Investigation Report 2011-R007 Car Strike at Knockaphunta Level Crossing (XM250), County Mayo, 24 th October 2010 Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU i Investigation Report 2011-R007 Document History Title Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 Document type Investigation Report Document number 2011-R007 Document issue date 19/10/2011 Revision number Revision date Summary of changes Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU ii Investigation Report 2011-R007 Purpose of an investigation by the Railway Accident Investigation Unit The Railway Accident Investigation Unit (RAIU) is a functionally independent investigation unit within the Railway Safety Commission (RSC). The purpose of an investigation by the RAIU is to improve railway safety by establishing, in so far as possible, the cause or causes of an accident or incident with a view to making recommendations for the avoidance of accidents in the future, or otherwise for the improvement of railway safety. It is not the purpose of an investigation to attribute blame or liability. The RAIU‟s investigations are carried out in accordance with the Railway Safety Act 2005 and European railway safety directive 2004/49/EC. Any enquiries about this report should be sent to: Railway Accident Investigation Unit 2 nd Floor 2 Leeson Lane Dublin 2 Ireland Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU iii Investigation Report 2011-R007 Summary At approximately 10:50 on Sunday 24 th October 2010 as the 10:15 passenger service from Athlone to Westport approached Knockphunta Level Crossing, the train driver saw a car approaching the level crossing while the level crossing gates were open to the railway. The train driver sounded the horn and applied the emergency brake; however the train struck the car whilst it was trying to reverse away from the level crossing. There were no fatalities or injuries as a result of this accident. There was damage to the front of the car. The immediate cause of the accident was that:  The car stopped at the level crossing, in a position that encroached into the path of the approaching train, and then was struck by the train when attempting to reverse away from the level crossing. The contributory factors were:  There are no road markings or marker posts at the Level Crossing identify the decision point for users to allow them to stop clear of the railway line and make a decision to cross safely or wait;  The level crossing gates, which provide a barrier to the railway, were open when the car driver arrived at the level crossing. The underlying factor was:  Iarnród Éireann has not introduced adequate measures to reduce the frequent misuse at the level crossing in relation to level crossing users leaving the gates open to the railway. As a result of the Railway Accident Investigation Unit investigation the following new safety recommendation, relating to the occurrence, has been made:  Iarnród Éireann should upgrade the Level Crossing to ensure that the operation of the Level Crossing is not reliant on any direct action by the level crossing user. Two safety recommendations previously issued by the Railway Accident Investigation Unit in February and July 2008 have also been reiterated. Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU iv Investigation Report 2011-R007 Table of Contents 1 Factual information 1 1.1 Relevant parties 1 1.2 The accident 2 1.3 Infrastructure 4 1.4 Traction and rolling stock 12 1.5 Signalling and communications 13 1.6 Operations 13 1.7 Fatalities, injuries and material damage 13 1.8 History of similar accidents and incidents 14 2 Analysis 15 2.1 Documentation on the operation of the Level Crossing 15 2.2 Operation of the Level Crossing 16 2.3 Misuse of the Level Crossing 17 3 Conclusion 18 4 Relevant actions already taken or in progress 20 4.1 Actions taken by IÉ 20 4.2 Actions taken by the RSA 21 5 Recommendations 22 5.1 General description 22 5.2 New recommendations relating to the occurrence 22 5.3 Reiterated recommendations 22 6 Additional information 24 6.1 List of abbreviations and acronyms 24 6.2 Glossary of terms 24 6.3 References 25 Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 1 Investigation Report 2011-R007 1 Factual information 1.1 Relevant parties 1.1.1 Parties involved in the occurrence Iarnród Éireann (IÉ) 1 is the railway undertaking 2 that owns and operates mainline railway services in Ireland. IÉ is also the railway infrastructure manager, managing the design, installation, testing, inspection, maintenance and renewal of the railway‟s physical assets. The IÉ departments associated with this accident are the:  The Intercity and Commuter Network Department – responsible for the supervision and operation of trains on the mainline, excluding the Dublin Urban Network. This includes the supervision of train drivers and the control of train movements through Centralised Traffic Control (CTC) in Dublin and regional controlling signal cabins;  The Chief Civil Engineer‟s (CCE) Department – responsible for the design, inspection, maintenance and renewal of the railway‟s structural infrastructure, including level crossings, and the management of risks relating to the use of passive level crossings that are operated by the level crossing user. The roles associated with this accident are the:  Train Driver – The driver of the train involved in the accident was an IÉ employee, passed as competent to drive trains, whose last competency assessment was on the 6 th May 2010;  Car Driver – The driver of the road vehicle struck by the train. He had a full Irish driving licence. He lived locally and was a regular user of the Knockaphunta Level Crossing (which will now be referred to as the Level Crossing for the remainder of this report) as he is a member of the local rugby club, which is located 1.2 km from the Level Crossing. 