Rail Accident Report
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Rail Accident Report Collision at Swanage station 16 November 2006 Report 35/2007 September 2007 This investigation was carried out in accordance with: l the Railway Safety Directive 2004/49/EC; l the Railways and Transport Safety Act 2003; and l the Railways (Accident Investigation and Reporting) Regulations 2005. © Crown copyright 2007 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.raib.gov.uk. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Fax: 01332 253301 Derby UK Website: www.raib.gov.uk DE21 4BA This report is published by the Rail Accident Investigation Branch, Department for Transport. Rail Accident Investigation Branch 3 Report 35/2007 www.raib.gov.uk September 2007 Collision at Swanage station 16 November 2006 Contents Introduction 6 Summary of the report 7 Key facts about the accident 7 Immediate cause, causal and contributory factors, underlying causes 7 Recommendations 8 The Accident 9 Summary of the accident 9 Location 9 The parties involved 10 External circumstances 10 The infrastructure 10 The train 12 Events preceding the accident 13 Events during the accident 14 Consequences of the accident 15 Events following the accident 15 The Investigation 16 Sources of evidence 16 Key facts 16 Previous occurrences of a similar character 17 Analysis 18 Identification of the immediate cause 18 Identification of causal factors 18 Identification of contributory factors 19 Rail Accident Investigation Branch Report 35/2007 www.raib.gov.uk September 2007 Conclusions 20 Immediate cause 20 Causal factors 20 Contributory factors 20 Additional observations 20 Actions already taken or in progress relevant to this report 21 Recommendations 22 Recommendations to address causal and contributory factors 22 Recommendations to address matters observed during this investigation 22 Appendices 23 Appendix A: Glossary of abbreviations and acronyms 23 Appendix B: Glossary of terms 24 Rail Accident Investigation Branch 5 Report 35/2007 www.raib.gov.uk September 2007 Introduction 1 The sole purpose of an investigation by the Rail Accident Investigation Branch (RAIB) is to prevent future accidents and incidents and improve railway safety. 2 The RAIB does not establish blame or liability, or carry out prosecutions. 3 Access was freely given by Swanage Railway Company Ltd to their staff, data and records in connection with the investigation. 4 Appendices at the rear of the report contain the following glossaries: l acronyms and abbreviations are explained in appendix A; and l technical terms (shown in italics when they first appear in this report) are explained in appendix B. Rail Accident Investigation Branch Report 35/2007 www.raib.gov.uk September 2007 Summary Key facts about the accident 5 At 12:21 hrs on Thursday 16 November 2006 an engineer’s train entered platform 2 at Swanage and collided with a rake of carriages that were stabled there. 6 Two members of Swanage Railway personnel were treated by ambulance staff, but neither required hospital treatment. 7 The locomotive and one carriage sustained damage to the buffers and surrounding bodywork. Location of accident © Crown Copyright. All rights reserved. Department for Transport 100020237 2007 Figure 1: Extract from Ordnance Survey maps showing location of accident Immediate cause, causal and contributory factors, underlying causes 8 The immediate cause was the locomotive driver did not register the signalled route of the train when he checked the signal before starting the train move. 9 A causal factor was that the driver controlled the locomotive from the rear cab (paragraph 69); 10 Contributory factors were: (a) the signalman selected a route into an occupied platform; and (b) the lack of a clear understanding of the shunting movements between the operations manager and the driver. 11 Three observations are made regarding improving the operational safety of the Swanage Railway. None of these refer to issues that caused or contributed to the accident. Rail Accident Investigation Branch 7 Report 35/2007 www.raib.gov.uk September 2007 Recommendations 12 Recommendations can be found in paragraph 87. They relate to the following areas: l amendment of the Swanage Railway rule book requirements for shunting; l safety critical communications on the Swanage Railway; l driver medical standards on the Swanage Railway; and l protection of Swanage Railway staff working in the interior of trains. Rail Accident Investigation Branch Report 35/2007 www.raib.gov.uk September 2007 The Accident Summary of the accident 13 An engineer’s train hauled by former British Railways (BR) class 33/1 diesel locomotive 33 108 ran into Swanage station and collided with a rake of carriages that were stabled in platform 2. 