Rail Accident Investigation Branch
Summary
At around 13:00 hrs on 4 May 2023, the 09:54 hrs Sunderland to London Kings Cross Grand Central service passed over three sets of points forming part of Spital Junction at excessive speed. The maximum permitted speed over the junction, which is to the north of Peterborough station, is initially 30 mph (48 km/h) reducing to 25 mph (40 km/h). The data recorder from the train indicated that the points had been traversed at a speed of 66 mph (106 km/h).
The speed of the train over the junction resulted in sudden sideways movements of the coaches. This led to some passengers being thrown from their seats, with some receiving minor injuries.
RAIBs investigation found that the overspeeding was caused by the driver of the train not reacting appropriately to the signal indication they had received on the approach to the junction. This signal was indicating that the train was to take a diverging route ahead which had a lower speed limit than the straight-ahead route. The drivers expectation was that the train was being routed straight ahead and their application of driving awareness skills was not sufficient to overcome that expectation.
UK railway signalling principles mean that the control of speed at diverging junctions such as this is dependent on drivers reacting to signal information given at considerable distances. This, and exemptions granted in the past from fitting engineered protective measures beyond the signal, places the reliance on drivers correctly observing and responding to all the information given by the signal. This was a factor in this incident.
Testing and analysis by RAIB also found that the junction indicator element of the signal may not have been as conspicuous as the main aspect of the signal at the point the driver observed and reacted to the signal. This is a possible factor.
Three underlying factors were identified by the investigation. Grand Central had not provided the driver with the necessary non-technical skills or additional strategies to manage the risk present at this signal. This was a possible underlying factor. Network Rail and East Coast Main Line train operators had not effectively controlled the risk of overspeeding at this junction both at the time the signals operation was changed in 2013 and following a previous overspeeding incident at the same location in April 2022. Thirdly, Network Rail does not control the risk of overspeeding at locations where there is a long distance between the approach released protecting signal and the junction itself, once a proceed aspect has been given to drivers.
RAIB observed that Grand Central had not identified the risks associated with the signal in its route risk assessment and was not managing the development plans for the driver in accordance with its own processes. RAIB also observed that Network Rails reliability centred maintenance regime does not include a means to effectively manage degradation of junction indicator modules fitted with light emitting diodes (LEDs).
A similar incident occurred at the same location (RAIB report 06/2023), 13 months before this incident. Following this more recent incident, RAIB issued urgent safety advice in May 2023 to Network Rail and operators of trains on the East Coast Main Line through Peterborough station. This advice alerted them that suitable arrangements may not be in place to mitigate the risk of trains travelling southbound through Spital Junction at excessive speeds when signalled from the Up Fast line on to the Up Slow lines at Peterborough station. Duty holders were advised that they should take immediate steps, either operationally, or by technical means, to mitigate this risk.
Video summary of the overspeeding incident at Peterborough - link opens in new tab
Recommendations
RAIB has made four new recommendations as a result of this investigation. The first recommendation is for Grand Central to review and amend its training and competence management processes to provide its drivers with the necessary non-technical skills or additional strategies to manage the risk encountered at signals which may show different aspects to those usually encountered.
The second recommendation asks Network Rail and train operators to review the processes by which they derive, share and implement safety learning from accidents and incidents that involve shared risks across organisations.
The third recommendation is for RSSB to review the standards specifying the relative brightness of main aspects and junction indicators on signals to understand the effects on conspicuity of the complete signal up to the maximum distance at which a signal is required to be readable, to minimise the risk of drivers not correctly reading signals.
The fourth recommendation, arising from an observation, is for Network Rail to manage the risk of a driver not seeing a route indication because of the gradual reduction in light output of LED signals, which occurs over time.
RAIB has also identified two learning points during the investigation. The first relates to train operators ensuring that their route risk assessments include the risks to their services from signals which may show different aspects to those usually encountered. The second reminds transport undertakings of the importance of managing the competence of safety?critical staff effectively and in accordance with their own processes.
Also mentioned within this report are the learning points from RAIBs investigation into a previous incident at this location on 17 April 2022. These relate to the need for train operators to ensure that drivers maintain alertness when approaching junction signals and that train operator emergency plans should specifically include processes to deal with the aftermath of overspeeding incidents.
Andrew Hall, Chief Inspector of Rail Accidents said:
An underlying factor behind this incident was that neither Network Rail nor the East Coast Main Line train operators effectively controlled the risk of overspeeding at Spital Junction both at the time the protecting signals operation was changed in 2014 and following the previous incident in 2022.
During the 2022 incident a train crossed the 30 mph limited junction at around 76 mph; a speed at which it is likely that some wheels lifted off the rails and close to a speed that could have caused the train to overturn. Thankfully a serious accident had been very narrowly avoided but thirteen months later, in this incident, the same junction was crossed at 66 mph in similar circumstances. This, once again, reinforces why learning from previous accidents and incidents and taking effective action in response to them is a vital means of improving safety and avoiding repeating mistakes of the past. The fact that the management of risks associated with an incident may be shared between more than one party does not alter this.
Notes to editors
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The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.