November 18, 2013 | Mark Paradies

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Issues Report on Signal Passed at Danger at Stafford 26 April 2012

Here’s the Summary from the report:


At about 13:35 hrs on 26 April 2012, a locomotive operated by Devon & Cornwall Railways passed signal SD4-81 at Stafford, which was displaying a red aspect, by about 94 metres.

The investigation found that the locomotive had been travelling at excessive speed as it approached the Stafford area. The driver was probably aware that he had been exceeding the maximum permitted speed for a locomotive running on its own, but he did not make a full brake application as soon as he saw the signal displaying a double yellow aspect, which was his preliminary warning of the red signal ahead. The driver probably did not have sufficient experience or competence for the task he was performing and Devon & Cornwall Railways had not followed its own process for managing the competence of drivers. The company also had insufficient management controls to ensure compliance with its safety management system.

The Office of Rail Regulation had not examined the implementation of Devon & Cornwall Railways’ safety management system following the issue of the company’s safety certificate nearly two years before this incident.

The RAIB has made two recommendations to Devon & Cornwall Railways, covering the competence of safety-critical staff and locomotive maintenance. Two recommendations have been addressed to the Office of Rail Regulation, covering its supervision of a new operator’s safety management system and the effectiveness of Devon & Cornwall Railways’ safety management system. One recommendation has been made to RSSB for the relevant rail industry standard to address the assessment of the training needs of train drivers and other staff transferring between employers. A key learning point has been identified relating to the examination and maintenance of vehicles that are used infrequently on the main line.

For the complete report including the recommendations, see:

Root Cause Analysis
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