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Valhalla, NY: No NTSB final report two years after fatal accident

7 Feb

Two years on from a level crossing accident that took six lives and injured 15, the National Transportation Safety Board (NTSB) has still to publish a final report with a definitive set of recommendations. In response to this scenario, local, state and federal representatives have pushed for the NTSB report to be released sooner rather than later. In response, an NTSB spokesperson has suggested spring 2017 when the wider world will hear further from NTSB.

LX info’s Aidan Nelson says “two years after an accident is surely long enough for any accident investigation body to publish a final report and recommendations therein to prevent a recurrence. Indeed, except in exceptional circumstances, 12 months should be the norm.  Where there are exceptional circumstances extending the timescale beyond one year, investigation bodies should be required to publish a report setting out the exceptional circumstances which are extending the timetable for the investigation as well as interim conclusions so far determined and recommendations resulting from these interim conclusions”.


Roudham, Norfolk, UK: Casualties in collision on private crossing

13 Apr

Investigation of the circumstances leading to the collision of a train with a farm tractor are centred on establishing whether the farm worker used the level crossing as required. In short, did the tractor driver obtain permission from the signaller by means of the telephone at the private user worked level crossing.

The collision which occurred on the Roudham user worked level crossing at about 12.30pm on Sunday April 10th led to both the train and tractor drivers being taken to hospital and seven passengers travelling on the train being treated for minor injuries at the scene of the collision which impacted travel over the route between Ely and Norwich for the rest of the day.




UK: RAIB Launches investigation into pedestrian fatality

22 Mar

Grimston Lane Footpath level crossing (source RAIB)

The independent Rail Accident Investigation Branch (RAIB) has announced that it is investigating the February 23rd, 2016 pedestrian fatality on Grimston Lane footpath level crossing in Trimley St Martin, Near Felixstowe, Suffolk.

This level crossing, which is over a single railway track, links two parts of Grimston Lane, an unclassified tarmac road on the western edge of Trimley St Martin, leading through farmland to Trimley Lower Street.

The RAIB investigation will identify the sequence of events which led to the accident and consider any factors which may have influenced the actions of the pedestrian. It will also consider whether the design and/or management of the crossing were factors in the accident.

The RAIB report will be published in due course.


UK: Ten years on and a very different place

16 Dec

If one event has changed the way in which Network Rail, Britain’s national rail infrastructure manager, thinks about safety, it was the death of two teenage girls on the station pedestrian crossing at Elsenham in Essex in December 2005.

This sea change was from a standard “level crossings are safe if used properly” blame the user rubric to one of a proactive national programme to reduce level crossing risk. But this took relentless pressure from the bereaved to get to the truth behind the deaths of Olivia Bazlinton and Charlotte Thompson. Most visible were Olivia’s parents Tina Hughes and Chris Bazlinton.

The pressure from the families exposed a very sorry state of affairs with unacceptably poor risk management given that long before these Elsenham fatalities, there was knowledge within Network Rail of the need for action to reduce risk so far as was reasonably practicable. This formed the basis of a belated successful prosecution of Network Rail for their failure to manage risk in accordance with health and safety legislation.

Although level crossing safety in Britain compared favourably internationally in 2005, it was in 2010 that Network Rail launched its level crossing safety improvement programme, within which Tina Hughes acts as a users’ champion, for which she was recognised with the award of an MBE.

A key component of the programme has been the recruitment of more than 100 level crossing managers each of whom manages safety at about 60 level crossings, both public and private. The work of these managers is underpinned by a range of initiatives from closure to upgrade, including the adoption of new technologies. Equally important is the relationship these managers build with the authorised users of private crossings and within the community in the case of public crossings.

