Great Western Coffee Shop

RAIB is investigating an incident that occurred at 17:25 hrs on Saturday 7 March 2015, in which train reporting number 1Z67, the 16:35 hrs service from Bristol Temple Meads to Southend, passed a signal at danger on the approach to Wootton Bassett junction, Wiltshire. The train subsequently came to a stand across the junction. The signal was being maintained at danger in order to protect the movement of a previous train. However, at the time that the SPAD occurred, this previous train had already passed through the junction and was continuing on its journey. No injuries, damage or derailment occurred as a result of the SPAD.

Wootton Bassett junction is situated between Chippenham and Swindon stations on the Great Western main line and is the point at which the line from Bristol, via Bath, converges with the line from South Wales. It is a double track high speed junction which also features low speed crossovers between the up and down main lines (see figure below for detail).
 
The junction is protected from trains approaching on the up main from Chippenham by signal number SN45, which is equipped with both the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS). This signal is preceded on the up main by signal SN43, which is also equipped with AWS and TPWS. The maximum permitted line speed for trains approaching the junction from this direction is normally 125 mph. However, on 7 March, a temporary speed restriction (TSR) of 85 mph was in place on the approach to signal SN45. A temporary AWS magnet had been placed on the approach to signal SN43 to warn drivers of this TSR.

The train which passed signal SN45 at danger consisted of steam locomotive number 34067 ^Tangmere^, and its tender, coupled to 13 coaches. The locomotive is equipped with AWS and TPWS equipment.

The RAIB^s preliminary examination has shown that, at around 17:24 hrs, train 1Z67 was approaching signal SN43 at 59 mph, when it passed over the temporary AWS magnet associated with the TSR. This created both an audible and visual warning in the locomotive^s cab. However, as the driver did not acknowledge this warning within 2.7 seconds, the AWS system on the locomotive automatically applied the train^s brakes. This brake application should have resulted in the train being brought to a stand. In these circumstances, the railway rule book requires that the driver immediately contact the signaller.

The RAIB has found evidence that the driver of 1Z67 did not bring the train to a stand and contact the signaller after experiencing this brake application. Evidence shows that the driver and fireman instead took an action which cancelled the effect of the AWS braking demand after a short period and a reduction in train speed of only around 8 mph. The action taken also had the effect of making subsequent AWS or TPWS brake demands ineffective.

Shortly after passing the AWS magnet for the TSR, the train passed signal SN43, which was at caution. Although the AWS warning associated with this signal was acknowledged by the driver, the speed of the train was not then reduced appropriately on the approach to the next signal, SN45, which was at danger. Because of the earlier actions of the driver and fireman, the TPWS equipment associated with signal SN45 was unable to control the speed of the train on approach to this signal.

As train 1Z67 approached signal SN45, the driver saw that it was at danger and fully applied the train^s brakes. However, by this point there was insufficient distance remaining to bring the train to a stand before it reached the junction beyond SN45. The train subsequently stopped, standing on both the crossovers and the up and down Badminton lines, at around 17:26 hrs. The signalling system had already set the points at the junction in anticipation of the later movement of 1Z67 across it; this meant that no damage was sustained to either the train or the infrastructure as a result of the SPAD.

The RAIB has found no evidence of any malfunction of the signalling, AWS or TPWS equipment involved in the incident.

The RAIB^s investigation will consider the factors that contributed to signal SN45 being passed at danger, including the position of the temporary AWS magnet associated with the TSR. The investigation will also examine the factors that influenced the actions of the train crew, the adequacy of the safety systems installed on the locomotive and the safety management arrangements.

Wootton Bassett
Wootton Bassett junction in 2012 - the lines shown from left to right are the Up Goods, Up Badminton, Down Badminton, Up Main and Down Main (image courtesy of Network Rail)

Wootton Bassett diagram
A diagram of the layout of Wootton Bassett junction - note that some features have been omitted for clarity (not to scale)

I was initially confused when I saw the email alert summary for this investigation in my inbox. A direct service from Bristol TM to Southend? Only on reading further and remembering being told about it on the day did I realise it was a railtour.

