Irish Railway Record Society

Journal 172 Accident Reports

RAIL ACCIDENT INVESTIGATION UNIT

The RAIU is a functionally independent investigation unit of the Railway Safety Commission and it has issued reports into a train colliding with level crossing gates and a locomotive colliding with empty carriages.

Bridgetown 

On 2 December 2008, an IÉ ballast train, 078 + plough van + 15 four-wheel ballast hoppers + plough van, departed Waterford for Rosslare Strand at 08:52. As the train approached Bridgetown level crossing, XH066, at 09:40 the gates of the crossing were observed by the train crew to be closed across the line. The driver sounded the horn and applied the brakes. The gatekeeper was in the process of closing the first gate (furthest from the train) across the road when the train horn was heard. The gatekeeper pushed the gate across the road and then moved into the wicket gate for safety. The train struck both gates and continued to travel approximately 39¹/₂m beyond XH066 before coming to a stop with the train on the crossing. The gatekeeper suffered shock and the gates were destroyed.

The train was crewed by a train driver, driver conductor and two guards. The train driver and driver conductor were travelling in the leading cab of the locomotive and the guards were travelling in the rear cab of the locomotive.

After the accident the semaphore distant signal protecting XH066 was found to be displaying an ON aspect, therefore indicating that trains should be prepared to stop in advance of the gates. The signal was reported by the train crew as displaying an OFF aspect, allowing trains to proceed and expect the gates to be open for rail traffic. The RAIU said ‘No fault was found with the signalling equipment... It was not possible to determine if the Down Distant Signal was showing ON, OFF or WRONG when the train passed it and if this was correctly reflected at the indicators or not, this is because the collision of the train with the gates could have affected the state of the equipment, dislodging evidence an obstruction or a fault.’

The RAIU said the immediate cause of the accident was that ‘the train struck the gates of Level Crossing XH066, which were closed across the railway line.

The two possible causal factors identified were:

The possible contributory factors were:

Recommendations

The RAIU noted ‘Relevant actions already taken or in progress

As of the 29th of October 2009, IÉ had advised that the following actions had been taken in relation to the accident.

All gatekeepers who work at level crossings with mechanically operated signals have been given a competence review and assessment on the correct operation of the crossing. This review has focussed on:

A formalised basic training course for new gatekeepers is currently being developed. This course is intended to supplement the existing practical training that gatekeepers currently receive. The current assessment process for gatekeepers will be reviewed in conjunction with the development of the training course and will include an assessment of the gatekeeper’s correct performance of their duties.

A review is currently underway of Railway Safety Standard 12 ’Training, Monitoring and Assessment of Gatekeepers’.

The conversion of all level crossing signals from mechanical to colour light operation between Limerick Junction and Rosslare has been approved as part of the 2009-2013 Railway Safety Programme. This will remove the mechanical signals, change the existing operating arrangements and provide safe signalling to contemporary standards for these level crossings. Semaphore signals are not inherently fail safe, reliance being placed on the crossing keeper to ensure that the signal has been replaced to the ON position following opening of the gates for road traffic.

All level crossings and mechanical signals on the line were examined. The signal wire runs were examined to ensure they were clear of vegetation overgrowth and had free movement. Following a review of wire adjusting mechanisms along this route, four ‘turn buckle’ type mechanisms were replaced with a more user friendly wheel operated mechanism.

The signal repeater indications and associated battery power supplies at all the crossings along this route were examined. New illuminated housings have been ordered and a programme is in place to illuminate all repeaters by March 2010. These new housings will have clear covers over the repeater indications so as to improve their visibility. Repeater name plates will be fitted as part of the new illuminated housing installation programme. The attention of all maintenance staff in the area associated with mechanical signals and level crossings has been drawn to the requirements of signalling standard I-SIG-2481 (issued 24/06/2008) and Test Procedure for Manned Gated Level Crossings I-SIG-2381.

Signalling Maintenance Standard for Mechanical Signals I-SIG-2442 and Test Procedure for Mechanical Signals I-SIG-2342 have been issued. They are currently being briefed to mechanical maintenance staff as part of a refresher training course. This briefing process will be concluded by the end of 2009.

A device to assist in measuring the angle of the semaphore signal when setting the ON and OFF band for the signal indications is currently being developed and will be tried by the mechanical lineman before year end. If satisfactory, it will be used as a checking aid when setting up all mechanical signal controllers.’

Waterford 

On 29 March 2009 the 17:35 Dublin-Waterford, 232 + 6 Mk III + EGV, arrived in the ‘Platform Line’ at Plunkett Station at 20:12. This is the long through platform, which is split in two, designated Nos. 3 and 4. The empty train was to be shunted to make way for a following arrival 40 minutes later and there was a change of train driver. The locomotive was uncoupled and went forward to the up main line at the Rosslare end of the station before running round.

The driver then tried to change from cab No.2 to cab No. 1 cab to travel in the opposite direction but could not as the MU-2-B1 valve was defective. Several attempts were made to operate the valve but this was unsuccessful. The train driver remained in the cab No. 2 and waited for the proceed aspect on the ground level shunt signal No. 25 to continue the movement. He drove from the rear cab of the locomotive without a shunter controlling the movement from the leading cab.

