Woman dies after cars struck by train at Moreton-on-Lugg in Herefordshire (16 January 2010)

[whole diary]

[Tim]

If indeed the signaller raised the barriers prematurely, it's difficult to understand why that might have occurred since he was overlooking the crossing and presumably knew where the train was. 
.

Human error might be why the barrier was raised prematurely?  Yes it would have been an odd and unusal thing for the signaller to do, but it is the odd and unusual mistakes that lead to accidents. 

My point about the design of the hardware is that such a mistake could in theory have been prevented from turning into an accident.  The system could quite easily have been set up so that after the home signal went to red the barriers could not be raised until after a delay sufficient to allow a train to stop (if the red signal was observed) or a train to pass (at normal line speed if the red signal had not been observed) had timed out.

However, IIUIC the system is set up so that as soon as the train is observed to have cleared the crossing the signaller is able to raise the barrier.   That system is safe in normal use because as you say the signaller overlooks the crossing and will know where the train is, but if the signaller makes a mistake the system is not fool proof.

Why isn't there a suffcient delay before the signaller can raise the barrier?  Well it would hold up traffic of longer so I suggested that that might be a reason.

The only alternative explanations I can think of would be that the signaller was blameless and the barrer malfunctioned and raised itself prematurely? or the train ought to have spotted before the crossing but didn't because of the train driver's actions or problems with the railhead or train brakes.

[Chris from Nailsea]

From the BBC^» (British Broadcasting Corporation - home page):

Woman killed on Herefordshire level crossing mourned

The funeral of a woman killed on a level crossing in Herefordshire has taken place.
Car passenger Jane Harding, a 52-year-old hairdresser from Marden, died when a train crashed into her vehicle at Moreton-on-Lugg on 16 January.
Barriers were up at the crossing, British Transport Police has said. Network Rail has apologised to Ms Harding's family.
The funeral took place at Hereford Cathedral during the afternoon.

[Chris from Nailsea]

From the BBC^» (British Broadcasting Corporation - home page):

No mirrors at fatal Herefordshire rail crossing

Network Rail has turned down a council request to install safety mirrors at a level crossing in Herefordshire where a woman died in a collision with a train.
Jane Harding, 52, was a passenger in a car that was hit by a train at Moreton-on-Lugg level crossing on 16 January.
The crash, which happened when barriers were up, is being investigated.
Moreton-on-Lugg Parish Council said it was told safety mirrors were "not necessary". Network Rail said the crossing was safe.
A spokesman said the company would not comment further until official crash investigations had been published by the Rail Accident Investigation Branch, British Transport Police and the Office of Rail Regulation.
Moreton-on-Lugg Parish Council chairman Allan Collett said: "We've asked Network Rail to install mirrors thinking they might want to do that to keep people happy so to speak, but they have refused to do that, saying that it's not necessary."
Previously Network Rail apologised to Mrs Harding's family and anyone else who had been affected by the crash.
A spokesman for Network Rail said in January: "We consider that the accident is most likely to have been due in some way to Network Rail."

[Chris from Nailsea]

From the BBC^» (British Broadcasting Corporation - home page):

Arrest after level crossing death in Herefordshire

A man has been arrested on suspicion of manslaughter following a fatal crash on a level crossing in Herefordshire six months ago.

Jane Harding, 52, died after being hit by a train at Moreton-on-Lugg. The barriers at the level crossing were up when her car crossed the track.

A signalman was later suspended by Network Rail, as standard procedure.

British Transport Police (BTP^▸ (British Transport Police)) has confirmed a 40-year-old man has been arrested.

He has since been released on bail while investigations continue.

[Chris from Nailsea]

The Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) has released its report into a fatal accident at Moreton-on-Lugg, near Hereford, 16 January 2010. The RAIB has made four recommendations.

Summary

On 16 January 2010, a collision occurred between a passenger train and two cars at the level crossing at Moreton-on-Lugg, near Hereford.  The front-seat passenger in one of the cars was fatally injured.  The driver was seriously injured and detained in hospital.
 
The two occupants of the other car attended hospital as a precaution.  There were no casualties on the train, which did not derail.