... I could see the steam over the tops of the houses before hearing the train whistle and seeing the steam move along.

You can't see steam: what you see is water vapour.  :P ::) ;D

Does this SPAD raise some difficult questions about steam locomotive drivers on main lines?

Has Southend got a Cathedral?

Suspect it was the Cathedrals Express on the 7th March which was later involved in the SPAD at Wootton Bassett Junction.

http://www.firstgreatwestern.info/coffeeshop/index.php?topic=15554.0 (http://www.firstgreatwestern.info/coffeeshop/index.php?topic=15554.0)

All west coast railway operations have now been suspended because of this for at least six weeks.

  Network Rail and West Coast Railways
West Coast Railways are working hard to reverse the current suspension imposed by Network Rail by fully satisfying their concerns. Passengers booked to travel with West Coast Railways and on their associated trips should not be concerned, if necessary West Coast Railways will charter the service of another licensed operator using the same traditional carriages and trips will be unaffected, but West Coast Railways hope this won^t be necessary and trust any issues will be resolved to the satisfaction of network rail.

Does this SPAD raise some difficult questions about steam locomotive drivers on main lines?

Just one minute earlier and there could have been a collision with a FGW HST, according to RAIL magazine.

http://www.railmagazine.com/news/network/2015/04/02/west-coast-railways-operating-licence-suspended

Earlier reports on the BBC website stated, most misleadingly, that "steam trains" had been banned from the national network, rather than the fact that one operator of steam, and other locomotives had been banned.

I emailed them to point out this factual error.

Erm ... Yes.  :o ::) :-X

Dear Fellow Traveller

Passenger safety is our number one priority.

You may have read or seen news relating to Network Rail (owners of the lines used by West Coast Railways) and West Coast Railways.

A recent breach of safety regulations involving one of our trains crossing a red light has lead to discussions by both parties to establish how this happened and more importantly the preventative measures in place to ensure it can^t happen again. Although no one was injured in any way West Coast Railways consider this to be sufficient to carry out a full internal enquiry with the support of Network Rail and at this time will not be running trains under their current used licence.

However all trips remain unaffected and will run as normal under licence of another operator, using the same vintage Mk2 carriages, passengers will not be affected and all schedules including the Jacobite will continue as normal, should there be any changes to services passengers will be notified in advance.

Safety is a primary importance to both West Coast Railways and Network Rail and as such both parties MUST be absolutely satisfied with the safety measures in place to prevent any such future happenings, through continued discussions and when both parties are satisfied it is hoped that West Coast Railways will resume operation under licence.

Should you have any questions regarding this please email bookings@westcoastrailways.net


Many Thanks

West Coast Railways

Sounds a pointless ban if they can just borrow somebody else's licence.
Would using somebody else's licence mean they need staff from the licence holder?

Sounds a pointless ban if they can just borrow somebody else's licence.
Would using somebody else's licence mean they need staff from the licence holder?

To some of us this news about WCRC is not surprising at all.

I'll be careful about saying much more until the RAIB have done their work.

Made page 3 of yesterday's Daily Telegraph, happy to scan the article and upload it if anyone would like to read it (when I'm back at work on Tuesday!)

If you read between the lines a little bit, it's quite clear from the Network Rail license withdrawal document I linked to a few posts back that there are some pretty significant issues!

Back at work Tuesday TG? Does this involve train travel ?

Made page 3 of yesterday's Daily Telegraph, happy to scan the article and upload it if anyone would like to read it (when I'm back at work on Tuesday!)

Would that be this article?
http://www.telegraph.co.uk/news/uknews/road-and-rail-transport/11512929/Train-company-that-owns-real-life-Hogwarts-Express-suspended-from-railways-over-safety-concerns.html

That's the one!

You know ignorant journalists - they won't have realised those two points don't align

You know ignorant journalists - they won't have realised those two points don't align

Don't they? Why?

I am finding it very difficult to understand where the Telegraph is coming from editorially regarding Network Rail 2 weeks ago they wanted NR in private hands to make the books balance there was not mention then about NR role in the safety of train operation and now the Telegraph have an article about the safe operation of a private enterprise operating on the National network

I'd imagine FGW, whose HST came very close to colliding with the WCRC charter, will be one of the parties making strong representations to the ORR consultation.

