The Rail Accident Investigation Branch (RAIB) has released its report into a collision between two freight trains that took place at Loversall Carr Junction near Doncaster on 5 July 2022.
On that day, at around 06:21, a freight train (headcode 4E11) passed a signal at danger and collided with the rear of a stationary freight train (4E82).
Train 4E11 was travelling from Felixstowe to Masborough (a freight terminal near Rotherham) and comprised Class 66 locomotive and 35 wagons. It had left the East Coast main line (ECML) at Loversall Carr junction near Doncaster and was travelling at 48mph (77km/h) when it passed signal D197 signal, which was at red (danger). This was to protect a second freight train, 4E82, which was standing in the section ahead. Train 4E11 struck 4E82 while travelling at approximately 28mph (45km/h).
The driver of 4E11 was taken to hospital as a precaution and was discharged later that same day. The driver of 4E82 did not sustain any injuries. The collision caused significant damage to the infrastructure, the leading locomotive and wagons of 4E11 and the rear wagons of 4E82.
The accident in more detail
Freight train 4E11, operated by GBRf, was carrying shipping containers from the port at Felixstowe to Masborough, near Rotherham. The train consist was a Class 66 diesel-electric locomotive (number 66729 leased from Porterbrook) and a mixed rake of 35 intermodal wagons of types FEA (13 wagons), FIA (one wagon), and FWA (21 wagons). The total train weight was 2112 tonnes, and its maximum permitted speed was 75mph (120km/h).
Train 4E82, operated by Freightliner, was another freight train travelling from Felixstowe port to a terminal at Tinsley, near Sheffield. This train was formed of a Class 66 locomotive and 29 intermodal wagons.
The accident occurred between Loversall Carr junction and Flyover West junction near Doncaster. The Down Slow/Up West Slow single line diverges from the Down Fast line of the ECML at Loversall Carr Junction and meets the line from Lincoln at Flyover West junction.
The Down Slow/Up West Slow line is a section of bi-directional single track with overhead electrification. The ECML Down Fast line has a permissible speed of 125mph (201km/h) on the approach to the junction. Trains diverging from the ECML at Loversall Carr junction have a reduced maximum permitted speed of 70mph (112km/h) when routed onto the Down Slow/Up West Slow line. There is a further reduction in maximum permitted speed to 50mph (80km/h) before signal D207.
The Down Slow/Up West Slow line is level after diverging from the ECML until signal D197, after which it has a rising gradient of 1:170. The track is straight from the junction until the approach to signal D197 which is on a slight left-hand curve (in the direction of travel of train 4E11). After signal D197, the track is again straight until it reaches Flyover West Junction. D207 is the next signal beyond D197. It protects trains on the Flyover lines from trains converging from the Down Slow/Up West Slow line at Flyover West Junction.
The Down Slow/Up West Slow line is mainly used by freight trains accessing Doncaster Decoy and Belmont yards (which are groups of sidings to the south of Doncaster) but is also occasionally used by passenger services running into Doncaster station. The yards are additionally used for stabling freight trains and as a location where freight train driver changes can take place without causing congestion on the ECML.
The accident took place during daylight (sunrise was at 04:42) and the weather was dry and cloudy, with a temperature around 13°C.
The driver of train 4E11 expected to be routed off the ECML at Loversall Carr Junction as they were being relieved by another driver at Decoy yard. The route via the junction and the Down Slow/Up West Slow provided the normal route for this train to reach Decoy yard and the driver was prepared to be routed this way. The driver was also expecting to see flashing aspects at signals D187 and D189. As the train approached these signals, signal D187 was displaying a double flashing yellow aspect, followed by D189 displaying a single yellow flashing aspect. These warned the driver that the diverging route at Loversall Carr Junction had been set for the train.
During this time, the driver was reducing the locomotive power setting, with the power handle reaching the ‘OFF’ position after the train passed signal D189 at a speed of 68mph (110km/h). The driver made an initial brake application – the normal minimum train brake application.
