Key findings in report into train crash in Norwich which put 11 people in hospital
PUBLISHED: 08:57 02 May 2014 | UPDATED: 08:57 02 May 2014
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A driver was allowed to continue frontline duties despite a catalogue of errors on the region’s railway lines, which culminated in him crashing into a stationary train at Norwich station.
The findings and timeline
1) Greater Anglia should complete the update of its competence management system to include consideration of non-technical skills.
2) Greater Anglia should update its accident and incident investigation procedures to include consideration of non-technical skills in the causation of accidents; and train all its investigators to assess the role of non-technical skills in the causation of accidents.
3) Greater Anglia should review and make any necessary changes to its audit procedure.
4) Greater Anglia should complete the review of its fatigue risk management system to identify and implement improvements.
5) Network Rail should assess the risk associated with permissive working at Norwich station. Greater Anglia should support Network Rail by providing an understanding of the current constraints and processes for short-term alterations to platform allocations.
On the evening of Saturday, July 20, train number 2C45 was timetabled to go to platform five of Norwich railway station.
Shortly before midnight, it was decided that the train would be routed to platform six behind two East Midlands Trains units, which had been stabled there for the night.
At 12.02am, the station supervisor contacted the signaller to ask him to route the train to platform six.
At 12.05am, the conductor on the train was told that the train was being redirected to warn him to position himself at the rear door to prevent passengers from alighting through that door.
At 12.08am, the train stopped at a signal outside the station and after a wait of 20 seconds the driver accelerated to 20mph and allowed the train to coast for 55 seconds as
it approached Norwich railway station.
About 185 metres away, the driver applied the brakes in two successive steps, which reduced the speed of the train to 15mph.
However, about 15 metres from the East Midlands Trains unit, the driver applied the emergency brakes while travelling at 12mph. It collided with unit 158774 at 8mph at about 12.11am.
At 12.17am, the station supervisor called the emergency services. Some of the passengers became aggressive to the driver and British Transport Police officers were called.
At 12.20am, a community first responder arrived and the first ambulance arrived at 12.26am.
At 12.35am the signal box was alerted to stop all train movements.
Eight passengers were taken to hospital after the low-speed collision in July, which may have been caused by the driver nodding off, an accident report revealed yesterday.
Officials from the Railway Accident Investigation Board (RAIB) urged Greater Anglia to review and improve its fatigue management and competence management after it emerged that the driver was responsible for 14 incidents during his 24-year career, including speeding, station overruns, stopping short at stations, and unscheduled stops, which was described as “not typical of even an average driver”.
An investigation was launched after a train coming from Great Yarmouth, carrying 35 passengers, collided at 8mph with a train at Norwich station at 12.11am on July 21.
A report from the RAIB said that during the last 20 seconds of the driver’s approach to the station, he “either had a lapse in concentration or a microsleep”.
Officials from the rail operator yesterday said that they had already taken actions to improve its procedures and a spokesman said the train driver, who has not been named, was still employed with the firm, but not in a train driving role.
Investigators said that a number of factors may have been responsible to explain the driver’s possible lapse in concentration, including the noise made by passengers coming back from a stag party immediately behind his cab. The RAIB added that the driver was tired through a lack of sleep, and his performance might also have been affected by the prescribed medication that he was taking.
The report said the driver was prone to lapses in concentration, and it had not been identified by Greater Anglia’s competence management system.
“Opportunities to formally review the driver’s operational history were missed,” the report said.
As a result of the collision, eight passengers with minor injuries were taken to hospital. Another three passengers attended hospital the following day and a further ten people were treated at the scene for cuts and bruises.
The report said the driver could not recall all of the events between passing a signal outside the station and the time of the collision. On the evening of the accident, the driver was on his second consecutive late shift and he had problems sleeping the night before because of a medical condition.
The driver had been on a development plan for most of the three years before the accident at Norwich, the report said.
Between June 2010 and July 2012, the driver had been involved in six incidents, including an overrun at Stratford station, a “door incident” at Diss, acceptance of a wrong route at Trowse junction, speeding at London Liverpool Street station, and he stopped short and released doors at Stratford station.
The RAIB issued four recommendations to Greater Anglia and one to Network Rail following the incident.
A Greater Anglia spokesman yesterday said: “We have studied and note the contents of the RAIB report and have already implemented the majority of the recommendations that have been made, in addition to the specific actions that we have taken since July 2013 to improve our management systems.
“From the commencement of Greater Anglia taking over the franchise just over two years ago we have ensured that the safety of our passengers and employees is at the heart of our operation and the key priority for us at all times.”
A Network Rail spokesperson added: “Network Rail will take note of any recommendations raised in the RAIB report. These will be considered carefully and we will take action as appropriate.”
John Woods, of the Norwich and Norfolk Transport Action Group, said: “A train coming into contact with another is not something that should be allowed to happen and we need to ensure that they tighten up procedures.”
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