October 29, 2012 | Mark Paradies

Monday Accident & Lessons Learned: UK RAIB Accident Report – Collision between a train and a lorry and trailer on Llanboidy automatic half barrier level crossing, 19 December 2011

Here’s the Summary from the UK Rail Accident Investigation Branch report:

At 09:44 hrs on Monday 19 December 2011, a train running from Milford Haven to Manchester struck a lorry and trailer on Llanboidy automatic half barrier (AHB) level crossing, near Whitland in Wales.

The impact between the train and the lorry caused the lorry to be separated from its trailer and pushed along the track by the train. The lorry driver left his cab prior to the impact but was struck by the trailer and slightly injured during the collision.

The lorry had stopped on the crossing when the barriers lowered for the approaching train. The train driver saw the lorry when the train was 270 metres away and travelling at 68 mph (109 km/h). The train driver applied the emergency brake, but the train was unable to stop before reaching the crossing. The train was not derailed but 27 passengers were injured in the collision, one seriously, and four received treatment

in hospital before being discharged later the same day. The train conductor and the catering host received minor injuries and were treated in hospital and the driver suffered shock.

The accident occurred because the lorry driver did not telephone the signaller for permission to cross and because local factors encouraged him to take a line towards the right of the road.

Road signs, in English and Welsh, on the approach to the crossing instructed drivers of large or slow vehicles to phone the signaller for permission to cross the railway. The road signs defined the terms ‘large’ and ‘slow’ and the lorry and trailer were of such a length, and were likely to have been travelling at such a speed, that the lorry fell within the scope of both of these terms.

A number of factors forced the lorry and trailer to use the right-hand side of the road to pass over the crossing; the orientation of the road over the crossing being misaligned with the rest of the road, the position of one of the road traffic light signals and the position of vehicles parked close to the crossing. While travelling slowly over the crossing the barrier on the exit side came down in front of the lorry, causing the lorry driver to stop his vehicle.

The RAIB has made six recommendations as follows:

– Network Rail in conjunction with the ORR to revise the crossing order and reduce the effect of road misalignment at the crossing;

– The ORR to revise its guidance to cover misalignment of the road and the ability for a large vehicle to exit an AHB crossing when the barriers descend;

– Network Rail to revise its risk management process for level crossings to include the effect of road misalignment;

– Network Rail to give guidance to its staff and contractors on where to park when working on or near level crossings;

– Angel Trains to examine how to mitigate the risk to the driver from detachment of cab panels during a collision; and

– Alstom and Angel Trains to review the coupler bump stop mounting and retention arrangements.

Does any of this sound familiar to people that have been trained in TapRooT® Courses? (The train example.)

Root Cause Analysis
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