The Rail Accident Investigation Department (RAIB), which reports to the Department for Transport, independently investigates accidents and disseminates its findings to beef up railway security.
At around 2: 15pm on 14th March the driver of an Avanti West Wing put together travelling from Glasgow to London Euston reported a advance miss with a tune worker advance to Euxton Junction on the West Wing Critical Line. The tune worker sharp was a controller of jam security (COSS) who, on the time of the incident, had been attempting to gain a lineside situation cabinet (LOC) to undertake scheduled maintenance work.
The COSS was alerted to the drawing end put together, which was travelling at 110 mph, by a shouted warning from a member of the public on a inside of sight footbridge and by the put together driver sounding the put together’s warning horn. The COSS managed to poke to a put of security approximately two seconds sooner than the put together reached his situation.
The RAIB represent chanced on that the advance miss came about on story of the COSS had misidentified which of the railway traces on the positioning had been closed to trains (known as a line blockage). Even supposing signage at idea to be one of the most access aspects old by the team because it’ll be showed the structure of the tune, the COSS didn’t recognise the error. The error was also now no longer challenged by the varied member of the team at some level of a briefing given by the COSS.
The jam of the incident was end to Euxton Junction, south of Preston. There are four railway traces at this level. The traces linked to this incident are designated because the Up Fleet and the Down Fleet. The diverse two traces are designated because the Up Slack and the Down Slack.
The COSS had been despatched a stable machine of labor (SSOW) as share of a stable work equipment (SWP) however had already started their shift sooner than it arrived. This contravenes Network Rail security long-established NR/L2/OHS/019 ‘Safety of of us at work on or advance the line’ which states that “once the particular person to blame has reviewed the SWP, they shall verify the SWP now no longer lower than a shift in advance”.
This pack contained small print of three SSOWs which had been to be old as share of the work. These integrated a separated machine of labor which, on the incident situation, would gain required the team to gain now no longer lower than two metres between the jam of labor and the nearest operating rail of the adjacent initiate line. The SWP also integrated one deliberate line blockage for the ‘up quick’ line, and a 2nd for the ‘down quick’ line to allow assorted objects of labor to gain put nearer to the traces sharp.
The team received a work teach requiring them to behavior two separate objects of maintenance work: finding out inside of a LOC, and a tune circuit inspection, both of which had been within the same home.
The COSS and the varied team persons are within the neighborhood based and conversant in the home the put the incident took put. Nevertheless, the COSS couldn’t retract beforehand going to the specified LOC and was ignorant of its true situation.
Attributable to this, the COSS checked the positioning of the LOC sooner than leaving the depot. Nevertheless, in doing so, the COSS identified a explicit LOC with the same figuring out number. This was located on an adjacent share of the line subsequent to the Down Fleet line, whereas the LOC to be labored on was located subsequent to the Up Fleet line.
In step with this, the COSS departed the depot with an wrong working out that the LOC on which the work was to be performed was located subsequent to the Down Fleet line.
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