Annual Report 2008
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Annual Report 2008 This report is published 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 2009 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. Preface Preface This is the Rail Accident Investigation Branch’s (RAIB) annual report for the calendar Annual Report 2008 RAIB year 2008. It is produced in accordance with the Railways (Accident Investigation and Reporting) Regulations 2005 (SI1992) and also meets the requirement of the European Railway Safety Directive (2004/49/EC). Section 1 – explains the background and organisation of the RAIB and sets out its aims, statutory duties and scope of accidents investigated. Section 2 – provides details of the RAIB’s investigatory work opened in 2008. Section 3 – provides a brief overview of progress of actions taken to implement recommendations made in RAIB’s reports by the parties identified as the responsible duty-holders, and an analysis of the causes of accidents. Section 4 – provides a summary of other Branch activities. Section 5 – contains the annexes which provide reference material as well as details of completed investigations, investigations opened in 2007 but not completed at the end of 2008, and the status of recommendations. 3 This page is left intentionally blank 4 RAIB Annual Report 2008 RAIB Annual Report 2008 RAIB Contents Chief Inspector’s foreword 6 1. Introduction to the Rail Accident Investigation Branch 8 2. Operations 16 3. Analysis of recommendations and causes 23 4. Other Branch activities 33 Annex A – List of investigations opened in 2006 and completed in 2008 35 List of investigations opened in 2006 and completed in 2008 35 List ofinvestigations opened and completed in 2008 36 Annex B – Summary of investigations opened in 2007 but not completed by 31.12.2008 37 Summary of investigations opened in 2008 but not completed by 31.12.2008 37 Annex C – Recommendation Progress Report 40 Annex C – Appendix 1 – Statistics, recommendations from reports published in 2006, with a status of open or complete in the RAIB 2007 Annual Report 41 Annex C – Appendix 2 – Statistics, recommendations from reports published in 2007, with a status of open or complete in the RAIB 2007 Annual Report 42 Annex C – Appendix 3 – Statistics, recommendations made in 2008 and status 43 Annex C – Appendix 4 – Recommendations made in 2008 to end implementer 44 Annex C – Appendix 5 – Recommendations made in 2006 that had an open or complete status from the 2007 Annual Report 45 Annex C – Appendix 6 – Recommendation made in 2007 that had an open or complete status from the 2007 Annual Report 64 Annex C – Appendix 7 – Recommendation made in 2008 120 Annex C – Appendix 8 – Recommendations closed by ORR between January 2009 and 01 May 2009 164 Annex C – Appendix 9 – List of investigations published in 2008 165 Annex D – Summary of schedules and notification requirements for accident and incidents on UK railways (annexes to the regulations) 166 Annex D – Appendix 1 – Summary of schedules and notification requirements for accident and incidents in the Channel Tunnel 167 Annex E – Statistics: summary of investigations by type and industry sector 168 Annex F – Glossary of abbreviations and acronyms 169 Annex G – Glossary of terms 169 Annex H – Annual Report feedback form 173 5 RAIB Annual Report 2008 RAIB Chief Inspector’s foreword Chief Inspector’s foreword This is the Rail Accident Investigation Branch’s (RAIB) fourth Annual Report. By the end of December 2008, the end of this reporting period, the Branch had been operational for 38 months. The aim of the Branch is to improve the safety of the public, rail passengers and rail staff by investigating accidents and near misses on the UK’s railways. This includes the mainline railway, metros, tramways and heritage railways. The Annual Report provides an opportunity to share information about the work and findings of the RAIB, and to publish the actions that have been taken in response to our safety recommendations. In February 2007 a rail accident occurred in Grayrigg, Cumbria where sadly, a lady lost her life, and 30 others were seriously injured. Last year was a particularly busy period for the Branch, the Grayrigg investigation, published in October 2008, generated a considerably higher workload than the other investigations we have undertaken to date. Nevertheless, during 2008, the Branch commenced 31 new investigations and published 27 reports and 3 bulletins. At this time we were still establishing our organisation and only operating with 75% of our intended compliment of investigators. The further staff, who will largely complete our establishment, are joining us now in 2009; they will join the investigator team once they complete their training. I am pleased that we continue to have a very positive relationship with the organisations in the industry whose interest and engagement play a significant part in the success of our investigations. The safety arrangements in the UK are such that for the vast majority of RAIB recommendations it is the Safety Authority’s responsibility to ensure the industry takes appropriate measures. The RAIB’s follow up on recommendations is limited to when this is relevant to a further investigation. The feedback from the Office of Rail Regulation (ORR), the safety authority for the majority of the UK’s railway system, indicates that for those recommendations where they have concluded their follow up, indicates there has been a running average of 98% reported as accepted and either implemented or in the process of implementation. The Branch is therefore bringing about positive changes and improvements to safety. The RAIB has now reached a very interesting juncture. In earlier RAIB annual reports I have remarked that because we have not been operational for long, and because we do not investigate all accidents on UK’s railways, we have not had a large data set on which to base observations. However, from the number of investigations we have now completed, there is clear evidence that some types of accident are recurring for the same or similar reasons; in some cases it is because the RAIB’s previous recommendations have yet to be implemented, or that they have not been implemented fully. The RAIB is now finding in more recent investigations that we are identifying the need for the same preventative measures as we have previously recommended. There are a number of key areas of industry activity where this has occurred including: l worksite planning and management; l management of fatigue for safety critical staff; l planning possessions and the weaknesses in the arrangements for conveying key information to safety critical staff; l inspection standards for track and related guidance to staff; 6 Chief Inspector’s foreword l location and signage of decision points at crossings, examination and assessment of risks associated with crossings and design for good sighting; and l management and operation of Road Rail vehicles. Annual Report 2008 RAIB These occurrences, which we have already brought to Network Rail’s attention, are a powerful message to the industry about the ongoing risks. Through its reports, the RAIB continues to bring recurring issues to the industry’s attention and believes that greater benefit can be obtained if our investigation reports, and their own, are considered in a wider context rather than just treating each report in isolation. Due to the timing of publication of the RAIB’s report into the Grayrigg accident the feedback on the recommendations is not covered in this Annual Report. In view of the seriousness of that accident, I feel this foreword would not be complete if it did not include comment on the status of delivery of the recommendations. The main focus of our recommendations concerned the design and maintenance of track points, and Network Rail’s safety management systems. Throughout the investigation, the RAIB worked closely with the industry and the ORR, and our emerging findings and areas of recommendations were made known to the industry as the investigation progressed. However, at the time of this publication, 11 months after the RAIB’s Grayrigg recommendations were published, for those recommendations where the industry have indicated that they intend to take measures, or believe that they have already taken sufficient action, the RAIB is not yet aware of the full details or the implementation timeframes. The ORR has reported that Network Rail has indicated to them that it has completed 15 of the 22 recommendations directed to Network Rail. However, the ORR is still in the process of satisfying itself whether the RAIB’s recommendations have been properly acted upon. The exception is for one recommendation made to Network Rail concerning working hours of staff engaged in safety critical work; in this case the ORR has stated that it does not intend to exercise its powers to require action of Network Rail. The RAIB is in dialogue with the ORR to secure greater clarity; it is the ORR’s sanction to follow up the recommendations made to industry.