Criminal investigation into steam special which overshot red light on main line

An incident in which a steam train passed through a red signal and just missed a High Speed Train on the main line in Wiltshire is now the subject of a criminal investigation.

Rail investigators from the Office of Rail and Road, the Government's railway safety body, are understood to have found "significant weaknesses" in the safety management systems at West Coast Railways after investigating the incident which happened near Royal Wootton Bassett.

On March 7, a steam train on an excursion passed through a red light and only narrowly missed colliding with a passing InterCity 125 train.

The Cathedrals Express service, a special train pulled by Battle of Britain class steam locomotive Tangmere number 34067, overshot the red light by 700 yards at a junction where the tracks to the West split into the line which continues to Chippenham and Bristol Temple Meads and the one for Bristol Parkway and South Wales. The steam special was travelling from Temple Meads to Southend and is thought to have narrowly missed the First Great Western 3.28pm service from Swansea to Paddington, which had just gone through.

It came to rest at the Wootton Bassett junction just one minute after the previous train had passed. Network Rail consider the incident the "most serious" of its kind to have happened on the West's railways in recent years.

Investigators have now decided that they will take matters further with an inquiry to see if health-and-safety laws have been breached and whether a prosecution in the courts could follow.

Network Rail withdrew temporarily the licence it gave to West Coast Railways, the company that runs the steam trains and operates the tours, to run trains on the railway network.

It is the first time any action of that kind had been taken against a company operating trains on Britain's privatised railways.

Now the Office of Rail and Road is considering whether or not to revoke the company's licence completely.

This is alongside the body deciding whether to mount a prosecution under health-and-safety legislation.

A spokesman for the Office of the Rail Regulator said: "The rail regulator has notified the West Coast Railway Company that it is reviewing the company's safety certification ^ needed to operate trains on the rail network. Our initial investigation has found significant weaknesses in the company's safety management systems. ORR is carrying out further assessments to determine whether health and safety laws were breached, and the enforcement action required," he added.

A spokesman for Network Rail said: "This decision has not been taken lightly. We have set out a number of actions to address the safety concerns raised and will continue to work with West Coast Railways to ensure their services can run safely in the future."

I have had an email from West Coast Railways saying that, as a result of the Network Rail announcement, the Jacobite service between Fort William to Maillaig will start on Monday as planned.

We welcome the commitment West Coast Railways has made to improving safety management; the changes to your Safety Management System (SMS); and the three new roles (Director/General Manager, Head of Safety and Non-Executive Director) being introduced to strengthen safety leadership and corporate governance. We note your appointment before services recommence of your new Non-Executive Director and Alex
McGregor of Lloyds Register as interim Head of Safety pending the permanent appointment; and for the ongoing engagement of First Class Partnerships to ensure that changes to the SMS are implemented effectively.

We recognise and welcome that you intend to put in place a phased return of services, to allow you and your most experienced staff to implement your new procedures before use with a wider range of services.

I'm very surprised in view of the ongoing RAIB investgation and possible crimal proceedings mentioned in CFN's post from the Western Gazette.

Improvement Notice for Hogwarts Express operator after 'nearly Britain's worst train crash'

(http://www.westerndailypress.co.uk/images/localworld/ugc-images/276309/Article/images/26553698/10122784-large.jpg)
The Battle of Britain class 34067 Tangmere locomotive, which failed to stop at a red light in Wiltshire

Rail safety police have issued a formal Improvement Notice on a heritage steam train operator ^ and could still prosecute them ^ after what would have been Britain's worst rail tragedy in generations was narrowly avoided in Wiltshire.

The Office of Rail and Road's official improvement notice order comes after the rail safety watchdog completed their investigation into West Coast Railways, which operated a steam train that was seconds from crashing into a high speed intercity train at a junction on the Great Western mainline in Wiltshire.

The incident, which happened back in March, was deemed so serious it could still lead to a criminal health and safety prosecution against the heritage train company, which operates a host of steam trains, including the Hogwarts Express.

