Collision between train and tractor at Oakwood Farm, Knaresborough, 14 May 2015

[whole diary]

[Chris from Nailsea]

From the Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) website:

Collision between a train and a tractor at Oakwood Farm User Worked Crossing, Knaresborough, 14 May 2015

On 14 May 2015, a passenger train collided with a tractor at Oakwood Farm user worked crossing near Knaresborough, North Yorkshire. The train was carrying 66 people and travelling at 65 mph (105 km/h), but did not derail. The collision caused the front of the tractor to become detached from its cab. The tractor driver suffered minor injuries, and the train driver was treated for shock. However, in different circumstances the consequences could have been much worse.

The tractor driver began crossing the railway after the illuminated warning at the crossing started to display a red light. Oakwood Farm user worked crossing is one of a small number in the country that had been fitted with remotely operated, powered gates. It is likely the tractor driver did not recheck the warning lights after first stopping on the approach to the crossing to press a button to open the gates. This button had not originally been intended to open the gates (it should only have been capable of being used to close them). It was situated at such a distance from the crossing that the time it took for the tractor driver to stop, open the gates and then drive onto the crossing, was greater than the time between the warning light turning red and the arrival of the train. There was no sign at the button to warn the driver to recheck the warning light before going over the crossing. The investigation also found that the warning light was not conspicuous among the many signs present at the crossing.

The underlying causes of the accident were that Network Rail did not ensure that the risks at the crossing were adequately mitigated, and that the process for the introduction of the gate operating equipment was adequately managed.

As a result of this accident, RAIB has made three recommendations to Network Rail.

The first is to improve the safety at Oakwood Farm user worked crossing and the second is to review the safety of other user worked crossings fitted, or planned to be fitted, with the remotely operated gate opening equipment.

The third recommendation is for Network Rail to review the robustness of its processes for introducing new equipment on to its railway infrastructure.

[JayMac]

Goes to show that some crossing aren't safe, presenting risks to users who are unfamiliar with them.

[ellendune]

Goes to show that some crossing aren't safe, presenting risks to users who are unfamiliar with them.

But, if I have read the report correctly, for these private crossings, part of the safety plan is that the landowner must ensure that those using them are trained in their use and so are familiar with them. 

[JayMac]

Yes. Mitigation of risk by both landowner and Network Rail was inadequate in this instance. This led to the crossing being used in an unsafe manner by a user unfamiliar with it.

All told, in my opinion, that made the crossing unsafe.

[Billhere]

I don't know for a fact but this sounds like the new type of crossing equipment that was being tried out and consequently suspended after there with problems with it (possibly this incident).

If I am correct then one was fitted at Rounham in the recent accident in Norfolk. They had apparently been fitted at a number of crossings in the East of the country and then taken out of use, and the one there had a cover over it. Judging by the photo you had to press the button to get permission to cross and then obeyed either the red or green light displayed.

That is a good point in that in that short time the light could change from green to red between pressing the button, turning your back on it, climbing back in the cab and moving off.

This modern technology is ok, but it is like the OD crossings, which will eventually replace Kintbury and Colthrop they are still far from infallible. In the case of the latter the KFC bargain bucket being blown about a crossing and preventing the barriers descending has entered railway folklore.

[Billhere]

Training of staff, always a problem, especially the Europeans who work here in the agricultural industry where the safety practises about railways are rather different to the way we go on.

I only dealt with two crossing incidents involving user worked crossings. Both were near misses, and in both cases no harm was caused. In the case of one the tractor driver had been tooing and froing for some period of time oblivious to the system to be used. Very lucky I would say on an intensely worked line with limited visibility.

I also worked with the Signaller who was on duty when the minibus with foreign workers got hit near Evesham and several died. User worked crossing again and didn't call up. There is a small handbook now produced to show how to go on, but in English only.

I should add here that amongst the four user worked crossings between Wolvercot and Heyford (the extent of Oxford Panel in that direction) we had good relations with many of the farmers who insisted in being as safe as we were. Prior to that I was at Wokingham where there was a farm crossing and the family were very well trained, they even had their four year old granddaughter calling up asking to cross over when she visited.

Up till now I have been involved with a NR^» (Network Rail - home page) national level crossing safety group. At the last meeting it appears that NR is regarded as the model that other European railways look to when deciding how to deal with a problem, and amongst the nationwide organisations that the group has tried to involve the farming community has been the most resistant along with the walkers and ramblers.