The locomotive was incorrectly routed back onto the Platform Line towards the carriages by the signalman. When the driver became aware of this he applied the brakes but the locomotive collided with the carriages. The locomotive suffered damage to the buffer housing and a buffer location pin was sheared. Four wheels on one bogie of the first carriage 7148 derailed. The gangways on all carriages and the generator van were damaged. The coupling system draw gear and buckeyes on carriages 7112 and 7148 were damaged. Numerous ceiling light covers fell due to the impact.

While the driver was moving the locomotive, the shunter was at track level at the rear end of the carriages removing the tail lights from the carriage. He observed that the locomotive was travelling towards the carriages on the Platform Line and turned to move away from the carriages but was struck by the rearmost carriage and fell forward onto the track. He was hospitalised but was released the same day. Two members of staff who were in the carriages fell over. The carriages moved approximately 3.4m. The accident occurred during hours of darkness. The weather at the time was cloudy and it had just stopped raining.

When the driver discovered he was on the wrong line he applied the brakes 43m before the collision. However, the brake reaction time, which is the time for the brake pressure to build up and react to a driver brake application, was 6 seconds. The locomotive was travelling at 28.6 km/h at the time of the collision, which was under the maximum allowed speed of 30 km/h for such a shunt movement.

Each cab of the 201-class has an MU-2-B1 valve. In order to drive a locomotive from one of the cabs the MU-2-B1 valve for other cab must first be cut out and then the MU-2-B1 valve for the cab being used to drive must be cut in. This allows the brakes to be released in order to move the locomotive. The valve is operated by pulling on the spring loaded lever which lifts a pin inside the valve allowing the driver to turn the handle between the cut in and cut out positions.

The MU-2-B1 valve in cab No. 2 of 232 had been previously recorded in the log book as not cutting out on 24 February 2009. The detent pin inside the valve, which allows the valve to be cut in and out, was found to be broken. The handle, lever and shaft as well as the associated components including the detent pin were replaced that day. The previous driver advised the driver carrying out the shunt that there were difficulties cutting out the MU-2-B1 valve in cab No. 2 when running round in Kilkenny. There were no instructions for drivers on the correct operation of this valve and the requirement to move the lever in order to turn the handle. This meant that there was possibility of drivers not operating the valves correctly and causing damage to them.

The turnout at the Rosslare end of the Platform Line, No. 18, is operated by the signalman in Waterford Central Cabin by pressing a push button to release the lever and moving the lever. The position of the points is detected electrically. While setting the route for locomotive 232 the signalman omitted to press the control button and move the lever to change the turnout direction at the No. 18 points for the movement. The signal panel did not identify this as the No. 18 points are not linked to the route indication on the panel; therefore the signalman was not aware of this omission. The direction the turnout at the No. 18 points is set for is indicated Normal or Reverse by white lights on the turnout release button light. Ground level disc signal No. 25 does not indicate if the route is set to travel on the Up Main Line or the Platform Line, it simply indicates if the driver has permission to proceed past the signal or not. When setting a route past signals No. 25 and 3 over points No. 18, the signal panel will display the track circuit indicators and the signal indicators as green if the route is clear regardless of whether or not the No. 18 points are set for the intended direction. The panel was showing green indications for the track circuits and signals along the route on the Up Main Line, meaning that the track was clear of other trains and the signals were showing a proceed aspect for the locomotive.

The RAIU made the following conclusions:

‘The locomotive struck the carriages as it was incorrectly routed back onto the Platform Line. As the movement was being controlled from the rear cab it was not immediately obvious that the locomotive was travelling back towards the carriages. When the mis-routing became apparent to the train driver, the brakes were applied but the locomotive collided with the carriages.

The risk of recurrence of similar accidents in Plunkett Station is mitigated by the replacement of locomotive hauled carriages by Diesel Multiple Units with driving cabs at both ends.’

It said the immediate cause of the accident was:

The causal factor identified was:

The contributory factors were:

Recommendations

The RAIU made two Recommendations:

‘The signalman worked in Waterford Central Cabin infrequently. The risks relating to the signalman omitting to remember all of the steps required to correctly route the locomotive were not managed as the training and competency management system for signalmen was found not to cover signalmen working as a relief signalman in a cabin other than their normal workplace. This has led to the recommendation:

The MU-2-B1 valve was found to be defective resulting in the train drivers having to manipulate the lever in order to operate the valve. The testing of MU-2-B1 valves is not part of the pre-service checks, which are intended to ensure locomotives are functioning correctly when they enter service. In addition, train drivers were not instructed in the correct operation of the MU-2-B1 valve, which led to unintentional damage to the detent pin of the valves, leading to the recommendation:

The Report notes ‘Relevant actions already taken or in progress. As of the 26 February 2010, IÉ had advised that the following actions had been taken in relation to the accident:

Copyright © 2010 by Irish Railway Record Society Ltd.
Revised: August 28, 2010 .