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At approximately 07:35 hrs on Tuesday 25 June 2013, train 2F83, the 07:00 hrs service from Cleethorpes to Barton-on-Humber, comprising a single-car class 153 unit, was driven onto Butterswood level crossing when the barriers were still raised and the road open to traffic. A car was approaching the crossing at the time and the car driver later reported the incident to Network Rail.

Northern Rail was the operator of train 2F83, but First Transpennine Express provided the train crew for the service.

Butterswood level crossing is situated on the line between Ulceby and Barton-on-Humber in north Lincolnshire and is around 2.5 miles south-east of Barrow-upon-Humber. It is of a type known as an automatic barrier crossing locally monitored (ABCL). When the crossing barriers are raised (ie the highway is open to traffic) an indicator, known as the driver^s crossing indicator, displays a flashing red aspect to approaching trains until such time that the signalling equipment detects that the barriers are closing.

Under normal circumstances the operation of the crossing is automatically initiated by the approach of a train. Once the road traffic signals have activated and the barriers have started to lower, the flashing red light on the train driver^s crossing indicator will be replaced by a flashing white light. This flashing white light is intended to inform train drivers that the crossing is functioning correctly and that they can continue at the speed indicated on a speed restriction board located before the crossing.

On this occasion, a power supply failure the previous night led to the crossing failing to activate as train 2F83 approached. The train driver did not notice that the crossing indicator was still displaying a red flashing light, indicating the crossing had not activated, until the train was around 160 metes from the crossing and travelling at about 40 mph. The driver applied the train^s emergency brake but was not able to stop the train before it reached the crossing.
 
(http://www.raib.gov.uk/cms_resources/Butterswood.JPG)
Butterswood level crossing

The RAIB^s investigation will examine the factors that may have influenced the actions of the train driver as the train approached the crossing. It will also consider the reason why the crossing failed to operate and any other relevant incidents that have occurred at the crossing.

The RAIB will publish its findings at the conclusion of its investigation. This report will be available on the RAIB website.

1 The intent of this recommendation is to provide a positive indication to train drivers when automatic locally monitored level crossings have failed to operate for the approaching train.

Network Rail, in consultation with RSSB, should conduct a human factors and technical review of the indications displayed at driver^s crossing indicators provided on the approach to automatic locally monitored level crossings, and evaluate alternative means (eg audible and visual) of indicating to train drivers that the level crossing has not operated as intended. A time-bound plan for improvements arising from the review should be developed using a risk-based approach.

2 The intent of this recommendation is to improve the reliability of all power supplies (including battery back-up arrangements) at automatic locally monitored level crossings.

Network Rail should review the arrangements in place at all types of automatic locally monitored level crossings, and make improvements to the reliability of those crossings. The review, and associated improvements, should include (but not be limited to):

• a. locations where parallel protective systems exist (such as multiple earthing systems combined with RCD protection) where their presence can lead to unnecessary loss of the main network power supply to the level crossing;
• b. the plans in place to ensure that UPS systems maintain adequate performance throughout their life (including plans to replace UPS battery systems during the life of the UPS system); and
• c. understanding the age of UPS systems in use, and the manufacturer^s life expectancy of those assets.

3 The intent of this recommendation is for Network Rail to be able to identify level crossings that have suffered a power supply failure so that prompt action can be taken to manage the consequences of the failure including consideration of the benefits of recent technological developments that allow remote condition monitoring at reasonable cost.

Network Rail should evaluate the practicality of remote condition monitoring of the power supply system, and key sub-systems whose failure can have the same effect as loss of power supply, at all locally monitored level crossings, so that prompt action can be taken to manage the failure (such as telling train drivers that the crossing has failed and arranging for technical staff to attend the level crossing to investigate the
failure).

4 The intent of this recommendation is for First TransPennine Express to identify and implement changes where necessary to its briefing methods in order to reduce the risk of drivers making errors at key locations such as locally monitored crossings.

First TransPennine Express should review and enhance its briefing techniques and guidance material for train drivers:

• a. to explain the role of the driver at locally monitored crossings;
• b. to ensure that it properly reflects the operation of key infrastructure assets such as level crossings (including revisions to its description of the arrangements at automatic locally monitored level crossings, beyond the level of detail described in the railway rule book);
• c. to allow its train drivers to practise dealing with unannounced level crossing failures, including, for example, the use of its train driving simulator or video-based hazard perception exercises;
• d. by using focused, risk-based, presentation material for briefing operational staff; and
• e. by stating clearly the action drivers should take when passing the special speed restriction board of any locally monitored automatic level crossing, when a flashing red light is visible at the drivers crossing indicator.

Note: Recommendation 4 may also apply to other train operators.