[stuving]

... Judging by the photo you had to press the button to get permission to cross and then obeyed either the red or green light displayed. ...

And that's one of the key points coming out of the report. It didn't work like that, but users - even trained ones - were likely to think it did.

In reality, the gate was opened by just the button, with no reference to the signaller or any railway systems. The lights were triggered by the train itself, again with no input from the signalling or signaller. Is it possible to word signs so as to make that clear - the important message being "look at the lights, that's the only thing that tells you if a train is coming, and if in doubt call the signaller"? I'm not sure it is.

[Tim]

This button had not originally been intended to open the gates (it should only have been capable of being used to close them).

Was the button malfunctioning then? 

[stuving]

This button had not originally been intended to open the gates (it should only have been capable of being used to close them).

Was the button malfunctioning then? 

No. The design spec. was altered, apparently without much thought. It's all in the report!

[Tim]

This button had not originally been intended to open the gates (it should only have been capable of being used to close them).

Was the button malfunctioning then? 

No. The design spec. was altered, apparently without much thought. It's all in the report!

sorry.  Read the report (which is a good clear read btw - well done RAIB^▸ (Rail Accident Investigation Branch)). 

[Bmblbzzz]

There is a small handbook now produced to show how to go on, but in English only.

I wonder if it would make much difference even if it came with a free babelfish? You can probably be fairly confident that direct, permanent staff will read it, but casual labour and other visitors are unlikely to.

Surely the crossing (any crossing) should be designed in a clear, legible way? With road crossings that most people are familiar with, the gate opening or closing is equal to being allowed or not allowed to cross. Breaking that simple principle seems odd. What was the reasoning behind it?

[Tim]

Surely the crossing (any crossing) should be designed in a clear, legible way? With road crossings that most people are familiar with, the gate opening or closing is equal to being allowed or not allowed to cross. Breaking that simple principle seems odd. What was the reasoning behind it?

The reasoning behind making the gates power operated was to reduce the incidence of them being left open by lazy/idiot users, by making them easier to close.  There is evidence that it worked and the gates were left open far less.  NRs^» (Network Rail - home page) reasoning was fine in that regard but didn't go far enough to consider the real risk that a user on seeing the gates open "(semi)automatically" would conclude that it was safe to cross.  The system in place was, I think a bit of a mess with miniature lights that didn't "look" like an order to traffic in the way that full size traffic lights or wig wag lights would be and a gate closure system that was not connected to the lights at all (but which users might think were because that kind of thing usually is).

The system was perfectly safe if used correctly but failed to take into account human factors which meant that it was unlikely to be used correctly. 

[Bmblbzzz]

I couldn't make out from the report if the ability to open as well as close the gates with the buttons was a result of a fault or a deliberate change to the system, but it's the lack of connection between power opening and the lights (and siren) that seems ill-advised to me.

[stuving]

I couldn't make out from the report if the ability to open as well as close the gates with the buttons was a result of a fault or a deliberate change to the system, but it's the lack of connection between power opening and the lights (and siren) that seems ill-advised to me.

A plain gated UWC^▸ (User Worked Crossing) has no linkage of that kind - you get out and open the gate. The lights then tell you whether you can cross. After crossing, you ought to get out and walk back to shut the gate - but in practice you often don't. So the push-button closer was fitted, just to make that task easier. Maybe it should not have been made to open the gate too.

Having all buttons open and close the gates was originally a mistake (or at least not as designed), but later the installation instructions were changed. It appears that the reasons for that change were not discovered, though the lack of a risk assessment of the revised design is noted. So you could say that the existing wiring became intentional by accident. 

[Billhere]

A little light reading before bed last night, the RAIB^▸ (Rail Accident Investigation Branch) report here  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/519117/R072016_160428_Oakwood_Farm.pdf

As has been remarked by Tim, a comprehensive report of the circumstances and the background which makes interesting reading. I always enjoy reading them, factual and thorough. I think the recommendations which read separately were fairly bland and didn't give a true picture of the sort of problems that there were, and a read of the report highlights no end of problems.

I think you can see what was trying to be achieved, a problem crossing, numerous users who left the gates open, and this seemed like an easy fix, but as it turned out a number of features were not taken into account, or trialled beforehand to see whether they were suitable.

A bit of an eye opener really.