Irish Railway Record Society

Journal 176 Accident Reports

RAIL ACCIDENT INVESTIGATION UNIT  

The RAIU, a functionally independent investigation unit of the Railway Safety Commission (RSC), has issued reports into the collision between Track Recording Vehicle (TRV) No. 700 (EM50) and the one of the gates at Buttevant Level Crossing (XC219) and into a person struck at level crossing XE039 Limerick-Ennis. Summaries are noted here.

Buttevant At 10:22 on Friday 2 July 2010, the 08:00 Dublin-Cork passed through the Buttevant Level Crossing without incident. Approximately thirty seconds later the TRV approached the crossing in the opposite direction as the Gate Keeper was in the process of closing the gates across the railway line. The TRV struck one of the gates damaging it and the vehicle. There were no injuries or fatalities.

The Gate Keeper was passed as competent to operate Buttevant Level Crossing on 22 June 2010. He was positioned in a raised cabin at the crossing. He had previously worked at Myrtlehill level crossing (Cork-Cobh) from 8 September 2008.

A TRV Driver and Operator were on board the TRV at the time of the accident. Both were employed by Lloyd Rail. Both the TRV Driver and Operator were deemed competent, and had followed the procedures in the IÉ Rule Book for the operation of TRVs.

At 09:38, the TRV departed Cork for Inchicore Works under a Special Running Notice. At 10:14:08 the TRV struck the Strike-In-Point for Buttevant Level Crossing on the Up Line. This initiated the procedures for the Gate Keeper to close the gates of the crossing to road traffic, therefore opening the gates to rail traffic.

At 10:20:41, the 08:00 Dublin-Cork struck the Strike-In-Point for the Level Crossing on the Down Line. At 10:22:47 the passenger train passed through the crossing and cleared it at 10:22:59. It was the first to arrive at the crossing as it was travelling at a faster speed than the TRV. After the train passed through the crossing, the Gate Keeper then began opening the gates to road traffic, therefore closing them across the railway line.

At 10:23:26, the TRV arrived at the crossing, striking the Down line gate. The TRV Driver applied the emergency brake, but the TRV continued through the crossing, coming to a stop 214m beyond it.

The TRV was not in recording mode at the time of the accident. The TRV is 12.8m long and weighs 23 tonnes. It has a forward facing camera, however, this only operates when the TRV is recording, and therefore was not recording at the time of the accident. The TRV does not have an event recorder fitted. The maximum permissible speed for a TRV is 64 km/h and it was travelling at this speed at the time of the accident. The TRV is not equipped with CAWS receiving equipment. The RAIU said that “the condition or operation of the TRV was not contributory to the accident.”

The train consisted of locomotive 234 + 8 Mk IV carriages, with locomotive leading. The train was travelling at approximately 144 km/h, which was the line limit. The RAIU said “The condition or operation of the train was not contributory to the accident.”

IÉ staff, under the supervision of the RAIU, tested the crossing equipment post accident, including the Indication Alarm and associated audible alarm, Gate Lock Lever and Gate Lever Lock. No faults were found with any of the equipment, and no faults have been recorded at the crossing since the accident.

The Gate Keeper was subjected to the screening for drugs post accident, as per IÉ‘s Drugs and Alcohol Policy, for which he tested positive for Cannabis on 2 July 2010. IÉ‘s Chief Medical Officer stated in his report that the presence of this substance in his system “has significant implications for his ability to perform his duties in a safe and satisfactory manner”.

The RAIU concluded “The Gate Keeper did not fully adhere to the 'Instructions to the Crossing Keeper for the Operation of Buttevant (XC219)' as he did not check the Indication Alarm, after the passing of the Train, to ensure that a second train was not approaching. The Gate Keeper may have assumed that the Train was the only train approaching the Level Crossing and therefore may not have checked the Indication Alarm which was displaying the yellow 'Warning' Lamp. This omission may have been, at least partly, as a result of the presence of Cannabis in his system, which is known to affect concentration and co-ordination.”

“Approach locking or route locking was not provided at the Level Crossing, which would have acted as an engineered safeguard, to ensure that the Level Crossing gates could not be closed across the railway line while the yellow 'Warning' Lamp is illuminating on the Indication Alarm. The absence of this engineered safeguard therefore allowed the Gate Keeper to close the Level Crossing gates across the railway while the TRV was approaching. These risks were not identified by any risk assessment as IÉ‘s Principles of Interlocking standard was issued fourteen years after the installation of the Level Crossing.”

“IÉ‘s Drugs and Alcohol Policy was not fully adopted in that the 5% random sampling for drugs of safety critical staff, required of the Policy, was not fully adopted. However, given that there only a 5% chance of the Gate Keeper been randomly selected, is it unlikely that the Gate Keeper would have been tested prior to the accident occurring.”

The RAIU noted that there were 14 gate strikes by trains at CX type level crossings over the 10 years prior to the accident, but none had a similar signalling system to Buttevant. Approach locking or route locking were not provided at Buttevant.

“At the time, or since, the installation of the Level Crossing 23 years ago, no interlocking system (such as the signal level backlocking system) was introduced to ensure that the interlocking associated with a signal or other movement authority would only be released when it is safe to do so, as set out in IÉ‘s signalling standard, I-SIG-2022 – Principles of Interlocking, Issue 1.0.”