Since 2010, Network Rail has:

  • Closed 987 level crossings
  • Improved sighting at 1,100 crossings
  • Fitted 494 level crossings with brighter LED lights
  • Fitted 113 level crossings  with spoken audible warnings to announce when “another train is coming” after one train has passed through. This control is a direct outcome of the Elsenham fatalities
  • Fitted 66 sets of barriers at automatic open level crossings
  • Fitted a further 66 crossings with a time delay, preventing a signaller from mistakenly raising the barriers as a train approaches. This control is a direct outcome of the Moreton-on-Lugg fatality
  • Fitted more than 20 level crossings with Home Office approved red light safety cameras which act like speed cameras and capture motorists crossing after the warning sequence has begun
  • Provided the British Transport Police with a fleet of 15 mobile safety vehicles with number plate recognition camera technology introduced to target misuse
  • Begun fitting 81 private level crossings with power operated gates
  • Developed and begun installing a less costly modular footbridge to facilitate elimination of footpath and station pedestrian level crossings
  • With RSSB further developed the All Level Crossing Risk Model (ALCRM) to allow a better understanding of the specific risks at each crossing and deploy appropriate warning and protection measures

At the time of writing, the last accidental fatality (excluding intentional deaths) was on February 8th, 2015. This is the longest time without an accidental fatality since the level crossing programme began in 2010.

Thus, the legacy of the deaths of Olivia and Charlotte in 2005 is that today Britain has the best level crossings safety record of any major railway in Europe, and probably the world.

Ottawa, ONT: TSB releases report on 2013 fatal collision with a bus

8 Dec

The Transportation Safety Board of Canada (TSB) investigation into the September 2013 collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario, identified numerous contributory factors including company practices, work-related driving distractions, speed, the configuration of the Transitway, and bus crashworthiness. As a result of the collision, the train derailed and the bus was extensively damaged. Six people, including the bus driver, died, and 34 passengers sustained injuries. There were no injuries to the crew or passengers on the train.

On September 18, 2013, at 0847:27 am, OC Transpo double-decker bus No. 8017, operating as Express Route 76, left the Fallowfield Bus Station in South Ottawa enroute toward downtown Ottawa along the Transitway. Around the same time, the automatic warning devices, consisting of flashing lights, bells and gates at the Woodroffe Avenue and Transitway railway crossings were activated and fully functional.

Meanwhile, VIA Rail passenger train No. 51 was approaching these crossings. The train was within normal operating parameters and slowing down to approach the Fallowfield train station. When the train crew realized that the bus would not stop in time, the emergency brakes were activated. About 3 seconds before impacting the train, the bus driver released the throttle and applied the brakes 35.6 metres away from the point of collision. The accident occurred just 39 seconds after the bus left the passenger terminal.

“This complex investigation identified 15 inter-related findings that played a part in this tragedy,” said Kathy Fox, Chair of the TSB. “Remove even one, and this may have had a very different outcome. But because of this accident, we are calling for concerted action to reduce the risk of railway crossing accidents.”

The main question focused on “Why didn’t the bus driver see the train and stop in time?” The investigation determined that, while accelerating toward the railway crossing, the bus was negotiating a significant left curve in the road. The driver’s view of the crossing was obstructed, and there was only a short time when the activated crossing signals were visible to the driver. During this critical time, the driver was also distracted by surrounding conversations about seating on the upper deck, and by the perceived need to monitor the upper deck on a small screen that was positioned up and to the left of the driver’s seat and to make an announcement about no standing on the upper deck. At the speed the bus was travelling, the driver was unable to stop in time, even after passengers began to shout “stop”.

“Given the same circumstances, this accident could have happened to just about any driver,” said Rob Johnston, the Investigator-in-charge.

To address the major safety deficiencies identified in the investigation, today, the Board is issuing five recommendations aimed at reducing the risks. The recommendations deal with the installation and use of in-vehicle video displays, crashworthiness standards, data recorders for commercial passenger buses, and grade separations at busy railway crossings, both in Ottawa and across Canada.

“Every day, vehicles and trains interact at thousands of railway crossings across Canada,” added Chair Fox. “The number of crossing accidents remains too high; that’s why it’s on the TSB’s Watchlist. Whether it’s a busy street or a country road, people need to understand that railway crossing safety is a responsibility shared by the regulator, transit operators, road authorities, bus manufacturers, and also vehicle drivers. Drivers need to slow down and be prepared to stop as if there were always a train approaching.”

Auckland, New Zealand: Urgent crossing safety recommendation from TAIC

27 Aug

New Zealand’s independent Transport Accident Investigation Commission (TAIC) has posted an urgent safety recommendation following a fatality on an active level crossing close to West Auckland’s Morningside station on January 29th, 2015.

New PictureMorningside station is an island platform, with the usual track for southbound trains passing to the east of the platform and the usual track for northbound trains passing on the opposite west side of the platform. The Morningside Drive level crossing crosses both these tracks and a loop track close to the southern end of the platform. The level crossing is protected by flashing lights, bells and barrier arms, directed at road and pedestrian traffic following Morningside Drive.

