 the RHTT arrived at Brundall and proceeded towards Lingwood.

E1.9. On leaving Brundall the driver achieved a maximum speed of 50 mph towards Chapel Road Crossing.

E1.10. At 14:03:30 the driver received an audible bell on the AWS equipment and sighted CR1 signal in the off position

E1.11. 14:03:55 the driver received an audible horn from the AWS equipment and re-sighted L3 signal.

E1.12. At approximately 14:04 the driver passed over Chapel Road crossing.

E1.13. The crossing keeper at Chapel road closed the level crossing to rail traffic after checking 3S01 was complete with tail lamp and replacing CR1 and CR2 lever.

E1.14. At approximately 14:04:30 the driver sights Lingwood Station Road level crossing and reacts to the gates being closed to rail traffic, the driver applies the emergency brake and sounds the warning horn continuously until coming to a stand at 14:05.

E1.15. Both crossing gates at Lingwood Station Road had been run through.

E1.16.

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E1.17. The driver of 3S01contacted his control via a mobile phone and then made his way to the crossing keeper’s direct line and contacted the signaller at Acle to report the incident.

E1.18. At some point around this time the driver believes he saw the crossing keeper holding a wire adjuster in the equipment (the panel concluded on questioning the driver this was in the adjuster for L1) and challenged him not to touch any equipment.

E1.19. Full testing of the equipment commenced and the Driver, RHTO and CK1 were for cause screened.

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F. Summary of evidence

F1. Slotting Arrangements F1.1. The Slotting arrangement on L3 signal at Lingwood is a standard pattern Upper

Quadrant signal, post mounted, two pull slot. The operation is detailed below.

a) In signalling terms the signal is controlled by Lingwood Station Ground Frame as L3 signal and Slotted by Lingwood Chapel Road Ground Frame as CR2.

b) The signal arm is not directly cleared by either Crossing Keepers’.

c) On the signal the slotting arrangement consists of three independent cranks, on a common pivot. The centre, Arm, crank is connected to the Signal Arm and in the absence of the other two cranks is weighted so that it pulls the Arm Off.

d) The Arm pull wire and the wire pulls from the Ground Frame levers are all attached to their respective cranks on the same side of the pivot.

e) On the other side of the pivot from the arm pull the Arm crank has a cross piece welded to the bottom of the crank. This passes under the slotting crank’s each side of the Arm crank. If either Ground Frame lever is Normal the respective slotting crank is weighted so that it will hold the Arm crank in the signal Arm on position.

f) Once both levers have been pulled the slotting cranks are pulled up in relation to the Arm crank crosspiece, allowing it to move as in (b) above.

g) Wire adjustment to compensate for temperature changes is provided for both wire pulls to the slotting cranks.

h) To allow for wire adjustment, the position of the respective slot cranks are repeated at the controlling Ground Frame. The Arm position is only repeated when ‘on’. This arrangement allows wire adjustment of either slot without the need for both to be pulled when clearing the signal. The picture below is an illustration of the arrangement in place from the original Signalling and Maintenance Testers Handbook

F1.2. This is of a similar arrangement.

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F3. GORT3119A, RS/521 F3.1. The panel reviewed the definitions for a stop signal contained within the RSSB

SPAD data collection form and signals, hand signals definitions handbook. The panel considered whether the level crossing gates when closed to the passage of trains presented a stop signal to the driver.

F3.2. The panel concluded that although signal L3 is a semaphore distant signal the gates themselves or the red light mounted on them did not formally meet any of the criteria for a stop signal.

F3.3. The panel concluded that this event was an operational incident and would not fall under the SPAD classification.

F4. Rail Head Treatment Operative. F4.1. The Rail Head Treatment Operative (RHTO) is employed by JSD Rail

.

F4.2. When the Operator was not undertaking a duty on RHTO was not working on the rail head treatment train circuits,

F4.3. The RHTO is competent in personal track safety (PTS) and in cab protocols, but has had no training in the recognition of signals or their meaning.

F4.4. The RHTO recalled the journey and observing the signals prior to the collision, he recalled that the signal (L3) looked like it was off the RHTO has engaged some drivers in conversation that provided him a basic understanding of mechanical signals, however the RHTO could not explain to the panel what off should look like, but stated the signal was not horizontal.

F4.5. Following the incident the RHTO was for caused screened after several hours but was “left to his own devices” with very limited duty of care.

F4.6. A DRS Manager took the RHTO to Norwich station so that he could arrange his own transport home.

F5. Crossing Keeper Chapel Road F5.1. The Crossing Keeper was interviewed by the panel and recalled the day in question.