As this standard was introduced 14 years after the installation of the crossing equipment at Buttevant, “its requirements in relation to approach locking or route locking were not included at the installation stage of the Level Crossing, nor were they subsequently introduced after the introduction of the standard.”

“However, this Level Crossing is likely to have been exempted from approach locking as the standard states that 'interlocking should be applied to level crossings, unless the signalman can observe train movements and risk assessment shows that approach locking need not be provided.' This was the case at Buttevant where the Gate Keeper had unobstructed views of the railway. This substitution of engineered safeguards for Gate Keeper actions therefore relies on the Gate Keeper to carry out his/her instructions correctly with no allowance for human error.”

“Had approach locking or route locking been provided it would have acted as an engineered safeguard in preventing the Level Crossing gates to be opened to the public road, and closed to the railway as a train was approaching. The operation of the gates would therefore only be permitted when the Level Crossing track circuits were clear of all trains, and would not allow for the human error to occur.”

The RAIU said that the immediate cause of this accident was that:

A causal factor was that:

The contributory factors were:

The underlying factor was

The RAIU made two recommendations:

The RAIU noted “Relevant actions already taken or in progress”.

XE309 At approximately 22:00 on 27 June 2010 the driver of the 21:45 Ennis-Limerick sounded the horn on the approach to user worked level crossing XE039 at 15 miles 135 yards (near Sixmilebridge). The train consisted of carriages 2724, 2715 and 2753. As the driver was sounding the horn he observed a farmer, 162m ahead of the train, pushing a cow through the gates of XE039 onto the railway, approaching the railway line from the train driver’s right. As the train continued to approach XE039 the driver applied the brake and sounded the horn twice. The farmer continued to push the cow but the train struck the farmer and the cow. As the train passed over XE039 the driver heard a noise and saw the cow fall to the left of the train, he was not aware that the train had struck the farmer. The train stopped 200m beyond XE039. The driver went back to XE039 on foot and found both the farmer and the cow on the side of the track on the opposite side of the track to the one they had approached from.

The driver rang the Limerick Check Signalman using his personal mobile telephone to advise that the farmer had been struck and the emergency services were required. He could not ring the controlling signalman, the Galway Line Signalman, as he did not have the telephone number with him at the crossing. The Limerick Check Signalman rang the Galway Line Signalman, and requested the attendance of the emergency services. The contact information for the driver was not given to the Emergency Services Operator.

The location of the accident site was initially given in railway terms as the 15 milepost in accordance with section A of the Rule Book (IÉ, 2007). The Galway Line Signalman did not have any other information to facilitate location of the accident and advised he would ring the emergency services back. The townland the accident occurred in was given eight minutes after initial contact was made with the Emergency Services Operator and the name of the townland provided was Rathaline. However, XE039 is located in the townland of Rathlaheen South. The emergency services were not advised of the presence of an access road leading to XE039, resulting in their accessing the railway at overbridge OBE48, 552m away from XE039 over ballasted track, delaying the emergency response. In this instance, as the driver was familiar with the area, he was able to guide the ambulance service to the access road, which allowed the ambulance be driven up to XE039.

Information available to the Traffic Regulator in CTC was not transmitted to the emergency services. This included the location of XE039 overlaid onto a map with co-ordinates and the access road for XE039. Had the information available to IÉ been used the delay could have been avoided.

“XE039 is an Occupation type LC [sic]. This means that it has manually operated gates that are opened and closed by the LC user, which are normally kept closed across the road.” The farmer, who was one of two users working on farmland on both sides of the railway, was fatally injured and pronounced dead at the scene. The accident occurred just before sunset and the weather was dry with some cloud.

The RAIU noted “XE039 is on the flight path for Shannon airport, which crosses the railway, and the glide slope for the airport is approximately 345m above the LC. It was observed that the noise of airplanes at XE039 is sufficiently loud to reduce a person’s ability to hear the engine and track noise of an approaching train. Flights were scheduled at Shannon airport around the time of the accident but it was not possible to determine if any airplanes were overhead as the train approached.”

“The performance of the train was not found to have contributed to the accident.”

“The 1s between the sighting of the Farmer and the application of the train brakes by the Train Driver shown by the event recorder demonstrates that there was no delay by the Train Driver in responding to the presence of the Farmer.” “Based on the braking performance of the train it is unlikely that had the Train Driver made an emergency brake when the Farmer was observed that the accident would have been prevented. The train would have stopping beyond XE039 regardless of how the brakes were applied.”

The RAIU noted “The controls put in place by IÉ were not found to be adequately managing the risks at XE039 as:

The RAIU noted that the immediate cause of the accident was:

The contributory factors identified were:

The underlying factors were:

The additional issue identified was:

The RAIU made the following safety recommendations:

The RAIU said “the following previous safety recommendation from June 2008 [‘Report into the collision at level crossing XN104 between Ballybrophy and Killonan on 28 June 2007’] is being reiterated:

The RAIU noted “… actions taken or in progress by IÉ in relation to this accident are:

Copyright © 2011 by Irish Railway Record Society Ltd.
Revised: November 18, 2011 .