The level crossing is controlled from the adjacent signal box.  The cause of the accident was that the signaller raised the barriers in error when the train was approaching and too close to be able to stop before reaching the level crossing.  He had just been involved in an absorbing telephone call that had interrupted his normal task of monitoring the passage of the train.  As a result he believed that the train had already passed over the crossing. 

There was no safeguard in the signalling system to prevent this from happening.  There was no plan to fit such a safeguard, and no industry requirement to formally consider the safety benefits of one.

The RAIB has made four recommendations to Network Rail.  They include assessing the need for additional engineered safety measures at level crossings like Moreton-on-Lugg and targeted improvements to its processes for managing risk at level crossings, and for determining when it should bring signalling assets into line with latest safety standards.

Edit note: Post modified to update link to RAIB report. CfN.

[eightf48544]

"There was no safeguard in the signalling system to prevent this from happening.  There was no plan to fit such a safeguard, and no industry requirement to formally consider the safety benefits of one."

I think that says it all.

[inspector_blakey]

A situation that, whilst not remedied by Railtrack or Network Rail, was very much the doing of British Rail and dates back as far as the crossing being converted from gates to full-width barriers by Western region in the 1970s.

I've skim-read the first half of the report, and at risk of repeating myself, I'm starting to find the sheer verbosity of the RAIB^▸ (Rail Accident Investigation Branch)'s reports frustrating. They are certainly thorough, but they go rather beyond that into unnecessary detail. I think if I sat down with a copy of that report and a red pen I could strike through endless paragraphs that, whilst perhaps of academic interest, have absolutely no bearing on the accident under discussion.

[eightf48544]

The other really scary thing about the lack of interlocking between barriers and signals is that Moreton on Lugg  is not the only crossing to lack this provision.

See Alan Williams in Modern Railways.

[SandTEngineer]

The other really scary thing about the lack of interlocking between barriers and signals is that Moreton on Lugg  is not the only crossing to lack this provision.

See Alan Williams in Modern Railways.

There is interlocking between the barriers and signals at Moreton.  What is not provided (at present) is electrical interlocking to prevent replacement of signals to danger and release of the level crossing locking without a time delay (long enough to ensure that a train approaching is brought safely to a stand if the signals are replaced to danger infront of it).

[eightf48544]

Yep concede there is some interlocking but lack of time delay is still a risk and the fact that other crossings aren't equipped either  makes it a greater risk

Just  for the sake of a time delay relay a fairly cheap piece of kit.

They still work every day at places like Dolphin Junction after nearly 40 years.

[bobm]

According to the BBC^» (British Broadcasting Corporation - home page) both Network Rail and the signalman on duty are to be prosecuted.

[Tim]

It always concerns me when they decide not to prosecute for Manslaughter but to prosecute under the Heath and Safety Act.  It always sounds to me a bit like they have decided that the person responsible for the acident didn't intend to cause the acident and wasn't reckless or negligent (or else why not charge him with manslaughter), but never-the-less still made a mistake.

I am not sure that criminal charges are the best way to punish someone for a non-deliberate mistake.  Do such charges really act as a deterent to others?  By all means move an acident prone signaller to a less safety critical job, but is a criminal prosecution really in the public interest.  As for fining NR^» (Network Rail - home page), wouldn't it make more sense to order them to spend the money on upgrading crossing equipement to make them safer?

[eightf48544]

Here here Tim agree entirely with you.

Make NR^» (Network Rail - home page) install the necessary equipment to provide a time delay mechanism between the signal being put back and the release of the barriers, at all crossings
without such a mechanism of which Alan Williams thinks there are a fair number. The work to be done in month.

[Chris from Nailsea]

At the risk of labouring the point, see pages 24 and 25 in the RAIB^▸ (Rail Accident Investigation Branch) report - the thoughts of the signalman can only be imagined. 

[eightf48544]

Thanks for posting report link Chris.

Very interesting that the signalman was distracted by the phone call from an unmanned level crossing. You can begin to see how the accident might have occurred. All the more reason to apply approach locking.