The ORR said the case against West Coast Railways was still being investigated, and the Improvement Notice would not preclude any future prosecution.

The Improvement Notice forces West Coast Railways to tighten up its safety procedures, and adhere to a strict regime of notifying the regulator of everything it does.

"Safety on the railways is ORR's absolute priority," said Ian Prosser, the director of railway safety at the ORR. "Following the serious incident where a West Coast Railway Company (WCRC) train passed a signal warning at danger near Wootton Bassett Junction on March 7, ORR inspectors have carried out an extensive investigation into the standards of safety on their passenger services.

"The regulator's initial investigation found shortfalls in the WCRC's safety management system and in response the company has introduced enhanced safety procedures and appropriate staff competence regimes. ORR inspectors have been on site examining the new safety arrangements and inspecting WCRC passenger services to ensure that the necessary changes are being fully implemented by the company.

"ORR has issued an Improvement Notice to ensure WCRC delivers further improvements. This will ensure workers are provided with suitable training and effective systems to control safety risks and have clearly defined performance indicators in place. ORR will closely monitor the company and will not hesitate to step in if any non-compliance with the Improvement Notice is found," he added.

West Coast had been suspended from operating any steam train on Britain's railways for around seven weeks after the incident, but had its licence restored recently.

The incident on March 7 was described as 'a minute away from one of the country's worst train crashes'. At around 5.30pm, a steam train heading from Bristol to Essex failed to stop at a red light at the junction near Wootton Bassett in Wiltshire where the Temple Meads and Parkway branches of the Great Western mainline meet on the way to London.

The steam train ^ which had hundreds of 'leisure passengers' on board - braked eventually, and stopped right on the junction, just seconds after the First Great Western service from Swansea to Paddington ^ with around 400 people on board ^ went through at around 70mph.

"This was potentially a catastrophe," said Nigel Harris, the editor of Rail Magazine. "We were a minute away from a high-speed train hitting a steam train."

An update to the RAIB's investigation into this incident has been published today, 19th October 2015.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469145/151019_Wootton_Bassett_web_update.pdf

Sobering reading. It's not the RAIB's job to apportion blame, but it's quite clear from reading this interim report where the blame lies.

It seems this incident was a classic case of the holes (and it seems some extra holes had been added by deliberate human action) almost completely lining up in the Swiss cheese.

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.

After reading the report, nice though it is to see them working at mainline speeds, I do wonder just how appropriate it is to be using these large steam locomotives on a hugely busy, fast, modern railway. In my opinion there are too many potential safety downsides - primarily several cumulative aspects of forward visibility which appear to have been a significant causative factor in this incident.

Safety equipment which was turned off allowing a steam train to pass a red signal had been turned off on previous occasions, a report has shown.

The train passed a signal near Royal Wootton Bassett in March and ended up across a junction.

A Rail Accident Investigation Branch (RAIB) report showed an Automatic Warning System (AWS) brake demand was by-passed by the train's crew.

The report said it was not the only occasion when it had been by-passed.

The driver of the Tangmere locomotive ignored two AWS warnings, the report showed.




He fully applied the brakes when he saw the red signal but there was insufficient distance to bring the train to a halt.

The report found the First Great Western service from Swansea to London Paddington had "fortunately" already passed through the junction before the stream train came to a halt.

The steam train was operated as a charter service by the West Coast Railway Company Ltd (WCRC).

The editor of Rail magazine, Nigel Harris, said: "Do not underestimate how serious this was. We were a heartbeat from absolute catastrophe.

"Because the driver missed the red signal his train stopped across the junction.

"No more than a minute before that a First Great Western express heading for London was occupying that junction at nearly 100 mph."

The RAIB said it was continuing to investigate the incident and "the extent of the practice" of by-passing the AWS.

The competence of the train crew involved, and how this was managed by WCRC, will also be investigated.

Yes, it's an interesting, and emotive, argument.  Adding to the chances of an incident happening there are other factors such as the crash-worthiness of the stock, judging from Phil Wakely's photo the consist was mostly MkI's - should such a train have been involved in an incident you can bet the carriages would have folded up like a pack of cards.