14 Two members of Swanage Railway personnel were treated by ambulance staff, but neither required hospital treatment. 15 The locomotive and one carriage became buffer-locked and both vehicles sustained damage to the buffers and surrounding bodywork. Figure 2: Damage sustained to the locomotive and carriage Location 16 The Swanage Railway is a 6 ¾ mile (10.8 km) standard gauge un-electrified heritage railway located in Dorset. Before 1972 it was part of the British Railways network, and it has been operated as a heritage railway since 1979. The Swanage Railway currently operates a passenger service between Swanage and Norden, a distance of 5½ miles (9.2 km). Figure 3 gives an overview of the line. 17 The accident occurred at Swanage, the eastern terminus of the line. Rail Accident Investigation Branch Report 35/2007 www.raib.gov.uk September 2007 To Furzebrook and Network Rail Norden 9.2 km Corfe Castle 6.4 km Harmans Cross 4.8 km Ponderosa work site 3.6 km Swanage 0 km Figure 3: Overview of the Swanage Railway, showing distances from Swanage station The parties involved 18 Four members of Swanage Railway staff were involved in the movement of the train: l the driver, a full time employee; l the signalman, a part time employee; l the operations manager, a full time employee; and l the train guard, a volunteer member of staff. 19 Each person was qualified and medically competent in accordance with Swanage Railway requirements for the duties that they were carrying out. External circumstances 20 On 16 November the weather was overcast with frequent rain showers. 21 Although it was raining at the time of the accident, this had no significant effect on the visibility of signals, points positions or the line ahead. The infrastructure 22 Swanage station has an island platform. Platform 1 is no longer directly accessible from the running line, and carriages providing storage and a catering outlet are permanently stabled in it. Platform 2 is the sole operational platform; a loop exists to the north of it. There is a single siding to the south of platform 1 and a locomotive depot outside the station. Access to platform 1 and the south siding is by a headshunt, which can only be accessed from platform 2 or the loop line (Figure 4). 23 Semaphore signalling is in use; Figure 4 shows a simplified signal configuration for trains arriving from Harmans Cross. Rail Accident Investigation Branch 10 Report 35/2007 www.raib.gov.uk September 2007 Swanage station area - Key Wagon simplified signalling for arriving trains N Class 08 locomotive Carriage Class 33 locomotive Ground signal Loco depot Turntable Home signal Signal box Loop Signal 2 Signal 19 Signal 25 26 points 29 points Platform 2 To Harmans Cross 1 Main line Goods shed road Figure 4: Layout of track at Swanage station, showing signals applicable to an arriving train 24 Ground signal no.25 controls the final approach to the station platform or loop. When the signal is in the proceed (or ‘off’) position a route indicator displays either the letter ‘M’ when the route is set for the Main (platform 2), or ‘L’ when the route is set for the Loop. The ‘M’ and ‘L’ are illuminated whenever in use (Figure 5). Figure 5: Signal 25 as seen looking towards Swanage station. The ‘M’ indication is displayed Rail Accident Investigation Branch 11 Report 35/2007 www.raib.gov.uk September 2007 The train 25 The train involved in the collision consisted of a locomotive, number 33 108, and 6 wagons. 26 The locomotive was built in the early 1960’s by the Birmingham Railway Carriage & Wagon Co for service on BR, and was purchased for preservation on withdrawal from BR service. It is now owned by the Class 33/1 Preservation Group, and operates on the Swanage Railway. The locomotive is an eight wheeled bogie diesel locomotive, and has driving cabs at both ends, and is colloquially referred to as the ‘Crompton’ on the Swanage Railway, a reference to the manufacturer of its electrical equipment (Figure 6). Figure 6: Class 33/1 locomotive 27 Two brake vans were provided, one coupled at each end of the wagons in the train, because the wagons in the train were not continuously braked. 28 There were 5 carriages stabled in platform 2. All were of the ex BR mark 1 type. The handbrake in the guard’s van in these carriages had been applied as a parking brake, in accordance with the Swanage Railway rule book. 29 The westernmost carriage in platform 2 carried a tail lamp capable of giving a red light that was visible to arriving trains.