As the train approached signal D191, it was displaying a single steady yellow aspect warning the driver to prepare to stop at the next signal (D197).
However, this was insufficient to prevent the train passing D197 at danger although the speed had reduced the speed of 4E11 o 48 mph (78 km/h) as the train passed the signal, 13 seconds before the collision.
Four seconds after passing signal D197, the driver used the locomotive’s emergency brake plunger. Despite this, train 4E11 collided with the rear of train 4E82 at 06:21 while travelling at 28mph (45km/h).
The impact moved train 4E82 forwards by almost 10 metres, coming to rest close to signal D207. Damage was caused to the locomotive of 4E11 and to multiple wagons in the train, mainly related to compression and overriding at the couplers. Train 4E82 also sustained damage to the rear four wagons and their containers. A total of nine wagons and one locomotive were derailed. Railway infrastructure was also damaged in the collision.
The driver of 4E11 remained in the locomotive cab during the accident and, although very shaken but not physically injured, made an emergency call to the signaller to report the accident using the locomotive’s radio system.
The signaller blocked the Down Slow/Up West Slow line from the ECML to signal D207 where 4E82 was standing and asked the drivers of both trains to check that the vehicles involved in the accident were not fouling the ECML.
Both drivers had to work together to open the cab door of the locomotive of 4E11 as its driver was unable to either open this door or egress through the locomotive engine room due to the damage it had sustained. The two drivers then walked to the rear of 4E11 and confirmed that the back of the train was not fouling the ECML.
As a precaution, the driver of 4E11went to hospital after the accident but was released later that day.
The line was closed for 26 days to enable recovery and infrastructure repair work and was reopened on 31 July 2022.
RAIB investigators concluded that the accident occurred because the driver did not control the speed of train 4E11 to enable it to stop at signal D197. This was because the driver had experienced a loss of awareness of the driving task, probably due to the effects of fatigue. It is also possible that the driver’s awareness was affected by their low workload before the train approached Loversall Carr junction, and by the expectation, based on previous experience, of the aspect which signal D197 would be showing.
Investigators found that the driver’s working pattern was likely to cause fatigue, having experienced a low quality of rest, primarily caused by an undiagnosed sleep condition. The management systems of freight operating company GB Railfreight (GBRf) had not detected that the driver was at risk of fatigue.
They also found that the engineered systems in place on the railway infrastructure and on the train did not mitigate the driver’s loss of awareness.
Underlying factors to the accident were the management of fatigue by GBRf, which did not follow current industry good practice. GBRf’s risk assessment processes also did not identify the hazards created by a driver driving while being fatigued.
Recommendations
As a result of the investigation, RAIB made two recommendations. The first is addressed to GBRf to reduce the risk of train driver fatigue, including improving risk assessments, processes and following industry good practice.
The second is addressed to the Rail Safety and Standards Board (RSSB), working in conjunction with freight and other train operators, to include the identification of sleep disorder indicators in current standards for safety-critical medical assessments.
A recommendation on the detection of driver attention loss was not made because a previous recommendation on this issue made as a result of the Kirby investigation (RAIB report 07/2022) is less than a year old and is still being considered by the rail industry.
RAIB also identified a learning point to remind train drivers of the importance and meaning of flashing yellow signals.
Andrew Hall, Chief Inspector of Rail Accidents said: “Fatigue in the rail freight industry is a known risk. The nature of freight train driving, often undertaken at night, means that careful fatigue risk management is crucial for maintaining safety.
“Unfortunately, this accident occurred because the driver experienced a loss of awareness of the driving task while probably fatigued. The assessment processes in place did not identify that the working pattern of the driver placed them at greater risk of suffering fatigue.
“Previous RAIB investigations into fatigue-related incidents have led to the development of good practice and guidance for managing fatigue within the rail industry. If we are to avoid such incidents in future, it is particularly important that freight operators access the guidance available to them and use it to effectively manage the risk of fatigue.”
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