Just today the unions have been complaining that steam hauled services on the Borders Line have been a health hazard due to the carriages not having retention tanks which is of course another issue - though of course there is still plenty of regular service trains still running about like that which for some strange reason wasn't mentioned...  :-\

As ever, there's a balance to find somewhere.

Please forgive my pedantry but it's 'brake' not 'break'.

'A heartbeat from absolute catastrophe' - how our worst train crash ever didn't happen in Wiltshire

This looks frighteningly similar to the previous incident

http://www.railmagazine.com/news/network/2015/11/24/west-coast-railways-steam-prohibited-on-main-line-network

West Coast Railways steam prohibited on main line network

The Office of Rail and Road has prohibited West Coast Railways from operating steam trains on the main line rail network.

In a statement released today (November 24), the regulator said: ^The Office of Rail and Road (ORR) has temporarily prohibited West Coast Railway Company Ltd from operating steam trains on the main line rail network, to protect the safety of its staff, volunteers, passengers and members of the public. The enforcement action follows an initial investigation into an incident near Doncaster on October 2 2015, which found staff on-board locomotive 45231 had turned off its Train Protection and Warning System (TPWS) isolation equipment, designed to apply an emergency brake if the driver makes an error. ORR will not allow the company to run trains where there are not effective controls in place for key safety systems. The regulator is working with the company to make the required improvements before services resume.^

The prohibition applies from 2300 on November 24, and WCR must seek formal approval from ORR before moving any steam locomotives. The notice does not affect operation of the company^s diesel trains.

ORR continues to investigate the serious incident where a West Coast Railways^ steam-hauled train passed a signal at danger near Wootton Bassett Junction on March 7 2015.

RAIL has approached WCR for a statement.

The enforcement action follows an initial investigation into an incident near Doncaster on October 2 2015 ...

The enforcement action, which the ORR says is to protect the safety of its staff, volunteers, passengers and members of the public, follows an initial investigation into an incident near Doncaster on 2nd October 2015, which found staff on-board LMS 'Black 5' No. 45231 had turned-off its Train Protection and Warning System (TPWS) isolation equipment, designed to apply an emergency brake if the driver makes an error.

An ORR spokesman said: ^ORR will not allow the company to run trains where there are not effective controls in place for key safety systems. The regulator is working with the company to make the required improvements before services resume.^

Railway Herald understands that the prohibition notice comes into force from 23:00 on 24th November and does not affect diesel operations, which can continue to operate.

Mayflower to operate to Minehead

Since the story broke, it is understood that WCR has been actively working with the Office of Rail and Road to resolve the issues, and it is now understood that the ORR has passed LNER 'B1' No. 61306 Mayflower for operation on the main line, meaning that the trip on 26th November to Minehead should proceed as planned, steam-hauled. Railway Herald also understoods that WCR are seeking agreement with the ORR for a second locomotive to be passed as well.

The ORR says that any modifications to the TPWS isolation equipment would need to be rolled-out to the entire steam fleet that is operated by WCR before the prohibition notice could be lifted.

At present, the status of other tours over the coming days is unknown. At present, they would have to use Mayflower, be diesel-hauled or rescheduled.

Related article from Railway Herald which suggests that locos with modified TPWS isolation equipment can still be operated by WCR:
http://railwayherald.com/uknews/orr-issues-prohibition-notice-on-wcr

There did seem to be quite a crowd of tabards on the footplate.

And Mayflower did go to Minehead, though perhaps not exactly as planned, losing 90 minutes at Reading. I don't know why, but for the first ten minutes (before I had to go) she was held by the signal, and the return journey was on time. There did seem to be quite a crowd of tabards on the footplate.

BNM, I think you should forward that masterpiece of photoshopping on to the MD of WCR...!  ;D

Is there a typo in that notice?  It states it runs from 24th August.

9 December 2015

The Office of Rail and Road (ORR) has today started criminal proceedings against train operator West Coast Railway Company Limited (WCRC) and one of its drivers. The charges relate to breaches of Health and Safety Law which led to a train passing a signal warning at danger on 7 March 2015.