1.1.2 Other relevant parties The Railway Safety Commission (RSC) is the national safety authority, which is responsible for the regulatory oversight of railway safety in Ireland in accordance with the Railway Safety Act 2005 and European railway safety directive. 1 All abbreviations are explained in the list of abbreviations section of this report. 2 All terms in italics are explained in the glossary of terms section of this report. Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 2 Investigation Report 2011-R007 The Road Safety Authority‟s (RSA) aim is to save lives and prevent injuries by reducing the number and severity of collisions on the road. Some of the ways that the RSA works to improve road safety in Ireland are by:  Developing and implementing information and education campaigns to increase awareness of road safety and promote safer driving;  Undertaking accident and road safety research in order to develop measures and recommendations to improve road safety;  Producing road safety strategy documents and monitoring their implementation. 1.2 The accident On Sunday 24 th October 2010, the 10:15 passenger service from Athlone to Westport (which will now be referred to as the Train for the remainder of this report) left Athlone Station, travelling in the Down direction. At approximately 10:44, as the Train approached the Level Crossing the Train Driver sounded the horn at the whistle board location, approximately 430 metres (m) before the Level Crossing. See Figure 1 for location of the Level Crossing. Figure 1 – Location Map (Ordnance Survey Ireland, 2003) Ordinance Survey Ireland Licence No. EN 0058211 © Ordinance Survey Ireland Government of Ireland As the Train continued to approach, a car travelled from the Up side of the Level Crossing and stopped at the Level Crossing. The Train Driver immediately re-sounded the horn and applied the emergency brake. The car then started to reverse off the Level Crossing, however, it did not clear the Level Crossing in time and was struck by the Train. Location of the accident Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 3 Investigation Report 2011-R007 The Train‟s approach to the Level Crossing was recorded on the forward facing closed circuit television (CCTV) fitted to the Train. See Figure 2 for snapshots taken from the CCTV. Figure 2 – CCTV snapshots of the Train‟s approach to the Level Crossing The Train came to a stop approximately 104 m beyond the Level Crossing. The Train Driver carried out all post accident procedures and then walked back to the Level Crossing. By the time he reached the Level Crossing, the Car Driver had driven away. Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 4 Investigation Report 2011-R007 The Car Driver approached the Level Crossing with the Level Crossing gates open. He stopped the car, in a position he thought to be safe, to check for approaching trains prior to crossing the railway line. While stopped at the Level Crossing, he saw the approaching Train and realised that he was not in a safe position. He then attempted to reverse off the Level Crossing (as shown from the CCTV). However, he did not clear the Level Crossing in time and his car was struck by the Train. The Car Driver did not recall hearing any of the Train horn soundings prior to the accident, however, the windows of the car had not been lowered. The weather at the time of the accident was dry. Met Éireann recorded a maximum temperature of 11.7 degrees Celsius, and an average wind speed of 12.7 kilometres per hour (km/h). There was good visibility at the time of the accident. 1.3 Infrastructure 1.3.1 General description Knockaphunta Level Crossing is located on a public regional road which connects the N5 national road (Longford to Westport) to the N84 national road (Castlebar to Galway). The speed limit for this section of road is 80 km/h. The line from Athlone to Westport is a single track bidirectional line. The track is plain line with flat bottom continuously welded rail (CWR) mounted on concrete sleepers in ballast. No factors in relation to the condition of the track were found to have contributed to the accident. 1.3.2 Knockaphunta Level Crossing The Level Crossing is located on the Mayo Line at 151 miles 1141 yards from Broadstone Station, County Dublin. IÉ have designated the level crossing as an „Occupational on Public Road‟ (OP) type crossing and is identified as asset number (no.) XM250, see Photograph 1. OP type crossings are unattended level crossings where the level crossing gates are normally closed to the public road traffic. They require the user to open and close the level crossing gates in order to cross the railway. Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 5 Investigation Report 2011-R007 Photograph 1 – Knockaphunta Level Crossing, approaching the Up side The metal gates positioned on each side of the Level Crossing are approximately 4.3 m wide and open away from the railway. The surface of the intersection of the road with the track is covered in rubber „Strail‟ units, which gives a level surface over the track. Cattle grids are installed on each side of the roadway, where it crosses the track to prevent cattle straying onto the railway line. There is concrete post and wire fencing running between the gates and the boundary hedges, see Photograph 2. There is a residential house (an old railway building) and shed positioned 15 m and 20 m, respectively, from the Up side of the Level Crossing, see Photograph 2. Photograph 2 – Residential house and shed Photograph 3 – View from the Up side of the level crossing IÉ‟s technical information sheet, MW50 „Accommodation level crossings‟ (now referred to as MW50 for the remainder of the report), requires that for a single track with a 110 km/h speed limit, the viewing distance must be greater than 350 m, see Photograph 3 for a view from the Level Crossing. This photograph illustrates the view the Car Driver would have had of the railway line. The actual viewing distance, as recorded by the RAIU, is 582 m. Therefore there was no requirement under MW50 for a whistle board to be erected, however, there is a whistle board located approximately [...]... Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 2.2 Operation of the Level Crossing The Car Driver approached the Level Crossing with the Level Crossing gates open to road traffic IÉ signage, in accordance with MW50, is present at the Level Crossing in relation to the operation of the Level Crossing and the closure of Level Crossing gates Level. .. signage states that the Level Crossing gates should be closed As a result the unfamiliar user may drive directly through the Level Crossing, when the Level Crossing gates are open to the railway, thinking it is safe to do so and may also leave the Level Crossing gates open after crossing RAIU 17 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010. .. by a train at XM096, the driver was fatally injured 14 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 2 Analysis 2.1 Documentation on the operation of the Level Crossing The frequency of use of the Level Crossing has increased from 116 to 130 daily vehicle users Allowing for the fact that there may be users that use the Level Crossing. .. photographs of the signage at the Level Crossing RAIU 6 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 Photograph 4 – Danger, warning and “keep these Photograph 5 – Signage in relation to the closure gates shut” signage, entering the Level Crossing of the gates, exiting the Level Crossing Upgraded signage, present at the time of the accident,... the reader to IÉ‟s 'The SAFE Use of Unattended Railway Level Crossings' booklet RAIU 10 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 Figure 3 – Extract from the RSC‟s Third Party Guidance on Railway Risk in relation to unmanned level crossings Details in relation to the operation of level crossing gates can also be found in the „Rules... road traffic, and that this misuse of the Level Crossing, relative to other level crossings, was above average RAIU 11 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 Misuse is indentified in Part 14, Section 131(1) of the Railway Safety Act 2005, stating that: “Where a person fails to shut and fasten the gate of a level crossing or passage... stop in a safe place prior to crossing the Level Crossing, however, given that the Level Crossing gates were open when he approached the Level Crossing, in conjunction with the absence of any obvious indications for a decision point, he miscalculated his RAIU 18 Investigation Report 2011-R007 th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 stopping distance and position,...th Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 October 2010 430m from the Level Crossing in the Down direction, as seen in Figure 2, which was erected some years ago The Level Crossing is not protected by roadside traffic signals and there is no lineside telephone provided at the Level Crossing A local rugby club is located approximately 1.2 km from the Level Crossing, ... the Level Crossing gates after crossing This is reflected by that fact that the misuse of the Level Crossing is higher than average at this Level Crossing, in comparison with other level crossings IÉ have taken no further action in preventing the misuse at this Level Crossing Two near misses were reported at this Level Crossing within six months of this accident On the 10/11/11, a car approached the Level. .. close the Level Crossing gates after operation There have also been two other near misses at the Level Crossing since the accident occurred, where vehicles approached the Level Crossing with the gates open to the railway and attempted to cross the Level Crossing while trains were approaching The immediate cause of the accident was that:  The car stopped at the Level Crossing, in a position that encroached . Investigation Report 2011-R007 Car Strike at Knockaphunta Level Crossing (XM250), County Mayo, 24 th October 2010 Car Strike at Knockaphunta Level. – Old signage at the Level Crossing Car Strike at Knockaphunta Level Crossing, XM250, County Mayo, 24 th October 2010 RAIU 8 Investigation Report 2011-R007