F5.2. CK2 was working his third late shift having had two free days,

F5.3. CK2 recalled that on taking duty there were no issues reported with the bells or indicators and that all the equipment was as expected.

F5.4. The weather was hot and CK2 expected he would have to adjust the signal wires, though did not do so prior to the incident.

F5.5. During the interview CK 2 was asked how the slotting arrangement worked, as he felt having better indications would be of benefit. The panel felt it would be advantageous for those involved in the operation of the slots for L3 and L1 to be given an overview of the arrangements in place so that they could understand the mechanisms present and the risks involved.

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F5.6. CK 2 explained that there were no indicators at the crossing to indicate the state of the line and that they relied upon the bells and the use of Abellio Greater Anglia’s (AGA) website to know what trains were running, or not.

F5.7. The panel noted that the website does not display any other train services other than those of AGA.

F5.8. CK 2 operated the gates as normal for the passage of 3S01 and when he seen that the train had passed complete with tail lamp he closed the gates to rail traffic and replaced his signal levers into the frame.

F6. Crossing Keeper Lingwood Station Road F6.1. CK 1 holds a competency certificate for his role and is medically fit for duties.

F6.2. The crossing keepers competency profile does not include any on-going assessment on the use of mechanical wire adjusters.

F6.3. CK 1 was interviewed with a limited number of panel members on the 4th November 2014

F6.4. CK 1’s day started at 03:30 when he awoke and prepared to leave for Lingwood Station Road.

F6.5. CK 1 arrived at his work location at 05:45.

F6.6. CK 1 was booked on duty for 12 hours, and recalled taking duty in misty and damp weather.

F6.7. As the day began to warm up CK 1 remembered having to adjust the wires for L1 and L3 signals.

F6.8. The day progressed and CK1 recalled some cancellations to train services and late running, he kept himself informed of this using the AGA web site.

F6.9. CK 1 recalled that the train previous to 3S01, 2P21 the 13:17 Great Yarmouth to Norwich service, had passed without significance but was late. The crossing equipment had worked as intended and nothing untoward was observed.

F6.10. CK 1 had not been expecting another train so was perplexed to hear a long blast on the horn and observe through the rear window a train approaching from the Brundall direction.

F6.11. CK 1 then heard a loud bang as the train collided with the gates. He left the crossing hut to check and see if anyone was hurt and observed that the indicator for L3 was showing “wrong” CK1 then recalled checking the area for damage as some large pieces of wood were laying around the lever frame.

F6.12. CK 1 saw the driver running towards him and recalled the driver saying that the signal had been off. CK1 phoned the signaller to report the incident.

F6.13. CK 1 stated that - apart from checking the equipment - at no time did he interfere or change anything.

F6.14. CK 1 was told to sit in his car by the mobile operations manager who attended as the rail incident officer, until he was for cause screened. He explained to the panel that he did not know why he had not hear the bells for the passage of 3S01, and that there were occasions when the bells did not work at the crossings although they had worked with no issue that day.

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F6.15. CK 1 was trained to adjust levers by his peers whilst training with other crossing keepers and his local operations manager during his examination for competency, he recalled that he had needed to adjust the signal wire during the day as it had been un-seasonally hot.

F7. Weather F7.1. Norwich Weather centre records for the 31 October 2014 show the temperature

variations as being

a) 04:00 13.4 deg C

b) 06:00 12.7 deg C

c) 08:00 13.3 deg C

d) 14:00 20.4 deg C (time of incident)

e) 16:00 17.8 deg C

f) 18:00 15.8 deg C (time of fault recreation)

F7.2. As a rule of thumb the co efficiency of signal wire is 125 mm expansion or contraction to 10 degrees of temperature change; there are however many variables.

F7.3. The Crossing keepers at Chapel Road and Lingwood reported during interview that they believed from their thermometers that the temperature for their locations had been closer to 24 deg C rather than the temperature stated by Norwich weather centre.

F7.4. The weather data indicates that the driver would have seen the angle of the signal at less than the 24 deg C found during destructive testing as the temperature had dropped by almost 5 deg C at the time of measuring. This would be due to the wire not being as tight at 14:00, the evidence shows that from 14:00 to the time of the test testing the wire was not interfered with so the only affect on the wire would be the environmental changes.

F8. Locomotive 57010 F8.1. 57010 underwent an A exam at Norwich Crown Point on the 27 October 2014 and

no issues were identified with the performance of the locomotive.

F8.2. The locomotive was photographed post incident and the windscreens of the leading and rear windscreens were found to be dirty although the main arc was clear within the sweep of the wipers.