The prosecutions follow ORR^s investigation into an incident involving a steam locomotive operated by WCRC, which passed a signal at danger near Wootton Bassett junction, Wiltshire. This extremely serious incident resulted in the train coming to a stop 550 metres after the signal, across a busy junction on the Great Western main line, directly in the path of high speed trains.

The train^s driver is facing charges under section 7(a) and 8 of the Health and Safety at Work etc. Act 1974 (HSWA). This relates to his alleged intentional misuse of the Train Protection and Warning System (TPWS) equipment. ORR^s investigation found that the driver directed a colleague to turn off this essential safety system, designed to apply an emergency brake if the driver makes an error.

WCRC is separately facing charges under section 3(1) and 2(1) of the HSWA. This is on account of its alleged failure to implement managerial controls, procedures, training and monitoring to prevent staff turning off the TPWS equipment.

ORR has been closely monitoring WCRC^s operation since this incident. ORR has also today launched a review of WCRC^s safety certificate, which is needed to operate its trains on the rail network.

Ian Prosser, HM Chief Inspector of Railways at ORR said:

^The safety of staff, volunteers, passengers and members of the public is our absolute priority. ^

^Britain^s railways have a good safety record. However, there have been a number of incidents over the past year involving West Coast Railway Company Limited trains. ^

^The incident at Wootton Bassett junction, where a WCRC train passed a signal at danger, was caused by alleged intentional misuse of a key safety system. This could have easily led to a catastrophic train collision. ^

^ORR inspectors are working with the rail industry, in particular the mainline heritage sector, to ensure that lessons are learned, and public safety is not put at risk.^

The first hearing is due to take place at Swindon Magistrates' Court on 11 January 2016.

With legal proceedings now active could I ask we all show our usual restraint with regard to commenting on the matters now coming before the courts?

Good. Serves them right.

Presumably this ban includes the "Jacobite" (or "Harry Potter Train" as many may know it) up in the West Highlands? (Fort William to Mallaig).

During the previous ban, weren't some specials taken over / run by other companies on West Coast's behalf?   If I recall that right, it may mean that some of the services still run - managed and operated by another of the specialist companies, but booked through WCRC and perhaps using their pool of rolling stock.

Presumably this ban includes the "Jacobite" (or "Harry Potter Train" as many may know it) up in the West Highlands? (Fort William to Mallaig).

Having seen how popular it is last Summer, that will be a big blow (and to the local economy aswell).

During the previous ban, weren't some specials taken over / run by other companies on West Coast's behalf?   If I recall that right, it may mean that some of the services still run - managed and operated by another of the specialist companies, but booked through WCRC and perhaps using their pool of rolling stock.

It could be a source of extra rolling stock for FGW, I'd love to see the looks on people's faces when the 0657 from Taplow rolls in pulled by a steam engine!

(more seriously, do they have diesel locos that could be used elsewhere, and what is likely to happen to the stock now that they are no longer able to operate?)

The Liskeard-Looe line has had a 94xx and a steam railmotor making "guest appearances".  The summer through services to Newquay hauled by a steamie,  D1015 (1062) - even a Deltic or a Vac - may be a possibility.  

The defendants did not enter any pleas to the charges they faced and District Judge Simon Cooper committed the case to Swindon Crown Court on February 19.

Looking at the Crown Court listings for yesterday, I couldn't find anything bearing any relation to the case.

New date - 18 March at Swindon Crown Court.

Our investigation, which is independent of any investigation by the Office of Rail and Road, is now complete; formal consultation with interested parties will start shortly. We expect to publish the final report in April.

Out of interest on a steam engine footplate, were there is normally more than one person, is it the driver who carries ultimate responsibility for the safe operating of the train?

 on quieter lines the odd small boy. 