At its southern end the station platform transforms into a pedestrian ramp leading down to a ‘T’ intersection with one of two pedestrian crossings for Morningside Drive. The bells for the Morningside Drive level crossing would be audible under usual circumstances to pedestrians walking down the ramp to join the pedestrian crossing. The flashing lights and barrier arms, however, are directed at vehicle drivers and pedestrians who are following Morningside Drive. The only visual cue to warn pedestrians walking down the ramp is a yellow sign warning them to ‘look for trains’.

At 18.40 on January 29th, 2015, a 24-year-old male alighted from a southbound train at Morningside station platform. The pedestrian walked alone along the platform to the eastern-end electronic ticket register, where he recorded the end of his journey at 18.41. He then walked down the pedestrian ramp to access the Morningside Drive pedestrian crossing.

The southbound train from which he had alighted was departing on the southbound track. It travelled over and moved clear of the Morningside Drive level crossing at 18.41:09. Twelve seconds later, a passenger train travelling in the opposite direction on the northbound track, arrived at the level crossing.

The pedestrian had walked to the end of the pedestrian ramp, during which time he was facing in the direction of the northbound train. He then turned right onto the pedestrian footpath and stepped out in front of the northbound train at 18.41:24. The train struck the pedestrian, who was fatally injured. The pedestrian’s movements were captured by the platform-mounted, closed-circuit television cameras.

The pedestrian was using a mobile phone to text while he was walking down the pedestrian ramp and he had bud-style earphones inserted in his ears, which were connected to his mobile phone.

Data recorders showed that the flashing lights, bells and barriers at the Morningside Drive level crossing were operating correctly and continuously for both train movements, and that the northbound train was being driven in accordance with rules and regulations.

TAIC has  addressed recommendations to the NZ Transport Agency, as the rail regulatory body, with notice of the recommendations issued to KiwiRail Limited, Auckland Transport and Transdev Auckland Limited.

Recommendation one

  • Safety issue – There are no active visual alarms or physical barriers to prevent pedestrians exiting the Morningside station platform inadvertently crossing the railway tracks at the Morningside Drive level crossing when trains are approaching.
  • The active warning lights, bells and barrier arms protecting the Morningside Drive level crossing are positioned to warn vehicle drivers and pedestrians on Morningside Drive. Pedestrians exiting Morningside station platform to the south have only a yellow sign reminding them to ‘look for trains’. The platform pedestrian egress can be used by a high number of passengers during peak periods. The station is one of the main egress points for passengers travelling by rail to special events at the nearby Eden Park facility.
  • There was one previous pedestrian fatality at the Morningside Drive level crossing during 2002. On April 8th, 2015 the driver of a northbound passenger train said that his train missed two pedestrians by about one metre at the same pedestrian intersection. Anecdotal information received by the Commission indicates that there are highly likely other similar near-miss incidents that have gone unreported. All of the reported incidents involved northbound trains at the same pedestrian crossing.
  • On July 30th, 2015 the TAIC recommended to the Chief Executive of the NZ Transport Agency that in the interests of passenger and pedestrian safety he liaise with the appropriate authorities to ensure that they address the safety issue whereby some form of active warning device or barrier is installed that will prevent pedestrians inadvertently stepping out in front of trains when entering or exiting the Morningside station platform. (010/15)
  • On August 14th, 2015 the Chief Executive of the NZ Transport Agency replied as follows:

KiwiRail and Auckland Transport are working on a solution to address the identified safety issues at the pedestrian level crossings at Morningside Station in West Auckland. The Transport Agency is actively monitoring this situation to ensure the resolution is implemented in an effective and timely manner.

We cannot yet provide a definitive timeframe for when these changes will be completed but give an undertaking to update the Commission once the next stages of this work have been determined by KiwiRail and Auckland Transport.