F9. Post Incident testing to T009 test plan F9.1. Full wrong side failure testing was undertaken post incident and the SFI/01/05

documentation was reviewed by the panel

F9.2. A summary of the findings are presented with the records attached to the appendix

F9.3. Prior to destructive testing the testers observed that the single most obvious finding was that Station Road slot was almost fully off with the indicator showing wrong.

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F9.4. When permission was given, Chapel Road slot 2 was pulled and lever 3 was in the on position and the L3 signal came off to 24 degrees.

F9.5. The signal wire to L3 slot was found to be excessively tight due to the signal wire adjuster being over tight. This was proved by slackening the adjuster and the indication was observed to return to the on position.

F9.6. The following additional issues were identified

a) the slot mechanicals were found to be very worn

b) Indicator shows wrong with signal at 11 degrees

c) Vegetation found to require cutting back 200 metres on approach to signal

d) Vegetation affecting signal silhouette

F10. On Train data Recorder F10.1. Interrogation of the On Train Data Recorder (OTDR) revealed that the driver had

driven according to his company policy except that on receipt of the warning horn for L3 he should have proceeded according to GE/RT8000 rule book module S7 section 5.2.

F11. Signal Maintenance records F11.1. The panel considered the records for the signal maintenance and found they met

the required standards, for content and frequency.

F11.2. The panel did not feel that the maintenance of L3 signal played a role in this event.

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G. Factors discussed

G1. Why were the crossing gates at Lingwood Station Road closed?

G1.1. CK 1 was questioned at the time of the incident and later formally by the investigation panel; he could not explain why he did not hear the bells to indicate a train was approaching.

G1.2. CK 1 had not been on a previous shift where the RHTT had operated so was relying on the information presented by the AGA website. This indicated to CK 1 that there was two hour gap between his last passenger service at approximately 13:47, so he was not expecting the bells for the RHTT. CK 1 cannot recall whether there were any loud vehicles on the crossing about this time, or whether he had needed to take a physical needs break.

G1.3. It is reasonable to assume that the bells did work at Lingwood Station Road crossing as the bells from Brundall to / from Acle were received at each end of the circuit, they had worked for the previous train and operated correctly when subsequently tested.

G1.4. On previous days the bells had failed but these failures affected the complete circuit and mechanical failures had been found to be the root cause of these faults.

G1.5. CK1 is a relief crossing keeper and to operate the crossing at Lingwood Station Road a journey of 2 hours in each direction is required. The fatigue index for the roster he had worked previous to the incident came out as

G1.6. 42.5 deg C maximum and 32 deg C average. The panel concluded that it was possible that fatigue meant that CK1 had not responded to the bells.

G1.7. The crossing keeper either did not hear the bells or did not respond to the bells as would be expected. Had he done so the gates would have been open to rail traffic with the L3 signal commensurately displaying a correct off indication.

G2. Why was L3 signal not correctly displaying a stop aspect? G2.1. CK1 had taken duty at 05:45 when the weather was cool and as his shift

progressed the temperature had increased, the known co-efficiency of signalling wire means that for every ten degrees celcius of temperature variation, the signal wire will expand or contract by approximately 125mm.

G2.2. The crossing keeper recalled that he had to adjust the signal wire during the morning approximately three times, although he appeared keen to point out this wasn’t something that he remembered particular well.

G2.3. CK1 felt that on starting duty the temperature was considerably cooler and that as it warmed up he had to adjust the signal wire to assure a good off indication. The crossing keeper’s training plans include an element covering signal wire adjustment.

G2.4. The investigation panel was of the opinion that CK1 adjusted the signal wire to take account of the weather variation, though in doing so, incorrectly adjusted the signal wire. This over adjustment may well have been due to a lack of experience and possibly a flaw in the training from his peers that he had received.

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G2.5. The panel has been unable to ascertain whether the indicator for L3 was showing a wrong indication prior to the passage of 3S01. It is reasonable to assume that L3 was not in fact correctly replaced to the ON position, as there was no sudden decrease in temperature and no vegetation found to be encroaching on the wire run.

G2.6. As the L3 slot wire was over tightened, the mechanical nature of the slotting arrangement meant that as CK2 locked his gates for the passage of 3S01 and then subsequently cleared his CR1. The slot lever CR2 was then operated allowing the L3 slot arm sufficient free travel to produce a signal arm that was imperfectly shown.

G3. Why did the driver of 3S01 not stop at Lingwood level Crossing gates?

G3.1. The driver of 3S01 was an experienced driver The panel did not feel the driver’s

competence was an underlying factor.