TIMINGS NOW CONFIRMED FOR THE DEVON BELLE
 
SATURDAY 2 APRIL 2016
 
Main Line Steam operated by DB Schenker
UK Railtours are agents for the A1 Steam Locomotive Trust

(https://ci6.googleusercontent.com/proxy/NlqPZHVV0gaCHTknI-yOkORGH6mEu0jH6WFbCnbCIiMcJ197eAAgmLJkfYQus7pAxv2LMpe3EyampVV5Bg-9U5fmIVakRUD2fIeEKfTUbt8I_8e-pSzZOEKZ7XVicmn5oNdrU5-06-U68ixvomi6tmJnL8Bx6v9812Jef48=s0-d-e1-ft#https://gallery.mailchimp.com/b36a5ca242e42976740b8d5f4/images/8c2303c1-f0ff-4c41-9457-049b0515e585.jpg)

The issues with West Coast Railway Company don^t affect us, so you can still enjoy Main Line Steam.

Here are the timings for The Devon Belle, hauled by 60163 ^Tornado^ throughout: 

^We shall continue to closely monitor WCR over the coming period to ensure that their approach is embedded into the culture of the company and that they fully comply with all the commitments they have made."

Signal passed at danger (SPAD) on the approach to Wootton Bassett Junction, Wiltshire, 7 March 2015

At around 17:25 hrs on Saturday 7 March 2015, train reporting number 1Z67, the 16:35 hrs steam hauled charter service from Bristol Temple Meads to Southend, passed signal SN45 at danger. Signal SN45, which is situated on the approach to Wootton Bassett Junction, was being maintained at danger to protect the movement of a scheduled passenger train. At the time that the incident occurred, this scheduled passenger train had already passed through the junction. No injuries, damage or derailment occurred as a result of the incident.

Train 1Z67 was operated by West Coast Railways and consisted of the steam locomotive ^Tangmere^ and 13 coaches. Although Tangmere is a heritage locomotive, it is fitted with modern safety systems including the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS).

RAIB^s investigation has found that signal SN45 was passed at danger because the driver did not reduce the train^s speed on approach to the signal. This meant that he was unable to stop the train in time, once he realised it was at danger. The driver had not reduced the train^s speed because he had not seen the preceding signal, which was at caution and should have alerted him that SN45 was at danger. He missed this preceding signal because he had become distracted by activity within the cab and possibly also because he was experiencing a higher workload than normal.

Train 1Z67 also passed signal SN45 at danger because the TPWS system was unable to reduce the speed of the train by automatically applying the brakes. This was because TPWS had been rendered ineffective by Tangmere^s crew when they had isolated the AWS system in order to by-pass an automatic brake application which had occurred at a speed restriction. Isolating AWS in this way was in contravention of the relevant rules but the RAIB has found that it had almost certainly become an accepted practice among some train crews on this locomotive. This was probably because warnings from AWS were not always apparent to drivers, who were also anxious to avoid delays resulting from brake demands. Measures intended to prevent the misuse of AWS isolations had either not been adopted by West Coast Railways or had not been effectively implemented.

The RAIB found three underlying factors. These were that the AWS system on Tangmere was installed in a way which meant that warnings from the system were not always apparent to drivers. In addition, the investigation found that a speed restriction which was in place on approach to the junction was based on incorrect information and had been implemented in a way which did not conform to the relevant rules and standards. The investigation also found that West Coast Railways had a weak safety culture and that this had affected the way its staff observed rules and instructions.

As a result of this incident, RAIB has made five recommendations. One recommendation is addressed to RSSB, working in conjunction with steam train operators and Network Rail, and relates to a review of the arrangements intended to assess, prevent and mitigate the risks associated with steam movements.

Three recommendations are addressed to West Coast Railways. These relate to a review of its safety management system and safety culture; the implementation of industry best-practice concerning the management of drivers^ knowledge of operating routes; and the arrangements for maintaining on train data recorders.

One recommendation is addressed to Network Rail. This concerns the way that emergency and temporary speed restrictions are designed and implemented.

RAIB has identified one key learning point. This is that allowing safety critical systems such as AWS and TPWS to function without improper interference is vital to the safe operation of the railway. By-passing safety systems, or isolating them other than in accordance with the requirements of the relevant rules, can have catastrophic consequences.

THE driver of a steam train involved in a 'near miss' had his head out of the window to see where he was going because the windscreen kept misting up, a court heard yesterday.

Melvyn Cox also told a colleague to turn off safety systems which would have automatically stopped the engine before the incident at Royal Wootton Bassett.

