Rail Accident Report Fatal accident at Mexico footpath crossing (near Penzance) 3 October 2011 Report 10/2012 June 2012 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 2012 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. Fatal accident at Mexico footpath crossing (near Penzance), 3 October 2011 Contents Summary 5 Introduction 6 Preface 6 Key definitions 6 The accident 7 Summary of the accident 7 Context 7 The sequence of events 11 The investigation 12 Sources of evidence 12 Acknowledgements 12 Key facts and analysis 13 Background information 13 Discounted factor 22 Identification of the immediate cause 25 Identification of causal factors 25 Observations 33 Previous occurrences of a similar character 38 Summary of conclusions 39 Immediate cause 39 Causal factors 39 Additional observations 39 Actions reported as already taken or in progress relevant to this report 41 Actions reported that address factors which otherwise would have resulted in a RAIB recommendation 41 Other reported actions 41 Previous RAIB recommendations relevant to this investigation 42 Learning point 44 Recommendations 45 Report 10/2012 3 June 2012 Appendices 48 Appendix A - Glossary of abbreviations and acronyms 48 Appendix B - Glossary of terms 49 Appendix C - Key standards current at the time 50 Report 10/2012 4 June 2012 Summary Summary At around 15:50 hrs on Monday 3 October 2011, a pedestrian was struck and fatally injured by a train on Mexico footpath crossing, near Penzance in Cornwall. On approaching the crossing round a curve, the train driver had observed a person standing to the side of the line and had sounded the warning horn immediately before the train reached the crossing. However, the pedestrian then attempted to cross and was struck. Although it is not possible to be certain why the pedestrian attempted to cross, the RAIB considers that she either misjudged the speed of the approaching train or misjudged her position in relation to the approaching train. She probably saw the train too late to make a reasoned judgement about whether she should cross. The driver had also sounded the train’s horn as required by a lineside ‘whistle’ board when the train was approximately 15-16 seconds from the crossing, and out of sight. If the pedestrian had heard and responded to the sounding of the train’s horn at this stage, it is likely that she would not have passed through the gate and onto the crossing until the train had passed. The RAIB considers that the sounding of the horn when the train was 15-16 seconds from the crossing did not serve its function of warning the crossing user of the approaching train for one of the following reasons: l the sound of the horn was inaudible to her; or l she heard a horn being sounded, but did not distinguish it as coming from a train; or l she did not register that the train horn was sounded, because she was only approaching the crossing at this time and not yet focused on crossing the railway. The RAIB has made five recommendations. Three recommendations have been made to Network Rail regarding improvements to sighting and warning arrangements for pedestrians using Mexico footpath crossing, developing a national approach to the location and marking of decision points at level crossings and optimising warning arrangements for pedestrians at level crossings provided with whistle boards. One recommendation (in two parts) has been made to RSSB regarding improving intelligence on near-miss incidents at level crossings and enhancing its processes for reviewing the effect of changes made in 2007 to arrangements for sounding train horns at whistle boards. One recommendation has been made to First Great Western regarding a change to standards to require objective testing of horns after a train has been involved in an incident or accident. Report 10/2012 5 June 2012 Introduction Introduction Preface 1 The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. 2 The RAIB does not establish blame or liability and does not carry out prosecutions. Key definitions 3 All dimensions and speeds in this report are given in metric units, except speed and locations which are given in imperial units in accordance with normal railway practice. Where appropriate the equivalent metric value is also given. 4 The report contains abbreviations and technical terms (shown in italics the first time they appear in the report). These are explained in appendices A and B. Report 10/2012 6 June 2012 The accident Summary of the accident The accident 5 At approximately 15:50 hrs on Monday 3 October 2011, train 2C47, the 13:50 hrs service from Plymouth to Penzance, struck and fatally injured a pedestrian, Mrs Jeanette Nicholls, on Mexico footpath crossing, near Penzance in Cornwall (see figure 1). Location of accident © Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2012 Figure 1: Extract from Ordnance Survey map showing location of accident Context Location 6 Mexico footpath crossing is located at 325 miles 02 chains1 from London Paddington (via Bristol) on the main line from Paddington to Penzance. Penzance station is situated approximately one and a half miles (2.5 km) to the west of the crossing and St Erth station around four miles (7 km) to the east. Mexico footpath crossing is a basic crossing for pedestrians and is not equipped with lights, horns or barriers. Pedestrians are required to check that it is safe to cross before doing so. Long Rock level crossing is situated approximately 200 metres to the west of Mexico footpath crossing; see figures 1 and 2. Long Rock is a public road level crossing with barriers, monitored by closed circuit television (CCTV) and controlled from the signal box at Penzance. 1 There are 80 chains in a mile. Report 10/2012 7 June 2012 The accident St Erth Mexico footpath Penzance crossing Long Rock CCTV crossing Figure 2: Google Earth image showing overview of Mexico footpath crossing and its immediate surroundings 7 The general layout at the crossing and key dimensions are given in figure 3. The crossing is on a stretch of single line, which is used by trains in both directions. The railway runs approximately east to west at this location and the footpath crossing, which crosses the railway at right angles, is referred to in the remainder of this report as being on a north/south axis. 8 Immediately to the south of the crossing is a footpath and cycle track with access to the beach. To the north of the crossing is a track leading to the main road and the village of Long Rock; see figure 4. There is a low bank which separates the railway from the coastal path to the east and west of the crossing. A pedestrian’s approach to the crossing from the south cuts through the bank, which restricts their view to the east. Organisations involved 9 Network Rail is the owner of the infrastructure at Mexico footpath crossing and employed the staff who undertook site visits to gather data about the crossing environment and its usage and used that data for risk assessments. 10 First Great Western operated train 2C47 and employed the driver of the train. 11 Network Rail and First Great Western freely co-operated with the investigation. Train involved 12 Train 2C47 was formed of a two-car Class 150 unit, no. 150121. The class 150 units were manufactured between 1984 and 1987 by British Rail Engineering Limited. 13 The RAIB has found no evidence to link the condition of the train with the cause of the accident. Report 10/2012 8 June 2012 To Long Rock village N The accident Access gate North gate to nearer running rail To Penzance Crossing deck To St Erth = 2.7 m Train 2C47 Sign to nearer Stop running rail Look South gate to Listen Beware nearer running rail = 3.40 m of Trains = 4.25 m Pedestrian Access gate From foot/cycle path and beach To scale Figure 3: Layout of Mexico footpath crossing Figure 4: Mexico footpath crossing from the south (beach) side Report 10/2012 9 June 2012 The accident Level crossing infrastructure 14 The crossing is equipped with self-closing metal gates on the north and south sides and signs which instruct users to stop, look and listen and beware of trains; see figure 5. The signs correspond with the template for non-vehicular crossings contained in the Private Crossings (Signs and Barriers) Regulations 1996. Figure 5: Signage at the crossing (view taken from south side) 15 The crossing is made of timber decking with a non-slip surface. There were no deficiencies in the condition of the crossing deck.