RAIB investigation into an incident at Lydney level crossing, 23 March 2011

[whole diary]

[Chris from Nailsea]

From the RAIB^▸ (Rail Accident Investigation Branch) website:

The RAIB is carrying out an investigation into an incident which occurred at the level crossing at Lydney station, Gloucestershire, on the railway between Severn Tunnel Junction and Gloucester, on Wednesday 23 March 2011.

Lydney level crossing has full-width power-operated lifting barriers which are normally controlled by a crossing keeper from the adjacent former signal box. At about 13:25 hrs the crossing keeper found that he was unable to raise one of the barriers after the passage of a train. Over the next hour, four trains passed over the crossing. The last of these, the 13:45 hrs Cardiff to Nottingham service, passed over the crossing at about 60 mph while the barriers were in the raised position.

There were some road vehicles waiting at the level crossing, where the red flashing lights were showing. The rail signal protecting the level crossing was showing green, and the train driver was unaware of the incident. Subsequent testing by Network Rail found that the level crossing equipment had functioned as it was designed to, but that it was possible to raise the barriers by hand without affecting the aspects of the protecting signals. At this particular level crossing, the keeper was not provided with any indication of the state of the signals or any means of controlling them (other than an emergency replacement switch).

The investigation will examine the sequence of events leading up to the incident, the implications of the design which enabled the signals to show a ^proceed^ aspect when the barriers were in the raised position, the adequacy of the instructions and training given to the staff who operated and maintained the crossing, and other factors which may have affected the incident.

Network Rail has been notified of the investigation and the RAIB^s preliminary findings.

The RAIB^s investigation is independent of any investigations by the safety authority (the Office of Rail Regulation).

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website.

[eightf48544]

There seems to be some funny logic in the interlocking of crossing barriers.

Yet another example of something one thought couldn't/shouldn't happen, barriers raised signals green.

[Chris from Nailsea]

The Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) has released its report into a train passing over Lydney level crossing with the crossing barriers raised, 23 March 2011.  The RAIB has made three recommendations.

The full report is available on the RAIB website:

Summary

At approximately 14:24 hrs on Wednesday 23 March 2011, train number 1M68, the 13:45 hrs service from Cardiff to Nottingham, passed over Lydney manually controlled barrier (MCB^▸ (Miniature Circuit Breaker)) level crossing while the barriers were in the raised position.  This crossing is on the main line between Gloucester and Newport.  The railway signal protecting the level crossing was showing green, and the train was travelling at 59 mph (94 km/h).  The red flashing lights intended to instruct road users to stop were operating and there were no road vehicles on the crossing.  No injuries or damage
resulted from the incident.

The crossing keeper had raised the up side barrier manually during the 90 minutes before the incident, due to a defect in the equipment controlling the barrier motors.  Shortly before the incident, the crossing keeper lowered the barriers for a train approaching from the direction of Gloucester.  He then raised both barriers manually just before the Cardiff to Nottingham train arrived at the crossing.  An annunciator (buzzer) intended to warn the crossing keeper about approaching trains did not give the usual warning.

The railway signals protecting Lydney crossing should have been placed at danger before the barriers could be raised safely.  The crossing keeper had no facility to control these signals, and did not inform signallers at Newport who could have kept the signals at danger while the barriers were raised.  Several possible reasons for not informing the signaller have been identified.
 
The RAIB has made recommendations to Network Rail relating to the adequacy of instructions and training given to crossing keepers and signallers; and, the process used for on-going assessment of staff competencies.  The RAIB has also recommended that Network Rail should modify standards for new and upgraded crossings so that protecting signals always display a stop aspect when the crossing barriers are raised.

[eightf48544]

The railway signals protecting Lydney crossing should have been placed at danger before the barriers could be raised safely.  The crossing keeper had no facility to control these signals, and did not inform signallers at Newport who could have kept the signals at danger while the barriers were raised.

Says it all!

[JayMac]

And that is pretty much what the RAIB^▸ (Rail Accident Investigation Branch) said in their recommendations following this incident.

Chris from Nailsea's forum signature sums it up perfectly:

'Level crossings on the railway network are safe - unless they are used in an unsafe manner.'   Discuss.

[Chris from Nailsea]

Erm ... that's exactly what the RAIB^▸ (Rail Accident Investigation Branch) said: eightf48544 was quoting from the quote in my post ... 

But thanks for the endorsement of my forum signature text! 

[JayMac]

Oh dear, thread read fail on my part.

I read the entire report from the RAIB^▸ (Rail Accident Investigation Branch), including the quoted summary here and failed to spot that eightf48544 was indeed quoting from said summary.  I mistakenly thought he was adding his own comment.

[Chris from Nailsea]

No problem, bignosemac! 

I, too, read the whole of that RAIB^▸ (Rail Accident Investigation Branch) report - and I ended up feeling some sympathy for the level crossing staff: the system let him down, I think. 

[ellendune]

I, too, read the whole of that RAIB^▸ (Rail Accident Investigation Branch) report - and I ended up feeling some sympathy for the level crossing staff: the system let him down, I think. 

Me too

[JayMac]

This sums up perfectly what the RAIB^▸ (Rail Accident Investigation Branch) is there for.

This incident could've had far worse consequences and it takes a robust investigation to look at every detail, large and small to try and ensure that similar incidences are prevented.

This RAIB investigation made for particularly sobering reading when you factor in what could be seen as very minor details, such as the state of the face board of the panel which showed whether there was a train 'in section' and the fact that this particular location is now unique in it's operation on the national rail network.