By the time he saw the red light it was too late to stop the train, going from Bristol to London, which was left straddling the junction seconds after a high speed passenger train had passed through.

Had he got there a minute earlier the steam train Tangmere could have been involved in a 'disastrous' smash with an Intercity 125 from South Wales to London.

West Coast Railway Company Limited was fined £200,000 plus £64,000 costs.

Mark Watson, prosecuting, told Swindon Crown Court how the two warning systems fitted to the train had been switched off prior to the incident.

As a result, when the driver failed to hear the alarm going off the brakes were not automatically applied, as they should have been.

Cox had his head out of the window as the front window was misted up due to a small steam leak.

It meant when a safety system was activated for a temporary speed limit, which didn't affect them, he was late pressing a button causing the brakes to kick in.

Instead of bringing the train to a halt and contacting the signalman, as the rulebook says, he told his fireman to switch off the safety system so they could carry on.

Moments later the horn sounded to warn of a yellow signal.

When the alarm went off again for the red light at signal SN45 they again carried on until Cox spotted it flashing at the side of the track and put on the emergency brake.

Mr Watson said: "As he was travelling at excessive speed, the heavy locomotive came to a stand across Wootton Bassett junction 690 metres from the signal.

"A London bound high speed train carrying approximately 240 passengers had passed the junction on the Badminton line a minute before.

"A collision was only narrowly avoided with the potential consequences that can be imagined."

Cox, of Shirley Close, Swanage, Dorset, and his employers both admitted two health and safety offences.

David Travers QC, for West Coast Railway, said the company had changed its health and safety training since the incident.

Mark Watson, for Cox, said: "He fully recognises his breach and the fact he put a number of people at risk.

"The public are very right to expect the very highest standards of care to be exercised by train drivers on the public railways.

"He fell inexcusably short of that standard on this particular day."

The court heard the train driver, who has been in the business since leaving school as a 15-year-old more than 50 years ago, had been left a broken man by the incident.

Judge Peter Blair QC imposed a four-month jail term suspended for 18 months.

Train operator fined for safety failings
27 June 2016

Train operator West Coast Railway Company Limited (WCRC) has been fined £200,000 and ordered to pay costs of £64,000. This follows a prosecution brought by the Office of Rail and Road (ORR) for breaches of health and safety laws which led to a train passing a signal at danger near Wootton Bassett on 7 March 2015.

Melvyn Cox, a train driver with 40 years’ experience, has also received a four-month prison sentence, suspended for 18 months.

ORR investigated an incident involving a steam locomotive operated by WCRC between Bristol and Southall, which passed a signal at danger near Wootton Bassett junction in Wiltshire. The train stopped almost 700 metres after the signal, across a busy junction on the Great Western main line.

ORR inspectors found significant failings in WCRC’s managerial controls. The company had not implemented appropriate procedures, training or monitoring of staff to stop intentional misuse of the Train Protection and Warning System (TPWS) equipment.

Our evidence showed the train’s driver Melvyn Cox directed a colleague to turn off this essential safety system, designed to automatically apply an emergency brake.

WCRC and Melvyn Cox both pleaded Guilty at Swindon Crown Court today.

Ian Prosser, HM Chief Inspector of Railways said:

Train operating companies and their drivers hold positions of great responsibility, with a duty to protect the safety of colleagues and passengers. Almost all undertake their roles in accordance with the rules and their training. West Coast Railway Company’s (WCRC) ineffective management led to their train driver deliberately misusing a key safety system on a train travelling between Bristol and Southall. This prosecution has led to WCRC taking significant steps to improve its management of safety, with support from the regulator. Rail safety remains one of the regulator’s key priorities and we will always take action against companies or individuals if failings are found.

It's unbelievable that crews still take chances with AWS/TPWS, but sadly some still do.

Full story from Swindon Advertiser (http://www.swindonadvertiser.co.uk/news/14583128.Railway_company_fined_over___200_000_after_driver_blamed_for_a_potentially_devastating___39_near_miss__39_/)

All I can say is Good. You don't play with people's lives. EVER.