Recommendation two

  • Safety issue – The regulatory and operational aspects of the Auckland metropolitan rail system do not expressly deal with responsibility for safety and control at the boundaries between station platforms and the rail corridor.
  • Under the Railways Act 2005, KiwiRail is required to have a rail licence and an approved ‘safety case’ outlining its rail activities. KiwiRail has a resultant safety system that details how it will operate safely in accordance with its ‘safety case’.
  • Auckland Transport is the owner of the Auckland metropolitan passenger trains. Also, Auckland Transport leases the railway stations in the Auckland area from KiwiRail. Auckland Transport currently has an exemption from holding a rail licence, and consequently is not required to have a ‘safety case’ and resultant safety system.
  • The KiwiRail Safety Case and resultant safety system, including the deed of lease and access agreements for Morningside station, do not expressly deal with who is responsible for controlling and protecting pedestrians crossing the boundaries between railway stations and the rail corridor. Consequently the parties have been operating on differing understandings about their responsibilities in relation to this issue.
  • On July 30th, 2015 TAIC recommended to the Chief Executive of the NZ Transport Agency that from a regulatory perspective he take the necessary steps to ensure that the relevant Safety Case(s) and resultant safety system(s) (including any lease or access agreements made under those systems) expressly articulate which party or parties is responsible for controlling and protecting pedestrians as they cross the boundaries between railway stations and the rail corridor. (012/15)
  • On August 14th, 2015 the Chief Executive of the NZ Transport Agency replied as follows:While the Transport Agency gives the Commission an undertaking to implement this recommendation, we must first consider the statutory and regulatory options in which to do this. This will involve engaging with a number of relevant parties— a process that will take time. We will advise the Commission of our progress in due course.

Recommendation three

  • Safety issue – The level of protection for people using pedestrian rail crossings in the Auckland metropolitan rail network is unlikely to be adequate because the risk assessment process for pedestrian rail crossings is not keeping pace with the infrastructure changes and increasing patronage on the metropolitan passenger trains.
  • There are 52 level crossings in the Auckland metro network that can be used by pedestrians. These crossings are equipped with a mixture of active and passive warning devices. Records show that there were 13 other pedestrian accidents within the Auckland metro network and 5 accidents within the Wellington metro network between January 1st 2006 and January 30th, 2015.
  • In recent years the following changes have occurred in the Auckland metropolitan rail network:
    • most of the rail network has been multi-tracked
    • a bi-directional signalling system has been installed to allow trains to use tracks in either direction
    • more new electric multiple unit trains have been introduced
    • the frequency of passenger trains has increased
    • there has been a substantial increase in train patronage in Auckland (25% for Morningside station) and it is projected to increase further as passenger train services are increased.
  • Some of the changes listed above also apply to the Wellington metropolitan rail network.
  • The NZ Transport Agency and KiwiRail use the Australian Level Crossing Risk Model to assess the risk factors for road and pedestrian rail crossings in New Zealand. The default frequency for the assessment is every two years. The model considers 130 variables at all types of level crossing, including the five factors referred to above. The most recent assessment report for the Morningside Drive pedestrian crossing had been undertaken during January 2014, one year before this accident.
  • An example of how the changes to the rail infrastructure have potentially compromised pedestrian safety is with the design of existing pedestrian ‘mazes’ that have been constructed to force pedestrians to face in the direction of approaching trains before they turn and cross the tracks. With the ability for trains to be routed in either direction along bi-directional lines, trains could now potentially be approaching from behind pedestrians.
  • On July 30th, 2015 TAIC recommendsedthat the Chief Executive of the NZ Transport Agency liaise with the relevant road control authorities in Auckland and Wellington, and KiwiRail, to review all pedestrian rail crossings and ensure that they address the safety issue whereby they have a level of protection commensurate with the level of risk currently and in the immediate future. (013/15)
  • On August 14th, 2015 the Chief Executive of the NZ Transport Agency replied as follows:Throughout New Zealand, a wide range of level crossing-related activities and work is being undertaken by a variety of rail participants and agencies. This work encompasses level crossing infrastructure, planning, funding, risk review and risk mitigation.

    Consequently, the Agency is commencing a ‘stock-take‘ of this work and the parties responsible for it to give us a greater knowledge base about the solutions being developed and by whom. When this work is completed and the Transport Agency has a comprehensive picture of the scope of activities underway, it will be in a clearer position to provide the Commission with information about this recommendation.

Ufton Nervet, UK: Coroner records intentional death

19 Aug

The verdict of the Coroner’s Inquest into the death of a man on the Ufton Nervet level crossing in Berkshire on October16th, 2014, records that the 60-year-old intended to take his own life.