G3.2. The investigation panel were aware that the driver had completed a signalling course in his personal time so as to operate signal boxes on preserved railways and generally enhance his personal knowledge. This may have led the driver to not react in the correct manner when he received an AWS warning horn prior to his viewing an imperfect aspect shown by L3 signal.

G3.3. The driver believed that he had disregarded the warning horn due to it being a hot day, reasoning that the signal would not have fully made its connection with the AWS due to the wire being slightly slack.

G3.4. GERT8000 rule book module S7 section 5.2 instructs specifically for the times a driver may encounter a warning horn at a semaphore distant signal which shows clear.

G3.5. The instruction states that the signal must be treated as being at caution if an AWS warning is received even if the driver believes the signal is displaying a clear indication. The panel noted that there were two exceptions to the action expected of a driver - neither of which applied to this incident.

G3.6. The driver could not fully explain why he did not act in the required manner but felt that the signal was showing a good off indication and that he responded to this rather than the AWS warning.

G3.7. The panel asked how the driver had sighted the signal. He advised that it had been in good time with no obscuration, and further stated that the signal was sighted through the main quadrant of the windscreen. Pictures post incident had shown the locomotive’s windscreen to be heavily contaminated, with only the wiper quadrant offering clear visibility.

G3.8. The driver had been accompanied in the locomotive cab by the JSD operative. Both stated during interview that cab discipline had been maintained; the panel had no reason to suspect that distraction was an underlying cause.

G3.9. The JSD operative was able to confirm that L3 signal was not in the horizontal position but was unable to describe where he felt the signal position actually had been.

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G3.10. The panel agreed that the driver would have seen an aspect that was imperfectly shown, which may have given the impression that it was off. However the driver did recall receiving a warning tone from the AWS equipment and the OTDR data confirmed such a warning was made.

G4. Post incident Management G4.1. Following the incident, the emergency services responded and the immediate area

was initially treated as a scene of crime.

G4.2. The Rail Accident Investigation Branch (RAIB) decided not to deploy their personnel to site or investigate the incident. The site was handed over to Network Rail by the British Transport Police (BTP) to undertake investigations.

G4.3. The Driver, JSD operative and crossing keeper were for cause screened and all results were negative – the panel do not believe alcohol or drugs played any part in this incident.

G4.4. The crossing keeper was offered transport home but declined as he was returning to duty in the morning after taking sufficient rest.

G4.5. Direct Rail Services staff looked after the driver and JSD operative post incident, although it was noted that the JSD Operative was left “wandering around” after the event. The panel felt that the Industry’s response could have organised a better method of care for the staff

G4.6. DRS took the JSD operative to the railway station at Norwich to make his own way home. The driver was allowed to drive his own vehicle home from there.

G4.7. The operation of the crossing was undertaken by hand signallers until the gates were replaced and the Level 3 Signalling Engineer deemed the testing and repairs to be sufficiently concluded to restore the crossing to normal working on the 07th November 2014.

G4.8. All staff required to undertake the duties of Crossing Keeper at Lingwood Station Road and Chapel Road were briefed on the use of wire adjusters and use of the indicators prior to the system being signed back into normal use..

G5. Actions already taken G5.1. The local infrastructure maintenance team and Local Operations Manager have

prepared a brief to all crossing keepers on the method to be used where signal wires require adjustment and highlighting the importance of checking the indications prior to operating a signal lever (and following operation?).

G5.2. The driver has been returned to full driving duties with an action plan and on-going monitoring.

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H. Incident factor causal analysis Underlying cause No.

(from section A4)

Incident Factors Person

Level 1

A4.1 Communications CK 1, Driver

A4.2 Practices and processes CK 1

A4.5,4.6 Information Driver, CK 1

A4.4 Equipment NWR

A4.2, 4.5,4.6 Knowledge, skills and experience CK1 Driver

# Supervision and Management #

# Work Environment #

# Teamwork #

# Personal #

# Workload #

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I2. Observers I2.1. The following observer(s) also attended the investigation:

I2.2. –Senior Investigator, Network Rail

I2.3. – Operations Manager, Network Rail

I2.4. – Driver Standards Manager, Direct Rail Services.

I2.5. The following trade union(s) was invited to attend the investigation and was

represented by: *

RMT *

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K. Feedback from consultation

K1. General K1.1. The following sections show the feedback obtained during the 10-day consultation

period.

K1.2. No feedback received from external or internal stakeholders.

K2. Feedback from Network Rail Section Comment Response

# # #

K3. Feedback from # Section Comment Response

# # #

K4. Feedback from # Section Comment Response

# # #

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Report of a Formal Investigation

Documents

Transcript of Report of a Formal Investigation